UNIVERSITY  OF  CAL'FORNIA 
CALIFORNIA  COLLEGE  01=  MEDICINE 


LIBRARY 

MAY  2  6  1970 

IRVINE,  CALIFORNIA  92664 


THE    PRINCIPLES    AND 
PRACTICE  OF  MEDICINE 


THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE 

DESIGNED  FOR  THE  USE  OF  PRACTITIONERS 
AND  STUDENTS  OF  MEDICINE 


BY 

SIR  WILLIAM   OSLER,  BT.,  M.D.,  F.R.S. 

FELLOW  OF  THE  ROYAL  COLLEGE  OF  PHYSICIANS,  LONDON;   REGIUS  PROFESSOR  OF  MEDICINE, 

OXFORD  UNIVERSITY;  HONORARY  PROFESSOR  OF  MEDICINE,  JOHNS  HOPKINS  UNIVERSITY, 

BALTIMORE;  FORMERLY  PROFESSOR  OF  THE  INSTITUTES  OF  MEDICINE,  MCGILL 

UNIVERSITY,  MONTREAL,  AND  PROFESSOR  OF  CLINICAL  MEDICINE  IN 

THE  UNIVERSITY  OF  PENNSYLVANIA,  PHILADELPHIA 


EIGHTH   EDITION— WITH  THE  ASSISTANCE   OF 


THOMAS  McCRAE,  M.D. 

FELLOW    OF    THE    ROYAL    COLLEGE    OF    PHYSICIANS,    LONDON ]    PROFESSOR    OF    MEDICINE, 

JEFFERSON    MEDICAL   COLLEGE,    PHILADELPHIA;    FORMERLY    ASSOCIATE 

PROFESSOR   OF   MEDICINE,    JOHNS   HOPKINS   UNIVERSITY 


NEW  YORK  AND   LONDON 
D.   APPLETON  AND   COMPANY 

1919 


BfoO 


COPYRIGHT,  1892,  1895,  1898,  1901,  1902,  1903,  1904,  1905,  1909,  1912,  1916, 
BY  D.  APFLETON    AND   COMPANY 


PRINTED  IN  THE  UNITED  STATES  OF  AMERICA 


TO   THE 

of  mg 
WILLIAM  ARTHUR  JOHNSON, 

PBIEST  OF  THE  PAEISH  OF   WESTON,    ONTAHM. 

JAMES  BOVELL, 

OF  THE  TORONTO   SCHOOL   OF  MEDICINE,    AND  OF  THE 
UNIVERSITY   OF  TRINITY   COLLEGE,   TORONTO. 

ROBERT  PALMER  HOWARD, 

DEAN   OF  THE  MEDICAL  FACULTY   AND   PROFESSOR  OF  MEDICINE, 
MCGILL  UNIVERSITY,    MONTREAL. 


PEEFACE  TO  THE  EIGHTH  EDITION. 


IN  the  twenty  years  that  have  passed  since  the  publication  of  the  first 
edition,  triennial  revisions  have  appeared  regularly,  with  one  exception — 
to  secure  protection  against  an  edition  pirated  in  Great  Britain,  a  fifth  edition 
had  to  be  issued  not  long  after  the  fourth.  Comparing  the  first  edition  with 
the  present,  very  little  remains  of  the  original  work.  The  essential  ground- 
work has  been,  as  far  as  possible,  my  personal  experience  in  hospital  and 
private  practice,  correlated  with  the  general  experience  of  the  profession,  as 
expressed  in  its  literature.  To  try  to  keep  the  book  up  to  date  has  been  a 
pleasure  and  an  ambition.  Adequately  to  express  my  appreciation  of  the 
generous  support  accorded  by  my  colleagues  is  impossible.  The  printed  page 
has  brought  me  "mind  to  mind"  with  men  in  all  parts  of  the  world;  and  to 
feel  that  I  may  have  been  helpful  in  promoting  sound  knowledge  is  my  greatest 
satisfaction. 

This  edition  has  been  rearranged  and  largely  rewritten.  I  have  grouped 
the  infectious  diseases  in  a  different  order,  and  considered  apart  those  of 
which  the  specific  germs  are  doubtful  or  undiscovered.  The  extraordinary 
growth  of  our  knowledge  of  this  department  has  necessitated  the  incorporation 
of  much  new  matter  in  every  section,  particularly  in  typhoid  fever,  typhus 
fever,  pneumonia,  tuberculosis  and  syphilis.  Properly  to  present  the  recent 
advances  many  chapters  :iave  had  to  be  recast.  New  sections  deal  with  Leish- 
maniasis,  the  Sporotrichoses,  the  Colon  infections,  Poliomyelitis,  Pellagra, 
Disorders  of  Metabolism,  Caisson  disease,  Ochronosis,  Hsmochromatosis,  the 
disorders  of  the  organs  of  internal  secretion,  and  the  diseases  of  the  blood. 

Dr.  A.  G.  Gibson  of  Oxford  has  helped  in  the  rewriting  of  the  section  on 
the  heart  and  arteries.  To  Dr.  H.  M.  Thomas  and  Dr.  Harvey  Gushing  I  am 
indebted  for  aid  in  the  revision  of  the  section  on  nervous  diseases. 

My  former  associate  at  the  Johns  Hopkins  Hospital,  Dr.  Thomas  McCrae, 
has  revised  the  sections  on  treatment,  and  the  section  on  diseases  of  the 
organs  of  locomotion.  He  has  also  seen  the  work  through  the  press. 

Messrs.  Appleton  have  provided  a  new  font  of  type  and  a  new  page. 

WILLIAM  OSLER. 

Oxford. 


PREFACE 


The  need  for  a  reprinting  has  given  the  opportunity  to  make  a  considerable 
number  of  alterations.  Many  of  these  are  in  the  section  dealing  with  infec- 
tious diseases.  The  experiences  of  war  have  added  much  to  our  knowledge 
of  these  diseases  and  the  present  one  is  no  exception,  particularly  in  reference 
to  paratyphoid  fever  and  cerebrospinal  fever.  Additional  proof  has  been 
given  of  the  efficiency  of  inoculation  against  typhoid  fever. 

Additions  have  been  made  to  the  description  of  typhoid  and  paratyphoid 
fever,  with  especial  reference  to  the  latter,  the  serum  changes  and  the  subject 
of  protective  inoculation.  Recent  work  on  the  pneumococcus  infections,  with 
its  bearing  on  the  problems  of  immunity,  demands  attention.  Our  knowledge 
of  cerebrospinal  fever  has  been  increased  by  the  studies  of  recent  epidemics, 
particularly  as  regards  the  different  strains  of  the  organism.  Additions  have 
been  made  to  the  subject  of  poliomyelitis,  especially  in  the  study  of  the  anom- 
alous forms.  There  has  been  additional  light  thrown  on  the  food  deficiency 
diseases,  for  example — pellagra.  The  treatment  of  diabetes  mellitus  has  been 
changed  by  the  important  advances  of  recent  work.  The  convenient  diet  tables 
brought  out  by  E.  P.  Joslin  are  included. 

Throughout  the  book  many  minor  changes  have  been  made  to  incorporate 
the  advances  in  our  knowledge. 

WILLIAM  OSLER. 


CONTENTS 


SECTION   I 

SPECIFIC  INFECTIOUS  DISEASES 

PAGE 

A.    Bacterial  Diseases         ...., 1 

I.     Typhoid  Fever 1 

II.     Colon  Bacillus  Infections 46 

III.  The  Pyogenic  Infections 48 

1.  Local  Infections  with  the  Development  of  Toxins  ...  48 

2.  Septiaemia 49 

3.  Septico-pyasmia 50 

4.  Terminal  Infections 53 

IV.  Erysipelas 54 

V.     Diphtheria -. 57 

VI.     The  Pneumonias  and  Pneumococcic  Infections 74 

A.  Lobar   Pneumonia        . 74 

B.  Broncho-pneumonia 101 

C.  Other  Pneumococcic  Infections 108 

VII.     Cerebro-spinal  Fever 108 

VIII.     Influenza 115* 

IX.    Whooping  Cough 119 

X.     Gonococcus  Infections 123 

XI.     Bacillary  Dysentery 126 

I.     Acute  Dysentery <  129 

II.     Chronic  Dysentery 130 

XII.    Malta  Fever 130 

XIII.  Cholera  Asiatica 132 

XIV.  The  Plague .138 

XV.     Tetanus 142 

XVI.     Glanders 146 

XVII.     Anthrax 148 

XVIII.     Leprosy 151 

XIX.    Tuberculosis 154 

I.     General  Etiology  and  Morbid  Anatomy     ....  154 

II.     Acute  Miliary  Tuberculosis 167 

III.  Tuberculosis  of  the  Lymphatic  System     ....  174 

1.  Tuberculosis  of  the  Lymph-glands  ....  174 

2.  Tuberculosis  of  the  Serous  Membranes  .        .        .  178 

IV.  Pulmonary   Tuberculosis 182 

1.     Acute  Pneumonic  Tuberculosis  of  the  Lungs  .        .  183 
ix 


x  CONTENTS 

PAGE 

2.  Chronic  Ulcerative  Tuberculosis  of  the  Lungs       .  187 

3.  Fibroid  Phthisis 202 

Complications  of  Pulmonary  Tuberculosis       .        .        .  202 
Diagnosis   of   Pulmonary   Tuberculosis      ....  206 
Concurrent  Infections  and  Diseases  Associated  with  Pul- 
monary  Tuberculosis 208 

Peculiarities  of  Pulmonary  Tuberculosis  at  the  Extremes 

of  Life 210 

Modes  of  Death  in  Pulmonary  Tuberculosis     .        .        .  210 

V.     Tuberculosis  of  the  Alimentary  Canal       ....  211 

VI.     Tuberculosis  of  the  Liver 213 

VII.     Tuberculosis  of  .the  Brain  and  Cord 214 

VIII.     Tuberculosis  of  the  Genito-urinary  System       .        .        .  215 

IX.     Tuberculosis  of  the  Mammary  Gland       ....  220 

X.     Tuberculosis  of  the  Circulatory  System     ....  221 

XI.     The  Prognosis  in  Tuberculosis 221 

XII.     Prophylaxis  in  Tuberculosis 222 

XIII.     Treatment  of  Tuberculosis 223 

B.  Non-Bacterial  Fungus  Infections — The  Mycoses 231 

I.     Actinomycosis     ...- 232 

II.     The  Sporotrichoses 234 

HI.     Nocardiosis 235 

IV.     Oi'diomycosis 235 

V.    Mycetoma 236 

VI.     Aspergillosis 236 

C.  Protozoan   Infections 237 

I.     Psorospermiasis 237 

II.     Amoebiasis 237 

in.    Malarial  Fever 243 

IV.     Trypanosomiasis <  258 

V.     Leishmaniasis 260 

VI.     Relapsing  Fever 261 

VII.     Syphilis 263 

I.     History,  Etiology,  and  Morbid  Anatomy     ....  263 

II.     Acquired    Syphilis 266 

III.  Congenital  Syphilis 268 

IV.  Visceral  Syphilis 270 

1.  Syphilis  of  the  Brain  and  Cord 270 

2.  Syphilis  of  the  Respiratory  Organs  ....  272 

3.  Syphilis  of  the  Liver 273 

4.  Syphilis  of  the  Digestive  Tract 275 

5.  Circulatory  System .        .  275 

6.  Renal  Syphilis 276 

7.  Syphilitic  Orchitis 276 

V..    Diagnosis,  Treatment,  Etc i        .  276 

VIII.    Diseases  Due  to  Parasitic  Infusoria 281 

D.  Diseases  Due  to  Metazoan  Parasites 282 

I.     Diseases  Due  to  Flukes — Distomiasis  «...  282 


CONTENTS 


XI 


II.     Diseases  Caused  by  Cestodes — Taeniasis 

1.  Intestinal   Cestodes;    Tapeworms        .        .       .        . 

2.  Somatic  Taeniasis 

III.  Diseases  Caused  by  Nematodes 

1.  Ascariasis 

2.  Trichiniasis 

3.  Ankylostomiasis 

4.  Filariasis 

5.  Dracontiasis 

6.  Other  Nematodes 

IV.  Parasitic  Arachnida  and  Ticks 

V.     Parasitic  Insects 

VI.    Parasitic  Flies 

K.     Infectious  Diseases  of  Doubtful  or  Unknown  Etiology       . 

I.     Small-pox ..-;''.       ...... 

II.     Vaccinia   (Cow-pox) — Vaccination 

III.  Varicella    (Chicken-pox) 

IV.  Scarlet  Fever 

V.    Measles 

VI.     Rubella  (German  Measles) 

VII.     Epidemic  Parotitis    (Mumps) 

VIII.     Typhus  Fever i    :  •;••-    . 

IX.    Yellow  Fever     .       .       .       . 

X.     Dengue 

XI.     Acute    Polio-myelitis 

XII.     Hydrophobia      .  

XIII.  Rheumatic  Fever 

XIV.  Acute  Tonsillitis 

XV.     Acute  Catarrhal  Fever 

XVI.     Febricula — Ephemeral   Fever 

XVII.     Infectious  Jaundice 

XVIII.     Milk-sickness 

XIX.     Glandular    Fever «, ; .,  Ji    •„ :-     .-   -  <~.  •  '< 

XX.     Miliary  Fever  (Sweating  Sickness)      .        .        .        .       ;.      .  *       , 
XXI.     Foot  and  Mouth  Disease — Epidemic  Stomatitis — Aphthous  Fever 
XXII.     Psittacosis 

XXIII.  Rocky  Mountain  Spotted  Fever;  Tick  Fever     .... 

XXIV.  Swine   Fever 

XXV.    Rat-bite  Fever  . 


PAGE 

284 
284 
287 
294 
*294 
296 
300 
305 
307 
308 
310 
311 
313 
315 
315 
326 
331 
333 
343 
348 
349 
351 
356 
362 
364 
368 
371 
380 
382 
383 
384 
385 
386 
386 
387 
388 
388 
388 
389 


SECTION  H 

DISEASES  DUE  TO  PHYSICAL  AGENT? 

I.     Sunstroke;  Heat  Exhaustion 390 

II.     Caisson  Disease „  393 

III.    Mountain  Sickness 395 


xii  CONTENTS 

SECTION   III 

THE  INTOXICATIONS 

PAGE 

I.     Alcoholism 396 

II.    Morphia  Habit 400 

III.  Lead  Poisoning -   ...  402 

IV.  Arsenical  Poisoning 406 

V.     Food    Poisoning 407 

VI.     Pellagra 411 

VII.    Beri-Beri 414 

SECTION   IV 

DISEASES  OF  METABOLISM 

I.    Gout 417 

II.     Diabetes  Mellitus 426 

III.  Diabetes  Insipidus 439 

IV.  Rickets  (Rhachitis) 441 

V.     Scurvy 446 

Infantile  Scurvy 449 

VI.    Obesity 450 

VII.    The  Lipomatoses 452 

VIII.     HaBmochromatosis 453 

IX.     Ochronosis  .                                                                                      .        .  454 


SECTION   V 
DISEASES  OF  THE  DIGESTIVE  SYSTEM 

A.  Diseases  of  the  Mouth 456 

Stomatitis 456 

B.  Diseases  of  the  Salivary  Glands 462 

C.  Diseases  of  the  Pharynx 464 

D.  Diseases  of  the  Tonsils 467 

I.     Suppurative  Tonsillitis .  467 

II.     Chronic   Tonsillitis 468 

E.  Diseases  of  the  (Esophagus 472 

I.    Acute  CEsophagitis 472 

II.     Spasm  of  the  (Esophagus 473 

III.  Stricture  of  the  (Esophagus 474 

IV.  Cancer  of  the  (Esophagus 475 

V.    Rupture  of  the  (Esophagus 475 

VI.     Dilatations  and  Diverticula 476 

F.  Diseases  of  the  Stomach 476 

I.    Acute  Gastritis         ....-• 47§ 


CONTENTS  xiii 

PAGE 

II.     Chronic    Gastritis .479 

III.  Cirrhosis  Ventrieuli 486 

IV.  Dilatation  of  the  Stomach 486 

V.     The  Peptic  Ulcer,  Gastric  and  Duodenal 490 

VI.     Cancer  of  the  Stomach 498 

VII.     Hypertrophic  Stenosis  of  the  Pylorus 505 

VIII.     Haemorrhage  from  the  Stomach 506 

IX.     Neuroses   of   the   Stomach *  509 

G.     Diseases  of  the  Intestines 516 

I.     Diseases  of  the  Intestines  Associated  with  Diarrhoea   .       .       .  516 

Catarrhal  Enteritis;  Diarrhoea 516 

Diphtheroid  or  Croupous  Enteritis 520 

Phlegmonous  Enteritis 520 

Ulcerative   Enteritis      .        . '/..'.  520 

II.     Diarrhoeal  Diseases  in  Children 524 

III.  Appendicitis       .        . -U       ,  531 

IV.  Intestinal   Obstruction 538 

V.     Constipation 545 

VI.     Enteroptosis 548 

VII.     Miscellaneous  Affections 551 

I.    Mucous  Colitis 551 

II.     Dilatation  of  the  Colon .       .552 

III.  Intestinal  Sand   ..........  553 

IV.  Diverticulitis — Perisigmoiditis 553 

V.     Affections  of  the  Mesentery   . 553 

H.     Diseases  of  the  Liver  . 555 

I.     Jaundice / 555 

1.  Obstructive  Jaundice 555 

2.  Toxasmic  and  HaBmolytic  Jaundice 557 

3.  Hereditary   Icterus 557 

II.     Icterus    Neonatorum 558 

III.  Acute  Yellow  Atrophy 559 

IV.  Affections  of  the  Blood-vessels  of  the  Liver     .       .       .       .       .  561 
V.    Diseases  of  the  Bile-passages  and  Gall-bladder       ....  563 

I.     Acute  Catarrh  of  the  Bile-ducts 563 

II.     Chronic  Catarrhal  Angiocholitis 564 

III.  Suppurative  and  Uleerative  Angiocholitis   .        .        .        .  565 

IV.  Acute  Infectious  Cholecystitis 565 

V.     Cancer  of  the  Bile-passages 567 

VI.     Stenosis  and  Obstruction  of  the  Bile-ducts  ....  567 

VI.     Cholelithiasis .568 

VII.     The  Cirrhoses  of  the  Liver 575 

1.  Alcoholic    Cirrhosis 576 

2.  Hypertrophic   Cirrhosis 580 

3.  Syphilitic    Cirrhosis .  581 

4.  Capsular   Cirrhosis — Perihepatitis 581 

VIII.    Abscess  of  the  Liver 583 

IX.     New  Growths  in  the  Liver                                             .  587 


XIV 


CONTENTS 

PAGE 

X.    Fatty  Liver 59° 

XI.    Amyloid  Liver 

XII.     Anomalies  in  Form  and  Position  of  the  Liver  .....     591 


I.     Diseases  of  the  Pancreas 


592 


I.  Pancreatic  Insufficiency 592 

II.  Pancreatic  Necrosis 

III.  Hemorrhage 

IV.  Acute  Pancreatitis 594 

V.  Chronic   Pancreatitis •  596 

VI.  Pancreatic  Cysts .       .  597 

VII.  Tumors  of  the  Pancreas •  598 

VIII.  Pancreatic  Calculi 599 

J.     Diseases  of  the  Peritoneum 60( 

I.  Acute  General  Peritonitis .  60( 

II.  Peritonitis  in  Infants 

III.  Localized   Peritonitis  • 604 

IV.  Chronic  Peritonitis 606 

V.  New  Growths  in  the  Peritoneum 607 

VI.  Ascites •  608 


SECTION  VI 
DISEASES  OF  THE  RESPIRATORY  SYSTEM 

A.  Diseases  of  the  Nose 612 

I.    Autumnal  Catarrh  (Hay  Fever)   . 612 

II.     Epistaxis 613 

B.  Diseases  of  the  Larynx 614 

I.     Acute  Catarrhal  Laryngitis 614 

II.     Chronic  Laryngitis 615 

III.  CEdematous  Laryngitis 616 

IV.  Spasmodic  Laryngitis      .                       617 

V.     Tuberculous  Laryngitis 618 

VI.     Syphilitic  Laryngitis       ....               619 

C.  Diseases  of  the  Bronchi 620 

I.     Acute    Bronchitis 620 

II.     Chronic  Bronchitis 622 

III.  Bronchiectasis 625 

IV.  Bronchial  Asthma 627 

V.     Fibrinous  Bronchitis 631 

D.  Diseases  of  the  Lungs 633 

I.     Circulatory  Disturbances  in  the  Lungs 633 

II.     Chronic  Interstitial  Pneumonia 639 

III.    Pneumonokoniosis .  642 


CONTENTS  xv 

PAGE 

IV.     Emphysema 645 

1.  Compensatory 645 

2.  Hypertrophie 646 

3.  Atrophic 650 

4.  Acute  Vesicular 650 

5.  Interstitial 650 

V.     Gangrene  of  the  Lung 650 

VI.     Abscess  of  the  Lung 652 

VII.     New  Growths  in  the  Lungs 653 

Diseases  of  the  Pleura 654 

I.     Acute  Pleurisy 654 

1.  Fibrinous  or  Plastic  Pleurisy 654 

2.  Sero-fibrinous  Pleurisy 655 

3.  Purulent  Pleurisy  (Empyema) .  660 

4.  Tuberculous  Pleurisy 662 

5.  Other  Varieties  of  Pleurisy.       .       .       .               .  .    .       .  662 

II.     Chronic  Pleurisy 667 

III.  Hydrothorax 668 

IV.  Pneumothorax 669 

V.     Affections  of  the  Mediastinum  672 


SECTION   VH 

DISEASES  OF  THE  KIDNEYS 

I.     Malformations 676 

II.     Movable  Kidney 676 

III.  Circulatory   Disturbances 679 

IV.  Anomalies  of  the  Urinary  Secretion 680 

1.  Anuria 680 

2.  Haematuria 681 

3.  Ha3moglobinuria 682 

4.  Albuminuria 684 

5.  Bacteriuria 687 

6.  Pyuria 687 

7.  Chyluria — Non-parasitic 688 

8.  Lithuria 688 

9.  Oxaluria 689 

10.  Cystinuria .        .       .  690 

11.  Phosphaturia .       .       .  690 

12.  Indicanuria 691 

13.  Melanuria 691 

14.  Alkaptonuria 692 

15.  Pneumaturia 692 

16.  Other  Substances         ....  693 
2 


xvi  CONTENTS 

PAGE 

V.    Uraemia ,693 

VI.     Acute  Bright's  Disease 696 

VII.     Chronic   Bright's  Disease 702 

1.  Chronic  Parenchymatous  Nephritis 702 

2.  Chronic  Interstitial  Nephritis 704 

VIII.    Amyloid  Disease 711 

IX.     Pyelitis 712 

X.     Hydronephrosis         . 715 

XI.     Nephrolithiasis 717 

XII.     Tumors  of  the  Kidney 722 

XIII.  Cystic  Disease  of  the  Kidney 723 

XIV.  Perinephric  Abscess 725 


SECTION   VIII 
DISEASES  OF  THE  BLOOD 

I.    Anaemia 727 

Local  Anaemia 727 

General  Anaemia 728 

Primary  or  Essential  Anaemia 730 

1.  Chlorosis 730 

2.  Idiopathic  or  Pernicious  Anaemia 733 

II.    Leukaemia 741 

III.  Hodgkin's  Disease 746 

IV.  Purpura .750 

V.    Haemophilia 755 

VI.     Erythraemia 757 

VII.     Enterogenous  Cyanosis 758 


SECTION   IX 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

A.  Diseases  of  the  Pericardium 760 

I.     Pericarditis 760 

Chronic  Adhesive  Pericarditis 767 

II.     Other  Affections  of  the  Pericardium 769 

B.  Diseases  of  the  Heart 770 

I.    Functional  Affections  of  the  Heart 770 

1.  Palpitation 770 

2.  Arrhythmia 771 

3.  Fibrillation  of  the  Heart 774 

4.  Rapid  Heart— Tachycardia 776 


CONTENTS  xvii 

PAGE 

5.  Slow  Heart — Bradycardia 777 

6.  Heart-block — Stokes-Adams'  Disease 778 

II.     Affections  of  the  Myocardium 780 

1.  Hypertrophy 780 

2.  Dilatation 782 

3.  Cardiac  Insufficiency 784 

III.  Endocarditis   . .       .797 

IV.  Chronic  Valvular  Disease 805 

General   Introduction 805 

Aortic  Incompetency 808 

Aortic   Stenosis 814 

Mitral  Incompetency    , 817 

Mitral  Stenosis 820 

Tricuspid  Valve  Disease 824 

Pulmonary  Valve  Disease 825 

Combined  Valvular  Lesions       .       .       .       .       .       .       .       .  826 

V.     Special  Pathological   Conditions 828 

1.  Aneurism  of  the  Heart 829 

2.  Rupture  of  the  Heart 830 

3.  New  Growths  and  Parasites 831 

4.  Wounds  and  Foreign  Bodies 831 

VI.     Congenital  Affections  of  the  Heart 832 

VII.    Angina  Pectoris       .       .       . 836 

C.    Diseases  of  the  Arteries 841 

I.     Arterio-sclerosis 841 

II.    Aneurism 847 

Aneurism  of  the  Thoracic  Aorta 849 

Aneurism  of  the  Abdominal  Aorta  .       .       .       .       .       .       .  859 

Aneurism  of  the  Branches  of  the  Abdominal  Aorta     .       .       .  860 

Arterio-venous  Aneurism 861 

Polyarteritis  Acuta  Nodosa 862 


SECTION   X 
DISEASES  OP  THE  DUCTLESS  GLANDS 

I.    Diseases  of  the  Suprarenal  Bodies 863 

1.  Addison's  Disease 863 

2.  Other  Affections  of  the  Suprarenal  Glands     .       .       .       .  867 
II.    Diseases  of  the  Thymus  Gland 868 

1.  Hypertrophy  of  the  Thymus 868 

2.  Atrophy  of  the  Thymus 869 

3.  Status  Thymico-lymphaticus 869 

III.    Diseases  of  the  Thyroid  Gland 869 

1.     Congestion  869 


xviii  CONTENTS 

PAGE 

2.  Thyroiditis 871 

3.  Tumors  of  the  Thyroid 871 

4.  Aberrant  and  Accessory  Thyroids 871 

5.  Goitre 872 

6.  Hypothyroidism  (Cretinism  and  Myxredema)   ....  873 

7.  Hyperthyroidism ;  Exophthalmic  Goitre 877 

IV.    Diseases  of  the  Parathyroid  Glands     .       .       .       .       .       .       .  880 

Tetany 881 

V.    Diseases  of  the  Spleen 883 

1.  General  Remarks 883 

2.  Movable  Spleen 883 

3.  Rupture  of  the  Spleen 884 

4.  Infarct,  Abscess,  and  Cysts  of  the  Spleen       ....  885 

5.  Primary  Splenomegaly  with  Ana3mia 885 

VI.     Diseases  of  the  Pituitary  Body 889 

Acromegaly 890 

VII.     Infantilism  892 


SECTION   XI 

DISEASES  OF  THE  NERVOUS  SYSTEM 

A      General  Introduction 894 

B.     System  Diseases 912 

I.     Introduction 912 

II.    Diseases  of  the  Afferent  or  Sensory  System      ;  913 

1.     Locomotor  Ataxia 913 

1         2.     General  Paralysis  of  the  Insane  and  Tabo-paralysis     .        .  921 

3.     Acute  Posterior   Ganglionitis 926 

III.     Diseases  of  the  Efferent  or  Motor  Tract 927 

A.  Of  Whole  Tract 927 

1.  Progressive  (Central)  Muscular  Atrophy  .        .        .  927 

2.  Progressive  Neural  Muscular  Atrophy       .        .        .  931 

3.  The  Muscular  Dystrophies 932 

B.  System  Diseases  of  the  Upper  Motor  Segment  .       .       .  935 

1.  Spastic  Paralysis  of  Adults 935 

2.  Spastic    Paralysis    of    Infants — Spastic    Diplegia — 

Birth  Palsies 936 

3.  Hereditary  Spastic  Paraplegia 937 

4.  Erb's  Syphilitic  Spinal  Paralysis 939 

5.  Secondary  Spastic  Paralysis 939 

6.  Hysterical  Spastic  Paraplegia 940 

C.  System  Diseases  of  the  Lower  Motor  Segment       .       .       .  940 

1.     Chronic   Anterior  Polio-myelitis   .       .       .  940 


CONTENTS  xix 

PAGE 

2.  Ophthalmoplegia 940 

3.  Acute  Polio-myelitis 940 

4.  Acute  and  Subacute  Polio-myelitis  in  Adults     .        .  941 

5.  Acute  Ascending   (Landry's)   Paralysis       .        .        .  941 
IV.     Combined  System  Diseases 942 

1.  Ataxia  Paraplegia 942 

2.  Primary  Combined  Sclerosis   (Putnam) 943 

3.  Hereditary  Ataxia 944 

4.  Progressive  Interstitial  Hypertrophic  Neuritis  of  Infants  .  945 

5.  Toxic  Combined  Sclerosis 945 

C.  Diffuse  Diseases  of  the  Nervous  System 946 

I.     Affections  of  the  Meninges 946 

Diseases  of  the  Dura  Mater 946 

Haamorrhagic  Pachymeningitis 946 

Diseases  of  the  Pia  Mater 948 

II.     Scleroses  of  the  Brain 951 

D.  Diffuse  and  Focal  Diseases  of  the  Spinal  Cord 954 

I.     Topical  Diagnosis 954 

II.    Affections  of  the  Blood-vessels .  956 

1.  Congestion 956 

2.  Anasmm 956 

3.  Embolism  and  Thrombosis 957 

4.  Endarteritis     . 957 

5.  Haemorrhage  into  the  Spinal  Membranes;  Haematorrhachis  .  957 

6.  Haemorrhage  into  the  Spinal  Cord;  Haematomyelia     .       .  958 

III.  Compression  of  the  Spinal  Cord 959 

IV.  Lesions  of  the  Cauda  Equina  and  Conus  Medullaris       .        .        .  962 
V.     Tumors  of  the  Spinal  Cord  and  Its  Membranes     .                .        .  963 

VI.     Syringomyelia 964 

VII.    Acute  Myelitis 965 

E.  Diffuse  and  Focal  Diseases  of  the  Brain 968 

I.     Topical  Diagnosis 968 

II.     Aphasia 976 

III.  Affections  of  the  Blood-vessels 982 

1.  Cerebral   Circulation 982 

2.  Hyperasmia  and  Anaemia 985 

3.  (Edema  of  the  Brain .986 

4.  Cerebral  Haemorrhage 987 

5.  Embolism  and  Thrombosis 998 

6.  Aneurism  of  the  Cerebral  Arteries 1003 

7.  Endarteritis 1004 

8.  Thrombosis  of  the  Cerebral  Sinuses  and  Veins       .        .        .  1004 

9.  Hemiplegia  in  Children 1006 

IV.  Tumors,  Infections,  Granulomata  and  Cysts  of  the  Brain       .        .  1009 
V.     Inflammation  of  the  Brain 1014 

1.  Acute    Encephalitis .  1014 

2.  Abscess  of  the  Brain 1015 

VI.     Hydrocephalus 1018 


XX  CONTENTS 

PAGE 

F.  Diseases  of  the  Peripheral  Nerves 1020 

I.  Neuritis       .       . 1020 

II.  Neuromata 1026 

III.    Diseases  of  the  Cerebral  Nerves 1028 

Olfactory  Nerves  and  Tracts 1028 

Optic  Nerve  and  Tract 1029 

1.  Lesions  of  the  Retina 1029 

2.  Lesions  of  the  Optic  Nerve 1030 

3.  Affections  of  the  Chiasraa  and  Tract 1031 

4.  Affections  of  the  Tract  and  Centres 1032 

Motor  Nerves  of  the  Eyeball 1035 

Fifth  Nerve 1039 

Facial  Nerve 1041 

Auditory  Nerve 1045 

The  Cochlear  Nerve 1045 

The  Vestibular  Nerve 1046 

Glosso-pharyngeal   Nerve 1048 

Pneumogastric  Nerve 1049 

Spinal  Accessory  Nerve 1052 

Hypoglossal  Nerve 1054 

IV.    Diseases  of  the  Spinal  Nerves 1055 

Cervical  Plexus 1055 

Brachial  Plexus 1057 

Lumbar  and  Sacral  Plexuses 1060 

Sciatica 1061 

G.  General  and  Functional  Diseases       . 1061 

I.    Paralysis  Agitans ' 1063 

Other  Forms  of  Tremor 1066 

II.  Acute  Chorea 1066 

III.  Other  Affections  Described  as  Chorea  .       .       . '  .       .       .  1074 

IV.  Infantile  Convulsions 1077 

V.     Epilepsy 1079 

VI.  Migraine 1087 

VII.    Neuralgia 1089 

VIII.     Professional  Spasms;  Occupation  Neuroses 1093 

IX.     Hysteria 1095 

X.    Neurasthenia 1106 

XL     The  Traumatic  Neuroses .  1116 

XII.     Other  Forms  of  Functional  Paralysis 1119 

H.    Vaso-motor  and  Trophic  Disorders 1120 

I.    Raynaud's  Disease   ,, 1120 

II.     Erythromelagia 1123 

III.  Angio-neurotic  (Edema 1123 

IV.  Persistent  Hereditary  (Edema  of  the  Legs 1124 

V.    Facial  Hemiatrophy 1125 

VI.     Scleroderma 1125 

VII.  Ainhum .  1127 


CONTENTS  xxi 
SECTION   XII 

DISEASES  OF  THE  LOCOMOTOR  SYSTEM 

PAGE 

A.  Diseases  of  the  Muscles       . 1128 

I.    Myositis '     .  1128 

II.    Myositis  Ossificans  Progressiva .  1129 

III.  Myalgia 1129 

IV.  Myotonia 1131 

V.     Paramyoclonus  Multiplex 1132 

VI.     Myasthenia  Gravis 1133 

VII.     Amyotonia    Congenita 1133 

B.  Diseases  of  the  Joints 1134 

I.     Arthritis  Deformans 1134 

II.     Intermittent  Hydrarthrosis 1143 

C.  Diseases  of  the  Bones 1143 

I.     Hypertrophic  Pulmonary  Arthropathy 1143 

II.     Osteitis  Deformans 1144 

III.  Leontiasis  Ossea 1145 

IV.  Osteogenesis  Imperfecta  .       .       ... 1145 

V.     Osteopsathyrosis 1146 

VI.    Achondroplasia         f 1146 

VII.     Oxycephala- 1147 


CHARTS  AND  ILLUSTRATIONS 


CHAET  PAGE 

I.     Typhoid  Fever  with  Relapses 16 

II.     Typhoid  Fever.     Haemorrhage  from  the  Bowels 23 

III.  Fever,  Pulse  and  Respiration  in  Lobar  Pneumonia   ....  82 

IV.  Blood  Count  in  Pneumonia  and  Comparative  Mortality     ...  87 
V.     Chronic  Tuberculosis 198 

Via.     Double  Tertian  Infection.     Quotidian  Fever  .       .        .                .        .  250 

VIb.     2Estivo-autumnal  Infection.    Remittent  Fever 250 

Vic.     ^Estivo-autumnal  Fever.    Quotidian  Paroxysms   .        .        .        .        .  251 

VId.     Quartan  Fever 251 

VII.     Malaria  Cases  Among  the  Employees  of  the  Isthmian  Canal  Com- 
mission,  1906-1910 256 

VIII.     Relapsing  Fever  (Murchison) 262 

IX.     Small-pox   (Strumpell)        .        ;        ...        .       ......        .        .        .318 

X.     Scarlet  Fever 336 

XI.     Measles 345 

XII.     Typhus  Fever  (Murchison) 354 

XIII.  Case  of  Sun  Stroke  Treated  by  the  Ice-bath;  Recovery      .        .        .  392 

XIV.  Uric  Acid  and  Phosphoric  Acid  Output  in  Case  of  Acute  Gout  .        .  419 
XV.     Blood  Chart  in  Purpura  Hasmorrhagica 729 

XVI.     Chlorosis 731 

XVII.     Pernicious  Anasmia 737 

XVIII.    Leukemia 744 

XIX.     Blood  Chart  of  Anaemia  in  Purpura  Ha3morrhagica     ....  753 

FIGURE 

1.  A  "Nodal"  Extra-systole 773 

2.  Extra-systoles  of  Ventricular  Type 773 

3.  Extra-systoles  Followed  by  Ventricular  Contractions  .        .        .        .        .  774 

4.  Pulse  Tracing  from  a  Case  of  Auricular  Fibrillation 775 

5.  Diagram  Showing  the  Sino-auricular  Node  and  the  Auricular  Bundle  .  778 

6.  Diagrams  after  Martius,  Showing  Schematically  the  Power  of  the  Heart 

Muscle 806 

7.  Schematic  Division  of  the  Phases  of  the  Heart's  Action  .....  808 

8.  Pulse  Tracing  in  Aortic  Insufficiency-;  Extra-systole 813 

9.  Pulse  Tracing  in  Aortic   Stenosis 816 

10.     Diagram  of  Motor  Path  from  Left  Brain  (van  Gehuchten)       .        .       .  896 


xxm 


xxiv  CHARTS   AND   ILLUSTRATIONS 

FIGURE  PAGE 

11.  Diagram  of  Motor  Path  from  Each  Hemisphere  (van  Gehuchten)   .       .  897 

12.  Diagrams  of  Cerebral  Localization 900 

13.  Diagram  of  Motor  and  Sensory  Representation  in  the  Internal  Capsule.  901 

14.  Diagram  of  Motor  and  Sensory  Paths  in  Crura 902 

15.  Diagram  of  Cross-section  of  the   Spinal  Cord 902 

16.  Anterior  Aspect  of  the  Segmental  Skin-fields  of  the  Body  ....  906 

17.  Posterior  Aspect  of  the  Segmental  Skin-fields  of  the  Body   .       .       .  907 

18.  Diagram  of  Motor  Path  from  Left  Brain 994 

19.  Diagram  of  Visual  Paths  (Violet) 1033 


THE 

PRINCIPLES   AND    PRACTICE 
OF    MEDICINE 


A.    BACTERIAL   DISEASES 

I.    TYPHOID    FEVER 

Definition. — A  general  infection  caused  by  the  bacillus  typhosus,  charac- 
terized anatomically  by  hyperplasia  and  ulceration  of  the  intestinal  lymph- 
follicles,  swelling  of  the  mesenteric  glands  and  spleen,  and  parenchymatous 
changes  in  the  other  organs.  There  are  cases  in  which  the  local  changes  are 
slight  or  absent,  and  there  are  others  with  intense  localization  in  the  lungs, 
spleen,  kidneys,  or  cerebro-spinal  system.  Clinically  the  disease  is  marked 
by  fever,  a  rose-colored  eruption,  diarrhoea,  abdominal  tenderness,  tympanites, 
and  enlargement  of  the  spleen ;  but  these  symptoms  are  extremely  inconstant, 
and  even  the  fever  varies  in  its  character. 

Historical  Note. — Huxham,  in  his  remarkable  Essay  on  Fevers,  had 
"taken  notice  of  the  very  great  difference  there  is  between  the  putrid  malig- 
nant and  the  slow  nervous  fever."  In  1813  Pierre  Bretonneau,  of  Tours, 
distinguished  "dothienenterite"  as  a  separate  disease;  and  Petit  and  Serres 
described  entero-mesenteric  fever.  In  1829  Louis'  great  work  appeared,  in 
which  the  name  "typhoid"  was  given  to  the  fever.  At  this  period  typhoid 
fever  alone  prevailed  in  Paris  and  many  European  cities,  and  it  was  univer- 
sally believed  to  be  identical  with  the  continued  fever  of  Great  Britain,  where 
in  reality  typhoid  and  typhus  coexisted.  The  intestinal  lesion  was  regarded 
as  an  accidental  occurrence  in  the  course  of  ordinary  typhus.  Louis'  students 
returning  to  their  homes  in  different  countries,  had  opportunities  for  studying 
the  prevalent  fevers  in  the  thorough  and  systematic  manner  of  their  master. 
Among  these  were  certain  young  American  physicians,  to  one  of  whom,  Ger- 
hard, of  Philadelphia,  is  due  the  great  honor  of  having  first  clearly  laid  down 
the  differences  between  the  two  diseases.  His  papers  in  the  American  Jour- 
nal of  the  Medical  Sciences,  1837,  are  the  first  which  give  a  full  and  satis- 
factory account  of  their  clinical  and  anatomical  distinctions.  The  studies  of 
James  Jackson,  Sr.  and  Jr.,  of  Enoch  Hale  and  of  George  C.  Shattuck,  of 

1 


2  SPECIFIC    INFECTIOUS   DISEASES 

Boston,  and  of  Alfred  Stille  and  Austin  Flint  made  the  subject  very  familiar 
in  American  medicine.  In  1842  Elisha  Bartlett's  work  appeared,  in  which, 
for  the  first  time  in  a  systematic  treatise,  typhoid  and  typhus  fever  were 
separately  considered  with  admirable  clearness.  In  Great  Britain  the  recog- 
nition of  the  difference  between  the  two  diseases  was  very  slow,  and  was  due 
largely  to  A.  P.  Stewart,  and,  finally,  to  the  careful  studies  of  Jenner  between 
1849  and  1850. 

Etiology. — GENERAL  PREVALENCE. — Typhoid  fever  prevails  especially  in 
temperate  climates,  in  which  it  constitutes  the  most  common  continued  fever. 
Widely  distributed  throughout  all  parts  of  the  world,  it  probably  presents 
everywhere  the  same  essential  characteristics,  and  is  everywhere  an  index  of 
the  sanitary  intelligence  of  a  community.  Imperfect  sewerage  and  contam- 
inated water-supply  are  two  special  conditions  favoring  the  distribution  of 
the  bacilli;  filth,  overcrowding,  and  bad  ventilation  are  accessories  in  lower- 
ing the  resistance  of  the  individuals  exposed.  While  from  an  infected  person 
the  disease  may  be  spread  by  fingers,  food  and  flies. 

In  England  and  Wales  in  1910  the  disease  was  fatal  to  1,848  persons,  a 
mortality  of  46  per  million  of  living  persons.  It  destroys  more  lives  in 
proportion  to  population  in  towns  than  in  the  country.  The  rate  was  lower 
in  1910  than  in  any  year  since  18G9.  Compared  with  the  quinquennial 
average,  there  was  a  very  marked  reduction. 

In  India  the  disease  is  very  prevalent;  no  race  or  creed  is  exempt,  and 
80  per  cent,  of  the  cases  of  continued  fever  lasting  three  weeks  prove  to  be 
typhoid  fever  (L.  Eogers). 

In  the  United  States  typhoid  fever  continues  to  be  disgracefully  prevalent. 
From  1900  to  1909  the  death  rate  in  the  registration  areas  was  29.5  per  100,- 
000.  It  is  estimated  that  from  35,000  to  40,000  persons  die  of  it  every  year, 
so  that  at  a  moderate  estimate  nearly  one  half-million  people  are  attacked 
annually.  It  is  more  prevalent  in  country. districts  than  in  cities,  and,  as 
Fulton  has  shown,  the  propagation  is  largely  from  the  country  to  the  town. 
What  is  needed  both  in  Canada  and  the  United  States /is  a  realization  by  the 
public  that  certain  primary  laws  of  health  must  be  obeyed. 

In  Germany  the  larger  cities  have  comparatively  little  typhoid  fever.  The 
story  of  Hamburg,  as  told  by  Eeincke  (Lancet,  i,  1904),  should  be  lead  by 
all  interested  in  the  disease.  During  the  past  twenty-five  years  the  death  rate 
in  Prussia  has  been  reduced  from  an  average  of  over  6  to  less  than  2  per 
10,000  of  the  population.  It  is  still  very  prevalent  in  some  of  the  country 
districts. 

Typhoid  fever  has  been  one  of  the  great  scourges  of  the  armies,  and  kills 
and  maims  more  than  powder  and  shot.  The  present  war  shows  the  results 
of  preventive  inoculation  in  a  striking  way. 

In  the  Spanish-American  War  the  report  of  the  Commission  (Reed, 
Vaughan,  and  Shakespeare)  shows  that  one-fifth  of  the  soldiers  in  the  national 
encampments  had  typhoid  fever — among  107,973  men  there  were  20,738  cases, 
with  1,580  deaths.  In  90  per  cent,  of  the  volunteer  regiments  the  disease 
broke  out  within  eight  weeks  a,fter  going  into  camp.  In  the  opinion  of  the 
Commission  the  most  important  factors  were  camp  pollution,  flies  as  carriers 
of  contagion,  and  the  contamination  through  the  air  in  the  form  of  dust. 

In  the  South  African  War  the  British  army,  557,653  officers  and  men,  had 


TYPHOID    FEVER  3 

57,684  cases  of  enteric  fever,  with  8,225  deaths  (Simpson),  while  only  7,582 
men  died  of  wounds  received  in  battle.  As  in  America,  the  disease  was  essen- 
tially one  of  the  standing  camps;  troops  constantly  on  the  move  were  rarely 
much  affected.  While  contaminated  water  was  no  doubt  an  important  fac- 
tor, as  it  alwa}rs  is  in  camp  pollution,  yet  certain  of  the  conditions  in  Africa 
were  peculiar.  Faecal  and  urinary  contamination  must  have  been  very  com- 
mon, as  in  the  cooking,  performed  in  the  open  air,  sand  "entered  largely  into 
every  article  of  food."  As  there  was  a  perfect  plague  of  flies,  they  were  with- 
out doubt  a  very  important  factor  in  the  infection  of  both  food  and  drink. 

On  the  other  hand,  the  Japanese  and  Russian  War  demonstrated  the  re- 
markable efficiency  of  modern  hygiene,  if  carried  out  in  an  intelligent  man- 
ner. In  the  great  war  at  present  raging  typhoid  fever  has  not  prevailed  to 
any  extent  in  the  Western  armies.  The  efficacy  of  inoculation  has  been 
demonstrated.  The  large  proportion  of  paratyphoid  cases  is  remarkable. 

Season. — Almost  without  exception  the  disease  is  everywhere  more  preva- 
lent in  the  autumn,  hence  the  old  popular  name  autumnal  fever.  The  exhaust- 
ive study  of  this  question  by  Sedgwick  and  Winslow  shows  everywhere  a  strik- 
ing parallelism  between  the  monthly  variations  in  temperature  and  the  preva- 
lence of  the  disease.  In  a  few  cities  the  curves  are  irregular,  showing,  in 
addition  to  the  usual  summer  rise,  two  secondary  maxima  in  the  winter  and 
spring,  and  these  authors  suggest  that  epidemics  at  these  seasons  are  charac- 
teristic of  cities  whose  water-supply  is  most  subject  to  pollution.  In  their 
opinion  "the  most  reasonable  explanation  of  the  seasonal  variations  of  typhoid 
fever  is  a  direct  effect  of  the  temperature  upon  the  persistence  in  nature  of 
the  germs  which  proceed  from  previous  victims  of  the  disease." 

Of  1,500  cases  at  the  Johns  Hopkins  Hospital  (upon  the  study  of  which 
this  section  is  based),  810  were  in  August,  September,  and  October. 

Sex. — Males  and  females  are  equally  liable  to  the  disease,  but  males  are 
much  more  frequently  admitted  into  hospitals,  2.4  to  1  in  our  series. 

Age. — Typhoid  fever  is  a  disease  of  youth  and  early  adult  life.  The 
greatest  susceptibility  is  between  the  ages  of  fifteen  and  twenty-five.  Of 
1,500  cases  treated  in  my  wards  at  the  Johns  Hopkins  Hospital  there  were 
under  fifteen  years  of  age,  231;  between  fifteen  and  twenty,  253;  between 
twenty  and  thirty,  680;  between  thirty  and  forty,  227;  between  forty  and 
fifty,  88;  between  fifty  and  sixty,  8;  above  sixty,  11;  age  not  given,  1.  Cases 
are  rare  over  sixty,  although  Manges  believes  that  they  are  more  common 
than  the  records  show.  As  the  course  is  often  atypical  the  diagnosis  may  be 
uncertain  and  the  disease  not  recognized  until  autopsy.  It  is  not  very  infre- 
quent in  childhood,  but  infants  are  rarely  attacked.  Murchison  saw  a  case 
at  the  sixth  month.  There  is  definite  evidence  that  the  disease  may  be  con- 
veyed to  the  fetus,  the  bacillus  passing  through  the  placenta. 

Immunity. — Xot  all  exposed  to  the  infection  take  the  disease.  Some  fam- 
ilies seem  more  susceptible  than  others.  One  attack  usually  protects.  Two 
attacks  have  been  described  within  a  year.  "Of  2,000  cases  of  enteric  fever 
at  the  Hamburg  General  Hospital,  only  14  persons  were  affected  twice  and 
only  1  person  three  times"  (Dreschfeld).  In  500  of  our  cases  in  which  special 
inquiry  was  made  as  to  a  previous  attack,  it  was  found  to  have  occurred  in 
11  (2.2  per  cent.).  The  interval  varied  from  nine  months  to  thirty  years. 
It  is  well  known  that  usually  within  a  short  time  after  recovery  the  immune 


4  SPECIFIC    INFECTIOUS    DISEASES 

substances  disappear  from  the  blood,  yet  in  most  cases  the  relative  immunity 
lasts  a  long  time,  frequently  for  life.  An  experimental  explanation  for  this 
fact  has  been  given  in  the  demonstration  that  animals  which  have  once  re- 
acted to  the  typhoid  infection,  react  in  throwing  out  immune  substances 
more  quickly  and  in  larger  amounts  when  danger  again  threatens  (Cole). 

BACILLUS  TYPHOSUS. — The  researches  of  Eberth,  Koch,  Gaffky,  and  others 
have  shown  that  there  is  a  special  micro-organism  constantly  associated  with 
typhoid  fever. 

(a)  General  Characters. — It  is  a  rather  short,  thick,  flagellated,  motile 
bacillus,  with  rounded  ends,  in  one  of  which,  sometimes  in  both  (particularly 
in  cultures),  there  can  be  seen  a  glistening  round  body,  at  one  time  believed 
to  be  a  spore;  but  these  polar  structures  are  probably  only  areas  of  degen- 
erated protoplasm.  It  grows  readily  on  various  nutritive  media,  and  can 
now  be  differentiated  from  Bacillus  coli,  with  which,  and  with  certain  other 
bacilli,  it  is  apt  to  be  confounded.  This  organism  now  fulfills  all  the  require- 
ments of  Koch's  law — it  is  constantly  present,  and  it  grows  outside  the  body 
in  a  specific  manner;  the  third  requirement,  the  production  of  the  disease 
experimentally,  has  been  successfully  met  by  the  conveyance  of  the  disease  to 
chimpanzees.  The  bacilli  or  their  toxins  inoculated  in  large  quantities  into 
the  blood  of  rabbits  are  pathogenic,  and  in  some  instances  ulcerative  and 
necrotic  lesions  in  the  intestine  may  be  produced.  But  similar  intestinal  le- 
sions may  be  caused  by  other  bacteria,  including  Bacillus  coli. 

Cultures  are  killed  within  ten  minutes  by  a  temperature  of  60°  C.  They 
may  live  for  eighteen  weeks  at  — 5°  C.,  although  most  die  within  two  weeks, 
and  all  within  twenty-two  weeks  (Park).  The  typhoid  bacillus  resists  ordi- 
nary drying  for  months,  unless  in  very  thin  layers,  when  it  is  killed  in  five 
to  fifteen  days.  The  direct  rays  of  the  sun  completely  destroy  them  in  from 
four  to  ten  hours'  exposure.  Bouillon  cultures  are  destroyed  by  carbolic  acid, 
1  to  200,  and  by  corrosive  sublimate,  1  to  2,500. 

(&)  Distribution  in  the  Body. — During  recent  years  our  ideas  in  regard 
to  the  distribution  of  the  typhoid  bacilli  have  been  much  modified,  owing  to 
the  demonstration  that  in  practically  all  cases  the  bacilli  enter  the  circulat- 
ing blood  and  are  carried  throughout  the  body.  During  life  they  may  be 
demonstrated  in  the  circulating  blood  in  a  large  proportion  of  cases,  in  75 
per  cent,  of  604  collected  cases  (Coleman  and  Buxton).  They  occur  in  the 
urine  in  from  25  to  30  per  cent,  of  the  cases.  They  may  be  isolated  from 
the  stools  in  practically  all  cases  at  some  stage.  They  are  probably  always 
present  in  the  rose  spots.  They  are  reported  to  have  been  cultivated  from 
the  sweat,  and  they  undoubtedly  occur  with  considerable  frequency  in  the 
sputum  (Eichardson,  Bau,  and  others).  At  autopsy  they  are  found  widely 
distributed,  most  numerous  and  constant  usually  in  the  mesenteric  glands, 
spleen,  and  gall-bladder,  but  are  found  in  almost  all  organs,  even  the  mus- 
cles, uterus,  and  lungs  (von  Drigalski).  Cultures  made  from  the  intestines 
at  autopsy  (according  to  Jiirgens,  and  also  von  Drigalski)  show  that  they 
are  very  few  or  can  not  be  cultivated  from  the  rectum  up  to  the  caecum,  but 
above  this  they  increase  in  number,  being  very  numerous  in  the  duodenum 
and  jejunum,  and  practically  constant  in  cultures  made  from  the  mucous 
membrane  of  the  stomach.  They  are  also  present  in  the  oesophagus  and 
frequently  on  the  tongue  and  tonsils.  From  endocardial  vegetations,  from 


TYPHOID    FEVER  5 

meningeal  and  pleural  exudates  and  from  foci  of  suppuration  in  various 
parts  of  the  body,  the  bacilli  have  also  been  isolated.  A  most  important  and 
remarkable  fact  is  that  at  times  they  may  be  present  in  the  stools  of  persons 
who  show  no  symptoms  of  typhoid  fever,  but  who  have  lived  in  very  close  asso- 
ciation with  typhoid-fever  patients.  This  is  especially  true  of  children. 

(c)  The  Bacilli  outside  the  Body. — In  sterile  water  the  bacilli  retain 
their  vitality  for  weeks,  but  under  ordinary  conditions,  in  competition  with 
saprophytes,  disappear  within  a  few  days.  The  question  of  the  longevity  of 
the  typhoid  bacillus  in  water  is  of  great  importance,  and  has  been  much 
discussed  in  connection  with  the  supposed  pollution  of  the  water  of  the  Mis- 
sissippi by  the  Chicago  drainage  canal.  The  experiments  of  E.  0.  Jordan 
would  indicate  that  the  vitality  was  retained  as  a  rule  not  longer  than  three 
days  after  infection.  Whether  an  increase  can  occur  in  water  is  not  finally 
settled.  Their  detection  in  the  water  is  difficult,  and  although  they  undoubt- 
edly have  been  found,  many  such  discoveries  previously  reported  are  not  cer- 
tain on  account  of  the  inaccurate  differentiation  of  the  typhoid  bacillus  and 
varieties  of  intestinal  bacilli  closely  resembling  it.  Both  Prudden  and  Ernst 
have  found  it  in  water  filters. 

There  are  cities  deriving  their  ice  supply  from  polluted  streams  with 
low  death  rates  from  typhoid  fever.  Sedgwick  and  Winslow  conclude  from 
their  careful  study  that  very  few  typhoid  germs  survive  in  ice.  The  Ogdens- 
burg  epidemic  in  1902-'03  was  apparently  due  to  infection  from  ice.  Typhoid 
bacilli  were  grown  from  frozen  material  in  it  (Hutchins  and  Wheeler). 

In  milk  the  bacilli  undergo  rapid  development  without  changing  its 
appearance.  They  may  persist  for  three  months  in  sour  milk,  and  may  live 
for  several  days  in  butter  made  from  infected  cream. 

Robertson  has  shown  that  under  entirely  natural  conditions  typhoid  bacilli 
may  live  in  the  upper  layers  of  the  soil  for  eleven  months.  Von  Drigalski 
says  if  stools  which  contain  typhoid  bacilli  are  kept  at  room  temperature  the 
B.  typhosus  disappears  in  a  few  days. 

The  direct  infection  by  dust  of  exposed  food-stuffs,  such  as  milk,  is  very 
probable.  The  bacilli  retain  their  vitality  for  many  weeks;  in  garden  earth 
twenty-one  days,  in  filter-sand  eighty-two  days,  in  dust  of  the  street  thirty 
days,  on  linen  sixty  to  seventy  days,  on  wood  thirty-two  days ;  on  thread  kept 
under  suitable  conditions  for  a  year. 

MODES  OP  CONVEYANCE. — (a)  Contagion. — Direct  aerial  transmission  does 
not  seem  probable.  Each  case  should  be  regarded  as  a  possible  source  of 
infection,  and  in  houses,  hospitals,  schools,  and  barracks  a  widespread  epi- 
demic may  arise  from  it.  Fingers,  food,  and  flies  are  the  chief  means  of 
local  propagation.  It  is  impossible  for  a  nurse  to  avoid  finger  contamination, 
and  without  scrupulous  care  the  germs  may  be  widely  distributed  in  a  ward 
or  throughout  a  house.  Cotton  or  rubber  gloves  are  used  in  some  institu- 
tions. Even  with  special  precautions  and  an  unusually  large  proportion  of 
nurses  to  patients,  it  was  not  possible  to  avoid  "house"  infection  at  the  Johns 
Hopkins  Hospital.  T.  B.  Futcher  has  analyzed  the  31  cases  contracted  in 
the  hospital  among  our  first  1,500  cases ;  physicians,  5  *  among  a  total  of 

*  Only  three  of  these  were  in  attendance  on  typhoid  cases.  Two  of  the  five  died.— 
Oppenheimer  and  Ochsner. 


288;  nurses,  15  of  a  total  of  407;  patients,  8  out  of  a  total  of  47,956  admis- 
sions; 4  of  these  occurred  in  a  small  ward  epidemic.  Two  orderlies  were 
infected  while  caring  for  typhoid  patients,  and  one  woman  in  charge  of  a 
supply  room,  where  she  only  handled  clean  linen.  Newman  concludes  from 
his  study  of  typhoid  fever  in  London  that  direct  personal  infection,  and  infec- 
tion through  food  are  the  two  common  channels  for  its  propagation. 

(b)  Infection  of  water  is  the  most  common  source  of  widespread  epi- 
demics, many  of  which  have  been  shown  to  originate  in  the  contamination 
of  a  well  or  a  spring.     A  very  striking  one  occurred  at  Plymouth,  Pa.,  in 
1885,  which  was  investigated  by  Shakespeare.     The  town,  with  a  population 
of  8,000,  was  in  part  supplied  with  drinking-water  from  a  reservoir  fed  by 
a  mountain  stream.     During  January,   February,  and  March,  in  a  cottage 
by  the  side  of  and  at  a  distance  of  from  60  to  80  feet  from  this  stream,  a 
man  was  ill  with  typhoid  fever.     The  attendants  were  in  the  habit  at  night 
of  throwing  out  the  evacuations  on  the  ground  toward  the  stream.     During 
these  months  the  ground  was  frozen  and  covered  with  snow.     In  the  latter 
part  of  March  and  early  in  April  there  was  considerable  rainfall  and  a  thaw, 
in  which  a  large  part  of  the  three  months'  accumulation  of  discharges  was 
washed  into  a  brook,  not  60  feet  distant.     At  the  very  time  of  this  thaw 
the  patient  had  numerous  and  copious  discharges.     About  the  10th  of  April 
cases  of  typhoid  fever  broke  out  in  the  town,  appearing  for  a  time  at  the 
rate  of  fifty  a  day.     In  all  about  1,200  people  were  attacked.     An  immense 
majority  of  all  the  cases  were  in  the  part  of  the  town  which  received  water 
from  the  infected  reservoir. 

The  experience  of  Maidstone  in  1897  illustrates  the  widespread  and  seri- 
ous character  of  an  epidemic  when  the  water-supply  becomes  badly  contami- 
nated. The  outbreak  began  about  the  middle  of  September,  and  within  the 
first  two  weeks  509  cases  were  reported.  By  October  27th  there  were  1,748 
cases,  and  by  November  17th  1,848  cases.  In  all,  in  a  population  of  35,000, 
about  1,900  persons  were  attacked. 

(c)  Typhoid  Carriers. — The  bacilli  may  persist' for  years  in  the  bile  pas- 
sages and  intestines  of  persons  in  good  health.     They  have  been  found  by 
Young  in  the  urinary  bladder,  and  by  Hunner  in  the  gall-bladder,  ten  and 
twenty  years  after  the  fever,  and  there  have  been  cases  of  typhoid  bone  lesion 
from  which  the  bacilli  were  isolated  many  years  after  the  primary  attack. 
Within  the  past  few  years  the  work  of  Strassburg  observers  has  called  attention 
to  a  group  of  chronic  typhoid  carriers  of  the  first  importance  in  the  spread 
of  the  disease.     One  woman,  a  baker,  had  typhoid  fever  ten  years  previously. 
The  bacilli  were  found  in  large  numbers  in  her  stools.     Every  new  (  iployee 
in  the  bakery  sooner  or  later  became  seriously  ill  with  typhoid-like  symptoms, 
and  in  two  persons  the  disease  proved  fatal.     Several  localized  epidemics  have 
been  traced  to  these  carriers,  particularly  in  asylums,  as  determined  by  the 
Strassburg  observers.     Soper  reports  an  instance  in  which  a  cook,  apparently 
in  perfect  health,  but  in   whose  stools  bacilli   had   been  present   in  large 
numbers,  had  been  responsible  for  the  occurrence  of  typhoid  in  seven  house- 
holds in  five  years.     Apparently  there  is  no  limit  to  the  length  of  time  in 
which  the  bacilli  may  remain  in  the  bile  passages  and  pass  into  the  stools. 
Dean  reports  a  case  of  a  carrier  of  twenty-nine  years'  standing,  and  instances 
of  even  longer  duration  are  recorded.     The  paratyphoid  bacillus  may  be  car- 


ried  in  the  same  way.     An  epidemic  of  19  cases  in -a  French  barrack  was 
traced  to  a  cook  who  was  infected  with  a  paratyphoid  bacillus. 

(d)  Infection  of  Food. — Milk  may  be  the  source  of  infection.     One  of 
the  most  thoroughly  studied  epidemics  due  to  this  cause  was  that  investigated 
by  Ballard  in  Islington.     The  milk  may  be  contaminated  by  infected  water 
used  in  cleaning  the  cans.    The  milk  epidemics  have  been  collected  by  Ernest 
Hart  and  by  Ivober. 

The  germs  may  be  conveyed  in  ice,  salads  of  various  sorts,  etc.  The 
danger  of  eating  celery  and  other  uncooked  vegetables,  which  have  grown 
in  soil  on  which  infected  material  has  been  used  as  a  fertilizer,  must  not 
be  forgotten. 

Much  attention  has  been  paid  of  late  years  to  the  oyster  as  a  source  of 
infection.  In  several  epidemics,  such  as  that  in  Middletown,  reported  by 
Conn,  that  in  Naples,  by  Lavis,  and  in  the  outbreak  which  occurred  at  Win- 
chester, the  chain  of  circumstantial  evidence  seems  complete.  Most  sugges- 
tive sporadic  cases  have  also  been  recorded  by  Broadbent  and  others.  Foote 
showed  that  oysters  taken  from  the  feeding-grounds  in  rivers  contain  a  larger 
number  of  micro-organisms  of  all  sorts  than  those  from  the  sea.  Chantemesse 
found  typhoid  bacilli  in  oysters  which  had  lain  in  infected  sea-water,  even 
after  they  had  been  transferred  to  and  kept  in  fresh  water  for  a  time.  C.  W. 
Field,  working  in  the  laboratories  of  the  Department  of  Health,  New  York 
(1904),  confirms  the  observations  of  both  Foote  and  Chantemesse,  but  he 
could  not  determine  that  the  bacilli  were  able  to  multiply  within  the  oysters. 
Mosny,  in  his  report  to  the  French  Government  (1900),  admits  the  possibility 
of  oyster  infection,  but  he  thinks  that  the  oyster  plays  a  very  small  role  in 
relation  to  the  total  morbidity  of  the  disease.  Mussels  have  also  been  found 
contaminated  with  typhoid  bacilli,  and  it  is  stated  that  dried  fish  have  carried 
the  infection. 

(e)  Flies. — The  importance  of  flies  in  the  transmission  of  the  disease 
yas  brought  out  very  strongly  in  the  Spanish-American  War  in  1898.     The 
Report  of  the  Commission   (Reed,  Vaughan,  and  Shakespeare)   states  that 
"flies  were  undoubtedly  the  most  active  agents  in  the  spread  of  typhoid  fever. 
Flies  alternately  visited  and  fed  on  the  infected  faecal  matter  and  the  food 
in  the  mess-tent.  .  .  .  Typhoid  fever  was  much  less  frequent  among  members 
of  ihe  messes  who  had  their  mess-tents  screened  than  it  was  among  those  who 
took  no  such  precautions/'     In  the  South  African  War  there  was  a  perfect 
plague  of  flies,  particularly  in  the  typhoid  fever  tents,  and  among  the  army 
surgeons  the  opinion  was  universal  that  they  had  a  great  deal  to  do  with  the 
dissp'  :nation  of  the  disease.     Firth  and  Horrocks  demonstrated  the  readi- 
ness with  which  flies,  after  feeding  on  typhoid  stools  or  fresh  cultures  of 
typhoid  bacilli,  could  infect  sterile  media.     One  of  the  most  interesting  studies 
on  the  question  was  made  in  the  Chicago  epidemic  of  1902  by  Alice  Hamil- 
ton.    Flies  caught  in  two  undrained  privies,  on  the  fences  of  two  yards,  on 
the  walls  of  two  houses,  and  in  the  room  of  a  typhoid-fever  patient,  were  used 
to  inoculate  eighteen  tubes,  and  from  five  of  these  tubes  typhoid  bacilli  were 
isolated. 

(/)   Contamination  of  the  Soil. — Filth,  bad  sewers,  or  cesspools  can  not 
in  themselves  cause  typhoid  fever,  but  they  furnish  the  conditions  suitable 
for  the  preservation  of  the  bacillus,  and  possibly  for  its  propagation. 
3* 


8  SPECIFIC    INFECTIOUS    DISEASES 

Dust  may  be  an  important  factor,  though  it  has  been  shown  that  the 
bacilli  die  very  quickly  when  desiccated.  In  the  dust  storms  during  the  South 
African  War  the  food  was  often  covered  with  dust.  Possibly,  too,  as  Bar- 
ringer  suggests,  the  dust  on  the  railway  tracks  may  become  contaminated. 
Men  working  on  the  tracks  are  very  liable  to  infection. 

TYPKS  OF  INFECTION. — We  may  recognize  the  following  groups:  (a) 
Ordinary  typhoid  fever  with  marked  enteric  lesions.  An  immense  majority 
of  all  the  cases  are  of  this  character;  and  while  the  spleen  and  mesenteric 
glands  are  involved  the  lymphatic  apparatus  of  the  intestinal  walls,  bears  the 
brunt  of  the  attack.  (6)  Cases  in  which  the  intestinal  lesions  are  very  slight, 
and  may  be  found  only  after  a  very  careful  search.  In  reviewing  the  cases  of 
"typhoid  fever  without  intestinal  lesions,"  Opie  and  Bassett  call  attention  to 
the  fact  that  in  many  negative  cases  slight  lesions  really  did  exist,  while  in 
others  death  occurred  so  late  that  the  lesions  might  have  healed.  In  some 
cases  the  disease  is  a  general  septicaemia  with  symptoms  of  severe  intoxication 
and  high  fever  and  delirium.  In  others  the  main  lesions  may  be  in 'organs — 
liver,  gall-bladder,  pleura,  meninges,  or  even  the  endocardium,  (c)  Cases  in 
which  the  typhoid  bacillus  enters  the  body  without  causing  any  lesion  of  the 
intestine.  In  a  number  of  the  earlier  cases  reported  as  such  the  demonstra- 
tion of  the  typhoid  bacillus  was  inconclusive.  In  others  the  intestine  showed 
tuberculous  ulcers,  through  which  the  organisms  may  have  entered.  But  after 
excluding  all  these,  a  few  cases  remain  in  which  the  demonstration  of  the 
typhoid  bacillus  was  conclusive,  cases  in  which  death  occurred  early, -and  yet 
after  a  very  careful  search  no  intestinal  lesions  could  be  found.  The,re  were 
4  cases  in  this  series.  Undoubtedly  the  intestinal  lesions  may  be  so  slight  as 
not  to  be  recognizable  at  autopsy,  (d)  Mixed  infections.  It  is  well  to 
distinguish,  as  Dreschfeld  pointed  out,  between  double  infections,  as  witli 
bacillus  tuberculosis,  the  diphtheria  bacillus.,  and  the  plasmodia  of  Laveran,  in 
which  two  different  diseases  are  present  and  can  be  readily  distinguished,  and 
the  true  mixed  or  secondary  infections,  in  which  the  conditions  induced  by 
one  organism  favor  the  growth  of  other  pathogenic  forms;  thus  in  ordinary 
typhoid  fever  secondary  infeetiori  jwith^the  colon  bacillus,  the  streptococcus, 
etaphyiococcus,  or  the  pneumococcus,  is  quite  common,  (e)  Paratyphoid  in- 
fections. Described  first  by  Achard  in  1896  and  then  by  Gwyn,  from  my 
clinic,  in  1898,  these  infections  have  been  shown  to  play  an  important  part  in 
the  story  of  typhoid  fever.  They  have  increased  in  frequency  in  the  United 
States  during  the  past  decade  and  in  the  present  great  war  the  cases  in  France 
have  outnumbered  those  of  ordinary  typhoid  fever.  Until  the  return  of  tho 
soldiers  from  France  and  the  East  these  infections  have  been  rare  in  England. 
The  two  forms  Paratyphoid  A  and  Paratyphoid  B  are  distinguished  from  each 
other  and  from  B.  ti/phosus  by  well-marked  cultural  and  serological  differences. 
An  attack  of  one  does  not  protect  against  the  others,  nor  does  inoculation 
against  B.  typhosus  protect  against  para-A  or  para-B.  Of  the  two  varieties 
para-B  is  the  more  prevalent  in  Europe  and  .more  important,  as  in  a  larger 
percentage  of  recoveries  carriers  are  present.  Clinically  the  paratyphoid  in- 
fections represent  a  milder  type  of  typhoid,  with  a  much  lower  death  rate. 
In  the  cases  I  have  seen,  enlargement  of  the  spleen  has  been  constant,  rose 
ppots  have  been  frequent,  and  intestinal  symptoms,  even  haemorrhages,  have 
occurred ;  perforation  has  been  rare.  Many  cases  have  a  very  brief  but  acute 


TYPIJOID    FEVER  9 

course,  resembling  food  poisoning.  The  sequelae  of  ordinary  typhoid  fever 
may  occur,  and  the  paratyphoid  organisms  have  been  isolated  from  the  lesions 
of  osteomyelitis,  an  inflamed  testis,  and  a  chondrosternal  abscess.  Anatom- 
ically there  are  three  groups,  ( 1 )  a  septicaemia  with  little  or  no  change  in  the 
bowels;  (2)  cases  not  distinguishable  from  ordinary  typhoid,  and  (3)  a 
dysenteric  form,  in  which  the  lesions  are  chiefly  in  the  large  bowel.  In  Daw- 
son  and  Whittingden's  recent  study  of  17  fatal  cases,  the  large  bowel  was 
involved  in  10.  For  practical  purposes  typhoid  and  paratyphoid  may  be  con- 
sidered the  same.  The  differences  are  bacteriological,  and  the  diagnosis  rests 
upon  the  cultural  peculiarities  of  the  organism  and  upon  the  agglutination  tests. 
(/)  Local  injections.  The  typhoid  bacillus  may  cause  a  local  abscess,  cystitis, 
or  cholecystitis  without  evidence  of  a  general  infection.  (g)-  Terminal 
typhoid  infections.  In  rare  instances  the  bacillus  causes  a  fatal  infection 
towards  the  end  of  other  diseases.  The  subjects  may,  of  course,  be  typhoid 
carriers.  In  two  cases  of  malignant  disease  at  the  Johns  Hopkins  Hos- 
pital the  bacilli  were  isolated  from  the  blood,  and  there  were  no  intestinal 
lesions. 

Products  of  the  Growth  of  the  Bacilli. — Brieger  isolated  from  cultures 
a  poison  belonging  to  the  group  of  ptomaines — typhotoxin.  Later  he  and 
Fraenkel  isolated  a  poison  belonging  to  the  group  of  toxalbumins.  Accord- 
ing to  Pfeiffer,  the  chief  poison  belongs  to  the  intracellular  group  of  toxins. 
Sidney  Martin  has  isolated  a  poison  which  is  in  the  nature  of  a  secretion, 
but  does  not  differ  from  that  contained  within  the  bacterial  cell.  Injected 
into  animals  it  causes  lowering  of  temperature,  diarrhoea,  loss  of  weight,  and 
degeneration  of  the  myocardium.  Its  chemical  nature  is  not  known.  Sim- 
ilar, but  weaker,  poisons  may  also  be  isolated  from  cultures  of  Bacillus  coli 
and  other  members  of  this  group.  N"o  toxins  have  yet  been  isolated  which 
cause  changes  in  animals  at  all  comparable  to  typhoid  fever  in  human  beings. 
Macfadyen  and  Eowland,  by  mechanically  breaking  up  the  bacilli  after  they 
had  been  frozen  by  means  of  liquid  air,  obtained  toxins,  which  injected  into 
monkeys  had  both  antitoxic  and  antibacterial  properties. 

Morbid  Anatomy. — INTESTINES. — A  catarrhal  condition  exists  throughout 
the  small  and  large  bowel.  Specific  changes  occur  in  the  lymphoid  elements, 
chiefly  at  the  lower  end  of  the  ileum.  The  alterations  which  occur  are  most 
conveniently  described  in  four  stages : 

(a)  Hyperplasia,  which  involves  the  glands  of  Peyer  in  the  jejunum  and 
ileum,  and  to  a  variable  extent  those  in  the  large  intestine.  The  follicles 
are  swollen,  grayish-white,  and  the  patches  may  project  3  to  5  mm.,  or  may  be 
still  more  prominent.  The  solitary  glands,  which  range  in  size  from  a  pin's 
head  to  a  pea,  are  usually  deeply  imbedded  in  the  submucosa,  but  project  to 
a  variable  extent.  Occasionally  they  are  very  prominent,  and  may  be  almost 
pedunculated.  Microscopic  examination  shows  at  the  outset  a  condition  of 
hyperasmia  of  the  follicles.  Later  there  is  a  great  increase  and  accumula- 
tion of  cells  of  the  lymph-tissue  which  may  even  infiltrate  the  adjacent  mucosa 
and  the  muscularis;  and  the  blood-vessels  are  more  or  less  compressed,  which 
gives  the  whitish,  anaemic  appearance  to  the  follicles.  The  cells  have  all 
the  characters  of  ordinary  lymph-corpuscles.  Some  of  them,  however,  are 
larger,  epithelioid,  and  contain  several  nuclei.  Occasionally  cells  containing 
red  blood-corpuscles  are  seen.  This  so-called  medullary  infiltration,  which  is 
3 


10 

always  more  intense  toward  the  lower  end  of  the  ileum,  reaches  its  height 
from  the  eighth  to  the  tenth  day  and  then  undergoes  one  of  two  changes, 
resolution  or  necrosis.  Death  very  rarely  takes  place  at  this  stage.  Resolution 
is  accomplished  by  a  fatty  and  granular  change  in  the  cells,  which  are 
destroyed  and  absorbed.  A  curious  condition  of  the  patches  is  produced  at 
this  stage,  in  which  they  have  a  reticulated  appearance,  the  plaques  a  surface 
reticulee.  The  swollen  follicles  in  the  patch  undergo  resolution  and  shrink 
more  rapidly  than  the  surrounding  framework,  or  what  is  more  probable  the 
follicles  alone,  owing  to  the  intense  hyperplasia,  become  necrotic  and  disin- 
tegrate, leaving  the  little  pits.  In  this  process  superficial  hemorrhages  may 
result,  and  small  ulcers  may  orginate  by  the  fusion  of  these  superficial  losses 
of  substance. 

Except  histologically  there  is  nothing  distinctive  in  the  hyperplasia  of  the 
lymph-follicles;  but  apart  from  typhoid  fever  we  rarely  see  in  adults  a  marked 
affection  of  these  glands  with  fever.  In  children,  however,  it  is  not  uncom- 
mon when  death  has  occurred  from  intestinal  affections,  and  it  is  also  met 
with  in  measles,  diphtheria,  and  scarlet  fever. 

(6)  Necrosis  and  Sloughing. — When  the  hyperplasia  of  the  lymph-follicles 
reaches  a  certain  grade,  resolution  is  no  longer  possible.  The  blood-vessels 
become  choked,  there  is  a  condition  of  anaemic  necrosis,  and  sloughs  form 
which  must  be  separated  and  thrown  off.  The  necrosis  is  probably  due  in 
great  part  to  the  direct  action  of  the  bacilli.  According  to  Mallory,  there 
occurs  a  proliferation  of  endothelial  cells  due  to  the  action  of  a  toxin.  These 
cells  are  phagocytic  in  character,  and  the  swelling  of  the  intestinal  lymphoid 
tissue  is  due  almost  entirely  to  their  formation.  The  necrosis,  he  thinks, 
is  due  to  the  occlusion  of  the  veins  and  capillaries  by  fibrinous  thrombi,  which 
owe  their  origin  to  degeneration  of  phagocytic  cells  beneath  the  lining  endo- 
thelium  of  the  vessels.  The  process  may  be  superficial,  affecting  only  the 
upper  part  of  the  mucous  coat,  or  it  may  extend  to  and  involve  the  submu- 
cosa.  The  "slough"  may  sometimes  lie  upon  the  Peyer's  patch,  scarcely 
involving  more  than  the  epithelium  (Marchand).  'It  is  always  more  intense 
toward  the  ileo-caecal  valve,  and  in  very  severe  cases  the  greater  part  of  the 
mucosa  of  the  last  foot  of  the  ileum  may  be  converted  into  a  brownish-black 
eschar.  The  necrotic  area  in  the  solitary  glands  forms  a  yellowish  cap 
which  often  involves  only  the  most  prominent  point  of  a  follicle.  The  extent 
of  the  necrosis  is  very  variable.  It  may  pass  deep  into  the  muscular  coat, 
reaching  to  or  even  perforating  the  peritoneum. 

(c)  Ulceration. — The  separation  of  the  necrotic  tissue — the  sloughing — 
is  gradually  effected  from  the  edges  inward,  and  results  in  the  formation 
of  an  ulcer,  the  size  and  extent  of  which  are  directly  proportionate  to  the 
amount  of  necrosis.  If  this  be  superficial,  the  entire  thickness  of  the  mucosa 
may  not  be  involved  and  the  loss  of  substance  may  be  small  and  shallow. 
More  commonly  the  slough  in  separating  exposes  the  submucosa  and  mus- 
cularis,  particularly  the  latter,  which  forms  the  floor  of  a  majority  of  all 
typhoid  ulcers.  It  is  not  common  for  an  entire  Peyer's  patch  to  slough 
away,  and  a  perfectly  ovoid  ulcer  opposite  to  the  mesentery  is  rarely  seen. 
Irregularly  oval  and  rounded  forms  are  most  common.  A  large  patch  may 
present  three  or  four  ulcers  divided  by  septa  of  mucous  membrane.  The 
terminal  6  or  8  Inches  of  the  mucous  membrane  of  the  ileum  may  form  a 


TYPHOID    FEVER  11 

large  ulcer,  in  which  are  here  and  there  islands  of  mucosa.  The  edges  of 
the  ulcer  are  usually  swollen,  soft,  sometimes  congested,  and  often  under- 
mined. At  a  late  period  the  ulcers  near  the  valve  may  have  very  irregular 
sinuous  borders.  The  base  of  a  typhoid  ulcer  is  smooth  and  clean,  being 
usually  formed  of  the  submucosa  or  of  the  muscularis. 

There  may  be  large  ulcers  near  the  valve  and  swollen  hypersemic  patches 
of  Peyer  in  the  upper  part  of  the  ileum. 

(d)  Healing. — This  begins  with  the  development  of  a  thin  granulation 
tissue  which  covers  the  base.  Occasionally  an  appearance  is  seen  as  if  an 
ulcer  had  healed  in  one  place  and  was  extending  in  another.  The  mucosa 
gradually  extends  from  the  edge,  and  a  new  growth  of  epithelium  is  formed. 
The  glandular  elements  are  reformed ;  the  healed  ulcer  is  somewhat  depressed 
and  is  usually  pigmented.  In  death  during  relapse  healing  ulcers  may  be 
seen  in  some  patches  with  fresh  ulcers  in  others. 

We  may  say,  indeed,  that  healing  begins  with  the  separation  of  the 
sloughs,  as,  when  resolution  is  impossible,  the  removal  of  the  necrosed  part 
is  the  first  step  in  the  process  of  repair.  In  fatal  cases,  we  seldom  meet  with 
evidences  of  cicatrization,  as  the  majority  of  deaths  occur  before  this  stage 
is  reached.  It  is  remarkable  that  no  matter  how  extensive  the  ulceration  has 
been,  healing  is  never  associated  with  stricture,  and  typhoid  fever  does  not 
appear  as  one  of  the  causes  of  intestinal  obstruction.  Within  a  very  short 
time  all  traces  of  the  old  ulcers  disappear. 

LARGE  INTESTINE. — The  cscum  and  colon  are  affected  in  about  one-third 
of  the  cases.  Sometimes  the  solitary  glands  are  greatly  enlarged.  The  ulcers 
are  usually  larger  in  the  caecum  than  in  the  colon. 

PERFORATION  OF  THE  BOWEL. — Incidence  at  Autopsy. — J.  A.  Scott's  fig- 
ures, embracing  9,713  cases  from  various  English,  Canadian,  and  American 
sources,  give  351  deaths  from  perforation  among  1,037  deaths  from  all 
causes,  a  percentage  of  33.8  of  the  deaths  and  3.6  of  the  cases.  The  German 
statistics  give  a  much  lower  proportion  of  deaths  from  perforation;  Munich 
in  2,000  autopsies,  5.7  per  cent,  from  perforation;  Basle  in  2,000  autopsies, 
1.3  per  cent,  from  perforation;  Hamburg  in  3,686  autopsies,  1.2  per  cent, 
from  perforation  (Hector  Mackenzie,  Lancet,  1903).  At  the  Johns  Hopkins 
Hospital  among  1,500  cases  of  typhoid  fever  there  were  43  with  perforation. 
Twenty  of  these  were  operated  upon,  with  7  recoveries.  One  other  case  died 
of  the  toxaemia  on  the  eighth  day  after  operation.  ,  At  the  Pennsylvania  Hos- 
pital there  were  139  cases  of  perforation  among  5,891  cases.  Chomel  remarks 
that  "the  accident  is  sometimes  the  result  of  ulceration,  sometimes  of  a  true 
eschar,  and  sometimes  it  is  produced  by  the  distention  of  the  intestine,  caus- 
ing the  rupture  of  tissues  weakened  by  disease."  As  a  rule,  sloughs  are 
adherent  about  the  site  of  perforation.  The  site  is  usually  in  the  ileum, 
232  times  in  Hector  Mackenzie's  collection  of  264  cases;  the  jejunum  twice, 
the  large  intestine  22  times,  and  the  appendix  9  times  in  his  series.  As  a 
rule,  the  perforation  occurs  within  twelve  inches  of  the  ileo-caecal  valve. 
There  may  be  two  or  three  separate  perforations.  J.  A.  Scott  described  two 
distinct  varieties :  first,  the  more  common  single,  circular,  pin-point  in  size, 
due  to  the  extension  of  a  necrotic  process  through  the  base  of  a  small  ulcer. 
The  second  variety,  produced  by  a  large  area  of  tissue  becoming  necrotic, 
ranges  in  size  from  the  finger-tip  to  3  cm.  in  diameter. 


12  SPECIFIC    INFECTIOUS    DISEASES 

Death  from  haemorrhage  occurred  in  99  of  the  Munich  cases,  and  in  12 
of  137  deaths  in  my  1,500  cases.  The  bleeding  seems  to  result  directly  from 
the  separation  of  the  sloughs.  I  was  not  able  in  any  instance  to  find  the 
bleeding  vessel.  In  one  case  only  a  single  patch  had  sloughed,  and  a  firm 
clot  was  adherent  to  it.  The  bleeding  may  also  come  from  the  soft  swollen 
edges  of  the  patch. 

The  mesenteric  glands  show  hypersemia  and  subsequently  become  greatly 
swollen.  Spots  of  necrosis  are  common.  In  several  of  my  cases  suppuration 
had  occurred,  and  in  one  a  large  abscess  of  the  mesentery  was  present.  The 
rupture  of  a  softened  or  suppurating  mesenteric  gland,  of  which  there  are 
only  a  few  cases  in  the  literature,  may  cause  either  fatal  haemorrhage  or 
peritonitis.  LeConte  has  successfully  operated  upon  the  latter  condition. 
The  bunch  of  glands  in  the  mesentery,  at  the  lower  end  of  the  ileum,  is 
especially  involved.  The  retroperitoneal  glands  are  also  swollen. 

The  spleen  is  invariably  enlarged  in  the  early  stages  of  the  disease.  In 
11  of  my  series  it  exceeded  20  ounces  (600  grams)  in  weights,  in  one  900 
grams.  The  tissue  is  soft,  even  diffluent.  Infarction  is  not  infrequent.  Rup- 
ture may  occur  spontaneously  or  as  a  result  of  injury.  In  the  Munich  autop- 
sies there  were  5  instances  of  rupture  of  the  spleen,  one  of  which  resulted 
from  a  gangrenous  abscess. 

The  bone-marrow  shows  changes  very  similar  to  those  in  the  lymphoid 
tissues,  and  there  may  be  foci  of  necrosis  (Longcope). 

The  liver  shows  signs  of  parenchymatous  degeneration.  Early  in  the 
disease  it  is  hypera3mic,  and  in  a  majority  of  instances  it  is  swollen,  some- 
what pale,  on  section  turbid,  and  microscopically  the  cells  are  very  granular 
and  loaded  with  fat.  Nodular  areas  (miscroscopic)  occur  in  many  cases,  as 
described  by  Hanford.  Eeed,  in  Welch's  laboratory,  could  not  determine 
any  relation  between  the  groups  of  bacilli  and  these  areas  (Studies  II).  Some 
of  the  nodules  are  lymphoid,  others  are  necrotic.  In  12  of  the  Munich  autop- 
sies liver  abscess  was  found,  and  in  3,  acute  yellow  atrophy.  In  3  of  this 
series  liver  abscess  occurred.  Pylephlebitis  may  follow  abscess  of  the  mesen- 
tery or  perforation  of  the  appendix.  Affections  of  the  gall-bladder  are  not 
uncommon,  and  are  fully  described  under  the  clinical  features. 

KIDNEYS. — Cloudy  swelling,  with  granular  degeneration  of  the  cells  of 
the  convoluted  tubules,  less  commonly  an  acute  nephritis,  may  be  present. 
Rayer,  Wagner,  and  others  described  the  occurrence  of  numerous  small  areas 
infiltrated  with  round  cells,  which  may  have  the  appearance  of  lymphomata, 
or  may  pass  on  to  softening  and  suppuration,  producing  the  so-called  miliary 
abscesses,  of  which  there  were  7,  cases  in  this  series.  The  typhoid  bacilli  have 
been  found  in  these  areas.  They  may  also  be  found  in  the  urine.  The  kid- 
neys in  cases  of  typhoid  bacilluria  may  show  no  changes  other  than  cloudy 
swelling.  Diphtheritic  inflammation  of  the  pelvis  of  the  kidney  may  occur. 
It  was  present  in  3  of  my  cases,  in  one  of  which  the  tips  of  the  papillae  were 
also  affected.  Catarrh  of  the  bladder  is  not  uncommon.  Diphtheritic  in- 
flammation of  this  viscus  may  also  occur.  Orchitis  is  occasionally  met  with. 

RESPIRATORY  ORGANS. — Ulceration  of  the  larynx  occurs  in  a  certain  num- 
ber of  cases;  in  the  Munich  series  it  was  noted  107  times.  It  may  come  on 
at  the  same  time  as  the  ulceration  in  the  ileum.  It  occurs  in  the  posterior 
wall,  at  the  insertion  of  the  cords,  at  the  base  of  the  epiglottis,  and  on  the 


TYPHOID   FEVER  13 

ary-epiglottidean  folds.  The  cartilages  are  very  apt  to  become  involred.  In 
the  later  periods  ulcers  may  be  present. 

(Edema  of  the  glottis  was  present  in  20  of  the  Munich  cases,  in  8  of 
which  tracheotomy  was  performed.  Diphtheritis  of  the  pharynx  and  larynx 
is  not  very  uncommon.  It  occurred  in  a  most  extensive  form  in  2  of  my 
cases.  Lobar  pneumonia  may  be  found  early  in  the  disease  (see  Pneumo- 
typhus),  or  it  may  be  a  late  event.  Hypostatic  congestion  and  the  condition 
of  the  lung  spoken  of  as  splenization  occur.  Gangrene  of  the  lung  occurred 
in  40  cases  in  the  Munich  series;  abscess  of  the  lung  in  14;  hsemorrhagic 
infarction  in  129.  Pleurisy  is  not  a  very  common  event.  Fibrinous  pleurisy 
occurred  in  about  6  per  cent,  of  the  Munich  cases,  and  empyema  in  nearly  2 
per  cent. 

CHANGES  IN  THE  CIRCULATORY  SYSTEM. — Heart  Lesions. — Endocarditis, 
while  not  a  common  complication,  is  probably  more  frequent  than  is  gener- 
ally supposed.  It  was  present  without  being  suspected  in  3  out  of  105  autop- 
sies in  this  series,  while  in  3  other  cases  of  my  series  the  clinical  symptoms 
suggested  its  presence.  The  typhoid  bacilli  have  been  found  in  the  vegeta- 
tions. Pericarditis  was  present  in  14  cases  of  the  Munich  autopsies.  Myo- 
carditis is  not  very  infrequent.  In  protracted  cases  the  muscle-fibre  is 
usually  soft,  flabby,  and  of  a  pale  yellowish-brown  color.  The  softening  may 
be  extreme,  though  rarely  of  the  grade  described  by  Stokes  in  typhus  fever, 
in  which,  when  held  apex  up  by  the  vessels,  the  organ  collapsed  over  the 
hand,  forming  a  mushroom-like  cap.  Microscopically,  the  fibres  may  show 
little  or  no  change,  even  when  the  impulse  of  the  heart  has  been  extremely 
feeble.  A  granular  parenchymatous  degeneration  is  common.  Fatty  degen- 
eration may  be  present,  particularly  in  long-standing  cases  with  anaemia. 
The  hyaline  change  is  not  common.  The  segmenting  myocarditis,  in  which 
the  cement  substance  is  softened  so  that  the  muscles  separate,  has  also  been 
found,  but  probably  as  a  post-mortem  change. 

Lesions  of  the  Blood-vessels. — Changes  in  the  arteries  are  not  infrequent. 
In  21  of  52  cases  in  our  series,  in  which  there  were  notes  on  the  state  of  the 
aorta,  fresh  endarteritis  was  present,  and  in  13  of  62  cases  in  which  the 
condition  of  the  coronary  arteries  was  noted  similar  changes  were  found 
(Thayer).  Arteritis  of  a  peripheral  vessel  with  thrombus  formation  is  not 
uncommon.  Bacilli  have  been  found  in  the  thrombi.  The  artery  may  be 
blocked  by  a  thrombus  of  cardiac  origin — an  embolus — but  in  the  great  major- 
ity of  instances  they  are  autochthonous  and  due  to  arteritis,  obliterating  or 
partial.  Thrombosis  in  the  veins  is  very  much  more  frequent  than  in  the 
arteries,  but  is  not  such  a  serious  event.  It  is  most  frequent  in  the  femoral, 
and  in  the  left  more  often  than  the  right.  The  consequences  are  fully  con- 
sidered under  the  symptoms. 

NERVOUS  SYSTEM. — There  are  very  few  obvious  changes  met  with.  Men- 
ingitis is  extremely  rare.  It  occurred  in  only  11  of  the  2,000  Munich  cases. 
The  exudation  may  be  either  serous,  sero-fibrinous,  or  purulent,  and  typhoid 
bacilli  have  been  isolated.  Five  cases  of  serous  and  one  of  purulent  menin- 
gitis occurred  in  our  series  (Cole).  Optic  neuritis,  which  occurs  sometimes 
in  typhoid  fever,  has  not,  so  far  as  I  know,  been  described  in  connection  with 
the  meningitis.  The  anatomical  lesion  of  the  aphasia — seen  not  infrequently 
in  children — is .  not  known,  possibly  it  is  an  encephalitis.  Parenchymatous 


14  SPECIFIC    INFECTIOUS    DISEASES 

changes  have  been  met  with  in  the  peripheral  nerves,  and  appear  to  be  not 
very  uncommon,  even  when  there  have  been  no  symptoms  of  neuritis. 

The  voluntary  muscles  show,  in  certain  instances,  the  changes  described 
by  Zenker,  which  occur,  however,  in  all  long-standing  febrile  affections,  and 
are  not  peculiar  to  typhoid  fever.  The  muscle  substance  within  the  sarco- 
lemma  undergoes  either  a  granular  degeneration  or  a  hyaline  transformation. 
The  abdominal  muscles,  the  adductors  of  the  thighs,  and  the  pectorals  are 
most  commonly  involved.  Eupture  of  a  rectus  abdominis  has  been  found 
post  mortem.  Haemorrhage  may  occur.  Abscesses  may  develop  in  the  mus- 
scles  during  convalescence. 

Symptoms. — In  a  disease  so  complex  as  typhoid  fever  it  will  be  well  first 
to  give  a  general  description,  and  then  to  study  more  fully  the  symptoms, 
complications,  and  sequelae  according  to  the  individual  organs. 

GENERAL  DESCRIPTION. — The  period  of  incubation  lasts  from  "eight 
to  fourteen  days,  sometimes  twenty-three"  (Clinical  Society),  during  which 
there  are  feelings  of  lassitude  and  inaptitude  for  work.  The  onset  is  rarely 
abrupt.  In  the  1,500  cases  chills  occurred  at  onset  in  334,  headache  in  1,117, 
anorexia  in  825,  diarrhoea  (without  purgation)  in  516,  epistaxis  in  323, 
abdominal  pain  in  443,  constipation  in  249,  pain  in  right  iliac  fossa  in  10. 
The  patient  at  last  takes  to  his  bed,  from  which  event,  in  a  majority  of  cases, 
the  definite  onset  of  the  disease  may  be  dated.  During  the  first  week  there 
is,  in  some  cases  (but  by  no  means  in  all,  as  has  long  been  taught),  a  steady 
rise  in  the  fever,  the  evening  record  rising  a  degree  or  a  degree  and  a  half 
higher  each  day,  reaching  103°  or  104°.  The  pulse  is  not  rapid  when  com- 
pared with  the  temperature,  full  in  volume,  but  of  low  tension  and  often 
dicrotic;  the  tongue  is  coated  and  white;  the  abdomen  is  slightly  distended 
and  tender.  Unless  the  fever  is  high  there  is  no  delirium,  but  the  patient 
complains  of  headache,  and  there  may  be  mental  confusion  at  night.  The 
bowels  may  be  constipated,  or  there  may  be  two  or  three  loose  movements 
daily.  Toward  the  end  of  the  week  the  spleen  becomes  enlarged  and  the 
rash  appears  in  the  form  of  rose-colored  spots,  seen 'first  on  the  skin  of  the 
abdomen.  Cough  and  bronchitic  symptoms  are  not  uncommon  at  the  outset. 

In  the  second  week,  in  cases  of  moderate  severity,  the  symptoms  become 
aggravated;  the  fever  remains  high  and  the  morning  remission  is  slight. 
The  pulse  is  rapid  and  loses  its  dicrotic  character.  There  is  no  longer  head- 
ache, but  there  are  mental  torpor  and  dulness.  The  face  looks  heavy;  the 
lips  are  dry;  the  tongue,  in  severe  cases,  becomes  dry  also.  The  abdominal 
symptoms,  if  present — diarrhoea,  tympanites,  and  tenderness — become  aggra- 
vated. Death  may  occur  during  this  week,  with  pronounced  nervous  symp- 
toms, or,  toward  the  end  of  it,  from  haemorrhage  or  perforation.  In  mild 
cases  the  temperature  declines,  and  by  the  fourteenth  day  may  be  normal. 

In  the  third  week,  in  cases  of  moderate  severity,  the  pulse  ranges  from 
110  to  130;  the  temperature  now  shows  marked  morning  remissions,  and 
there  is  a  gradual  decline  in  the  fever.  The  loss  of  flesh  is  now  more  notice- 
able, and  the  weakness  is  pronounced.  Diarrhoea  and  meteorisni  may  now 
occur  for  the  first  time.  Unfavorable  symptoms  at  this  stage  are  the  pul- 
monary complications,  increasing  feebleness  of  the  heart,  and  pronounced 
delirium  with  muscular  tremor.  Special  dangers  are  perforation  and  haemor- 
rhage. 


TYPHOID    FEVER  15 

With  the  fourth  week,  in  a  majority  of  instances,  convalescence  begins. 
The  temperature  gradually  reaches  the  normal  point,  the  diarrhoea  stops, 
the  tongue  cleans,  and  the  desire  for  food  returns.  In  severe  cases  the  fourth 
and  even  the  fifth  week  may  present  an  aggravated  picture  of  the  third;  the 
patient  grows  weaker,  the  pulse  is  more  rapid  and  feeble,  the  tongue  dry, 
and  the  abdomen  distended.  He  lies  in  a  condition  of  profound  stupor,  with 
low  muttering  delirium  and  subsultus  tendinum,  and  passes  the  fasces  and 
urine  involuntarily.  Failure  of  the  circulation  and  secondary  complications 
are  the  chief  dangers  of  this  period. 

In  the  fifth  and  sixth  weeks  protracted  cases  may  still  show  irregular 
fever,  and  convalescence  may  not  set  in  until  after  the  fortieth  day.  In  this 
period  we  meet  with  relapses  in  the  milder  forms  or  slight  recrudescence  of 
the  fever.  At  this  time,  too,  occur  many  of  the  complications  and  sequelae. 

SPECIAL  FEATURES  AND  SYMPTOMS. — Mode  of  Onset. — As  a  rule,  the 
symptoms  come  on  insidiously,  and  the  patient  is  unable  to  fix  definitely 
the  time  at  which  he  began  to  feel  ill.  The  following  are  the  most  important 
deviations  from  this  common  course: 

(a)  Onset  with  Pronounced,  Sometimes  Sudden,  Nervous  Manifestations. 
—Headache,  of  a  severe  and  intractable  nature,  is  by  no  means  an  infrequent 
initial  symptom.  Again,  a  severe  facial  neuralgia  may  for  a  few  days  put 
the  practitioner  off  his  guard.  In  cases  in  which  the  patients  have  kept 
about  and,  as  they  say,  fought  the  disease,  the  very  first  manifestation  may  be 
pronounced  delirium.  Such  patients  may  even  leave  home  and  wander  about 
for  days.  In  rare  cases  the  disease  sets  in  with  the  most  intense  cerebro- 
spinal  symptoms,  simulating  meningitis — severe  headache,  photophobia,  re- 
traction of  the  head,  twitching  of  the  muscles,  and  even  convulsions.  Occa- 
sionally drowsiness,  stupor,  and  signs  of  basilar  meningitis  may  exist  for  ten 
days  or  more  before  the  characteristic  symptoms  develop;  the  onset  may  be 
with  mania  and  marked  mental  symptoms. 

(&)  With  Pronounced  Pulmonary  Symptoms. — The  initial  bronchial  ca- 
tarrh may  be  of  great  severity  and  obscure  the  other  features  of  the  disease. 
More  striking  still  are  those  cases  in  which  the  disease  sets  in  with  a  single 
chill,  with  pain  in  the  side  and  all  the  characteristic  features  of  lobar  pneu- 
monia, or  of  acute  pleurisy;  or  tuberculosis  is  suspected. 

(c)  With  Intense  Gastro-intestinal  Symptoms. — The  incessant  vomiting 
and  pain  may  lead  to  a  suspicion  of  poisoning,  or  the  patient  may  be  sent 
to  the  surgical  wards  for  appendicitis. 

(d)  With  symptoms  of  an  acute  nephritis,  smoky  or  bloody  urine,  with 
much  albumin  and  tube-casts. 

(e)  Ambulatory  Form. — Deserving  of  especial  mention  are  those  cases 
of  typhoid  fever  in  which  the  patient  keeps  about  and  attempts  to  do  work, 
or  perhaps  takes  a  long  journey  to  his  home.    He  may  come  under  observa- 
tion for  the  first  time  with  a  temperature  of  104°  or  105°,  and  with  the  rash 
well  out.    Many  of  these  cases  run  a  severe  course,  and  in  general  hospitals 
they  contribute  largely  to  the  total  mortality.     Finally,  there  are  rare  in- 
stances in  which  typhoid  is  unsuspected  until  perforation  or  a  profuse  hem- 
orrhage from  the  bowels  occurs. 

FACIAL  ASPECT. — Early  in  the  disease  the  cheeks  are  flushed  and  the 
eyes  bright.  Toward  the  end  of  the  first  week  the  expression  becomes 


16 


SPECIFIC    INFECTIOUS   DISEASES 


TYPHOID    FEVER  17 

listless,  and  when  the  disease  is  well  established  the  patient  has  a  dull  and 
heavy  look.  There  is  never  the  rapid  anaemia  of  malarial  fever,  and  the  color 
of  the  lips  and  cheeks  may  be  retained  even  to  the  third  week. 

FEVER. —  (a)  Regular  Course.  (Chart  I.) — In  the  stage  of  invasion  the 
fever  rises  steadily  during  the  first  five  or  six  days.  The  evening  tempera- 
ture is  about  a  degree  or  a  degree  and  a  half  higher  than  the  morning  re- 
mission, so  that  a  temperature  of  104°  or  105°  is  not  uncommon  by  the  end 
of  the  first  week.  Having  reached  the  fastigium  or  height,  the  fever  then 
persists  with  very  slight  daily  remissions.  The  fever  may  be  singularly  per- 
sistent and  but  little  influenced  by  bathing  or  other  measures.  At  the  end 
of  the  second  and  throughout  the  third  week  the  temperature  becomes  more 
distinctly  remittent.  The  difference  between  the  morning  or  evening  record 
may  be  3°  or  4°,  and  the  morning  temperature  may  even  be  normal.  It  falls 
by  lysis,  and  the  temperature  is  not  considered  normal  until  the  evening 
record  is  at  98.4°. 

(b)  Variations  from  the  typical  temperature  curve  are  common.    We  do 
not  always  see  the  gradual  step-like  ascent  in  the  early  stage;  the  patients 
do  not  often  come  under  observation  at  this  time.    When  the  disease  sets  in 
with  a  chill,  or  in  children  with  a  convulsion,  the  temperature  may  rise  at  once 
to  103°  or  104°.    In  many  cases  defervescence  occurs  at  the  end  of  the  second 
week  and  the  temperature  may  fall  rapidly,  reaching  the  normal  within  twelve 
or  twenty  hours.    An  inverse  type  of  temperature,  high  in  the  morning  and  low 
in  the  evening,  is  occasionally  seen,  but  has  no  especial  significance. 

Sudden  falls  in  the  temperature  may  occur;  thus,  as  shown  in  Chart  II, 
a  drop  of  6.4°  may  follow  an  intestinal  hasmorrhage,  and  the  fall  may  be  very 
apparent  even  before  the  blood  has  appeared  in  the  stools.  Sometimes  dur- 
ing the  anaemia  which  follows  a  severe  hasmor-rhage  from  the  bowels  there  are 
remarkable  oscillations  in  the  temperatuie.  Hyperpyrexia  is  rare.  In  only 
58  of  1,500  cases  did  the  fever  rise  above  106°.  Before  death  the  fever  may 
rise;  the  highest  I  have  known  was  109.5°. 

(c)  Post-typhoid  Variations. —  (1)  Recrudescences. — After  a  normal  tem- 
perature of  perhaps  five  or  six  days,  the  fever  may  rise  suddenly  to  102°  or 
103°,  without  constitutional  disturbance,  furring  of  the  tongue,  or  abdomi- 
nal symptoms.     After  persisting  for  from  two  to  four  days  the  temperature 
falls.     Of  1,500  cases,  92  presented  these  post-typhoid  elevations,  brief  notes 
of  which  are  given  in  the  Studies  on  Typhoid  Fever.    Constipation,  errors  in 
diet,  or  excitement  may  cause  them.     These  attacks  are  a  frequent  source  of 
anxiety  to  the  practitioner.    They  are  very  common,  and  it  is  not  always  possi- 
ble to  say  upon  what  they  depend.    In  some  cases  typhoid  or  colon  bacilli  are 
found  in  the  blood.    As  a  rule,  if  the  rise  in  temperature  is  the  result  of  a  com- 
plication, such  as  pleurisy  or  thrombosis,  there  is  an  increase  in  the  leucocytes. 
Naturally  one  suspects  at  the  outset  a  relapse,  but  there  is  an  absence  of  the 
step-like  ascent,  and,  as  a  rule,  the  fever  falls  after  lasting  a  few  days. 

(2)  The  Sub-febrile  Stage  of  Convalescence. — In  children,  in  very  ner- 
vous patients,  and  in  cases  of  anaemia,  the  evening  temperature  may  keep 
up  for  weeks  after  the  tongue  has  cleaned  and  the  appetite  has  returned. 
This  may  usually  be  disregarded,  and  is  often  best  treated  by  allowing  the 
patient  to  get  up,  and  by  stopping  the  use  of  the  thermometer.  Of  course, 
it  is  important  not  to  overlook  any  latent  complications, 


18  SPECIFIC    INFECTIOUS    DISEASES 

(3)  Hypothermia. — Low  temperatures  in  typhoid  fever  are  common, 
following  the  tubs,  or  spontaneously  in  the  third  and  fourth  week  in  the 
periods  of  marked  remissions,  and  following  haemorrhage.  An  interesting 
form  is  the  persistent  hypothermia  of  convalescence.  For  ten  days  or  more, 
particularly  in  the  protracted  cases  with  great  emaciation,  the  temperature 
may  be  96.5°  or  97°.  It  is  of  no  special  significance. 

(d)  The  Fever  of  the  Edapse. — This  is  a  repetition  in  many  instances 
of  the  original  fever,  a  gradual  ascent  and  maintenance  for  a  few  days  at  a 
certain  height  and  then  a  decline.     It  is  usually  shorter  than  the  original 
pyrexia,  and  rarely  continues  more  than  two  or  three  weeks.      (Chart  I.) 

(e)  Afebrile    Typhoid. — There   are   cases   described   in   which   the   chief 
features  of  the  disease  have  been  present  without  the  existence  of  fever.    They 
are  extremely  rare  in  this  country.     I  have  seen  a  case,  afebrile  at  the  thir- 
teenth day,  and  in  which  the  rose  spots  and  other  features  persisted  till  the 
twenty-eighth  day. 

(/)  Chills  occur  (1)  sometimes  with  the  fever  of  onset;  (2)  occasionally 
at  intervals  throughout  the  course  of  the  disease,  and  followed  by  sweats  (so- 
called  sudoral  form)  ;  (3)  with  the  advent  of  complications,  pleurisy,  pneu- 
monia, otitis  media,  phlebitis,  etc.;  (4)  with  active  antipyretic  treatment  by 
the  coal-tar  remedies;  (5)  occasionally  during  the  period  of  defervescence 
without  relation  to  any  complication,  probably  due  to  a  septic  infection;  (6) 
after  the  injection  of  vaccines  or  serum;  (e)  according  to  Herringham,  chills 
may  result  from  constipation.  There  are  cases  in  which  throughout  the  latter 
half  of  the  disease  chills  recur  with  great  severity.  (See  Chills  in  Typhoid 
Fever,  Studies  II,  Johns  Hopkins  Reports.) 

SKIN. — The  characteristic  rash  consists  of  hyperaBmic  spots,  which  appear 
from  the  seventh  to  the  tenth  day,  usually  at  first  upon  the  abdomen.  They 
are  slightly  raised,  flattened  papules,  which  can  be  felt  distinctly,  of  a  rose- 
red  color,  disappearing  on  pressure,  and  ranging  in  diameter  from  2  to  4  mm. 
They  were  present  in  93.2  per  cent,  of  the  white  patients  and  20.6  per  cent. 
of  the  colored.  They  come  out  in  successive  crops,  and  after  persisting  for 
two  or  three  days  they  disappear,  occasionally  leaving  a  brownish  stain.  The 
spots  may  be  present  upon  the  back,  and  not  upon  the  abdomen.  The  erup- 
tion may  be  very  abundant  over  the  whole  skin  of  the  trunk,  and  on  the 
extremities.  There  were  81  in  which  they  occurred  on  the  arms,  17  on  the 
forearms,  43  on  the  thighs,  legs  15,  face  5,  hands  3.  The  cases  with  very 
abundant  eruption  are  not  necessarily  more  severe.  As  already  noted,  the 
typhoid  bacilli  have  been  found  in  the  spots.  Of  variations  in  the  rash,  fre- 
quently the  spots  are  capped  by  small  vesicles.  A  profuse  miliary  or  su- 
daminal  rash  is  not  uncommon--  'In  38  cases  in  my  series  there  were  pur- 
puric  spots.  Tlrcee-trf  the  cases  were  true  hsemorrhagic  typhoid  fever.  The 
raeimiay  not  appear  until  the  relapse.  In  21  cases  in  our  series  the  rose 
spots  came  out  after  the  patient  was  afebrile. 

A  branny  desquamation  is  not  rare  in  children,  and  common  in  adults 
after  hydrotherapy.  Occasionally  the  skin  peels  off  in  large  flakes.  A  yellow 
color  .of  the  palms  of  the  hands  and  soles  of  the  feet  is  not  uncommon. 

Among  other  skin  lesions  the  following  may  be  mentioned : 

Erythema. — It  is  not  very  uncommon  in  the  first  week  of  the  disease  to 
find  a  diffuse  erythematous  blush — E.  typhosum.  Sometimes  the  skin 


TYPHOID    FEVER  19 

have  a  peculiar  mottled  pink  and  white  appearance.  E.  exudativum,  E.  nodo- 
sum,  and  urticaria  may  be  present. 

Herpes. — Herpes  is  certainly  rare  in  typhoid  fever  in  comparison  with 
its  great  frequency  in  malarial  fever  and  in  pneumonia.  It  was  noted  in 
20  of  our  1,500  cases,  usually  on  the  lips. 

The  Tdches  bleudtres — Peliomata — Maculce  cerulece. — These  are  pale-blue 
or  steel-gray  spots,  subcuticular,  from  4  to  10  mm.  in  diameter,  and  of  irregu- 
lar outline.  They  are  due  to  lice  (see  PEDICULOSIS). 

Skin  Gangrene. — Areas  of  superficial  gangrene  may  follow  the  prolonged 
use  of  an  ice-bag.  In  children  noma  may  occur;  as  reported  by  McFarland 
in  the  Philadelphia  epidemic  of  1898,  there  were  many  cases  with  multiple 
areas  of  gangrene  of  the  skin.  The  nose,  ears,  and  genitals  may  be  attacked. 

Sweats. — At  the  height  of  the  fever  the  skin  is  usually  dry.  Profuse 
sweating  is  rare,  but  it  is  not  very  uncommon  to  see  the  abdomen  or  chest 
moist  with  perspiration,  particularly  in  the  reaction  which  follows  the  bath. 
Sweats  in  some  instances  constitute  a  striking  feature  and  may  occasionally 
be  associated  with  chilly  sensations  or  actual  chills.  Jaccoud  and  others  in 
France  have  especially  described  this  sudoral  form  of  typhoid  fever.  There 
may  be  recurring  paroxysms  of  chill,  fever,  and  sweats  (even  several  in 
twenty-four  hours),  and  the  case  may  be  mistaken  for  one  of  malarial  fever. 
Profuse  sweats  may  occur  with  hemorrhage  or  perforation. 

(Edzma  of  the  skin  occurs:  (1)  As  the  result  of  vascular  obstruction, 
most  commonly  of  a  vein,  as  in  thrombosis  of  the  femoral  vein.  (2)  In  con- 
nection with  nephritis,  very  rarely.  (3)  In  association  with  the  anaemia  and 
cachexia.  The  hair  falls  out  after  the  attack,  but  complete  baldness  is  rare. 
I  have  once  seen  permanent  baldness.  The  nutrition  of  the  nails  suffers,  and 
during  and  after  convalescence  tranverse  ridges  may  occur.  A  peculiar  odor 
is  exhaled  from  the  skin  in  some  cases.  Whether  due  to  a  cutaneous  exhalation 
or  not,  there  certainly  is  a  very  distinctive  smell  connected  with  many  patients. 
Nathan  Smith  describes  it  as  of  a  "semi-cadaverous,  musty  character/' 

Lineoe  atrophicce. — Lines  of  atrophy  may  appear  on  the  skin  of  the  abdo- 
men, lateral  aspects  of  the  thighs  and  about  the  knees,  similar  to  those  seen 
after  pregnancy.  They  have  been  attributed  to  neuritis,  and  Duckworth  has 
reported  a  case  in  which  the  skin  adjacent  to  them  was  hyperaesthetic. 

Bed-sores  are  not  uncommon  in  protracted  cases,  with  great  emaciation. 
As  a  rule,  they  result  from  pressure  and  are  seen  upon  the  sacrum,  more 
rarely  the  ilia,  the  shoulders,  and  the  heels.  These  are  less  common,  I  think, 
since  the  introduction  of  hydrotherapy.  Scrupulous  care  and  watchfulness 
do  much  for  their  prevention,  but  it  is  to  be  remembered  that  in  cases  with 
profound  involvement  of  the  nerve  centres  acute  bed-sores  of  the  back  and 
heels  may  occur  with  very  slight  pressure,  and  with  astonishing  rapidity. 

Boils  and  superficial  abscesses  constitute  a  common  and  troublesome  sequel. 

CIRCULATORY  SYSTEM. — The  blood  presents  important  changes.  The  fol- 
lowing statements  are  based  on  studies  which  W.  S.  Thayer  has  made  in 
my  wards  (Studies  I  and  III)  :  During  the  first  two  weeks  there  may  be 
little  or  no  change  in  the  blood.  Profuse  sweats  or  copious  diarrho3a  may, 
as  Hayem  has  shown,  cause  the  corpuscles — as  in  the  collapse  stage  of  cholera 
— to  rise  above  normal.  In  the  third  week  a  fall  usually  takes  place  in  cor- 
puscles and  hemoglobin,  and  the  number  may  sink  rapidly  even  to  1,300,000 


20  SPECIFIC    INFECTIOUS    DISEASES 

per  c.  mm.,  gradually  rising  to  normal  during  convalescence.  When  the  patient 
first  gets  up,  there  may  be  a  slight  fall  in  the  number  of  corpuscles.  The 
average  maximum  loss  is  about  1,000,000  to  the  c.  mm. 

The  amount  of  haemoglobin  is  always  reduced,  and  usually  in  a  greater 
relative  proportion  than  the  number  of  red  corpuscles,  and  during  recovery 
the  normal  color  standard  is  reached  at  a  later  period.  Leucopenia  is  present 
throughout  the  course.  Cold  baths  increase  temporarily  the  number  of  leuco- 
cytes in  the'  peripheral  circulation.  The  absence  of  leucocytosis  may  be  at 
"times  of  'real  diagnostic  value  in  distinguishing  typhoid  fever  from  various 
septic  fevers  and  acute  inflammatory  processes.  The  polymorphonuclear  leu- 
cocytes are  normal  in  number,  while  the  large  mononuclears  are  relatively 
increased.  When  an  acute  inflammatory  process  occurs  in  typhoid  fever  the 
leucocytes  show  an  increase  in  the  polynuclear  forms,  and  this  may  be  of  great 
diagnostic  moment. 

The  post-typhoid  anaemia  may  reach  an  extreme  grade.  In  one  of  my 
patients  the  blood-corpuscles  sank  to  1,300,000  per  c.  mm.  and  the  haemoglobin 
to  about  20  per  cent.  These  severe  grades  of  anaemia  are  not  common  in  my 
experience.  In  the  Munich  statistics  there  were  54  cases  with  general  and 
extreme  anaemia.  Of  changes  in  the  blood  plasma  very  little  is  known. 

The  pulse  in  typhoid  fever  presents  no  special  characters.  It  is  increased 
in  rapidity,  but  not  always  in  proportion  to  the  height  of  the  fever,  and  this 
may  be  a  very  special  feature  in  the  early  stages.  There  is  no  acute  disease 
with  which,  in  the  early  stage,  a  dicrotic  pulse  is  so  frequently  associated. 
Even  with  high  fever  the  pulse  may  not  be  greatly  accelerated.  As  the  dis- 
ease progresses  the  pulse  becomes  more  rapid,  feebler,  and  small.  In  15  per 
cent,  of  our  cases  the  pulse  rate  rose  above  140.  In  the  extreme  prostration 
of  severe  cases  it  may  reach  150  or  more,  and  is  a  mere  undulation — the  so- 
called  running  pulse.  The  lowered  arterial  pressure  is  manifest  in  the  dusky 
lividity  of  the  skin  and  coldness  of  the  hands  and  feet. 

During  convalescence  the  pulse  gradually  returns  to  normal,  and  oc- 
casionally becomes  very  slow.  After  no  other  acute  fever  do  we  so  frequently 
meet  with  bradycardia.  I  have  counted  the  pulse  as  low  as  30,  and  instances 
are  on  record  of  still  fewer  beats  to  the  minute.  Tachycardia,  while  less  com- 
mon, may  be  a  very  troublesome  and  persistent  feature  of  convalescence. 

Blood  Pressure. — This  is  usually  from  115-125  mm.  Hg.  (Eiva-Eocci 
instrument)  in  systole.  The  diastolic  pressure  has  the  normal  relationship 
to  the  systolic,  and  averages  85-100  mm.  Hg.  There  is  a  gradual  fall  during 
the  course  to  about  100-110  mm.  Hg.  at  the  beginning  of  apyrexia.  In  two 
or  three  weeks  later  the  pressure  has  usually  returned  to  normal.  Haemor- 
rhage usually  produces  a  marked  fall  both  in  the  systolic  and  diastolic  pres- 
sure. In  some  case*  of  perforation  there  is  a  sharp  rise  in  systolic  pressure. 
Tube  and  ice  sponges  usually  cause  a  rise  of  10-20  mm.  Hg. 

The  heart-sounds  may  be  normal  throughout  the  course.  In  severe  cases, 
the  first  sound  becomes  feeble  and  there  is  often  to  be  heard,  at  the  apex  and 
along  the  left  sternal  margin,  a  soft  systolic  murmur,  which  was  present  in 
22  per  cent,  of  our  cases.  Absence  of  the  first  sound  is  rare.  Gallop  rhythm 
is  not  uncommon.  In  the  extreme  feebleness  of  the  graver  forms,  the  first 
and  second  sound  become  very  similar,  and  the  long  pause  is  much  shortened 
(embryocardia). 


TYPHOID    FEVER  21 

Of  cardiac  complications,  pericarditis  is  rare  and  has  been  met  with  chiefly 
in  children  and  in  association  with  pneumonia.  It  was  present  in  three  of 
my  series  and  occurred  in  only  14  of  the  2,000  Munich  post  mortems.  Endo- 
carditis was  found  post  mortem  in  three  cases,  and  the  physical  signs  sug- 
gested its  presence  in  three  other  cases  in  the  series.  Myocarditis  is  more 
common,  and  is  indicated  by  a  progressive  weakening  of  the  heart-sounds  and 
enfeeblement  of  the  action  of  the  organ. 

Complications  in  the  Arteries. — Arteritis  with  thrombus  formation  oc- 
curred in  four  cases  in  the  series,  one  in  the  branches  of  the  middle  cerebral, 
two  in  the  femoral,  and  one  in  the  brachial.  In  one  case  gangrene  of  the  leg 
followed.  I  saw  a  similar  case  with  Eoddick,  in  Montreal,  in  which  oblitera- 
tion of  the  left  femoral  artery  occurred  on  the  sixteenth  day,  and  of  the  vessel 
on  the  right  side  on  the  twentieth  day,  with  gangrene  of  both  feet.  Pain, 
tenderness,  and  swelling  occur  over  the  artery,  with  diminution  or  disappear- 
ance of  the  pulsations  and  coldness  and  blueness  of  the  extremity.  In  two 
of  the  cases  these  symptoms  gradually  disappeared,  and  the  pulsation  returned 
not  only  in  the  peripheral,  but  in  the  affected  vessels  (Thayer).  Keen  refers 
to  46  cases  of  arterial  gangrene,  of  which  8  were  bilateral,  19  on  the  right 
side,  and  19  on  the  left. 

Thrombi  in  the  Veins. — In  our  series  there  were  43  instances,  distributed 
in  the  following  veins:  femoral  23,  popliteal  5,  iliac  5,  veins  of  the  calf  5, 
internal  saphenous  3,  pulmonary  artery  and  common  iliac  1,  axillary  vein 
1  (Thayer).  I  saw  one  case  in  the  right  circumflex  iliac  vein.  Femoral 
thrombosis  is  the  most  common,  and  almost  invariably  in  the  left  vessel, 
due,  as  Liebermeister  suggests,  to  the  fact  that  the  left  iliac  vein  is 
crossed  by  the  right  iliac  artery,  and  the  blood  flow  is  not  so  free. 
The  symptoms  of  this  complication  are  very  definite — the  fever  may  increase 
or  recur.  Chills  occurred  in  11  of  all  the  cases.  Pain  and  swelling  at  the  site 
are  constantly  present,  and  the  thrombotic  mass  can  be  felt,  not  always  at 
first,  nor  is  it  well  to  feel  for  it.  Swelling  of  the  leg  follows  as  a  rule,  but 
it  is  rarely  so  extreme,  and  never,  I  think,  so  painful  as  the  puerperal  phleg- 
masia  alba  dolens.  In  the  iliac  thrombosis  the  pain  may  be  severe  and  lead 
to  the  suspicion  of  perforation,  as  in  one  of  our  cases.  Leucocytosis  is  usually 
present,  in  12  cases  it  rose  above  10,000.  Five  of  the  43  cases  died,  2  only 
as  a  result  of  the  thrombus;  in  the  case  of  axillary  thrombosis  from  pulmo- 
nary embolism,  in  one  embolism  of  the  inferior  cava  and  right  auricle  from  the 
dislocation  of  a  piece  of  thrombus  from  the  left  iliac  vein.  Thayer  examined 
16  of  the  patients  at  varying  periods  after  convalescence,  and  found  in  every 
case  more  or  less  disability  from  the  varices  and  persistent  swelling.  In  some 
cases,  however,  the  recovery  is  complete. 

DIGESTIVE  SYSTEM. — Loss  of  appetite  is  early,  and,  as  a  rule,  the  relish 
for  food  is  not  regained  until  convalescence.  Thirst  is  constant,  and  should 
be  fully  and  freely  gratified.  The  tongue  presents  the  changes  inevitable  in  a 
prolonged  fever.  Early  in  the  disease  it  is  moist,  swollen,  and  coated  with  a 
thin  white  fur,  which,  as  the  fever  progresses,  becomes  denser.  It  may  remain 
moist  throughout.  In  severe  cases,  particularly  those  with  delirium,  the 
tongue  becomes  very  dry,  partly  owing  to  the  fact  that  such  patients  breathe 
with  the  mouth  open.  It  may  be  covered  with  a  brown  or  brownish-black  fur, 
or  with  crusts  between  which  are  cracks  and  fissures.  In  these  cases  the  teeth 


22  SPECIFIC    INFECTIOUS    DISEASES 

and  lips  may  be  covered  with  a  dark  brownish  matter  called  sordes- — a 
fcure  of  food,  epithelial  debris,  and  micro-organisms.  By  keeping  th«  mouth 
and  tongue  clean  from  the  outset,  the  fissures,  which  are  extremely  painful, 
may  be  prevented.  Acute  glossitis  occurred  in  one  case  at  the  onset  of  the 
relapse.  During  convalescence  the  tongue  gradually  becomes  clean,  and  the 
fur  is  thrown  off,  almost  imperceptibly  or  occasionally  in  flakes. 

The  secretion  of  saliva  is  often  diminished ;  .salivation  is  rare. 

Parotitis  was  present  in  45  of  the  2,000  Munich  cases.  It  occurred  in 
14  cases  in  my  series ;  of  these,  5  died.  It  is  most  frequent  in  the  third  week 
in  very  severe  cases.  Extensive  sloughing  may  follow  in  the  tissues  of  the 
neck.  Usually  unilateral,  and  in  a  majority  of  cases  going  on  to  suppura- 
tion, it  is  regarded  as  a  very  fatal  complication,  but  recovery  has  followed 
in  nine  of  my  cases.  It  undoubtedly  may  arise  from  extension  of  inflammation 
along  Steno's  duct.  This  is  probably  not  so  serious  a  form  as  when  it  arises 
from  metastatic  inflammation.  In  four  cases  the  submaxillary  glands  were 
involved  alone,  in  one  a  cellulitis  of  the  neck  extended  from  the  gland  and 
proved  fatal.  Parotitis  may  occur  after  the  fever  has  subsided.  A  remarkable 
localized  sweating  in  the  parotid  region  is  an  occasional  sequel  of  the  abscess. 

The  pharynx  may  be  the  seat  of  catarrh  or  ulceration.  Sometimes  the 
fauces  are  deeply  congested.  Membranous  pharyngitis,  a  serious  and  fatal 
complication,  may  come  on  in  the  third  week.  Difficulty  in  swallowing  may 
result  from  ulcers  of  the  oesophagus,  and  in  one  of  our  cases  stricture  fol- 
lowed.* Thyroiditis  may  occur  with  abscess  formation. 

The  gastric  symptoms  are  extremely  variable.  Nausea  and  vomiting  are 
not  common.  There  are  instances,  however,  in  which  vomiting,  resisting  all 
measures,  is  a  marked  feature  from  the  outset,  and  may  directly  cause  death 
from  exhaustion.  Vomiting  does  not  often  occur  in  the  second  and  third 
weeks,  unless  associated  with  some  serious  complication.  Ulcers  have  been 
found  in  the  stomach.  Hasmatemesis  occurred  in  4  of  our  cases. 

Intestinal  Symptoms. — Diarrhoea  is  a  very  variable  symptom,  occurring 
in  from  20  to  30  per  cent,  of  the  cases.  Of  1,500  cases,  516  had  diarrhoaa 
before  entering,  260  during  their  stay  in  hospital.  It  frequently  follows  the 
giving  of  purgatives  and  the  small  percentage  in  the  hospital  may  be  due  to 
the  fact  that  we  use  no  purges  or  intestinal  antiseptics.  Its  absence  must 
not  be  taken  as  an  indication  that  the  intestinal  lesions  are  of  slight  extent. 
I  have  seen,  on  several  occasions,  the  most  extensive  infiltration  and  ulcera- 
tion of  the  Peyer's  glands  of  the  small  intestine,  with  the  colon  filled  with 
solid  faeces.  The  diarrhoea  is  caused  less  by  the  ulcers  than  by  the  associated 
catarrh,  and,  as  in  tuberculosis,  it  is  probable  that  when  this  is  in  the  large 
intestine  the  discharges  are  more  frequent.  It  is  most  common  toward  the 
end  of  the  first  and  throughout  the  second  week,  but  it  may  not  occur  until 
the  third  or  even  the  fourth  week.  The  number  of  discharges  ranges  from 
3  to  8  or  10  in  the  twenty-four  hours.  They  are  usually  abundant,  thin, 
grayish-yellow,  granular,  of  the  consistency  and  appearance  of  pea-soup,  and 
resemble  very  much,  as  Addison  remarked,  the  normal  contents  of  the  small 
bowel.  The  reaction  is  alkaline  and  the  odor  offensive.  On  standing,  the 
discharges  separate  into  a  thin  serous  layer,  containing  albumin  and  salts, 

'Mitchell,  CEsophageal  Complications  in  Typhoid  Fever   (Studies  II). 


TYPHOID    FEVER  23 

and  a  lower  stratum,  consisting  of  epithelial  debris,  remnants  of  food,  and 
numerous  crystals  of  triple  phosphates.  Blood  may  be  in  small  amount,  and 
onlj  recognized  by  the  microscope.  Sloughs  of  the  Fever's  glands  occur 
either  as  grayish-yellow  fragments  or  occasionally  as  ovoid  masses,  an  inch 
or  more  in  length,  in  which  portions  of  the  bowel  tissue  may  be  found.  The 


CHAET  II. — HEMORRHAGE  FROM  THE  BOWELS.    RAPID  FALL  OF  TEMPERATURE. 


bacilli  are  not  found  in  the  stools  until  the  end  of  the  first  or  the  middle  of 
the  second  week.    Constipation  was  present  in  51  per  cent,  of  this  series. 

Hemorrhage  from  the  bowels  is  a  serious  complication,  occurring  in  about 
7  per  cent,  of  all  cases.  It  had  occurred  in  99  of  the  2,000  fatal  Munich 
cases.  In  1,500  cases  treated  in  my  wards  haemorrhage  occurred  in  118,  and 
in  12  death  followed  the  hemorrhage.  It  occurred  in  1,6-il  (7  per  cent.)  of 


24  SPECIFIC    INFECTIOUS    DISEASES 

23,721  collected  cases  (McCrae).  There  may  be  only  a  slight  trace  of  blood 
in  the  stools,  but  often  it  is  a  profuse,  free  haemorrhage.  It  occurs  most 
commonly  between  the  end  of  the  second  and  the  beginning  of  the  fourth 
week,  the  time  of  the  separation  of  the  sloughs.  Occasionally,  early  in  the 
course,  it  results  simply  from  the  intense  hyperaemia.  It  usually  comes  on 
without  warning.  A  sensation  of  sinking  or  collapse  is  experienced  by  the 
patient,  the  temperature  falls,  and  may,  as  in  the  annexed  chart,  drop  6°  or  7° 
in  a  few  hours.  Fatal  collapse  may  supervene  before  the  blood  appears  in 
the  stool.  Hemorrhage  usually  occurs  in  cases  of  considerable  severity,  but 
Graves  and  Trousseau  held  that  it  was  not  a  very  dangerous  symptom. 

It  must  not  be  forgotten  that  melaena  may  also  be  part  of  a  general  hem- 
orrhagic  tendency  (to  be  referred  to  later),  in  which  case  it  is  associated  with 
petechiae  and  haematurla.  There  may  be  a  special  family  predisposition  to 
intestinal  haemorrhages  in  typhoid  fever. 

Meieorism,  a  frequent  symptom,  is  not  serious  if  of  moderate  grade,  but 
when  excessive  is  usually  of  ill  omen.  Owing  to  defective  tone  in  the  walls, 
in  severe  cases  to  their  infiltration  with  serum,  gas  accumulates  in  the  stom- 
ach, small  and  large  bowel,  particularly  in  the  last.  Pushing  up  the  dia- 
phragm, it  interferes  very  much  with  the  action  of  the  heart  and  lungs,  and 
may  also  favor  perforation.  Gurgling  in  the  right  iliac  fossa  exists  in  a  large 
proportion  of  the  cases,  and  indicates  simply  the  presence  of  gas  and  fluid 
fasces  in  the  colon  and  caecum. 

Abdominal  pain  and  tenderness  were  present  in  three-fifths  of  a  series 
of  500  cases  studied  with  special  reference  to  the  point  by  T.  McCrae. 
In  some  it  was  only  present  at  the  onset.  Pain  occurred  during  the  course  in 
about  one-third  of  the  cases.  This  is  due  in  some  instances  to  conditions 
apart  from  the  bowel  lesions,  such  as  pleurisy,  distention  of  the  bladder,  and 
phlebitis.  It  may  be  associated  with  diarrhoea,  severe  constipation,  peri- 
?plenitis,  or  acute  abdominal  complications.  Pain  occurs  with  some  cases  of 
haemorrhage,  but  is  most  constantly  present  with  perforation.  In  a  large 
group  no  cause  could  be  found  for  the  pain,  and  if  /other  symptoms  be  asso- 
ciated the  condition  may  lead  to  error  in  diagnosis.  Operation  for  appendi- 
citis has  been  performed  in  the  early  stage  of  typhoid  fever,  owing  to  the 
combination  of  pain  in  the  right  iliac  fossa,  fever  and  constipation. 

PERFORATION. — From  one-fourth  to  one-third  of  the  deaths  are  due  to 
perforation,  and  as  there  were  35,379  deaths  from  typhoid  fever  in  the  United 
States  in  the  year  1900,  this  gives  between  9,000  and  12,000  deaths  from  this 
cause.  Among  34,916  collected  cases  perforation  occurred  in  3.1  per  cent. 
(McCrae).  While  it  may  occur  as  early  as  the  first  week,  in  the  great  ma- 
jority it  is  at  the  height  of  the  disease  in  the  third  week,  and  much  more  fre- 
quently in  the  severe  cases,  particularly  those  associated  with  tympanites, 
diarrhoea,  and  haemorrhage.  It  may  occur,  however,  in  very  mild  attacks  and 
with  great  suddenness,  when  the  patient  is  apparently  progressing  favorably. 

Symptoms  of  Perforation. — By  far  the  most  important  single  indication  is 
a  sudden,  sharp  pain  of  increasing  severity,  often  paroxysmal  in  character.  It 
is  rarely  absent,  except  in  the  small  group  of  cases  with  profound  toxaemia. 
The  situation  is  most  frequent  in  the  hypogastric  region  and  to  the  right  of 
the  middle  line.  Tenderness  on  pressure  is  present  in  the  great  majority  of 
cases,  usually  in  the  hypogastric  and  right  iliac  regions,  sometimes  diffuse; 


TYPHOID    FEVER  25 

it  may  only  be  brought  out  on  deep  pressure.  As  LeConte  points  out,  when 
the  perforation  happens  to  be  in  contact  with  the  parietal  peritoneum  the 
local  features  on  palpation  are  much  more  marked  than  when  the  perforated 
ulcer  is  next  to  a  coil  or  to  the  mesentery.  There  may  be  early  irritability 
of  the  bladder,  with  frequent  micturition,  and  pain  extending  toward  the 
penis.  A  third  important  sign  is  muscle  rigidity,  increased  tension,  and 
spasm  on  any  attempt  to  palpate.  The  temperature  may  rise  for  a  few  hours 
to  fall  later  or  may  drop  at  once.  The  pulse  and  respiration  rate  are  usually 
increased.  Following  these  features  in  a  few  hours  there  is  usually  a  reaction, 
and  then  the  features  of  general  peritonitis  become  manifest  to  a  more  or  less 
marked  degree.  Among  the  general  features,  the  facies  of  the  patient  shows 
changes ;  there  is  increased  pallor,  a  pinched  expression  of  the  face,  and  as  the 
symptoms  progress  and  toward  the  end  a  marked  Hippocratic  facies,  a  dusky 
suffusion,  and  the  forehead  bathed  in  a  clammy  perspiration.  The  tempera- 
ture rises  with  the  increase  of  the  peritonitis.  The  pulse  quickens,  is  running 
and  thready,  the  heart's  action  "becomes  progressively  more  feeble,  and  there 
is  an  increase  in  the  frequency  of  the  respiration.  Vomiting  is  a  variable 
feature;  it  is  present  in  a  majority  of  the  cases.  Hiccough  is  common  and 
may  occur  early,  but  more  frequently  late. 

The  local  abdominal  features  are  often  more  important  than  the  general, 
as  it  is  surprising  to  notice  how  excellent  the  condition  of  a  patient  may  be 
with  perforative  peritonitis.  Limitation  of  the  respiratory  movements  is  usu- 
ally present,  perhaps  confined  to  the  hypogastric  area.  Increasing  distention 
is  the  rule,  but  perforation  and  peritonitis  may  occur,  it  is  to  be  remembered, 
with  an  abdomen  flat  or  even  scaphoid.  Increasing  pain  on  pressure,  increas- 
ing muscle  spasm  and  tension  of  the  wall  are  important  signs.  Percussion 
may  reveal  a  flat  note  in  the  flanks,  due  to  exudate.  A  friction  may  be  present 
within  a  few  hours  of  the  onset  of  the  perforation.  Obliteration  of  the  liver 
flatness  in  the  nipple  line  may  be  caused  by  excessive  tympany,  but  rapid 
obliteration  of  liver  flatness  in  a  flat,  or  a  not  much  distended  abdomen,  is  a 
valuable  sign.  Examination  of  the  rectum  may  show  fullness  or  tenderness 
in  the  pelvis.  Advance  in  the  abdominal  signs  is  an  important  point. 

In  a  majority  of  all  cases  there  is  a  rise  in  the  leucocytes,  and  when  pres- 
ent may  be  a  valuable  help,  but  it  Js  not  constant.  Increase  in  the  blood  pres- 
sure is  not  constant. 

General  peritonitis,  without  perforation  of  the  bowel,  may  occur  by  exten- 
sion from  an  ulcer,  or  by  rupture  of  a  softened  mesenteric  gland,  or,  as  in 
one  recent  case  in  my  series,  from  inflammation  of  the  Fallopian  tubes.  It 
was  present  in  2.2  per  cent,  of  the  Munich  autopsies. 

Perforation  is  almost  invariably  fatal.  In  a  few  cases  healing  takes  place 
spontaneously,  as  is  beautifully  shown  in  one  of  the  Pennsylvania  Hospital 
specimens,  or  the  orifice  may  be  closed  by  a  tag  of  omentum,  as  in  a  remark- 
able case  reported  by  J.  Milton  Miller.  There  is  a  group  of  cases  in  which 
hemorrhage  complicates  the  perforation  and  adds  to  the  difficulty  in  diagnosis. 
In  7  of  our  43  cases  hemorrhage  accompanied  the  perforation ;  in  3  others  the 
hemorrhage  had  occurred  some  days  before. 

The  diagnosis  of  perforation,  easy  enough  at  times,  is  not  without  serious 
difficulties.  The  conditions  for  which  it  has  been  mistaken  in  my  wards  have 
been :  appendicitis,  occurring  during  the  course  of  the  typhoid  fever,  phlebitis 
4 


26  SPECIFIC    INFECTIOUS    DISEASES 

of  the  iliac  vein  with  great  pain,  haemorrhage,  and  in  one  case  a  local  perito- 
nitis without  perforation,  for  which  no  cause  was  found.  Recovery  followed 
the  exploratory  operation,  which  was  made  in  all  but  one  (haemorrhage  case) 
of  the  cases.  Exploration  is  justifiable  and  better  than  delay  in  suspicious  cases. 

ASCITES  occurs  in  rare  instances  (McPhedran). 

The  SPLEEN  is  usually  enlarged,  and  the  edge  was  felt  below  the  costal 
margin  in  71.6  per  cent,  of  my  cases.  Percussion  is  uncertain,  as,  owing  to 
distension  of  the  stomach  and  colon,  even  the  normal  area  of  dulness  may  not 
be  obtainable.  Enlargement  is  often  not  marked  in  elderly  patients. 

LIVER. — Symptoms  on  the  part  of  this  organ  are  rare. 

(a)  Jaundice  was  present  in  only  8  cases  of  my  series.  Catarrh  of  the 
ducts,  toxasmia,  abscess,  and  occasionally  gall-stones  are  the  usual  causes. 

(&)  Abscess. — Solitary  abscess  is  exceedingly  rare  and  occurred  in  but  3 
cases  in  my  series.  It  may  occur  early  in  the  disease,  but  most  frequently  is  a 
sequel,  von  Eberts  has  collected  30  cases,  in  9  of  which  the  typhoid  bacillus 
was  isolated  from  the  pus.  In  about  half  the  cases  the  right  lobe  was  affected. 
Eighteen  of  the  patients  recovered.  Abscess  may  follow  the  intestinal  lesion 
or  a  complication  as  parotitis.  Suppuratve  pylephlebitis  may  follow  perfora- 
tion of  the  appendix.  Suppurative  cholangitis  has  been  described. 

(c)  Cholecystitis  occurred  in  19  cases  of  the  series.     Pain  in  the  region 
of  the  gall-bladder  is  the  most  constant  symptom.    Tenderness,  muscle  spasm 
with  rigidity,  and  a  gall-bladder  tumor  are  present  in  a  majority  of  the  cases. 
Jaundice  is  inconstant.    Leucocytosis  usually  occurs.    With  perforation  there 
may  be  a  marked  drop  in  the  fever  and  the  onset  of  signs  of  peritonitis.    In 
simple  cholecystitis  the  urgency  of  the  symptoms  may  abate,  and  recovery  fol- 
low.    Suppuration  may  occur  with  infection  of  the  bile  passages.     Months 
or  years  after    (eighteen  years  in  Hunner's    case)    the    bacilli    may    cause 
cholecystitis  or  gall-stones.     Typhoid  bacilli  have  been  found  as  a  cause  of 
cholecystitis  in  patients  who  never  had  typhoid  fever. 

(d)  Gall-stones. — Bernheim  called   attention  to  the  frequency  of  chole- 
lithiasis after  typhoid  fever.     It  is. probably  associated  with  the  presence  of 
typhoid  bacilli  in  the  gall-bladder  (see  under  Gall-Stones). 

PANCREAS. — HaBmorrhagic  pancreatitis  has  occurred  rarely. 

RESPIRATORY  SYSTEM. — Epistaxis,  an  e&rly  symptom,  precedes  typhoid 
fever  more  commonly  than  any  other  febrile  affection.  It  is  occasionally 
profuse  and  serious  and  may  occur  during  the  course. 

Laryngitis  is  not  very  common.  The  ulcers  and  the  perichondritis  have 
already  been  described.  (Edema,  apart  from  ulceration,  is  rare.  In  the 
United  States  the  laryngeal  complications  of  typhoid  fever  seem  much  less 
frequent  than  on  the  Continent.  I  have  twice  seen  severe  perichondritis ;  both 
of  the  cases  recovered,  one  after  the  expectoration  of  large  portions  of  the 
thyroid  cartilage.  Keen  and  Liming  have  collected  221  cases  of  serious  surgi- 
cal complications  of  the  larynx.  General  emphysema  may  follow  the  per- 
foration of  an  ulcer.  Stenosis  is  a  very  serious  sequence.  It  would  appear 
that  paralysic  of  the  laryngeal  muscles  is  more  common  than  we  have  sup- 
posed. Przedborski  (Volkmann's  Sammlung,  No.  182)  systematically  ex- 
amined the  larynx  in  100  consecutive  cases  and  found  25  with  paralysis.  The 
condition  is  nearly  always  due  to  neuritis,  sometimes  in  connection  with 
affections  of  other  nerves. 


TYPHOID    FEVEE  27 

Bronchitis  is  one  of  the  most  frequent  initial  symptoms.  It  is  indicated 
by  the  presence  of  sibilant  rales.  The  smaller  tubes  may  be  involved,  pro- 
ducing urgent  cough  and  even  slight  cyanosis.  Collapse  and  lobular  pneu- 
monia may  also  occur. 

Lobar  pneumonia  is  met  with  under  two  conditions : 

(a)  At  the  outset,  the  pneumo-typhus  of  the  Germans.  This  occurred  in 
three  of  our  cases.  After  an  indisposition  of  a  day  or  so,  the  patient  is  seized 
with  a  chill,  has  high  fever,  pain  in  the  side,  and  within  forty-eight  hours 
there  are  signs  of  consolidation  and  the  evidences  of  an  ordinary  lobar  pneu- 
monia. The  intestinal  symptoms  may  not  occur  until  toward  the  end  of  the 
first  week  or  later;  the  pulmonary  symptoms  persist,  crisis  does  not  occur; 
the  aspect  of  the  patient  changes,  and  by  the  end  of  the  second  week  the 
clinical  picture  is  that  of  typhoid  fever.  Spots  may  then  be  present  and 
doubts  as  to  the  nature  of  the  case  are  solved.  In  other  instances,  in  the 
absence  of  a  characteristic  eruption,  the  case  remains  doubtful,  and  it  is 
impossible  to  say  whether  the  disease  has  been  pneumonia,  in  which  the  so- 
called  typhoid  symptoms  have  developed,  or  whether  it  was  typhoid  fever 
with  early  implication  of  the  lungs.  This  condition  may  depend  upon  an 
early  localization  of  the  typhoid  bacillus  in  the  lung. 

(&)  Lobar  pneumonia  forms  a  serious  and  by  no  means  infrequent  com- 
plication of  the  second  or  third  week — in  19  of  our  cases.  It  was  present  in 
over  8  per  cent,  of  the  Munich  cases.  The  symptoms  are  usually  not  marked. 
There  may  be  no  rusty  sputum,  and,  unless  sought  for,  the  condition  is  fre- 
quently overlooked.  The  etiological  agent  in  these  cases  is  still  in  dispute.- 
Typhoid  bacilli  have  been  isolated  from  the  sputum  by  Jehle,  Bau,  and  others. 
They  have  also  been  isolated  from  the  consolidated  lungs  at  autopsy,  but  in 
such  cases  the  pneumococci  may  have  been  originally  present,  and  the  typhoid 
bacilli  secondary  invaders.  In  all  cases  of  pneumonia  during  typhoid  fever 
occurring  in  the  Johns  Hopkins  Hospital  and  coming  to  autopsy,  the  pneu- 
mococcus  could  be  demonstrated  in  the  consolidated  lung.  Infarction,  ab- 
scess, and  gangrene  are  occasionally  pulmonary  complications. 

Hypostatic  congestion  of  the  lungs  and  oedema,  due  to  enfeebled  circula- 
tion, occur  in  the  later  periods  of  the  disease.  The  physical  signs  are  defective 
resonance  at  the  bases,  feeble  breath-sounds,  and,  on  deep  inspiration,  moist  rales. 

Haemoptysis  may  occur.     Creagh  reports  a  case  in  which  it  caused  death. 

Pleurisy  was  present  in  about  8  per  cent,  of  the  Munich  autopsies.  It 
occurred  in  2  per  cent,  of  my  series.  It  may  occur  at  the  outset — pleuro- 
typhoid — or  slowly  during  convalescence,  in  which  case  it  is  almost  always 
purulent  and  due  to  the  typhoid  bacillus. 

Pneumothorax  is  rare.  Hale  White  has  reported  two  cases,  in  both  of 
which  pleurisy  existed.  After  death,  no  lesions  of  the  lungs  or  bronchi  were 
discovered.  The  condition  may  be  due  to  straining,  or  to  the  rupture  of  a 
small  pysemic  abscess.  It  may  occur  also  during  convalescence. 

NERVOUS  SYSTEM. — C erebro-spinal  Form. — As  already  noted,  the  disease 
may  set  in  with  intense  and  persisting  headache,  or  an  aggravated  form  of 
neuralgia.  There  are  cases  in  which  the  effect  of  the  poison  is  manifested 
on  the  nervous  system  early  and  with  the  greatest  intensity.  There  are  head- 
ache, photophobia,  retraction  of  the  neck,  marked  twitchings  of  the  muscles, 
rigidity,  and  even  convulsions.  In  such  cases  the  diagnosis  of  meningitis  is 


28  SPECIFIC    INFECTIOUS    DISEASES 

invariably  made.  The  cases  showing  marked  meningeal  features  during  the 
course  of  the  disease  may  be  divided  into  three  groups.  First,  those  with 
symptoms  suggestive  of  meningitis,  but  without  localizing  features  and  with- 
out at  post  mortem  the  anatomical  lesions  of  meningitis.  In  every  series  of 
cases  numerous  such  examples  occur.  Secondly,  the  cases  of  so-called  serous 
meningitis.  There  is  a  localization  of  typhoid  bacilli  in  the  cerebro-spinal 
fluid  and  a  mild  inflammatory  reaction,  but  without  suppurative  meningitis. 
Cole  has  collected  thirteen  such  cases,  five  of  them  occurring  in  our  series. 
Probably  more  frequent  lumbar  punctures  will  show  that  this  occurs  not 
infrequently.  Thirdly,  true  typhoid  suppurative  meningitis  due  to  B.  typho- 
sus.  Only  one  such  case  occurred  in  our  series,  and  Cole  has  collected  thir- 
teen from  the  literature.  Meningitis  in  typhoid  fever  is  occasionally  due  to 
other  organisms,  as  the  tubercle  bacillus,  or  the  micrococcus  intracellularis. 
Marked  convulsive  movements,  local  or  general,  with  coma  and  delirium,  are 
seen  also  in  thrombosis  of  the  cerebral  veins  and  sinuses. 

Delirium,  usually  present  in  very  severe  cases,  is  certainly  less  frequent 
under  a  rigid  plan  of  hydrotherapy.  It  may  exist  from  the  outset,  but  usu- 
ally does  not  occur  until  the  second  and  sometimes  not  until  the  third  week. 
It  may  be  slight  and  only  nocturnal.  It  is,  as  a  rule,  a  quiet  delirium,  though 
there  are  cases  in  which  the  patient  is  very  noisy  and  constantly  tries  to  get 
out  of  bed,  and,  unless  carefully  watched,  may  escape.  The  patient  does 
not  often  become  maniacal.  In  heavy  drinkers  the  delirium  may  have  the 
character  of  delirium  tremens.  Even  in  patients  who  have  no  positive  deli- 
•rium,  the  mental  processes  are  usually  dulled  and  the  aspect  is  listless  and 
apathetic.  In  severe  cases  the  patient  passes  into  a  condition  of  uncon- 
sciousness. The  eyes  may  be  open,  but  he  is  oblivious  to  all  surrounding  cir- 
cumstances and  neither  knows  nor  can  indicate  his  wants.  The  urine  and 
fasces  are  passed  involuntarily.  In  this  pseudo-wakeful  state,  or  coma  vigil, 
as  it  is  called,  the  eyes  are  open  and  the  patient  is  constantly  muttering.  The 
lips  and  tongue  are  tremulous;  there  are  twitchings  of  the  fingers  and  wrists 
— subsultus  tendinum  and  carphologia.  He  picks  at  the  bedclothes  or  grasps 
at  invisible  objects.  These  are  among  the  most  serious  symptoms  of  the 
disease  and  always  indicate  danger. 

Convulsions  in  typhoid  fever  are  rare.  There  were  7  instances  in  my 
series.  They  occur :  first,  at  the  onset  of  the  disease,  particularly  in  children ; 
secondly,  as  a  manifestation  of  the  toxaemia ;  and  thirdly,  as  a  result  of  severe 
cerebral  complications — thrombosis,  meningitis,  or  acute  encephalitis.  Occa- 
sionally in  convalescence  convulsions  may  occur  from  unknown  causes.  Of 
the  7  cases  3  died. 

Neuritis,  which  is  not  uncommon — 11  cases  in  the  series — may  be  local  or 
a  widespread  affection. 

Multiple  neuritis  comes  on  usually  during  convalescence.  The  legs  may 
be  affected,  or  the  four  extremities.  The  cases  are  often  difficult  to  differen- 
tiate from  those  with  subacute  poliomyelitis.  Recovery  is  the  rule. 

Local  Neuritis. — This  may  occur  during  the  height  of  the  fever  or  after 
convalescence  is  established.  It  may  set  in  with  agonizing  pain,  and  with 
sensitiveness  of  the  affected  nerve  trunks.  The  local  neuritis  may  affect  the 
nerves  of  an  arm  or  of  a  leg,  and  involve  chiefly  the  extensors,  so  that  there 
is  wrist-drop  or  foot-drop.  The  arm  or  leg  may  be  much  swollen  and  the 


TYPHOID    'FEVER  29 

skin  over  it  erythematous.  A  curious  condition,  probably  a  local  neuritis,  is 
that  which  was  first  described  by  Handford  as  tender  toes,  and  which  appears 
to  be  more  common  after  the  bath  treatment.  The  tips  and  pads  of  the  toes, 
rarely  the  pads  at  their  bases,  become  exquisitely  sensitive,  so  that  the  patient 
can  not  bear  the  weight  of  the  bedclothes.  There  is  no  discoloration  and  no 
swelling,  and  it  disappears  usually  within  a  week  or  ten  days. 

Painful  muscles  are  not  uncommon,  particularly  in  the  calves.  I  have 
reported  a  series  of  cases  (Studies  III).  Painful  cramps  may  also  occur.  In 
some  of  the  cases  of  painful  legs  the  condition  is  a  myositis;  in  others  the 
swelling  and  pain  may  be  due  to  thrombosis  in  the  deeper  veins. 

Poliomyelitis  may  occur  with  the  symptoms  of  acute  ascending  paralysis 
and  prove  fatal  in  a  few  days.  More  frequently  it  is  less  acute,  and  causes 
either  a  paraplegia  or  a  limited  atrophic  paralysis  of  one  arm  or  leg. 

Hemiplegia  is  a  rare  complication.  Smithies  (1907)  collected  40  cases  in 
26  of  which  aphasia  occurred  and  in  10  the  hemiplegia  was  preceded  by  con- 
vulsions. In  21  cases  the  paralysis  was  on  the  right  side.  The  lesion  is 
usually  thrombosis  of  the  arteries,  less  often  a  meningo-encephalitis.  The 
aphasia  usually  disappears. 

Aphasia^  apart  from  hemiplegia,  occurs  rarely  and  usually  in  children. 
The  prognosis  is  good. 

True  tetany  occurs  sometimes,  and  has  been  reported  in  connection  with 
certain  epidemics.  It  may  set  in  during  the  height  of  the  disease. 

Typhoid  Psychoses. — There  are  three  groups  of  cases:  first,  an  initial 
delirium,  which  may  be  serious,  and  cause  the  patient  to  wander  away  from 
his  home,  or  he  may  even  become  maniacal ;  secondly,  the  psychosis  associated 
directly  with  the  pyrexia  and  the  toxaemia;  in  a  few  cases  this  outlasts  the 
disappearance  of  the  fever  for  months  or  even  years ;  and,  lastly,  the  asthenic 
psychosis  of  convalescence,  more  common  after  typhoid  than  after  any  other 
fever.  The  prognosis  is  usually  good.  Edsall  has  studied  the  condition  in 
children,  finding  69  cases,  of  which  43  recovered. 

There  is  a  distressing  post-typhoid  neurasthenia,  in  which  for  months  or 
even  for  years  the  patient  is  unable  to  get  into  harmony  with  his  surroundings. 

SPECIAL  SENSES. — Eye. — Conjunctivitis,  simple  or  phlyctenular,  some- 
times with  keratitis  and  iritis,  may  develop.  Panophthalmitis  has  been  re- 
ported in  one  case  in  association  with  hemorrhage  (Finlay).  Loss  of  accom- 
modation may  occur,  usually  in  the  asthenia  of  convalescence.  Oculo-motor 
paralysis  has  been  seen,  due  probably  to  neuritis.  Eetinal  haemorrhages  may 
occur  alone  or  in  association  with  other  haemorrhagic  features.  Double  optic 
neuritis  has  been  described  in  the  course  of  the  fever.  It  may  be  independent 
of  meningitis.  Atrophy  may  follow,  but  these  complications  are  excessively 
rare.  Cataract  may  follow  inflammation  of  the  uveal  tract.  Other  rare  com- 
plications are  thrombosis  of  the  orbital  veins  and  orbital  hemorrhage.  (See 
de  Schweinitz  in  Keen's  monograph  for  full  consideration  of  the  subject.) 

Ear. — Otitis  media  is  not  infrequent,  2.5  per  cent,  in  Hengst's  collected 
cases.  We  have  never  found  the  typhoid  bacillus  in  the  discharge.  Serious 
results  are  rare;  only  one  case  of  mastoid  disease  occurred  in  our  series. 
The  otitis  may  set  in  with  a  chill  and  an  aggravation  of  the  fever. 

RENAL  SYSTEM. — Retention  of  urine  is  an  early  symptom  and  may  be  the 
cause  of  abdominal  pain.  It  may  recur  throughout  the  attack.  Suppression 


30  SPECIFIC    INFECTIOUS   DISEASES 

of  urine  is  rare.  The  urine  is  usually  diminished  at  first,  has  the  ordinary 
febrile  characters,  and  the  pigments  are  increased.  Later  in  the  disease  it  is 
more  abundant  and  lighter  in  color.' 

Polyuria  is  not  very  uncommon.  While  most  common  during  conva- 
lescence, the  increase  may  be  sudden  in  the  second  week  at  the  height  of  the 
fever,  as  in  a  case  reported  by  Fussell.  The  amount  of  urine  depends  very 
much  on  the  fluid  taken.  Patients  treated  by  what  is  known  as  the  washing- 
out  method,  in  which  large  quantities  of  water  are  taken,  may  pass  enor- 
mous amounts,  18  or  19  litres.  One  of  my  patients  passed  as  much  as  23 
litres  in  one  day ! 

The  Diazo-reaction  of  Ekrlich  was  found  in  894  of  1,467  cases.  It  may 
be  present  previous  to  the  occurrence  of  the  rash,  and  as  late  as  the  twenty- 
second  day.  The  value  of  the  test  is  lessened  by  its  occurrence  in  cases  of 
miliary  tuberculosis,  in  malarial  fever,  and  occasionally  in  the  acute  diseases 
associated  with  high  fever.  In  cases  passing  large  quantities  of  urine,  the 
diazo-reaction  is  very  feeble  or  even  absent.  The  urotoxic  coefficient  in 
typhoid  fever  is  high  and  is  said  to  be  increased  by  the  tubs. 

BaciUuria  caused  by  the  typhoid  bacilli  occurs  in  about  one-third  of  the 
cases.  The  urine  may  be  turbid  from  their  presence  and  in  the  test-tube  give 
a  peculiar  shimmer.  There  may  be  millions  of  bacilli  to  the  cubic  milli- 
metre without  pyuria  or  any  symptoms  of  renal  or  bladder  trouble.  The 
routine  administration  of  hexamine  diminishes  the  occurrence  of  typhoid 
bacilluria.  The  bacilli  may  be  present  in  the  urine  for  years  after  the  attack 
(see  Gwyn,  Studies  III).  Of  51  cases  during  the  session  of  1900-1901  in  my 
clinic,  Cole  found  typhoid  bacilli  in  the  urine  in  16. 

The  renal  complications  in  typhoid  fever  may  be  thus  grouped: 

(a)  Febrile  albuminuria  is  common  and  of  no  special  significance.  It 
was  present  in  999  of  1,500  cases,  66  per  cent.  Tube  casts  were  present  in 
568  cases,  37.8  per  cent.  Hcemoglobinuria  occurred  in  one  case. 

(6)  Acute  nephritis  at  the  onset  or  during  the  xheight  of  the  disease — 
the  nephro-typhus  of  the  Germans,  the  fievre  typhoid  a  forme  renale  of  the 
French — may  set  in,  masking  in  many  instances  the  true  nature  of  the 
malady.  After  an  indisposition  of  a  few  days  there  may  be  fever,  pain  in 
the  back,  and  the  passage  of  a  small  amount  of  bloody  urine. 

(c)  Nephritis  during  convalescence  is  rare,  and  is  usually  associated  with 
anasmia  and  oadema.     Chronic  nephritis  is  a  most   exceptional  sequel. 

(d)  The  lymphomatous  nephritis,  described  by  E.  Wagner,  and  already 
referred  to  in  the  section  on  morbid  anatomy,  produces,  as  a  rule,  no  symptoms. 

(e)  Pyuria,  a  not  uncommon  complication,  may  be  "associated  with  the 
typhoid  or  the  colon  bacillus,  less  often  with  staphylococci.     It  disappears 
during  convalescence.     It  is  usually  due  to  a  simple  catarrh  of  the  bladder, 
rarely  to  an  intense  cystitis. 

(/)  Post-typhoid  Pyelitis. — One  or  both  kidneys  may  be  involved,  either 
at  the  height  of  the  disease  or  during  convalescence.  There  may  be  blood 
and  pus  at  first,  later  pus  alone,  varying  in  amount.  A  severe  pyelonephritis 
may  follow.  The  colon  bacillus  is  often  the  organism  present.  Perinephric 
abscess  is  a  rare  sequel. 

GENERATIVE  SYSTEM. — Orchitis  is  occasionally  met  with.  Kinnicutt  has 
collected  53  cases  in  the  literature.  It  is  usually  associated  with  -a  catarrhal 


TYPHOID    FEVER  31 

urethritis.  Induration  or  atrophy  may  occur,  and  more  rarely  suppuration. 
It  was  present  in  4  cases  in  my  series.  In  1  case  double  hydrocele  developed 
suddenly  on  the  nineteenth  day  (Dunlap).  Prostatitis  occurs  rarely. 

Acute  mastitis,  which  may  go  on  to  suppuration,  is  a  rare  complication. 
It  was  present  in  3  cases  of  my  series  during  the  fever  and  in  one  late  in 
convalescence. 

OSSEOUS  SYSTEM. — Among  the  most  troublesome  of  the  sequelae  are  the 
6 one  lesions  which  in  a  few  cases  occur  at  the  height  of  the  disease  or 
even  earlier.  A  boy  was  admitted  in  the  second  week  of  an  attack  of  typhoid 
fever  with  acute  periostitis  of  the  frontal  bone  and  of  one  rib.  Of  237  cases 
collected  by  Keen  there  was  periostitis  in  110,  necrosis  in  85,  and  caries  in 
13.  They  are,  I  am  sure,  much  more  frequent  than  the  figures  indicate.  Six 
cases  came  under  my  notice  in  the  course  of  a  year,  and  formed  the  basis  of 
Parsons'  paper  (Studies  II).  The  legs  are  chiefly  involved.  In  Keen's 
series  the  tibia  was  affected  in  91  cases,  the  ribs  in  40.  The  typhoid  bone 
lesion  is  apt  to  form  what  the  old  writers  called  a  cold  abscess.  Only  a  few 
of  the  cases  are  acute.  Chronicity,  indolence,  and  a  remarkable  tendency  to 
recurrence  are  perhaps  the  three  most  striking  features.  A  bony  node  may 
be  left  by  the  typhoid  periostitis. 

Arthritis  was  present  in  8  cases  of  my  series.  Keen  has  collected  84  cases 
from  the  literature.  It  may  be  monarticular  or  polyarticular.  One  of  the 
most  important  points  relating  to  it  is  the  frequency  with  which  spontaneous 
dislocations  occur,  particularly  of  the  hip. 

Typhoid  Spine  (Gibney). — During  the  disease  but  more  often  during 
convalescence,  the  patient  complains  of  pain  in  the  lumbar  and  sacral  regions, 
perhaps  after  a  slight  jar  or  shock.  Stiffness  of  the  back,  pain  on  movement", 
sometimes  radiating,  and  tenderness  on  pressure  are  the  chief  features,  but 
there  are  in  addition  marked  nervous  manifestations.  There  is  rigidity  and 
fixation  of  the  spine,  usually  in  the  lower  part.  Kyphosis  occurs  in  some  cases. 
The  X-ray  plates  may  show  definite  bony  change.  There  is  usually  spondylitis 
or  perispondylitis.  The  duration  is  weeks  or  months,  but  the  outlook  is  good. 

The  muscles  may  be  the  seat  of  the  degeneration  already  referred  to,  but  it 
rarely  causes  any  symptoms.  Haemorrhage  occasionally  occurs  into  the  muscles, 
and  late  in  protracted  cases  abscesses  may  follow.  Eupture  of  a  muscle,  usu- 
ally the  rectus  abdominis,  may  occur,  possibly  associated  with  acute  haemor- 
rhagic  myositis. 

Post-typhoid  Septicaemia  and  Pyaemia.— In  very  protracted  cases  there  may 
recur  after  defervescence  a  slight  fever  (100°-101°  F.),  with  sweats,  which  is 
possibly  septic.  In  other  cases  for  two  or  three  weeks  there  are  recurring 
chills,  often  of  great  severity.  They  are  usually  of  no  moment  in  the  absence 
of  signs  of  complication.  (See  Studies  II  and  III.) 

Typhoid  pyaemia  is  not  very  uncommon,  (a)  Extensive  furunculosis  may 
be  associated  with  irregular  fever  and  leucocytosis.  (6)  Following  the  fever 
there  may  be  multiple  subcutaneous  "cold"  abscesses,  often  with  a  dark,  thin 
bloody  pus.  A  score  or  more  of  these  may  appear  in  different  parts.  Pratt 
has  isolated  the  bacillus  in  pure  culture  from  the  subcutaneous  abscesses. 
(c)  A  crural  thrombus  may  suppurate  and  cause  a  widespread  pyaemia,  (d) 
In  rare  instances  suppuration  of  the  mesenteric  glands,  of  a  splenic  infarct, 
a  sloughing  parotid  bubo,  a  perinephric  or  perirectal  abscess,  acute  necrosis 


32  SPECIFIC    INFECTIOUS    DISEASES 

of  the  bones,  or  a  multiple  suppurative  arthritis  may  cause  pyaemia.  In  other 
cases  following  bed-sores  or  a  furunculosis  there  occurs  a  general  infection 
with  pyogenic  organisms  with  fatal  result.  In  three  such  cases  in  our  series 
staphylococci  were  cultivated  from  the  blood.  In  one  case  with  many  chills 
late  in  the  disease,  and  the  general  condition  excellent,  typhoid  bacilli  were  cul- 
tivated from  the  blood.  The  colon  bacillus  may  also  be  found  in  blood  cultures. 

Association  of  Other  Diseases. — Erysipelas  is  a  rare  complication,  most 
commonly  met  with  during  convalescence.  Measles  or  scarlet  fever  may  de- 
velop during  the  fever  or  in  convalescence.  Chicken-pox  and  noma  have 
been  reported  in  children.  Pseudo-membranous  inflammations  may  occur  in 
the  pharynx,  larynx,  or  genitals. 

Malarial  and  typhoid  fevers  may  be  associated,  but  a  majority  of  the  cases 
of  so-called  typho-malarial  fever  are  either  remittent  malarial  fever  or  true 
typhoid.  It  is  interesting  to  note  that  among  1,500  cases  of  typhoid  fever 
plasmodia  were  found  in  the  blood  in  only  3  cases.  (See  Lyon.  Studies 
III.)  Many  of  the  typhoid  fever  patients  came  from  malarious  regions. 

The  symptoms  of  influenza  may  precede  the  typhoid  fever,  or  the  two 
diseases  may  run  concurrently.  There  are  cases  of  chronic  influenza  which 
simulate  typhoid  fever  very  closely. 

Typhoid  Fever  and  Tuberculosis. —  (a)  The  diseases  may  coexist.  A  per- 
son with  chronic  tuberculosis  may  contract  the  fever.  Of  105  autopsies  in 
typhoid  fever,  7  presented  marked  tuberculous  lesions.  Miliary  tuberculosis 
and  typhoid  fever  may  occur  together.  (6)  Cases  of  typhoid  fever  with  pul- 
monary and  pleuritic  symptoms  may  suggest  tuberculosis  at  the  onset,  (c) 
There  are  five  types  of  tuberculous  infection  which  may  simulate  typhoid 
fever:  the  acute  miliary  form;  tuberculous  meningitis;  tuberculous  peritoni- 
tis; the  acute  toxaemia  of  certain  local  lesions;  and  forms  of  ordinary  pul- 
monary tuberculosis.  And,  lastly,  pulmonary  tuberculosis  may  follow  typhoid. 
In  a  large  majority  of  such  cases  from  the  onset  the  disease  has  been  tuberculo- 
sis, which  has  begun  with  a  low  fever  and  features  suggestive  of  typhoid  fever. 

In  epilepsy  and  in  chronic  chorea  the  fits  and  movements  usually  cease 
during  an  attack,  and  in  typhoid  fever  in  a  diabetic  subject  the  sugar  may 
be  absent  during  the  height  of  the  disease. 

Varieties  of  Typhoid. — Typhoid  fever  presents  an  extremely  complex 
symptomatology.  Mary  forms  have  been  described,  some  of  which  present  ex- 
aggeration of  common  symptoms,  others  modification  in  the  course,  others  again 
greater  intensity  of  action  of  the  poison  on  certain  organs.  As  we  have  seen, 
when  the  nervous  system  is  specially  involved,  it  has  been  called  the  cerebro- 
spinal  form ;  when  the  kidneys  are  early  and  severly  affected,  nephro-typhoid ; 
when  the  disease  begins  with  pulmonary  symptoms,  pneumo-typhoid ;  with 
pleurisy,  pleuro-typhoid ;  when  the  disease  is  characterized  throughout  by  pro- 
fuse sweats,  the  sudoral  form  of  the  disease.  It  is  enough  to  remember  that 
typhoid  has  no  fixed  and  constant  course,  that  it  may  set  in  occasionally  with 
symptoms  localized  in  certain  organs,  and  that  many  of  its  symptoms  are 
extremely  variable — in  one  epidemic  uniform  and  text-book-like,  in  another 
slight  or  not  met  with.  This  diversified  symptomatology  has  led  to  many 
clinical  errors,  and  in  the  absence  of  the  salutary  lessons  of  morbid  anatomy 
it  is  not  surprising  that  practitioners  have  so  often  been  led  astray.  We  may 
recognize  the  following  varieties: 


TYPHOID    FEVEE  33 

(a)  The  mild  and  abortive  forms.  Much  attention  has  been  paid  of  late 
to  the  milder  varieties  of  typhoid  fever — the  typhus  levissimus  of  Griesinger. 
Woodruff,  of  the  United  States  Army,  has  called  special  attention  to  the  great 
danger  of  neglecting  these  mild  forms,  which  are  often  spoken  of  as  mountain 
fever  and  malarial  fever,  "acclimation,"  "ground,"  and  "miasmatic"  fevers. 
During  the  prevalence  of  an  epidemic  there  may  be  cases  of  fever  so  mild  that 
the  patient  does  not  go  to  bed.  The  onset  may  be  sudden,  particularly  in 
children.  The  general  symptoms  are  elight,  the  pulse  rate  not  high,  the  fever 
rarely  above  102°.  Eose  spots  ars  usually  present,  with  splenic  enlargement. 
Diarrhoea  is  rare.  The  Widal  reaction  is  present  in  a  majority  of  the  patients. 
There  may  be  a  marked  tendency  to  relapse.  While  infrequent,  characteristic 
complications  and  sequelae  may  give  the  first  positive  clue  to  the  nature  of 
the  trouble.  J.  B.  Briggs  has  studied  44  of  these  mild  cases  from  my  clinic, 
in  which  the  fever  lasted  14  days  or  less.  Bose  spots  were  present  in  24,  and 
the  Widal  reaction  in  26.  There  were  three  relapses.  It  can  not  be  too  forci- 
bly impressed  upon  the  profession  that  it  is  just  by  these  mild  cases,  to  which 
so  little  attention  is  paid,  that  the  disease  may  be  kept  up  in  a  community. 

(6)  The  grave  form  is  usually  characterized  by  high  fever  and  pronounced 
nervous  symptoms.  In  this  category  come  the  very  severe  eases,  setting  in 
with  pneumonia  and  nephritis,  and  with  the  very  intense  gastro-intesti  nal 
or  cerebro-spinal  symptoms. 

(c)  The  latent  or  ambulatory  form  of  typhoid  fever,  which  is  particularly 
•common  in  hospital  practice.     The  symptoms  are  usually  slight,  and  the  pa- 
tient scarcely  feels  ill  enough  to  go  to  bed.     He  has  languor,  perhaps  slight 
diarrhoea,  but  keeps  about  and  may  even  attend  to  his  work  throughout  the 
entire  attack.     In  other  instances  delirium  sets  in.     The  worst  cases  of  this 
form  are  seen  in  sailors,  who  keep  up  and  about,  though  feeling  ill  and 
feverish.     When  brought  to  the  hospital  they  often  have  symptoms  of  a  most 
severe  type   of  the   disease.     Haemorrhage  or  perforation  may  be  the  first 
marked   symptom   of   this   ambulatory   type.      Sir  W.   Jenner   called   atten- 
tion to  the  dangers  of  this  form,  and  particularly  to  the  grave  prognosis  in 
the  case  of  persons  who  have  travelled  far  with  the  disease  in  progress. 

(d)  Haemorrhagic    Typhoid    Fever. — This    is    excessively   rare.      Among 
Ouskow's  6,513  cases  there  were  4  fatal  cases  with  general  haemorrhagic  fea- 
tures.    Only  three  instances  were  present  in  our  series.     Haemorrhages  may 
be  marked  from  the  outset,  but  more  commonly  they  come  on  during  the 
course   of  the   disease.     The   condition  is  not  ncessarily   fatal.      Several  of 
those  reported  by  Xicholls  from  the  Boyal  Victoria  Hospital,  Montreal,  re- 
covered.    (See  Hamburger,  Studies  III.) 

(e)  An  afebrile  typhoid  fever  is  recognized  by  authors,     Liebenneister 
says  that  the  cases  were  not  uncommon  at  Basel.    The  patients  presented  lassi- 
tude, depression,  headache,  furred  tongue,  loss  of  appetite,  slow  pulse,  and 
even  the  spots  and  enlarged  spleen.     I  have  see*  the  temperature  normal  on 
the  sixteenth  day,  while  the  spots  did  not  come  out  until  later. 

TYPHOID  FEVER  ix  CHILDEEX. — Griffith  collected  a  series  of  325  cases  in 
children  under  two  and  a  half  years;  111  of  these  were  in  the  first  year.  Out 
of  a  total  of  278  cases  in  which  the  result  was  recorded.  142  died.  The  cases 
are  not  very  uncommon.  The  high  mortality  in  Griffith's  paper  was  probably 
due  to  the  fact  that  only  the  more  serious  cases  are  reported.  The  abdominal 


34  SPECIFIC    INFECTIOUS    DISEASES 

symptoms  are  usually  mild;  fatal  haemorrhage  and  perforation  are  rare. 
Among  sequelae,  aphasia,  noma,  and  bone  lesions  are  stated  to  be  more  com- 
mon in  children  than  in  adults.  Two  of  our  cases  were  under  one  year  of  age. 

TYPHOID  FEVER  IN  THE  AGED. — After  the  sixtieth  year  the  disease  runs 
a  less  favorable  course,  and  the  mortality  is  very  high.  The  fever  is  not  so 
high,  but  complications  are  more  common,  particularly  pneumonia  and  heart- 
failure. 

TYPHOID  FEVER  IN  PREGNANCY. — Pregnancy  affords  no  immunity  against 
typhoid.  In  1,500  of  our  cases  to  September  10,  1904,  438  of  which  were 
females,  there  were  6  cases.  Goltdammer  noted  26  pregnancies  in  600  cases 
of  typhoid  fever  in  the  female.  It  is  more  commonly  seen  in  the  first  half  of 
pregnancy.  The  pregnancy  is  interrupted  in  about  65  per  cent,  of  the  cases, 
usually  in  the  second  week  of  the  disease.  In  the  obstetrical  department  of 
the  Johns  Hopkins  Hospital  (J.  W.  Williams)  there  have  been  (to  January, 
1905)  three  cases  of  puerperal  infection  with  bacillus  typhosus.  One  case 
showed  a  localized  lesion  of  the  chorion,  from  which  cultures  were  obtained 
(Little). 

TYPHOID  FEVER  IN  THE  FETUS. — From  the  recent  studies  of  Fordyce, 
J.  L.  Morse,  and  F.  W.  Lynch,  we  may  conclude  that  the  typhoid  bacillus  may 
pass  through  the  placenta  to  the  child,  causing  a  typhoid  septicamia,  without 
intestinal  lesions.  Lynch  has  recently  collected  16  such  cases.  Infection  of 
the  fetus  does  not  necessarily  follow,  but  when  infected  the  child  dies,  either 
in  utero  or  shortly  after  birth.  The  Widal  reaction  has  been  obtained  with 
fetal  blood.  Its  presence  does  not  indicate  that  the  child  has  survived  infec- 
tion in  utero,  as  the  agglutinating  substances  may  filter  through  the  placenta. 
They  may  also  be  transmitted  to  the  nursling  through  the  milk,  and  cause  a 
transient  reaction.  The  reaction  could  not  be  obtained  with  fetal  blood  from 
which  typhoid  bacilli  were  cultivated  (Lynch). 

RELAPSE. — Relapses  vary  in  frequency  in  different  epidemics,  and,  it  would 
appear,  in  different  places.  The  percentages  of  different  authors  range  from 
3  per  cent,  to  15  or  18  per  cent.  (Immermann).  In '1,500  cases  there  were 
172  relapses,  11.4  per  cent.  Among  28,057  collected  cases  8.8  per  cent,  had 
a  relapse  (McCrae). 

We  may  recognize  the  ordinary,  the  intercurrent,  and  the  spurious  relapse. 

The  ordinary  relapse  sets  in  after  complete  defervescence.  The  average 
duration  of  the  interval  in  Irvine's  cases  was  a  little  over  five  days. 

In  one  of  my  cases  there  was  complete  apyrexia  for  twenty-three  days,  fol- 
lowed by  a  relapse  of  forty-one  days'  duration;  then  apyrexia  for  forty-two 
days,  followed  by  a  second  relapse  of  two  weeks'  duration.  As  a  rule,  two  of 
the  three  important  symptoms — step-like  temperature  at  onset,  roseola,  an 
enlarged  spleen — should  be  present  to  justify  the  diagnosis  of  a  relapse.  The 
intestinal  symptoms  are  variable.  The  onset  may  be  abruptly  with  a  chill,  or 
the  temperature  may  have  a  typical  ascent,  as  shown  in  Chart  I.  The  number 
of  relapses  ranges  from  1  to  5.  In  a  case  at  the  Pennsylvania  Hospital  in  1904 
the  disease  lasted  eleven  months  and  four  days,  during  which  there  were  six 
relapses.  The  relapse  is  usually  less  severe,  of  shorter  duration  and  the 
mortality  is  low. 

The  intercurrent  relapse  is  common,  often  most  severe,  and  is  responsible 
for  a  great  many  of  the  most  protracted  cases.  The  temperature  drops  and 


TYPHOID    FEVER  35 

the  patient  improves;  but  after  remaining  between  100°  and  102°  for  a  few 
days,  the  fever  again  rises  and  the  patient  enters  upon  another  attack,  which 
may  be  more  protracted,  and  of  much  greater  intensity  than  the  original  one. 

Spurious  relapses  are  very  common.  They  have  already  been  mentioned 
as  post-typhoid  elevations  of  temperature.  They  are  recrudescences  of  the 
fever  due  to  a  number  of  causes.  It  is  not  always  easy  to  determine  whether 
a  relapse  is  present,  particularly  in  cases  in  which  the  fever  persists  for  only 
five  or  seven  days  without  rose-spots  and  without  enlargement  of  the  spleen. 

Undoubtedly  a  reinfection  from  within,  yet  of  the  conditions  favoring  the 
occurrence  of  relapse  we  as  yet  know  little.  Durham  has  advanced  an  inter- 
esting theory:  Every  typhoid  infection  is  a  complex  phenomenon  caused  by 
groups  of  bacilli  alike  in  species  but  not  identical,  as  shown  by  their  serum 
reactions.  The  antibodies  formed  in  the  blood  during  the  primary  attack  neu- 
tralizes only  one  (or  several)  groups,  the  remaining  groups  still  preserving 
their  pathogenic  power.  Following  an  error  in  diet,  or  some  indiscretion, 
these  latter  groups  may  multiply  sufficiently  to  cause  a  reinfection.  Multiple 
relapses  may  be  similarly  explained. 

Diagnosis. — There  are  several  points  to  note.  In  the  first  place,  typhoid 
fever  is  the  most  common  of  all  continued  fevers.  Secondly,  it  is  extraordi- 
narily variable  in  its  manifestations.  Thirdly,  there  is  no  such  hybrid  malady 
as  typho-malarial  fever.  Fourthly,  errors  in  diagnosis  are  inevitable,  even 
under  the  most  favorable  conditions. 

DATA  FOR  DIAGNOSIS. —  (a)  General. — No  single  symptom  or  feature  is 
characteristic.  The  onset  is  often  suggestive,  particularly  the  occurrence  of 
epistaxis,  and  (if  seen  from  the  start)  the  ascending  fever.  The  steadiness  of 
the  fever  for  a  week  or  longer  after  reaching  the  fastigium  is  an  important 
point.  The  irregular  remittent  character  in  the  third  week,  and  the  intermit- 
tent features  with  chills,  are  common  sources  of  error.  While  there  is  nothing 
characteristic  in  the  pulse,  dicrotism  is  so  much  more  common  early  in  typhoid 
fever  that  its  presence  is  always  suggestive.  The  rash  is  the  most  valuable 
single  sign,  and  with  the  fever  usually  clinches  the  diagnosis.  The  enlarged 
spleen  is  of  less  importance,  since  it  occurs  in  all  febrile  conditions,  but  with 
the  fever  and  the  rash  it  completes  a  diagnostic  triad.  The  absence  of  leucocy- 
tosis  and  the  presence  of  Ehrlich's  reaction  are  valuable  accessory  signs. 

(6)  Specific. —  (1)  Isolation  of  Typhoid  Bacilli  from  the  Blood. — New 
methods  have  given  better  results  in  this  procedure,  which  is  especially  use- 
ful early  in  the  disease,  in  doubtful  cases  and  in  the  acute  septic  forms.  The 
hypodermic  puncture  of  a  vein  for  the  blood  causes  little  or  no  pain. 

(2)  Isolation  of  Typhoid  Bacilli  from  the  Stools. — Cultures  from  the 
stools  have  proved  of  diagnostic  value.     A  satisfactory  method  is  that  of  von 
Drigalski  and  Conradi  (Zeit.  f.  Hygiene,  Bd.  39),  largely  used  in  the  cam- 
paign against  typhoid  in  Germany,  with  which  those  familiar  with  bacteri- 
ologic  methods  are  able  to  isolate  the  bacilli  in  a  majority  of  the  cases. 

(3)  Isolation  of  Typhoid  Bacilli  from  the   Urine. — Neumann,  Horton- 
Smith,  Richardson,  and  Gwyn  have  shown  the  great  frequency  of  typhoid 
bacilli  in  the  urine.     In  some  cases  they  may  be  obtained  before  the  Widal 
test  is  positive.     Routine  cultures  do  not  offer  great  difficulties,  and  may  fre- 
quently be  of  diagnostic  value. 

(4)  Isolation  of  Typhoid  Bacilli  from  the  Rose-spots. — Neufeld,  Cursch- 


36  SPECIFIC    INFECTIOUS    DISEASES 

maun,  and  Richardson  have  demonstrated  the  presence  of  the  bacilli  in  rose- 
spots  in  32  of  40  cases  examined.  As  the  procedure  causes  considerable  dis- 
comfort it  can  not  be  used  as  a  routine  method. 

(5)  The  Agglutination  Test. — In  1894  Pfeiffer  showed  that  cholera  spi- 
rilla, when  introduced  into  the  peritoneum  of  an  immunized  animal,  or  when 
mixed  with  the  serum  of  immunized  animals,  lose  their  motion  and  break  up. 
This  "Pfeiffer's  phenomenon"  was  thoroughly  studied  by  Durham  and  the 
specificity  of  the  reaction  demonstrated.     A.  S.  Griinbaum  and  Widal  made 
the  method  available  in  clinical  work. 

Macroscopic  Method. — This  may  be  done  with  living  or  dead  organisms 
and  has  the  advantage  of  use  away  from  a  laboratory.  The  diluted  serum 
and  organisms  are  mixed  in  a  tube  of  small  calibre  (dilution  1  to  50  or  1  to 
100).  With  a  positive  reaction  there  should  be  complete  precipitation  leaving 
a  clear  fluid  above  in  twenty-four  hours. 

Microscopic  Method. — The  serum  is  mixed  with  a  young  bouillon  culture 
of  the  typhoid  bacillus,  or  with  a  suspension  of  a  young  agar  culture,  in  such 
a  manner  as  to  dilute  the  serum  to  the  required  degree.  A  hanging-drop 
preparation  of  the  mixture  is  made,  and  if  the  reaction  is  positive  the  bacilli 
will  within  a  given  time  lose  their  motility  and  collect  in  clumps.  With 
Dreyer's  method  of  standard  cultures  of  constant  and  known  sensitiveness  it  is 
possible  to  follow  the  patient's  serum  changes  in  typhoid  or  paratyphoid  infec- 
tion. 

Whatever  be  the  infection  the  agglutination  for  that  bacillus  will  show 
(a)  a  marked  rise  in  an  early  stage  and  (I)  a  marked  fall  later  in  the  infection. 
If  the  patient's  serum  already  contains  agglutinins  for  one  or  more  of  the 
bacilli  (owing  to  inoculation),  the  following  phenomena  will  be  noted  (a) 
there  is  no  change  in  the  inoculation  agglutinins  or  (6)  a  slight  rise  occurs, 
followed  by  a  slight  fall — an  alteration  which  may  be  caused  by  a  number  of 
non-specific  stimuli. 

A  well  marked  rise  or  fall  of  the  titre  is  the  only  positive  evidence  of 
active  infection  that  can  be  obtained  with  the  agglutination  test  and  is 
probably  the  best  evidence  afforded  by  any  test  except  a  successful  blood 
culture. 

On  the  whole  the  serum  reaction  is  of  great  value,  in  spite  of  certain 
difficulties  and  objections,  and  with  the  newer  methods  the  reactions  of  equal 
importance  in  inoculated  and  uninoculated  persons  and  in  the  paratyphoids. 

(6)  Ophthalmo-Reaction. — A  solution  of  one-third  to  one-half  of  a  milli- 
gram  of   "typho-protein"   derived   from  many   different   strains   of   typhoid 
bacilli  is  instilled  into  the  conjunctival  sac.    A  typical  reaction  is  marked  by 
deep  congestion  of  the  conjunctiva  of  the  lower  lid  and  the  caruncle.     It 
reaches  its  maximum  in  six  hours.     A  positive  reaction  is  obtained  most  often 
during  the   febrile   period,   frequently   before   the  agglutination   reaction   is 
given.     The  simplicity  of  the  method  and  the  absence  of  discomfort  are 
valuable  features.     A  cutaneous  method  has  also  been  employed. 

COMMON  SOURCES  OF  ERROR  IN  DIAGNOSIS. — An  early  and  intense  local- 
ization of  the  infection  in  certain  organs  may  give  rise  to  doubt  at  first. 

Cases  coming  on  with  severe  headache,  photophobia,  delirium,  twitching 
of  the  muscles  and  retraction  of  the  head  are  almost  invariably  regarded  as 
verebro-spinal  meningitis.  Under  such  circumstances  it  may  for  a  few  days 


TYPHOID    FEVER  37 

be  impossible  to  make  a  satisfactory  diagnosis.  I  have  thrice  performed 
autopsies  on  cases  of  this  kind  in  which  no  suspicion  of  typhoid  fever  had 
been  present,  the  intense  cerebro-spinal  manifestations  having  dominated  the 
scene.  Until  the  appearance  of  abdominal  symptoms,  or  the  rash,  it  may  be 
quite  impossible  to  determine  the  nature  of  the  case.  Cerebro-spinal  menin- 
gitis is,  however,  a  rare  disease;  typhoid  fever  a  very  common  one,  and  the 
onset  with  severe  nervous  symptoms  is  by  no  means  infrequent.  The  lumbar 
puncture  is  now  a  great  help. 

I  have  already  spoken  of  the  misleading  pulmonary  symptoms,  which 
occasionally  occur  at  the  very  outset  of  the  disease.  The  bronchitis  rarely 
causes  error,  though  it  may  be  intense  and  attract  the  chief  attention.  More 
difficult  are  the  cases  setting  in  with  chill  and  followed  rapidly  by  pneu- 
monia. I  have  brought  such  a  case  before  the  class  one  week  as  typical 
pneumonia,  and  a  fortnight  later  shown  the  same  case  as  undoubtedly  one 
of  typhoid  fever.  There  is  less  danger  of  mistaking  the  pneumonia  which 
occurs  at  the  height  of  the  disease,  and  yet  this  is  possible,  as  in  a  case 
admitted  a  few  years  ago  to  my  wards — a  man  aged  seventy,  insensible,  with 
a  dry  tongue,  tremor,  ecchymoses  upon  the  wrists  and  ankles,  no  rose-spots, 
enlargement  of  the  spleen,  and  consolidation  of  his  right  lower  lobe.  It 
was  very  natural,  particularly  since  there  was  no  history,  to  regard  such 
a  case  as  senile  pneumonia  with  profound  constitutional  disturbance,  but 
the  autopsy  showed  the  characteristic  lesions  of  typhoid  fever.  Early 
involvement  of  the  pleura  or  the  kidneys  may  for  a  time  obscure  the  diag- 
nosis. 

Of  diseases  with  which  typhoid  fever  may  be  confounded,  malaria,  certain 
forms  of  pyasmia,  acute  tuberculosis,  and  tuberculous  peritonitis  are  the  most 
important. 

From  malarial  fever,  typhoid  is,  as  a  rule,  readily  recognized.  There 'is 
no  such  disease  as  typho-malarial  fever — that  is,  a  separate  and  distinct  mal- 
ady. Typhoid  fever  and  malarial  fever  may  coexist  in  the  same  patient. 
In  patients  returning  from  Cuba  and  Porto  Rico  during  the  late  war  the  two 
conditions  were  often  found  together,  but  in  the  United  States  it  is  excessively 
rare.  The  term  typho-malarial  fever  should  be  abandoned.  The  autumnal 
type  of  malarial  fever  may  present  a  striking  similarity  in  its  early  days  to 
typhoid  fever.  Differentiation  may  be  made  only  by  the  blood  examination. 
There  may  be  no  chills,  the  remissions  may  be  extremely  slight,  there  is  a 
history  perhaps  of  malaise,  weakness,  diarrhoea,  and  sometimes  vomiting. 
The  tongue  is  furred  and  white,  the  cheeks  flushed,  the  spleen  slightly  en- 
larged, and  the  temperature  continuous,  or  with  very  slight  remissions.  The 
ffistivo-autumnal  variety  of  the  malarial  parasite  may  not  be  present  in  the 
circulating  blood  for  several  days.  Every  year  in  Baltimore  we  had  one  or 
two  cases  in  which  the  diagnosis  was  in  doubt  for  a  few  days. 

Pycemia. — The  long-continued  fever  of  obscure,  deep-seated  suppuration, 
without  chills  or  sweats,  may  simulate  typhoid.  The  more  chronic  cases  of 
ulcerative  endocarditis  are  usually  diagnosed  typhoid  fever.  The  presence  or 
absence  of  leucocytosis  is  an  important  aid.  The  Widal  reaction  and  the 
blood  cultures  now  offer  additional  and  valuable  help. 

Acute  miliary  tuberculosis  is  not  infrequently  mistaken  for  typhoid  fever. 
The  points  in  differential  diagnosis  will  be  discussed  under  that  disease. 


38  SPECIFIC    INFECTIOUS    DISEASES 

Tuberculous  peritonitis  in  certain  of  its  forms  may  closely  simulate  typhoid 
fever,  and  will  be  referred  to  in  another  section. 

The  early  abdominal  pain,  etc.,  may  lead  to  the  diagnosis  of  appendicitis. 

The  "disease"  described  by  Brill  (a  mild  form  of  typhus  fever)  may  be 
regarded  as  typhoid  fever,  but  the  character  of  the  rash,  the  absence  of  the 
agglutination  reaction,  negative  results  of  blood  cultures  and  the  course  are 
against  this.  However,  the  majority  of  cases  are  probably  'diagnosed  as 
typhoid  fever. 

Prognosis.  —  (a)  DEATH-RATE. — The  mortality  is  very  variable,  ranging  in 
private  practice  from  5  to  12  and  in  hospital  practice  from  7  to  20  per  cent. 
In  some  large  epidemics  the  death-rate  has  been  very  low.  In  the  Maidstone 
epidemic  it  was  between  7  and  8  per  cent.  In  recent  years  the  mortality  from 
typhoid  fever  has  certainly  diminished,  and,  under  the  influence  of  Brand,  the 
reintroduction  of  hydrotherapy  has  reduced  the  death-rate  in  institutions  in  a 
remarkable  manner,  even  as  low  as  5  or  6  per  cent.  Of  the  1,500  cases  treated 
in  my  wards,  9.1  per  cent  died.  The  mortality  in  the  Spanish- American  War 
was  very  low — 7  per  cent. — and  may  be  attributed  to  the  picked  set  of  men  and 
to  the  care  and  attention  which  the  patients  received. 

(&)  SPECIAL  FEATURES  IN  PROGNOSIS. — Unfavorable  symptoms  are  high 
fever,  toxic  symptoms  with  delirium,  meteorism,  and  hemorrhage.  Per- 
foration renders  the  outlook  hopeless  unless  operation  is  done  early.  Fat  sub- 
jects stand  typhoid  fever  badly.  The  mortality  in  women  is  greater  than  in 
men.  The  complications  and  dangers  are  more  serious  in  the  ambulatory 
form  in  which  the  patient  has  kept  about  for  a  week  or  ten  days.  Early 
involvement  of  the  nervous  system  is  a  bad  indication;  and  the  low,  mutter- 
ing delirium  with  tremor  means  a  close  fight  for  life.  Prognostic  signs  from 
the  fever  alone  are  deceptive.  A  temperature  above  104°  may  be  well  borne 
for  many  days  if  the  nervous  system  is  not  involved. 

(c)  SUDDEN  DEATH. — It  is  difficult  in  many  cases  to  explain  this  most 
lamentable  of  accidents  in  the  disease.  There  are  cases  in  which  neither  cere- 
bral, renal,  nor  cardiac  changes  have  been  found;  there  are  instances  too  in 
which  it  does  not  seem  likely  that  there  could  have  been  a  special  localization 
of  the  toxins  in  the  pneumogastric  centres.  McPhedran,  in  reporting  a  case 
of  the  kind,  in  which  the  post-mortem  showed  no  adequate  cause  of  death, 
suggests  that  the  experiments  of  McWilliam  on  sudden  cardiac  failure  prob- 
ably explain  the  occurrence  of  death  in  certain  of  the  cases  in  which  neither 
eYnbolism  nor  uraemia  is  present.  Under  conditions  of  abnormal  nutrition 
there  is  sometimes  induced  a  state  of  delirium  eordis,  which  may  occur  spon- 
taneously, or,  in  the  case  of  animals,  on  slight 'irritation  of  the  heart,  with 
the  result  of  extreme  irregularity  and  finally  failure  of  action.  Sudden  death 
occurs  more  frequently  in  men  than  in  women,  according  to  Dewevre's  statis- 
tics, in  a  proportion  of  114  to  26.  It  may  occur  at  the  height  of  the  fever, 
and,  as  pointed  out  by  Graves,  may  also  happen  during  convalescence.  There 
were  four  cases  in  my  series. 

Prophylaxis. — In  cities  the  prevalence  of  typhoid  fever  is  directly  propor- 
tionate to  the  inefficiency  of  the  drainage  and  the  water-supply.  With  their 
improvement  the  mortality  has  been  reduced  one-half  or  even  more.  Fulton 
has  shown  that  in  the  United  States,  at  least,  the  disease  exists  to  a  propor- 
tionately greater  extent  in  the  country  than  it  does  in  the  city,  and  that  the 


TYPHOID    FEVER  39 

propagation  of  this  disease  is  in  general  from  the  country  to  the  town.  In 
the  water-supply  of  the  latter  the  chances  for  dilution  of  the  contaminating 
fluids  are  so  much  greater  than  in  the  country,  where  the  privy  vault  is  often 
in  such  close  proximity  to  the  well. 

But  it  is  not  only  through  water  that  the  disease  is  transmitted.  Other 
methods  play  an  important  though  not  so  frequent  role.  The  bacilli  may  be 
carried  by  milk,  oysters,  uncooked  vegetables,  etc.  Flies  play  an  important 
part  in  the  spread  of  the  disease.  Many  cases  undoubtedly  arise  by  direct 
infection.  But  through  whatever  channel  the  infection  occurs,  for  new  cases 
to  arise  the  virus  must  be  obtained  from  another  patient.  It  has  been  dem- 
onstrated by  Jordan,  Russell,  Zeit  and  others  that  under  ordinary  circum- 
stances the  bacilli  do  not  live  and  thrive  long  outside  the  body.  To  stamp  out 
typhoid  fever  requires  (1)  the  recognition  of  all  cases,  including  the  typhoid 
earners  and  (2)  the  destruction  of  all  typhoid  bacilli  as  they  leave  the  patient. 
It  is  as  much  a  part  of  the  physician's  duty  to  look  after  these  points  as 
to  take  care  of  the  patient.  Mild  cases  of  fever  are  to  be  regarded  with 
suspicion. 

From  the  standpoint  of  prophylaxis,  the  question  practically  narrows  down 
to  disinfection  of  the  urine,  stools,  sputum  (in  the  few  cases  where  bacilli  are 
present),  and  of  objects  which  may  accidentally  be  contaminated  by  these 
excretions.  The  nurse  or  attendant  should  be  taught  to  regard  every  speci- 
men of  urine  as  a  pure  culture  of  typhoid  bacilli,  and  to  exercise  the  greatest 
care  in  preventing  the  scattering  of  drops  of  urine  over  the  patient,  bedding 
or  floor,  or  over  the  hands  of  the  attendant. 

To  disinfect  the  urine  the  best  solutions  are  carbolic  acid,  1-20,  in  an 
amount  equal  to  that  of  the  urine,  or  bichloride  of  mercury,  1-1,000,  in  an 
amount  one-fifteenth  that  of  the  fluid  to  be  sterilized.  These  mixtures  with 
the  urine  should  stand  at  least  two  hours.  Hexamine  causes  disappearance 
of  the  bacilli  from  the  urine  when  bacilluria  is  present,  but  under  no  circum- 
stances should  its  administration  permit  the  disinfection  of  the  urine  to  be 
neglected. 

For  the  stools,  heat  is  the  most  efficient  means  and  can  be  employed  in 
hospitals  by  special  hoppers  in  which  steam  is  used.  Of  solutions,  carbolic 
acid  or  freshly  prepared  milk  of  lime  is  most  useful.  The  stool  should  be 
mixed  with  at  least  thrice  its  volume  of  these  solutions  and  allowed  to  stand 
for  several  hours. 

With  hydrotherapy  the  disinfection  of  the  bath  water  offers  a  somewhat 
difficult  problem.  E.  Babucke  found  chloride  of  lime  the  best  substance  to 
use,  and  that  even  when  the  water  contains  coarse  faecal  matter,  250  gm. 
(one-half  pound)  of  chloride  of  lime  will  render  the  ordinary  bath  of  200 
litres  sterile  in  one-half  hour. 

If  there  be  any  expectoration,  the  sputum  should  receive  the  same  care  as 
in  tuberculosis.  It  is  best  to  collect  it  in  small  cloths,  which  may  be  burned. 

All  the  linen  leaving  the  patient's  bed  or  person  should  be  soaked  for  two 
hours  in  1-20  carbolic  acid  solution  or  1-2000  bichloride  solution,  and  then 
sent  to  the  laundry,  where  it  should  be  boiled.  All  dishes  should  be  boiled  be- 
fore leaving  the  patient's  room. 

The  nurse  should  wear  a  rubber  apron  when  giving  tubs  or  working  over 
a  typhoid  patient,  and  this  should  be  washed  frequently  with  a  carbolic  aeid 


40  SPECIFIC    INFECTIOUS    DISEASES 

or  bichloride  of  mercury  solution.  The  nurse  should  wear  rubber  gloves  when 
giving  tubs,  or  else  soak  her  hands  throughly  in  1-1,000  bichloride  solution 
after  she  has  finished. 

It  is  impossible  here  to  deal  with  all  the  possible  modes  of  spread  of  the 
infection.  Keeping  in  mind  that  everything  leaving  the  patient  should  be 
sterilized  whenever  there  is  a  chance  of  its  having  been  contaminated  by  the 
discharges,  a  nurse  of  ordinary  intelligence,  even  one  of  the  family,  can  carry 
out  very  satisfactory  prophylaxis. 

Should  the  typhoid  fever  patient  be  isolated  ?  To  prevent  direct  infection 
of  other  members  of  the  family  a  moderate  degree  of  isolation  should  be  car- 
ried out,  though  this  need  not  be  absolute  as  in  the  exanthemata.  The  win- 
dows should  have  fly  screens  in  summer.  After  recovery  the  room  should  be 
disinfected. 

An  important  question  is  as  to  the  necessity  for  the  isolation  of  typhoid 
patients  in  special  wards  in  hospitals.  At  present  this  is  not  generally  done 
in  the  United  States.  When,  however,  in  a  hospital  with  as  good  sanitary 
arrangements  as  the  Johns  Hopkins  possesses,  and  in  which  all  possible  pre- 
cautions are  taken  to  prevent  the  infection  spreading  from  patient  to  patient, 
1.81  per  cent,  of  all  the  cases  have  been  of  hospital  origin,  the  advisability  of 
isolation  of  typhoid  fever  patients  is  certainly  worth  considering.  On  the 
other  hand,  in  the  general  hospital,  with  students  in  the  wards,  the  cases  are 
more  thoroughly  studied,  and  in  the  graver  complications,  as  perforation,  it  is 
of  the  greatest  advantage  to  have  the  early  co-operation  of  the  house  surgeon. 

During  the  past  few  years  an  active  campaign  has  been  started  in  Ger- 
many with  the  object  of  ultimately  stamping  out  this  disease  by  means  of 
early  diagnosis  and  the  institution  of  rigid  measures  for  preventing  the  dis- 
tribution of  the  infecting  agent  from  the  patients  so  diagnosed.  With  a  corps 
of  assistants  Koch  fitted  up  a  laboratory  in  Trier,  a  locality  where  the  disease 
had  a  firm  hold.  By  bacteriological  methods  he  was  able  to  demonstrate  that 
72  persons  were  suffering  from  typhoid  infection.  So  soon  as  the  nature  of 
a  case  was  established,  isolation  and  vigorous  disinfection  were  practiced. 
The  result  was  that  within  three  months  no  more  typhoid  bacilli  were  dis- 
coverable, the  patients  were  cured,  no  fresh  cases  arose,  and,  so  far  as  that 
group  of  villages  was  concerned,  typhoid  was  exterminated. 

When  epidemics  are  prevalent  the  drinking-water  and  the  milk  used  in 
families  should  be  boiled.  Travellers  should  drink  light  wines  or  mineral 
water  rather  than  ordinary  water  or  milk.  Care  should  be  taken  to  thor- 
oughly cook  oysters  which  have  been  fattened  or  freshened  in  streams  con- 
taminated with  sewage. 

While  in  camps  it  is  easy  to  boil  and  filter  the  .water,  with  troops  on 
the  march  it  is  a  very  different  matter,  and  it  is  impossible  to  restrain  men 
from  relieving  their  thirst  the  moment  they  reach  water.  Various  chemical 
methods  have  been  recommended  of  which  chlorination  (the  use  of  calcium 
hypochlorite,  5  to  15  pounds  for  each  million  gallons  of  water)  has  proved 
the  most  satisfactory. 

ANTI-TYPHOID  INOCULATION. — Introduced  by  Wright  the  method  has 
proved  of  inestimable  value  in  the  United  States  Army,  in  India  and  during 
the  present  war.  The  material  used  is  a  bouillon  or  agar  culture  of  bacilli 
heated  to  a  temperature  of  53°  to  55°  <j.  in  order  to  kill  them.  Lysol  or 


TYPHOID    FEVER  41 

tricrescl  may  be  added.    Three  inoculations  are  given  at  intervals  of  ten  days. 

A  triple  vaccine  against  typhoid  and  paratyphoid  A  and  B  is  now  prepared 
and  should  be  used.  Untoward  results  are  rare.  Of  31,000  inoculated  at  the 
Valcartier  camp,  Quebec,  only  one  had  a  local  abscess  and  there  were  no  serious 
sequels.  The  inoculation  fever  begins  in  from  four  to  six  hours  and  may 
reach  101°  or  even  103°  to  104°.  Headache,  chilliness,  pains  in  the  back  and 
limbs,  and  vomiting  may  occur.  In  many  there  is  only  a  transient  indisposi- 
tion. More  SQT,  ere  symptoms  may  occur,  such  as  arthritis,  fugitive  erythema, 
diarrhoea,  abdominal  pains,  septica?mia,  with  pneumonia,  pleurisy  and  peri- 
carditis. In  a  few  cases  a  fever  resembling  typhoid  has  followed.  I  was  not 
able  to  find  a  fatality  due  directly  to  the  inoculation.  A  light  diet,  avoidance 
of  stimulants  and  rest  lessen  the  possibility  of  serious  sequels.  The  evidence 
so  far  points  to  a  persistence  of  the  protective  effect  for  at  least  two  years 
after  inoculation. 

Treatment. — (a)  GENERAL  MANAGEMENT. — The  profession  was  long  in 
learning  that  typhoid  fever  is  not  a  disease  to  be  treated  mainly  with  drugs. 
Careful  nursing  and  a  regulated  diet  are  the  essentials  in  a  majority  of  the 
cases.  The  patient  should  be  in  a  well-ventilated  room  (or  in  summer  out 
of  doors  during  the  day),  strictly  confined  to  bed  from  the  outset,  and  there 
remain  until  convalescence  is  well  established.  The  bed  should  be  single,  not 
too  high,  and  the  mattress  should  not  be  too  hard.  The  woven  wire  bed,  with 
soft  hair  mattress,  upon  which  are  two  folds  of  blanket,  combines  the  two 
great  qualities  of  a  sick-bed,  smoothness  and  elasticity.  A  rubber  cloth  should 
be  placed  under  the  sheet.  An  intelligent  nurse  should  be  in  charge.  When 
this  is  impossible,  the  attending  physician  should  write  out  specific  instruc- 
tions regarding  diet  and  treatment  of  the  discharges  and  bed-linen. 

(6)  DIET. — More  liberality  in  diet  is  now  generally  practiced,  as  was 
advised  years  ago  by  Austin  Flint  and  strongly  supported  by  Shattuck, 
Kinnicutt  and  others.  The  patient  should  be  nourished  as  well  as  possible 
and  food  given  with  a  value  of  2,500  to  3,000  calories  and  containing  about 
70  grams  of  protein  if  conditions  permit.  The  bulk  of  the  food  should  be 
liquid  and  milk  or  its  modifications  form  the  largest  part.  Milk  in  any 
form,  cream,  ice  cream,  cocoa,  tea  or  coffee  with  cream,  strained  soups,  eggs, 
either  the  white  or  the  whole  egg,  raw  or  soft  boiled,  gruels  and  jellies  may 
be  given.  The  milk  may  be  boiled  or  diluted,  or  some  modification  given — 
peptonised  milk,  fermented  milk,  malted  milk,  buttermilk  or  whey.  Soft 
food  is  often  permissible,  such  as  milk  toast,  custard,  junket,  crackers  and 
milk,  bread  and  butter,  and  mashed  potatoes.  It  is  important  to  give  carbo- 
hydrate freely  to  spare  the  body  proteins,  and  this  is  aided  by  the  addition  of 
milk  sugar  to  the  diet;  a  teaspoonful  can  be  given  with  each  feeding  of  milk. 
Sugar  can  also  be  given  freely  in  lemonade.  The  food  should  be  chosen 
for  each  patient  and  a  routine  diet  not  allowed.  In  case  of  digestive  dis- 
turbance— undigested  food  in  the  stools,  diarrhoea,  meteoriBm — the  diet 
should  be  made  very  simple,  buttermilk,  whey,  peptonised  milk  or  albumin 
water  usually  being  suitable.  The  beef  extracts,  meat  juices,  and  artificially 
prepared  foods  are  unnecessary,  and  in  private  practice  among  people  in 
moderate  circumstances  add  greatly  to  the  expense  of  the  illness.  Water 
should  be  given  freely  at  fixed  intervals.  A  good  plan  is  to  have  a  jug  of 
water  beside  the  patient  and  tubing  with  a  glass  mouth-piece,  so  that  he  can 
5 


42 

drink  as  much  as  he  wishes.  It  is  desirable  to  have  the  patient  take  at  least 
four  litres  of  water  daily  and  larger  amounts  are  an  advantage.  The  water 
causes  polyuriaj  and  is  a  sort  of  internal  hydrotherapy  by  which  the  toxins 
may  be  washed  out.  Barley  water,  lemonade,  soda  water,  or  iced-tea  may  be 
used. 

Special  care  must  be  given  to  the  mouth,  which  should  be  cleaned  after 
each  feeding.  A  mouth  wash  should  be  used  freely  (such  as  carbolic  acid 
3  i,  4  c.  c.,  glycerine  §  i,  30  c.  c.,  and  boric  acid,  saturated  solution,  to  §  x, 
300  c.  c.). 

Alcohol  is  unnecessary  in  a  great  majority  of  the  cases.  Of  late  years 
I  have  used  it  much  less  freely;  but  when  the  heart  is  feeble  and  the  toxic 
symptoms  are  severe,  eight  to  twelve  ounces  of  whisky  may  be  given  in  the 
twenty-four  hours. 

(c)  HYDROTHERAPY. — The  tfse  of  water,  inside  and  outside,  was  no  new 
treatment  in  fevers  at  the  end  of  the  eighteenth  century,  when  James  Currie 
(a  friend  of  Burns  and  the  editor  of  his  poems)  wrote  his  Medical  Reports 
on  the  Effects  of  Water,  Cold  and  Warm,  as  a  Eemedy  in  Fevers  and  other 
Diseases.  In  this  country  it  was  used  with  great  effect  and  recommended 
strongly  by  Nathan  Smith,  of  Yale.  Since  1861  the  value  of  bathing  in 
fevers  has  been  specially  emphasized  by  the  late  Dr.  Brand,  of  Stettin. 

Hydrotherapy  may  be  carried  out  in  several  different  ways,  of  which, 
in  typhoid  fever,  the  most  satisfactory  are  sponging,  the  wet  pack,  and  the 
full  bath. 

(1)  Cold  Sponging. — The  water  may  be  tepid,  cold,  or  ice-cold,  according 
to  the  height  of  the  fever.     A  thorough  sponge-bath  should  take  from  fifteen 
to  twenty  minutes.     The  ice-cold  sponging  is  not  quite  as  formidable  as  the 
full  bath,  for  which,  when  there  is  an  insuperable  objection  in  private  prac- 
tice, it  is  an  excellent  alternative.     But  frequently  it  is  difficult  to  get  the 
friends  to  appreciate  the  advantages  of  the  sponging.    When  such  is  the  case, 
and  in  children  and  delicate  persons,  it  can  be  made  a  little  less  formidable 
by  sponging  limb  by  limb  and  then  the  back  and  ab'domen. 

(2)  The  cold  pack  is  not  so  generally  useful  in  typhoid  fever,  but  in  cases 
with   very  pronounced  nervous   symptoms,  if  the  tub  is   not  available,  the 
patient  may  be  wrapped  in  a  sheet  wrung  out  of  water  at  60°  or  65°,  and 
then  cold  water  sprinkled  over  him  with  an  ordinary  watering-pot. 

(3)  The  Bath. — The  tub  should  be  long  enough  so  that  the  patient  can 
be  completely  covered  except  his  head.     Our  rule  for  some  years  has  been  to 
give  a  bath  every  third  hour  when  the  temperature  was  above  102.5°.     The 
patient  remains  in  the  tub  for  fifteen  or  twenty  minutes,  is  taken  out,  wrapped 
in  a  dry  sheet,  and  covered  with  a  blanket.     While  in  the  tub  the  limbs  and 
trunk  are  rubbed  thoroughly,  either  with  the  hand  or  with  a  suitable  rubber. 
It  is  well  to  give  the  first  one  or  two  baths  at  a  temperature  of  80°  to  85°'. 
There  is  no  routine  temperature  and  that  between  70°  and  85°  which  suits 
best  is  chosen.     It  is  important  to  see  that  the  canvas  supports  are  properly 
arranged,  and  that  the  rubber  pillow  is  comfortable  for  the  patient's  head. 
The  first  bath  should  not  be  given  at  night,  and  it  should  be  superintended  by 
the  physician.     The  amount  of  complaint  made  by  the  patient  is  largely 
dependent  upon  the  skill  and  care  with  which  the  baths  are  given.     Food  is 
usually  given,  sometimes  a  stimulant,  after  the  bath.     The  blueness  and  shiv- 


TYPHOID    FEVER  43 

ering,  which  often  follow  the  bath,  are  not  serious  features.  The  rectal  tem- 
perature is  taken  immediately  after  the  bath,  and  again  three-quarters  of  an 
hour  later.  Centra-indications  are  peritonitis,  haemorrhage,  phlebitis,  severe 
abdominal  pain,  and  great  prostration. 

The  good  effects  of  the  baths  are:  (i)  The  influence  on  the  nervous  sys- 
tem; delirium  lessens,  tremor  diminishes  and  toxic  features  are  less  marked, 
(ii)  Increased  excretion  of  toxins  by  the  kidney,  (iii)  The  tonic  effect 
on  the  circulation;  the  heart  rate  falls,  the  pulse  becomes  smaller  and 
harder,  and  the  blood  pressure  rises.  Vaso-motor  paresis  is  lessened,  (iv) 
With  hydrotherapy  the  initial  bronchitis  is  benefited,  and  there  is  less 
chance  of  passive  congestion  of  the  bases  of  the  lungs,  (v)  The  liability  to 
bed-sores  is  diminished  and  the  frequent  cleansing  of  the  skin  is  beneficial. 
The  addition  of  half  a  pound  of  alum  to  the  water  is  an  advantage. 
Should  boils  occur,  one  bath-tub  should  be  used  for  that  patient  alone,  (vi) 
Eeduction  of  the  temperature  may  occur  but  is  not  an  important  effect,  (vii) 
The  mortality  is  reduced.  In  general  hospitals  from  six  to  eight  patients  in 
every  hundred  are  saved  by  this  plan  of  treatment.  At  the  Brisbane  Hospital, 
where  F.  E.  Hare  used  it  so  thoroughly,  the  mortality  was  reduced  from  14.8 
per  cent,  to  7.5.  There  is  a  remarkable  uniformity  in  ^he  death-rate  of 
institutions  using  the  method — usually  from  6  to  8  per  cent. 

(d)  MEDICINAL  TREATMENT. — There  is  no  specific  drug  treatment,  but 
it  is  usually  advisable  to  give  hexamine  after  the  second  week,  twenty  to  thirty 
grains  (1.3  to  2  gm.)  daily.     In  private  practice  it  may  be  safer,  for  the  young 
practitioner  especially,  to  order  an  acid  or  a  mild  fever  mixture.     The  ques- 
tion of  medicinal  antipyretics  is  important:  they  are  used  far  too  often  and 
too  rashly  in  typhoid  fever.     An  occasional  dose  of  antifebrin  or  antipyrin 
may  do  no  harm,  but  the  daily  use  of  these  drugs  is  most  injurious.    Quinine 
in  moderate  doses  is  still  much  employed,  but  its  value  is  doubtful.     In  the 
various  antiseptic  drugs  which  have  been  advised  I  have  no  faith.     Most  of 
them  do  no  harm,  except  that  in  private  practice  their  use  has  too  often 
diverted  the  practitioner  from  more  rational  and  safer  courses. 

(e)  VACCINE  AND  SERUM  THERAPY. — Treatment  by  vaccines  during  the 
height  of  the  disease  is  still  in  an  experimental  stage.     Various  forms  of  vac- 
cines are  used  and  given  subcutaneously  or  intravenously.    Doses  varying  from 
50  to  500  million  bacilli  are  given,  usually  three  or  four  days  apart.     As 
patients  react  very  differently,  the  smaller  doses  are  safer  at  first,  especially 
if  given  intravenously.     In  long-continued  attacks  when  progress  is  slow,  for 
complications  due  to  the  presence  of  typhoid  bacilli  in  organs  or  tissues,  and 
for  carriers  vaccine  therapy  is  helpful.     No  serum  of  proved  value  has  been 
obtained. 

(/)  TREATMENT  OF  SPECIAL  SYMPTOMS. — For  severe  toxaemia  water 
should  be  given  freely  by  mouth  if  possible,  otherwise  by  the  bowel  or  by  in- 
fusion. Hydrotherapy  should  be  used  actively,  best  by  tub  baths.  '  Whisky 
is  generally  indicated,  four  to  ten  ounces  being  given  in  the  twenty-four 
hours.  For  headache  and  delirium  an  ice-bag  or  cold  compresses  should  be 
kept  to  the  head.  If  the  patient  is  very  delirious  and  restless  a  dose  of  mor- 
phia hypodermically  is  the  best  treatment.  Lumbar  puncture  is  also  useful, 
the  fluid  being  allowed  to  run  as  long  as  it  flows  under  pressure.  Every 
delirious  patient  should  be  constantly  watched.  It  is  important  to  secure  sleep 


44  SPECIFIC    INFECTIOUS    DISEASES 

in  the  case  of  these  patients,  for  which  morphia  is  most  reliable.  Hydro- 
therapy,  internal  and  external,  is  our  greatest  aid  in  the  treatment  of  the 
nervous  conditions.  The  abdominal  pain  and  tympanites  are  best  treated  with 
fomentations  or  turpentine  stupes.  The  latter,  if  well  applied,  give  great 
relief.  Sir  William  Jenner  used  to  lay  great  stress  on  the  advantages  of  a 
well-applied  turpentine  stupe.  He  directed  it  to  be  applied  as  follows:  A 
flannel  roller  was  placed  beneath  the  patient,  and  then  a  double  layer  of  thin 
flannel,  wrung  out  of  very  hot  water,  with  a  drachm  of  turpentine  mixed  with 
the  water,  was  applied  to  the  abdomen  and  covered  with  the  ends  of  the 
roller.  When  the  stomach  is  greatly  distended  the  passage  of  a  stomach  tube 
gives  relief.  When  the  gas  is  in  the  large  bowel,  a  tube  may  be  passed  or  a 
turpentine  enema  given.  For  tympanites,  with  a  dry  tongue,  turpentine  may 
be  given,  T\[  xv  (1  c.  c. )  every  three  hours,  or  the  oil  of  cinnamon,  TTl  iii-v, 
every  two  hours  (Caiger).  If  whey  and  albumen-water  are  substituted  for 
milk,  the  distension  lessens.  Charcoal,  bismuth,  ft  -naphthol,  and  eserine, 
•fa  gr.  hypodermically,  may  be  tried.  Opium  should  not  be  given. 

For  the  diarrhoea,  if  severe — that  is,  if  there  are  more  than  three  or  four 
stools  daily — a  starch  and  opium  enema  may  be  given;  or,  by  the  mouth,  a 
combination  of  bismuth,  in  large  doses,  with  Dover's  powder;  or  the  acid 
diarrhoea  mixture,  acetate  of  lead  (gr.  ii),  dilute  acetic  acid  (  Til  xv-xx), 
and  acetate  of  morphia  (gr.  £-£).  The  amount  of  food  should  be  reduced, 
and  whey  and  albumen-water  in  small  amounts  be  substituted  for  the  milk. 
An  ice-bag  or  cold  compresses  relieve  the  soreness  which  sometimes  accom- 
panies the  diarrhoea. 

Constipation  is  present  in  many  cases,  and  though  I  have  never  seen  it 
do  harm,  yet  it  is  well  every  second  day  to  give  an  ordinary  enema.  The 
addition  of  turpentine  (5  ss,  15  c.  c.)  is  advisable  if  there  is  meteorism. 

Hcemorrhage. — As  absolute  rest  is  essential,  the  greatest  care  should  be 
taken  in  the  use  of  the  bed-pan.  It  is  perhaps  better  to  allow  the  patient  to 
pass  the  motions  into  a  large  pad.  Ice  may  be  given,  and  a  light  ice-bag 
placed  on  the  abdomen.  The  amount  of  food  should  1be  restricted  for  eight 
or  ten  hours.  If  there  is  a  tendency  to  collapse,  stimulants  should  be  given, 
and,  if  necessary,  hypodermic  injections  of  camphor.  Injection  of  salt  solu- 
tion beneath  the  skin  or  directly  into  a  vein  may  revive  a  failing  heart,  but 
should  only  be  done  in  case  of  emergency.  Turpentine  is  warmly  recommended 
by  certain  authors.  Should  opium  be  given?  One-fifth  of  the  cases  of  per- 
foration occur  with  haemorrhage,  and  the  opium  may  obscure  the  features 
upon  which  alone  the  diagnosis  of  perforation  may  be  made.  Opium  increases 
any  tendency  to  tympanites.  We  have  abandoned  the  use  of  opium  and  have 
given  calcium  lactate  in  doses  of  gr.  xv  (1  gm.)  every  four  hours.  The  in- 
jection of  blood  serum  is  sometimes  of  value. 

Perforation  and  Peritonitis. — Early  diagnosis  and  early  operation  mean 
the  saving  of  one-third  of  the  cases  of  this  heretofore  uniformly  fatal  com- 
plication. The  aim  should  be  to  operate  for  the  perforation,  and  not  to  wait 
until  a  general  peritonitis  diminishes  by  one-half  the  chances  of  recovery. 
An  incessant,  intelligent  watchfulness  on  the  part  of  the  medical  attendant 
and  the  early  co-operation  of  the  surgeon  are  essentials.  Every  case  of  more 
than  ordinary  severity  should  be  watched  with  special  reference  to  this  com- 
plication. Thorough  preparation  by  early  observation,  careful  notes,  and 


TYPHOID    FEVER  45 

knowledge  of  the  conditions  will  help  to  prevent  needless  exploration.  No 
case  is  too  desperate;  we  have  had  one  recovery  after  three  operations. 
Twenty  cases  of  perforation  in  my  series  were  operated  upon  with  seven 
recoveries;  in  an  eighth  case  the  patient  died  of  the  toxaemia  on  the  eighth 
day  after  the  laparotomy.  In  doubtful  cases  it  is  best  to  operate,  as  experi- 
ence shows  that  patients  stand  an  exploration  very  well. 

Cholecystitis. — A  majority  of  the  cases  recover,  but  if  the  symptoms  are 
very  severe  and  progressive,  operation  should  be  advised.  For  chronic 
cholecystitis  hexamine  should  be  given  in  large  doses  and  the  vaccine  treat- 
ment employed. 

With  signs  of  failure  of  the  circulation,  hydrotherapy  should  be  carried 
on  actively  and  strychnine  given  hypodermically  (gr.  -fa  to  jfo,  0.001  to 
0.003  gm.)  every  three  hours.  Saline  infusions  (500  c.  c.)  are  useful  espe- 
cially if  the  patient  is  not  taking  much  water  by  mouth.  Alcohol  is  generally 
of  value.  Digitalis  may  be.  given  as  the  tincture  (mxv,  1  c.  c.)  or  digitaline 
(gr.  ^V,  0.002  gm.)  intramuscularly.  For  collapse,  camphor  (gr.  ii,  0.13 
gm.)  or  ether  hypodermically  should  be  given.  The  bath  treatment  is  the 
best  preventive  of  circulatory  failure.  For  phlebitis  the  limb  should  be  kept 
absolutely  at  rest  and  wrapped  in  raw  cotton.  The  application  of  a  sedative 
lotion  may  relieve  pain. 

Bacilluria. — When  bacilli  are  present,  as  demonstrated  by  cultures  or 
shown  by  the  microscope,  hexamine  may  be  given  in  ten-grain  doses  and  kept 
up,  if  necessary,  for  several  weeks.  A  patient  should  not  be  discharged  with 
bacilli  in  his  urine. 

For  orcliitis,  mastitis,  parotitis,  etc.,  an  ice-bag  should  be  applied.  Incision 
and  drainage  are  advisable  on  the  first  signs  of  suppuration. 

In  protracted  cases  very  special  care  should  be  taken  to  guard  against 
bed-sores.  Absolute  cleanliness  and  careful  drying  of  the  parts  after  an 
evacuation  should  be  enjoined.  Pressure  should  be  avoided  by  the  use  of 
rubber  rings.  The  patient  should  be  turned  from  side  to  side  and  propped 
with  pillows,  and  the  back  can  then  be  sponged  with  alcohol. 

Bone  Lesions. — The  use  of  a  typhoid  vaccine  is  well  worthy  of  trial.  Ty- 
phoid periostitis  does  not  always  go  on  to  suppuration,  though,  as  a  rule,  it 
requires  operation.  This  should  be  done  very  thoroughly  and  the  diseased 
parts  completely  removed,  as  otherwise  recurrence  is  inevitable.  For  typhoid 
spine  fixation  by  a  plaster  jacket  or  some  form  of  apparatus  is  advisable. 
Trauma  should  be  guarded  against.  In  the  milder  cases  active  counter-irri- 
tation is  useful.  If  pain  is  severe,  large  doses  of  sedatives  are  necessary. 

(#)THE  MANAGEMENT  OF  CONVALESCENCE. — Convalescents  from  typhoid 
fever  frequently  cause  greater  anxiety  than  patients  in  the  attack.  The  ques- 
tion of  food  has  to  be  met  at  once,  as  the  patient  acquires  a  ravenous  appetite 
and  clamors  for  a  fuller  diet.  My  custom  has  been  not  to  allow  solid  food 
until  the  temperature  has  been  normal  for  ten  days.  This  is,  I  think,  a  safe 
rule,  leaning  perhaps  to  the  side  of  extreme  caution;  but,  after  all,  with  the 
many  soft  foods,  the  patient  can  take  a  fairly  varied  diet.  Many  leading 
practitioners  allow  solid  food  to  a  patient  so  soon  as  he  desires  it.  I  had  a 
lesson  in  this  matter  which  I  have  never  forgotten.  A  young  lad  in  the 
Montreal  General  Hospital,  in  whose  case  I  was  much  interested,  passed 
through  a  tolerably  sharp  attack  of  typhoid  fever.  Two  weeks  after  the  even- 


46  SPECIFIC    INFECTIOUS    DISEASES 

ing  temperature  had  been  normal,  and  only  a  day  or  two  before  his  intended 
discharge  he  ate  several  mutton  chops,  and  within  twenty-four  hours  was  in 
a  state  of  collapse  from  perforation.  A  small  transverse  rent  was  found  at 
the  bottom  of  an  ulcer  which  was  in  process  of  healing.  It  is  not  easy  to 
Bay  why  solid  food,  particularly  meats,  should  disagree,  but  in  so  many  in- 
stances an  indiscretion  in  diet  is  followed  by  slight  fever,  the  so-called  febris 
carnis,  that  it  is  in  the  best  interests  of  the  patient  to  restrict  the  diet  for  some 
time  after  the  fever  has  fallen.  Whether  an  error  in  diet  may  cause  relapse 
is  doubtful.  The  patient  may  be  allowed  to  sit  up  for  a  short  time  about  the 
end  of  the  first  week  of  convalescence,  and  the  period  may  be  prolonged  with 
a  gradual  return  of  strength.  He  should  move  about  slowly,  and  when  the 
weather  is  favorable  should  be  in  the  open  air  as  much  as  possible.  He  should 
be  guarded  at  this  period  against  all  unnecessary  excitement.  Emotional 
disturbance  not  infrequently  is  the  cause  of  recrudescence  of  the  fever.  Con- 
stipation is  not  uncommon  in  convalescence  and.  is  best  treated  by  enemata. 
A  protracted  diarrhoea,  which  is  usually  due  to  ulceration  in  the  colon,  may 
retard  recovery.  In  such  cases  the  diet  should  be  restricted  to  milk  and  the 
patient  confined  to  bed;  large  doses  of  bismuth  and  astringent  injections  will 
prove  useful.  The  recrudescence  of  the  fever  does  not  require  special  meas- 
ures. The  treatment  of  the  relapse  is  essentially  that  of  the  original  attack. 

Post-typhoid  insanity  requires  the  judicious  care  of  an  expert.  The  cases 
usually  recover.  The  swollen  leg  after  phlebitis  is  a  source  of  great  worry. 
A  bandage  or  a  well-fitting  elastic  stocking  should  be  worn  during  the  day. 
The  outlook  depends  on  the  completeness  with  which  the  collateral  circulation 
is  established.  In  a  good  many  cases  there  is  permanent  disability. 

The  post-typhoid  neuritis,  a  cause  of  much  alarm  and  distress,  usually 
gets  well,  though  it  may  take  months,  or  even  a  couple  of  years,  before  the 
paralysis  disappears.  After  the  subsidence  of  the  acute  symptoms  systematic 
massage  of  the  paralyzed  and  atrophic  muscles  is  the  most  satisfactory  treat- 
ment. 

Typhoid  Carriers. — Treatment  of  these  is  difficult.  Hexamine  should  be 
given  persistently  and  in  large  doses.  Drainage  of  the  gall  bladder  and  X-ray 
exposures  over  it  have  been  successful  in  some  cases.  The  employment  of  an 
autogenous  vaccine  offers  the  best  chance  of  success.  Doses  increasing  from  25 
to  1,000  or  1,500  million  bacilli  are  given  at  intervals  of  10  days. 

Lastly,  no  patient  should  be  discharged  from  observation  until  we  are 
certain  that  he  can  not  infect  others. 


II.  COLON  BACILLUS  INFECTIONS 

The  colon  bacillus,  or  more  properly  speaking  the  group  of  colon  bacilli, 
in  their  biological  and  pathological  peculiarities  are  closely  related  to  the 
organisms  of  the  typhoid  group.  Normal  inhabitants  of  the  intestines,  where 
in  all  probability  they  serve  a  useful  function,  the  bacillus  coli  communis 
may  be  taken  as  the  typical  member  of  the  group.  The  serogenic,  the  food- 
poisoning,  the  paratyphoid  and  the  dysenteric  groups  must  be  excluded. 
There  are  great  difficulties  in  determining  the  extent  of  the  lesions  caused  by 
this  organism,  which  varies  extraordinarily  in  virulence.  To  it  has  been 


COLON  BACILLUS  INFECTIONS  47 

attributed  a  host  of  maladies  from  appendicitis  to  old  age,  but  more  con- 
seivative  pathologists  limit  very  much  its  pathogenic  scope.  It  is  not  easy 
to  separate  the  effects  of  the  B.  coli  from  those  of  other  organisms  with  which 
it  is  so  often  associated.  The  needful  bacteriological  distinction  must  be  con- 
sidered in  connection  with  agglutination  and  opsonic  tests. 
Eecognized  infections  may  be  classed  as  follows: 

A.  General  Heemic  Infections. — There  are  several  groups  of  cases: 

(a)  Terminal  Infections. — After  death  the  colon  bacillus  swarms  in  the 
body,  invading  the  blood  and  contaminating  all  parts.  In  protracted  illnesses, 
in  acute  intestinal  and  peritoneal  affections  it  may  be  present  in  the  blood 
some  time  before  death  and  may  be  responsible  for  the  terminal  fever. 

(&)  Cases  running  a  course  resembling  typhoid  fever.  To  this  group 
much  attention  has  been  paid  of  late  and  there  are  now  some  50  cases  in  the 
literature  ( Draper ) . 

(c)    Cases  of  general  infection  with  secondary  abscesses. 

B.  Sub-infections. — Adami  has  suggested  that  a  large  number  of  chronic 
diseases  have  their  origin  in  a  mild,  continuous  infection  with  B.  coli  and  he 
has  brought  forward  evidence  to  show  that  such  affections  as  anasmia  and  cir- 
rhosis of  the  liver  may  be  due  to  it.    Metchnikoff  induced  the  lesions  of  early 
cirrhosis  and  of  arterio-sclerosis  by  administering  the  products  of  the  growth 
of  the  B.  coli.     The  question  is  under  discussion  and  is  far  from  settled. 

C.  Local  Infections. — Here  we  are  on  safer  ground  and  we  know  of  three 
definite  lesions  produced  by  the  organism. 

(a)  Peritonitis. — In  perforation  of  the  bowel,  in  strangulated  hernia,  in 
obstruction  in  various  types  of  ulcer,  the  associated  peritonitis  may  be  due 
to  B.  coli. 

(&)  Cholecystitis  and  cholangitis,  either  of  the  simple  catarrhal  type  or 
suppurative,  may  be  caused  by  it. 

(c)  Infection  of  the  Urinary  Tract. — The  bladder  and  the  pelves  of  the 
kidneys  are  chiefly  affected.  There  are  three  possible  channels  of  infection — 
by  the  ureter,  the  blood  stream,  and  the  lymphatics.  The  first  route  is  proba- 
bly the  common  one  in  women  and  children;  but  lymphatic  infection  from 
the  bowel  plays  a  very  important  role  in  a  great  many  of  the  cases.  Bowel 
troubles  have  been  present,  constipation  or  diarrhoea.  It  has  been  shown  ex- 
perimentally that  with  very  slight  abrasion  of  the  mucosa  of  the  colon  the 
bacilli  may  enter  the  lymphatics.  An  interesting  point  is  the  relative  fre- 
quency of  involvement  of  the  right  kidney;  Franke  states  that  the  caecum 
and  ascending  colon  are  connected  by  a  train  of  lymphatics  with  the  right 
kidney,  an  anatomical  communication  not  present  with  the  left.  Clinically 
there  are  three  important  groups  of  cases.  (1)  In  children,  in  whom  it  seems 
by  no  means  uncommon.  In  Jeffrey's  study  of  60  cases  at  the  Hospital  for 
Sick  Children  a  large  proportion  occurred  in  females  (53).  Death  followed 
•in  9  cases.  (2)  In  connection  with  pregnancy.  The  cases  are  common  and 
important  and  may  occur  at  any  time  during  pregnancy  or  follow  delivery. 
The  pelvis  of  the  right  kidney  is  most  often  attacked.  (3)  The  group  of  cases 
in  adults,  men  and  women,  in  whom,  without  any  obvious  cause,  and  in  the 
majority  of  cases  that  I  have  seen,  without  any  previous  intestinal  trouble, 
acute  pyelitis  or  pyelocystitis  comes  on.  The  infection  is  obstinate  and  very 
difficult  to  treat,  even  with  vaccines.  An  interesting  and  distressing  sequel 


48  SPECIFIC    INFECTIOUS   DISEASES 

is  a  chronic  arthritis.  In  one  instance  the  condition  was  very  similar  to  that 
of  a  gonorrhceal  synovitis  and  periarthritis.  The  clinical  picture  presents, 
nothing  peculiar.  (4)  Intestines.  To  the  bacillus  coli  almost  all  the  diseases 
of  the  bowels  from  ulcers  of  the  duodenum  to  appendicitis  have  been  attributed. 
Ulcers  of  the  stomach  and  of  the  duodenum  have  been  produced  by  feeding 
cultures  of  B.  coli  to  dogs,  and  from  the  peptic  ulcers  of  very  young  infants 
Helmholz  has  isolated  the  organism  in  pure  culture.  The  not  infrequent 
association  of  appendicitis  and  peptic  ulcer  has  been  attributed  to  toxins  from 
the  appendix  and  large  bowel.  There  is  great  difficulty  in  determining  the 
precise  etiological  relationship  of  B.  coli  to  the  various  lesions  of  the  gastro- 
intestinal tract.  (5)  Other  local  infections  with  which  the  colon  bacillus 
has  been  associated  are  acute  meningitis,  abscess  of  the  brain,  endocarditis, 
and  suppuration  in  various  parts.  Only  in  a  small  proportion  of  these  cases 
has  the  association  been  demonstrated  by  cultural  and  biological  tests. 


m.    THE   PYOGENIC   INFECTIONS 

(Septicaemia,  Saprcemia,  Pycemia} 

Definition. — A  group  of  non-specific  diseases,  induced  by  a  number  of 
micro-organisms,  of  which  the  pyogenic  cocci  are  the  most  important,  char- 
acterized by  fever,  chills,  leucocytosis,  often  a  profound  intoxication  and 
sometimes  by  foci  of  suppuration. 

A  hard-and-fast  line  can  not  be  drawn  between  an  infection  and  an  intoxi- 
cation, but  agents  of  infection  alone  are  capable  of  reproduction,  whereas  those 
of  intoxication  are  chemical  poisons,  some  of  which  are  produced  by  the 
agency  of  bacteria,  or  by  vegetable  and  animal  cells.  Infectious  diseases  which 
are  communicated  directly  from  one  person  to  another  are  termed  contagious, 
and  the  infecting  agent  is  sometimes  spoken  of  as  a  contagium.  "Whether 
or  not  an  infectious  disease  is  contagious  in  the  ordjnary  sense  depends  upon 
the  nature  of  the  infectious  agent,  and  especially  upon  the  manner  of  its 
elimination  from  and  reception  by  the  body.  Most  but  not  all  contagious 
diseases  are  infectious.  Scabies  is  a  contagious  disease,  but  it  is  not  infec- 
tious" (Welch). 

There  are  three  chief  clinical  types  of  pyogenic  infection: 

1.  LOCAL  INFECTIONS  WITH  THE  DEVELOPMENT  OF  TOXINS 

This  is  the  common  mode  of  invasion  of  many  of  the  infectious  diseases. 
Tetanus,  diphtheria,  erysipelas,  and  pneumonia  are  diseases  which  have  sites 
of  local  infection  in  which  the  pathogenic  organisms  develop ;  but  the  constitu- 
tional effects  are  caused  by  the  absorption  of  the  poisonous  products.  The 
diphtheria  toxin  produces  all  the  general  symptoms,  the  tetanus  toxin  every 
feature  of  the  disease  without  the  presence  of  their  respective  bacilli.  Certain 
of  the  symptoms  following  the  absorption  of  the  toxins  are  general  to  all; 
others  are  special  and  peculiar,  according  to  the  organism  which  produces 
them.  A  chill,  fever,  general  malaise,  prostration,  rapid  pulse,  restlessness,  and 
headache  are  the  most  frequent.  With  but  few  exceptions  the  febrile  disturb- 
ance is  the  most  common  feature.  The  most  serious  effects  are  upon  the  ner- 


THE    PYOGENIC    INFECTIONS  49 

vous  system  and  upon  the  circulation,  and  the  gravity  of  the  symptoms  on  the 
part  of  these  organs  is  to  some  extent  a  measure  of  the  intensity  of  the  intoxi- 
cation. The  organisms  of  certain  local  infections  produce  poisons  which  have 
special  actions;  thus,  the  diphtheria  toxin,  besides  having  the  effects  already 
referred  to,  is  especially  prone  to  attack  the  nervous  system  and  to  cause 
peripheral  neuritis.  The  tetanus  toxin  has  a  specific  action  on  the  motor 
neurones. 

2.     SEPTIOEMIA 

Formerly,  and  in  a  surgical  sense,  the  term  "septicaemia"  was  used  to 
designate  the  invasion  of  the  blood  and  tissues  of  the  body  by  the  organisms 
of  suppuration,  but  in  the  medical  sense  the  term  may  be  applied  to  any  con- 
dition in  which,  with  or  without  a  local  site  of  infection,  there  is  microbic 
invasion  of  the  blood  and  tissues,  but  without  metastatic  foci  of  suppuration. 
Owing  to  the  great  development  of  bacteria  in  the  blood,  and  in  order  to 
separate  it  sharply  from  local  infectious  processes  with  toxic  invasion  of  the 
body,  it  is  proposed  to  call  this  condition  bacteraemia;  toxaemia  denotes  the 
latter  state. 

(a)  Progressive  Septicaemia  from  Local  Infection. — The  common  strepto- 
coccus and  staphrlococcus  infection  is,  as  a  rule,  first  local,  and  the  toxins 
alone  pass  into  the  blood.  In  other  instances  the  cocci  appear  in  the  blood  and 
throughout  the  tissues,  causing  a  septicaemia  which  intensifies  greatly  the 
severity  of  the  case.  Other  infections  in  which  the  bacterial  invasion,  local 
at  first,  may  become  general  are  pneumonia,  anthrax,  gonorrhoea,  and  puer- 
peral fever. 

The  clinical  features  of  this  form  are  well  seen  in  the  cases  of  puerperal 
septicaemia  or  in  dissection  wounds,  in  which  the  course  of  the  infection  may 
be  traced  along  the  lymphatics.  The  symptoms  usually  set  in  within  twenty- 
four  hours,  and  rarely  later  than  the  third  or  fourth  day.  There  is  a  chill 
or  chilliness,  with  moderate  fever  at  first,  which  gradually  rises  and  is  marked 
by  daily  remissions  and  even  intermissions.  The  pulse  is  small  and  com- 
pressible, and  may  reach  120  or  higher.  Gastro-intestinal  disturbances  are 
common,  the  tongue  is  red  at  the  margin,  and  the  dorsum  is  dry  and  dark. 
There  may  be  early  delirium  or  marked  mental  prostration  and  apathy.  As 
the  disease  progresses  there  may  be  pallor  of  the  face  or  a  yellowish  tint. 
Capillary  haemorrhages  are  not  uncommon. 

In  streptococcus  cases  we  are  beginning  to  recognize  the  fact  that  these 
infections  are  not  always  so  serious  as  we  thought.  Death  may  occur  within 
twenty-four  hours  or  be  delayed  for  several  days,  even  for  weeks,  and  recovery 
may  occur.  One  patient  showed  streptococci  in  the  blood  for  six  weeks,  but 
ultimately  recovered  (Cole). 'On  post-mortem  examination  there  may  be 
no  gross  focal  lesions  in  the  viscera,  and  the  seat  of  infection  may  present 
only  slight  changes.  The  spleen  is  enlarged  and  soft,  the  blood  may  be  ex- 
tremely dark  in  color,  and  haemorrhages  are  common,  particularly  on  the 
serous  surfaces.  Neither  thrombi  nor  emboli  are  found.  Certain  clinical  fea- 
tures separate  the  streptococcus  from  the  staphylococcus  infection,  chiefly 
in  the  absence  of  delirium,  a  rather  abnormal  mental  acuteness,  and  in  the 
presence  of  a  greater  degree  of  anaemia. 


50  SPECIFIC    INFECTIOUS    DISEASES 

Many  instances  of  septicaemia  are  combined  infections ;  thus,  in  diphtheria 
streptococcus  septicaemia  is  a  common,  and  the  most  serious,  event.  The  local 
disease  and  the  symptoms  produced  by  absorption  of  the  toxins  dominate  the 
clinical  picture ;  but  the  features  are  usually  much  aggravated  by  the  systemic 
invasion.  A  similar  infection  may  occur  in  typhoid  fever  and  in  tuberculosis, 
and  may  obscure  the  typical  picture.  These  secondary  septicaemias  are  caused 
most  frequently  by  the  streptococcus,  but  may  result  from  the  invasion  of 
other  bacteria. 

(b)  General  Septicaemia  without  Recognizable  Local  Infection. — Crypto- 
genetic  Septicaemias. — This  is  a  group  of  very  great  interest  to  the  physician, 
the  full  importance  of  which  we  are  only  now  beginning  to  recognize. 

The  subjects  when  attacked  may  be  in  perfect  health;  more  commonly 
they  are  already  weakened  by  acute  or  chronic  illness.  The  pathogenic  organ- 
isms are  varied.  Streptococcus  pyogenes  is  the  most  common;  the  forms  of 
staphylococcus  more  rare.  Other  occasional  causal  agents  are  Micrococcus 
lanceolatus  (pneumococcus),  Bacillus  proteus,  Bacillus  pyocyaneus  and  Bacil- 
lus influenza.  Between  May  1,  1892,  and  June  1,  1895,  there  were  examined 
in  the  post-mortem  room  from  my  wards  21  cases  of  general  infection,  of 
which  13  were  due  to  Streptococcus  pyogenes,  2  to  Staphylococcus  pyogenes, 
and  6  to  the  pneumococcus.  In  19  of  these  cases  the  patients  were  already  the 
subjects  of  some  other  malady,  which  was  aggravated,  or  in  most  instances 
terminated,  by  the  general  septicaemia.  The  symptoms  vary  somewhat  with 
the  character  of  the  micro-organisms.  In  the  streptococcus  cases  there  may 
be  chills  with  high,  irregular  fever,  and  a  more  characteristic  septic  state  than 
in  the  pneumococcus  infection. 

These  cases  come  correctly  under  the  term  "cryptogenetic  septicaemia"  as 
employed  by  Leube,  inasmuch  as  the  local  focus  of  infection  is  not  evident 
during  life  and  may  not  be  found  after  death.  Although  most  of  these  cases 
are  terminal  infections,  yet  it  is  well  to  bear  in  mind  that  there  are  instances 
of  this  type  of  affection  coming  on  in  apparently  healthy  persons.  The  fever 
may  be  extremely  irregular,  characteristically  septic,  and  persist  for  many 
weeks.  Foci  of  suppuration  may  not  develop,  and  may  not  be  found  even  at 
autopsy.  I  have  on  several  occasions  met  with  cases  of  an  intermittent  pyrexia 
persisting  for  weeks,  in  which  it  seemed  impossible  to  give  any  explanation 
of  the  phenomena,  and  some  which  ultimately  recovered,  and  in  which  tuber- 
culosis and  malaria  could  be  almost  positively  excluded.  These  cases  require 
to  be  carefully  studied  bacteriologically.  Dreschfeld  has  described  them  as 
idiopathic  intermittent  fever  of  pyaemic  character.  Local  symptoms  may  be 
absent,  though  in  three  of  his  cases  there  was  enlargement  of  the  liver,  and 
in  two  the  condition  was  a  diffuse  suppurative  hepatitis.  The  pyocyanic 
disease,  or  cyano-pyaemia,  is  an  extremely  interesting  form  of  infection  with 
Bacillus  pyocyaneus,  of  which  a  large  number  of  cases  have  been  reported. 

3.     SEPTICO-PYvEMIA 

The  pathogenic  micro-organisms  which  invade  the  blood  and  tissues  may 
settle  in  certain  foci  and  there  cause  suppuration.  When  multiple  abscesses 
are  thus  produced  in  connection  with  a  general  infection,  the  condition  is 
known  as  pyaemia  or,  perhaps  better,  septico-pyaemia.  There  are  no  specific 


THE   PYOGENTC    INFECTIONS  51 

organisms  of  suppuration,  and  the  condition  of  pyaemia  may  be  produced  by 
organisms  other  than  the  streptococci  and  staphylococci,  though  these  are  the 
most  common.  Other  forms  which  may  invade  the  system  and  cause  foci  of 
suppuration  are  Micrococcus  lanceolatus,  the  gonococcus,  Bacillus  coli,  Bacil- 
lus typliosus,  Bacillus  proieus,  Bacillus  pyocyaneus,  Bacillus  influenzce.  In  a 
large  proportion  of  all  cases  of  pyaemia  there  is  a  focus  of  infection,  either  a 
suppurating  external  wound,  an  osteomyelitis,  a  gonorrhoea,  an  otitis  media, 
an  empyema,  or  an  area  of  suppuration  in  a  lymph-gland  or  about  the  appen- 
dix. In  a  large  majority  of  all  these  cases  the  common  pus  cocci  are  present. 

In  a  suppurating  wound,  for  example,  the  pus  organisms  induce  hyaline 
necrosis  in  the  smaller  vessels  with  the  production  of  thrombi  and  purulent 
phlebitis.  The  entrance  of  pus  organisms  in  small  numbers  into  the  blood 
does  not  necessarily  produce  pyaemia.  Commonly  the  transmission  to  various 
parts  from  the  local  focus  takes  place  by  the  fragments  of  thrombi  which  pass 
as  emboli  to  different  parts,  where,  if  the  conditions  are  favorable,  the  pus 
organisms  excite  suppuration.  A  thrombus  which  is  not  septic  or  contami- 
nated, when  dislodged  and  impacted  in  a  distant  vessel,  produces  at  most  only 
a  simple  infarction;  but,  coming  from  an  infected  source  and  containing  pus 
microbes,  an  independent  centre  of  infection  is  established  wherever  the  em- 
bolus  may  lodge.  These  independent  suppurative  centres  in  pyaemia,  known 
as  enibolic  or  metastatic  abscesses,,  have  the  following  distribution: 

(a)  In  external  wounds,  in  osteo-myelitis,  and  in  acute  phlegmon  of  the 
skin,  the  embolic  particles  very  frequently  excite  suppuration  in  the  lungs, 
producing  the  well-known  wedge-shaped  pyaemic  infarcts;  from  these,  or 
rarely  by  paradoxical  embolism,  or  direct  passage  of  bacteria  or  minute  emboli 
through  the  pulmonary  capillaries,  metastatic  foci  of  inflammation  may  occur 
in  other  parts. 

(&)  Suppurative  foci  in  the  territory  of  the  portal  system,  particularly  in 
the  intestines,  produce  metastatic  abscesses  in  the  liver  with  or  without  sup- 
purative pylephlebitis. 

Endocarditis  is  an  event  which  is  very  liable  to  occur  in  all  forms  of  sep- 
ticaemia, and  modifies  materially  the  character  of  the  clinical  features.  Strep- 
tococci and  staphylococci  are  the  most  common  organisms  present  in  the  vege- 
tations, but  pneumococci,  gonoccocci,  tubercle  bacilli,  typhoid  bacilli,  anthrax 
bacilli,  and  other  forms  have  been  isolated.  The  vegetations  which  grow  at 
the  site  of  the  valve  lesion  become  covered  with  thrombi,  particles  of  which 
may  be  dislodged  and  carried  as  emboli  to  different  parts  of  the  body,  causing 
multiple  abscesses  or  infarcts. 

Symptoms  of  Septico-pysemia. — In  a  case  of  wound  infection,  prior  to  the 
onset  of  the  characteristic  symptoms,  there  may  be  signs  of  local  trouble,  and 
in  the  case  of  a  discharging  wound  the  pus  may  change  in  character.  The 
onset  of  the  disease  is  marked  by  a  severe  rigor,  during  which  the  temperature 
rises  to  103°  or  104°  and  is  followed  by  a  profuse  sweat.  These  chills  are 
repeated  at  intervals,  either  daily  or  every  other  day.  In  the  intervals  there 
may  be  slight  pyrexia.  The  constitutional  disturbance  is  marked  and  there 
are  loss  of  appetite,  nausea,  and  vomiting,  and,  as  the  disease  progresses,  rapid 
emaciation.  Transient  erythema  is  not  uncommon.  Local  symptoms  usually 
occur.  If  the  lungs  become  involved  there  are  dyspnoea  and  cough.  The 
physical  signs  may  be  slight.  Involvement  of  the  pleura  and  pericardium  ia 


52  SPECIFIC   INFECTIOUS   DISEASES 

common.  The  anaemia,  often  profound,  causes  great  pallor  of  the  skin,  which 
later  may  be  bile-tinged.  The  spleen  is  enlarged,  and  there  may  be  intense 
pain  in  the  side,  pointing  to  perisplenitis  from  embolism.  Usually  in  the 
rapid  cases  a  typhoid  state  supervenes,  and  the  patient  dies  comatose. 

In  the  chronic  cases  the  disease  may  be  prolonged  for  months;  the  chills 
recur  at  long  intervals,  the  temperature  is  irregular,  and  the  condition  of  the 
patient  varies  from  month  to  month.  The  course  is  usually  slow  and  progress- 
ively downward. 

Diagnosis. — Pyaemia  is  a  disease  frequently  overlooked  and  often  mistaken 
for  other  affections. 

Cases  following  a  wound,  an  operation,  or  parturition  are  readily  recog- 
nized. On  the  other  hand,  the  following  conditions  may  be  overlooked : 

Osteo-myelitis. — Here  the  lesion  may  be  limited,  the  constitutional  symp- 
toms severe,  and  the  course  of  the  disease  very  rapid.  The  cause  of  the  trouble 
may  be  discovered  only  post  mortem. 

So,  too,  acute  septico-pyaemia  may  follow  gonorrhoea  or  a  prostatic  abscess. 

Cases  are  sometimes  confounded  with  typhoid  fever,  particularly  the  more 
chronic  instances,  in  which  there  are  diarrhoea,  great  prostration,  delirium, 
and  irregular  fever.  The  spleen,  too,  is  often  enlarged.  The  marked  leuco- 
cytosis  is  an  important  differential  point. 

In  some  of  the  instances  of  ulcerative  endocarditis  the  diagnosis  is  very 
difficult,  particularly  in  what  is  known  as  the  typhoid,  in  contradistinction 
to  the  septic,  type  of  this  disease.  In  acute  miliary  tuberculosis  the  symp- 
toms occasionally  resemble  those  of  septicaemia,  more  commonly  those  of 
typhoid  fever. 

The  post-febrile  arthritides,  such  as  occur  after  scarlet  fever  and  gonor- 
rhoea, are  really  instances  of  mild  septic  infection.  The  joints  may  some- 
times suppurate  and  pyaemia  develop.  So,  also,  in  tuberculosis  of  the  kidneys 
and  calculous  pyelitis  recurring  rigors  and  sweats  due  to  septic  infection  are 
common.  In  some  latitudes  septic  and  pyaemic  processes  are  too  often  con- 
founded with  malaria.  In  early  tuberculosis,  or  even  when  signs  of  excava- 
tion are  present  in  the  lungs,  and  in  cases  of  suppuration  in  various  parts, 
particularly  empyema  and  abscess  of  the  liver,  the  diagnosis  of  malaria  is 
made.  The  practitioner  may  take  it  as  a  safe  rule,  to  which  he  will 
find  very  few  exceptions,  that  an  intermittent  fever  which  resists  quinine  is 
not  malaria. 

Other  conditions  associated  with  chills  which  may  be  mistaken  for  pyasmia 
are  profound  anaemia,  certain  cases  of  Hodgkin's  disease,  the  hepatic  inter- 
mittent fever  associated  with  the  lodgment  of  gall-stones  at  the  orifice  of  the 
common  duct,  rare  cases  of  essential  fever  in  nervous  women,  and  the  inter- 
mittent fever  sometimes  seen  in  rapidly  growing  cancer. 

Treatment. —  (a)  GENERAL. — Nourishment  should  be  given  as  liberally 
as  possible.  Water  should  be  forced  and  it  is  well  to  give  it  'by  the  drop 
method  into  the  bowel  and  by  infusion  if  there  is  any  difficulty  in  taking  it 
by  mouth.  Hydrotherapy  by  tub  baths  is  useful.  Alcohol  is  generally  indi- 
cated, and  with  severe  toxaemia  should  be  given  in  full  doses. 

(&)  SURGICAL. — In  pyaemia,  when  the  pus  is  accessible,  free  evacuation 
and  drainage  is  often  the  only  treatment  required.  In  a  case  of  empyema 
with  weeks  of  high  and  irregular  fever  the  day  after  operation  the  temperature 


THE    PYOGENIC    INFECTIONS  53 

may  be  normal,  and  remain  so.  In  some  cases  with  a  local  infection  Bier's 
method  of  hyperaemia  has  been  used  with  success,  but  where  the  focus  of 
manufacture  of  the  poison  is  accessible  the  knife  should  be  used.  Unfortu- 
nately, in  only  too  many  cases  the  focus  of  infection  is  not  accessible;  it  then 
is  a  septicaemia,  and  for  such  cases  the  bacteriologists  have  introduced  the 
treatment  with  vaccines. 

(c)  VACCINE  TREATMENT. — By  blood  cultures  or  by  cultures  from  the 
focus  of  infection  the  organism  is  isolated,  then  a  vaccine  is  prepared,  and,  if 
Wright's  method  is  followed,  the  use  and  dose  are  regulated  by  the  opsonic 
index  of  the  patient.    "Stock"  vaccines  may  be  used,  but  are  not  as  useful  as 
an  autogenous  vaccine.    In  many  cases  in  which  the  germ  cannot  be  isolated 
and  the  condition  is  one  of  septic  fever  the  ordinary  antistreptococcus  serum 
or  one  of  the  polyvalent  serums  is  used.     Good  results  are  not  infrequently 
obtained. 

(d)  DRUGS. — There  are  none  which  control  septic  fever.     The  coal-tar 
products  are  of  doubtful  service.     Quinine  may  be  used.     The  intravenous 
injection  of  antiseptic  drugs  has  not  been  proved  to  be  of  value. 


4.     TERMINAL    INFECTIONS 

There  is  truth  in  the  paradoxical  statement  that  persons  rarely  die  of  the 
disease  with  which  they  suffer.  Secondary,  terminal  infections  carry  off  many 
incurable  cases.  Flexner  analyzed  255  cases  of  chronic  renal  and  cardiac 
disease  in  which  complete  bacteriological  examinations  were  made  at  autopsy. 
Excluding  tuberculous  infection,  213  gave  positive  and  42  negative  results. 
The  infections  may  be  local  or  general.  The  former  are  extremely  common, 
and  are  found  in  a  large  proportion  of  all  cases  of  Bright's  disease,  arterio- 
sclerosis, heart  disease,  cirrhosis  of  the  liver,  and  other  chronic  disorders. 
Affections  of  the  serous  membranes  (acute  pleurisy,  pericarditis,  or  perito- 
nitis), meningitis,  and  endocarditis  are  the  most  frequent  lesions.  It  is  per- 
haps safe  to  say  that  the  majority  of  cases  of  advanced  arterio-sclerosis  and 
of  Bright's  disease  succumb  to  these  intercurrent  infections.  The  infective 
agents  are  very  varied.  The  streptococcus  is  the  most  common,  but  the  pneu- 
mococcus,  staphylococcus  and  gonococcus,  and  the  proteus,  pyocyaneus,  and 
gas  bacillus  are  also  found.  It  is  surprising  in  how  many  instances  of 
arterio-sclerosis,  of  chronic  heart  disease,  of  Bright's  disease,  and  particularly 
of  cirrhosis  of  the  liver  in  Flexner's  series  the  fatal  event  was  determined  by 
an  acute  tuberculosis  of  the  peritoneum  or  pleura. 

The  general  terminal  infections  are  somewhat  less  common.  Of  85  cases 
of  chronic  renal  disease  in  which  Flexner  found  micro-organisms  at  autopsy, 
38  exhibited  general  infections;  of  48  cases  of  chronic  cardiac  disease,  in  14 
the  distribution  of  bacteria  was  general.  The  blood-serum  of  persons  suffer- 
ing from  advanced  chronic  disease  was  found  by  him  to  be  less  destructive  to 
the  staphylococcus  aureus  than  normal  human  serum.  Other  diseases  in  which 
general  terminal  infection  may  occur  are  Hodgkin's  disease,  leukaemia,  and 
chronic  tuberculosis. 

And,  lastly,  probably  of  the  same  nature  is  the  terminal  entero-colitis  so 
frequently  met  with  in  chronic  disorders. 


54  SPECIFIC    INFECTIOUS    DISEASES 


IV.    ERYSIPELAS 

Definition. — A  special  pyogenic  infection  caused  by  the  streptococcus  ery* 
sipelatis,  characterized  by  inflammation  of  the  skin  with  fever  and  toxaemia. 

Etiology. — Erysipelas  is  a  widespread  affection,  endemic  in  most  com- 
munities, and  at  certain  seasons  epidemic.  We  are  as  yet  ignorant  of  the 
atmospheric  or  telluric  influences  which  favor  the  diffusion  of  the  poison. 

It  is  particularly  prevalent  in  the  spring  of  the  year.  Of  2,012  cases  col- 
lected by  Anders,  1,214  occurred  during  the  first  five  months  of  the  year. 
April  had  the  largest  number  of  cases.  The  affection  prevails  extensively  in 
old,  ill-ventilated  hospitals  and  institutions  in  which  the  sanitary  conditions 
are  defective.  With  the  improved  sanitation  of  late  years  the  number  of  cases 
has  materially  diminished.  It  has  been  observed,  however,  to  break  out  in  new 
institutions  under  the  most  favorable  hygienic  circumstances.  Erysipelas  is 
both  contagious  and  inoculable;  but,  except  under  special  conditions,  the 
poison  is  not  very  virulent  and  does  not  seem  to  act  at  any  great  distance.  It 
can  be  conveyed  by  a  third  person.  The  poison  attaches  itself  to  the  furniture, 
bedding,  and  walls  of  rooms  in  which  patients  have  been  confined. 

The  disposition  to  the  disease  is  widespread,  but  the  susceptibility  is 
specially  marked  in  the  case  of  individuals  with  wounds  or  abrasions  of  any 
sort.  Eecently  delivered  women  and  persons  who  have  been  the  subjects  of 
surgical  operations  are  particularly  prone  to  it.  A  wound,  however,  is  not 
necessary,  and  in  the  so-called  idiopathic  form,  although  it  may  be  difficult  to 
say  that  there  was  not  a  slight  abrasion  about  the  nose  or  lips,  in  very  many 
cases  there  certainly  is  no  observable  external  lesion.  In  some  cases  the  infec- 
t*-on  apparently  spreads  through  the  tissues  from  the  nasal  cavity  to  the  skin. 

Chronic  alcoholism,  debility,  and  Bright's  disease  are  predisposing  agents. 
Certain  persons  show  a  special  susceptibility  to  erysipelas,  and  it  may  recur 
in  them  repeatedly.  There  are  instances,  too,  of  a  family  predisposition. 

The  specific  agent  of  the  disease  is  a  streptococcus  growing  in  long  chains, 
which  is  included  under  the  group  name  Streptococcus  pyogenes,  with  which 
Streptococcus  erysipelatis  appears  to  be  identical.  The  fever  and  constitu- 
te onal  symptoms  are  due  in  great  part  to  the  toxins ;  the  more  serious  visceral 
complications  are  the 'result  of  secondary  metastatic  infection. 

Morbid  Anatomy. — Erysipelas  is  a  simple  inflammation.  In  its  uncom- 
plicated forms  there  is  seen, '  post  mortem,  little  else  than  inflammatory 
oedema.  Investigations  have  shown  that  the  cocci  are  found  chiefly  in  the 
lymph-spaces  and  most  abundantly  in  the  zone  of  spreading  inflammation. 
In  the  uninvolved  tissue  beyond  the  inflamed  margin  they  are  to  be  found 
in  the  lymph-vessels,  and  it  is  here,  according  to  Metschnikoff  and  others, 
that  an  active  warfare  goes  on  between  the  leucocytes  and  the  cocci  (phago- 
cytosis). In  more  extensive  and  virulent  forms  of  the  disease  there  is  usually 
suppuration. 

Infarcts  occur  in  the  lungs,  spleen,  and  kidneys,  and  there  may  be  the  gen- 
eral evidences  of  pyaemic  infection.  Some  of  the  worst  cases  of  malignant 
endocarditis  are  secondary  to  erysipelas;  thus,  of  23  cases,  3  occurred  in  con- 
nection with  this  disease.  Septic  pericarditis  and  pleuritis  also  occur.  The 
disease  may  in  rare  cases  extend  to  and  involve  the  meninges.  Pneumonia 


ERYSIPELAS  55 

is  not  a  very  common  complication.    Acute  nephritis  is  also  met  with;  it  is 
often  ingrafted  upon  an  old  chronic  trouble. 

Symptoms. — The  following  description  applies  specially  to  erysipelas  of  the 
face  and  head,  the  form  of  the  disease  which  the  physician  is  most  commonly 
called  upon  to  treat. 

The  incubation  is  variable,  probably  from  three  to  seven  days. 

The  stage  of  invasion  is  often  marked  by  a  rigor,  and  followed  by  a  rapid 
rise  in  the  temperature  and  other  characteristics  of  an  acute  fever.  When 
there  is  a  local  abrasion,  the  spot  is  slightly  reddened;  but  if  the  disease  is 
idiopathic,  there  is  seen  within  a  few  hours  slight  redness  over  the  bridge  of 
the  nose  and  on  the  cheeks.  The  swelling  and  tension  of  the  skin  increase  and 
within  twenty-four  hours  the  external  symptoms  are  well  marked.  The  skin 
is  smooth,  tense,  and  cedematous.  It  looks  red,  feels  hot,  and  the  superficial 
layers  of  the  epidermis  may  be  lifted  as  small  blebs.  The  patient  complains  of 
an  unpleasant  feeling  of  tension  in  the  skin;  the  swelling  rapidly  increases; 
and  during  the  second  day  the  eyes  are  usually  closed.  The  first-affected  parts 
gradually  become  pale  and  less  swollen  as  the  disease  extends  at  the  periphery: 
When  it  reaches  the  forehead  it  progresses  as  an  advancing  ridge  perfectly  well 
defined  and  raised;  and  often,  on  palpation,  hardened  extensions  can  be  felt 
beneath  the  skin  which  is  not  yet  reddened.  Even  in  a  case  of  moderate  sever- 
ity, the  face  is  enormously  swollen,  the  eyes  are  closed,  the  lips  greatly  oedema^ 
tous,  the  ears  thickened,  the  scalp  is  swollen,  and  the  patient's  features  art 
quite  unrecognizable.  The  formation  of  blebs  is  common  on  the  eyelids,  ears, 
and  forehead.  The  cervical  lymph-glands  are  SAvollen,  but  are  usually  masked 
in  the  oedema  of  the  neck.  The  temperature  keeps  high  without  marked  remis- 
sions for  four  or  five  days  and  then  defervescence  takes  place  by  crisis.  Leu- 
cocytosis  is  present.  Kirkbride  has  noted  the  presence  in  one  case  of  leucin 
and  tyrosin  in  the  urine.  The  general  condition  of  the  patient  varies  much 
with  his  previous  state  of  health.  In  old  and  debilitated  persons,  particularly 
in  those  addicted  to  alcohol,  the  constitutional  depression  from  the  outset  may 
be  very  great.  Delirium  is  present,  the  tongue  becomes  dry,  the  pulse  feeble, 
and  there  is  marked  tendency  to  death  from  toxa?mia.  In  the  majority  of 
cases,  however,  even  with  extensive  lesions,  the  constitutional  disturbance,  con- 
sidering the  height  of  the  fever  range,  is  slight.  The  mucous  membrane  of  the 
mouth  and  throat  may  be  swollen  and  reddened.  The  erysipelatous  inflamma- 
tion may  extend  to  the  larynx,  but  the  severe  oedema  of  this  part  occasionally 
met  with  is  commonly  due  to  the  extension  of  the  inflammation  Irom  without 
inward. 

There  are  cases  in  which  the  inflammation  extends  from  the  face  to  the 
neck,  and  over  the  chest,  and  may  gradually  migrate  or  wander  over  the 
greater  part  of  the  body  (E.  migrans). 

The  close  relation  between  the  erysipelas  coccus  and  the  pus  organisms 
is  shown  by  the  frequency  with  which  suppuration  occurs  in  facial  erysipelas. 
Small  cutaneous  abscesses  are  common  about  the  cheeks  and  forehead  and 
neck,  and  beneath  the  scalp  large  collections  of  pus  may  accumulate.  Sup- 
puration seems  to  occur  more  frequently  in  some  epidemics  than  in  others,  and 
at  the  Philadelphia  Hospital  during  one  year  nearly  all  the  cases  in  the  ery- 
sipelas wards  presented  local  abscesses. 

Complications. — Meningitis   is   rare.    The   cases   in  which   death  occurs 


56  SPECIFIC    INFECTIOUS    DISEASES 

with  marked  brain  symptoms  do  not  usually  show,  post  mortem,  meningeal 
affection. 

Pneumonia  is  an  occasional  complication.  Ulcerative  endocarditis  and 
septicffimia  are  more  common.  Albuminuria  is  almost  constant,  particularly 
in  persons  over  fifty.  True  nephritis  is  occasionally  seen.  Da  Costa  has 
called  attention  to  curious  irregular  returns  of  the  fever  which  occur  during 
convalescence  without  any  aggravation  of  the  local  condition. 

Diagnosis. — The  diagnosis  rarely  presents  any  difficulty.  The  mode  of 
onset,  the  rapid  rise  in  fever,  and  the  characters  of  the  local  disease  are  quite 
distinctive. 

Prognosis. — Healthy  adults  rarely  die.  The  general  mortality  in  hospitals 
is  about  7  per  cent.;  in  private  practice  about  4  per  cent.  (Anders).  In  the 
new-born,  when  the  disease  attacks  the  navel,  it  is  almost  always  fatal.  In 
drunkards  and  in  the  aged  erysipelas  js  a  serious  affection,  and  death  may 
result  either  from  the  intensity  of  the  fever  or,  more  commonly,  from  toxae- 
mia. The  wandering  or  ambulatory  erysipelas,  which  has  a  more  protracted 
course,  may  cause  death  from  exhaustion. 

Treatment. — Isolation  should  be  strictly  carried  out,  particularly  in  hos- 
pitals. A  practitioner  in  attendance  upon  a  case  of  erysipelas  should  not 
attend  cases  of  confinement. 

The  disease  is  self-limited  and  a  large  majority  of  the  cases  get  well  with- 
out any  internal  medication.  The  diet  should  be  nutritious  and  light.  Large 
amounts  of  water  should  be  given.  Stimulants  are  not  required  except  in  the 
old  and  feeble.  For  the  restlessness,  delirium,  and  insomnia,  chloral  or  the 
bromides  may  be  given;  or,  if  these  fail,  opium.  When  the  fever  is  high  the 
patient  may  be  bathed  or  sponged,  or,  in  private  practice,  if  there  is  an  objec- 
tion to  this,  antipyrin  or  antifebrin  may  be  given. 

Antistreptococcic  serum  may  be  tried  or,  better  still,  an  autogenous  vac- 
cine, with  the  use  of  which  good  results  have  been  obtained. 

Of  internal  remedies  believed  to  influence  the  disease,  the  tincture  of  the 
perchloride  of  iron  has  been  highly  recommended. '  At  the  Montreal  General 
Hospital  this  was  the  routine  treatment,  and  doses  of  half  a  drachm  to  a 
drachm  were  given  every  three  or  four  hours.  I  am  by  no  means  convinced 
that  it  has  any  special  action;  nor,  so  far  as  I  know,  has  any  medicine,  given 
internally,  a  definite  control  over  the  course  of  the  disease. 

Of  local  treatment,  the  injection  of  antiseptic  solutions  at  the  margin  of 
the  spreading  areas  has  been  much  practised.  Two-per-cent.  solutions  of  car- 
bolic acid,  corrosive  sublimate  (1  to  4,000),  and  the  biniodide  of  mercury  have 
been  much  used.  The  injection  should  be  made  not  into  but  just  a  little  be- 
yond the  border  of  the  inflamed  patch.  F.  P.  Henry  has  treated  a  large 
number  of  cases  at  the  Philadelphia  Hospital  with  the  last-mentioned  drug, 
and  this  mode  of  practice  is  certainly  most  rational. 

Of  local  applications,  ichthyol  is  at  present  much  used  (as  a  salve,  1  to  4 
of  lanolin).  Bichloride  of  mercury  solution  (1  to  5,000),  salicylic  acid  (1  to 
500),  collodion,  or  ichthyol  in  collodion  (1  to  4),  may  be  used.  Painting  the 
skin  ahead  of  the  advancing  area  with  tincture  of  iodine  is  sometimes  ef- 
fectual. Perhaps  as  good  an  application  aa  any  is  cold  water,  which  was 
highly  recommended  by  Hippocrates. 


DIPHTHERIA 


V.    DIPHTHERIA 

Definition.  — A  specific  infectious  disease,  characterized  by  a  local  fibrinous 
exudate,  usually  upon  the  mucous  membrane  of  the  throat,  and  by  constitu- 
tional symptoms  due  to  toxins  produced  at  the  site  of  the  lesion.  The  pres- 
ence of  the  Klebs-Loeffler  bacillus  is  the  eticlogical  criterion  by  which  true 
diphtheria  is  distinguished  from  other  forms  of  membranous  inflammation. 

Cases  of  angina,  diagnosed  as  diphtheria,  may  be  due  to  other  organisms 
and  to  these  the  term  diphtheroid  is  applied.  Though  usually  milder,  severe 
constitutional  disturbance,  and  even  paralysis,  may  follow  these  diphtheroid 
forms. 

History. — Known  in  the  East  for  centuries,  and  referred  to  in  the  Baby- 
lonian Talmud,  it  is  not  until  the  first  century  A.  D.  that  an  accurate  clinical 
account  appears  in  the  writings  of  Aretaeus.  The  paralysis  of  the  palate  was 
recognized  by  ^tius  (sixth  century  A.  D.)  Throat  pestilences  are  mentioned 
in  the  Middle  Ages.  Severe  epidemics  occurred  in  Europe  in  the  sixteenth 
and  seventeenth  centuries,  particularly  in  Spain.  In  England  in  the  latter 
part  of  the  eighteenth  century  it  was  described  by  Fothergill  and  Huxham, 
and  in  America  by  Bard.  Washington  died  of  the  disease.  Ballonius  recog- 
nized the  affection  of  the  larynx  and  trachea  in  1762,  Home  in  Scotland 
described  it  as  croup.  The  modern  description  dates  from  Bretonneau,  of 
Tours  (1826),  who  gave  to  it  the  name  diphtherite.  Throughout  the  nine- 
teenth century  it  prevailed  extensively  in  all  known  countries,  and  it  is  at 
present  everywhere  epidemic.  After  innumerable  attempts,  in  which  Klebs 
took  a  leading  part,  the  peculiar  organism  of  the  disease  was  isolated  by 
Loeffler.  The  toxin  was  determined  by  the  work  of  Roux,  Yersin,  and  others, 
and  finally  the  antitoxin  was  discovered  by  Behring. 

Etiology. — Everywhere  endemic  in  large  centres  of  population,  the  disease 
becomes  at  times  epidemic.  It  is  more  prevalent  on  the  continent  of  Europe 
than  in  Great  Britain,  and  Ireland  has  less  than  other  countries.  In  England 
and  Wales  in  1909,  5,476  persons  died  of  the  disease,  the  lowest  mortality 
since  1859.  The  large  cities  of  the  United  States  have  been  much  afflicted, 
and  widespread  epidemics  have  occurred  in  country  districts.  In  the  tropics 
it  is  not  a  very  serious  disease.  Pandemics  occur  cyclically,  at  irregular 
intervals,  under  conditions  as  yet  imperfectly  known.  Dry  seasons  seem 
to  favor  the  disease,  which,  like  typhoid  fever,  shows  an  autumnal  preva- 
lence. 

MODES  OF  INFECTION. — The  disease  is  highly  contagious.  The  bacilli  may 
be  transmitted  (a)  from  one  person  to  another;  few  diseases  have  proved  more 
fatal  to  physicians  and  nurses.  (&)  Infected  articles  may  convey  the  bacilli, 
which  may  remain  alive  for  many  months;  scores  of  well-attested  instances 
have  been  recorded  of  this  mode  of  transmission,  (c)  Persons  suffering  from 
atypical  forms  of  diphtheria  may  convey  the  disease;  nasal  catarrh,  mem- 
branous rhinitis,  mild  tonsillitis,  otorrhcea  may  be  caused  by  the  diphtheria 
bacilli,  and  from  each  of  these  sources  cases  have  been  traced,  (d)  From 
the  throats  of  healthy  contacts — diphtheria  carriers,  persons  who  present  no 
signs  of  the  disease — the  bacilli  have  been  obtained  by  culture,  (e)  Even 
healthy  children  without  any  naso-pharyngeal  catarrh,  who  have  not  been  in 
6 


58  SPECIFIC    INFECTIOUS   DISEASES 

contact  with  the  disease,  may  in  large  cities  harbor  the  bacilli.  In  1,000 
children  from  the  New  York  tenements  Shelley  found  18  with  virulent  and 
38  with  non-virulent  bacilli,  and  the  percentage  in  Chicago  has  been  some- 
times much  higher.  Long  after  recovery  has  taken  place  virulent  bacilli  have 
been  isolated  from  the  throat.  It  is  important  to  bear  in  mind  under  d  and  e 
that  it  is  only  persons  who  harbor  the  virulent  forms  who  are  capable  of 
transmitting  the  disease.  In  schools  the  interchange  of  articles,  such  as 
sweets,  pencils,  etc.,  and  the  habit  which  children  have  of  putting  everything 
into  their  mouths  afford  endless  opportunities  for  the  transmission  of  the 
disease.  As  Westbrook  remarks,  diphtheria  is  transmitted  usually  by  almost 
direct  exchange  of  the  flora  of  the  nose  and  mouth.  (/)  Numerous  epidemics 
have  been  traced  to  milk,  since  Power  in  1878  determined  this  method  of 
spread.  Virulent  bacilli  have  been  found  in  the  milk,  and  Dean  and  Todd  and 
Ashby  have  found  virulent  organisms  in  the  acquired  lesions  on  the  teats  of 
cows,  (g)  A  few  instances  of  accidental  infection  from  cultures  and  through 
animals  are  on  record. 

PREDISPOSING  CAUSES. — Age  is  the  most  important.  Sucklings  are  not 
often  attacked,  but  Jacobi  saw  three  cases  in  the  new-born.  Early  in  the 
second  year  the  disposition  increases  rapidly,  and  continues  at  its  height  until 
the  fifth  year.  At  Baginsky's  clinic,  Berlin,  among  2,711  cases,  1,235  occurred 
from  the  second  to  the  fifth  years  inclusive.  In  New  York  between  1891- 
1900  among  the  deaths  80.8  per  cent,  occurred  under  five,  17  per  cent,  be- 
tween five  and  ten — figures  which  show  the  extraordinary  preponderance  of 
the  disease  among  children.  Girls  are  attacked  in  slightly  larger  numbers 
than  boys.  November,  December,  and  January  are  the  months  of  greatest 
prevalence  in  the  United  States;  in  London  the  months  of  October  and 
November. 

Soil  and  altitude  have  little  or  no  influence  on  the  prevalence  of  the  dis- 
ease; nor  does  race  play  an  important  role.  Individual  susceptibility  is  a 
very  special  factor ;  not  only  do  very  many  of  those  exposed  escape,  but  even 
those,  too,  in  whose  throats  virulent  bacilli  lodge  and  grow.  The  Schick  re- 
action (intradermic  injection  of  diphtheria  toxin)  is  of  great  value  in  deter- 
mining the  presence  of  immunity. 

The  KLEBS-LOEFFLER  BACILLUS  occurs  in  a  large  number  of  all  suspected 
cases — 72  per  cent,  based  upon  an  analysis  of  27,000  cases  in  the  literature  by 
Graham  Smith.  It  is  found  chiefly  in  the  false  membrane,  and  does  not 
extend  into  the  subjacent  mucosa.  The  organisms  are  localized,  and  only 
a  few  penetrate  into  the  interior.  Post  mortem  the  bacilli  may  be  found  in 
the  blood  and  in  the  internal  organs.  Occasionally  they  are  found  in  the 
blood  during  life.  It  may  be  the  predominating  or  sole  organism  in  the 
broncho-pneumonia  so  common  in  the  disease.  Outside  the  throat,  the  Klebs- 
Loeffler  bacillus  has  been  found  in  diphtheritic  conjunctivitis,  in  otitis  media, 
sometimes  in  wound  diphtheria,  upon  the  genitals,  in  fibrinous  rhinitis,  and 
in  ulcerative  endocarditis. 

Morphological  Characters. — The  bacillus  is  non-motile,  varies  from 
2.5  to  3  ft  in  length  and  from  0.5  to  0.8  //  in  thickness.  In  appearance  it  is 
multiform,  varying  from  short,  rather  sharply  pointed  rods  to  irregular  bizarre 
forms,  with  one  or  both  ends  swollen,  and  staining  more  or  less  unevenly 
and  intensely.  Westbrook  recognizes  three  main  types — granular,  barred,  and 


DIPHTHEEIA  59 

solid  staining.  Branching  forms  are  occasionally  met  with.  The  bacillus 
stains  in  sections  or  on  the  cover-glass  by  the  Gram  method. 

The  bacillus  is  very  resistant,  and  cultures  have  been  made  from  a  bit  of 
membrane  preserved  for  five  months  in  a  dry  cloth.  Incorporated  with  dust 
and  kept  moist,  the  bacilli  were  still  cultivable  at  the  end  of  eight  weeks; 
kept  in  a  dried  state  they  no  longer  grew  at  the  end  of  this  period  (Bitter). 

The  Klebs-Loeffler  bacillus  has  very  varying  grades  of  virulence  down 
even  to  complete  absence  of  pathogenic  effects.  The  name  pseudo-bacillus 
of  diphtheria  should  not  be  given  to  this  avirulent  organism. 

The  Presence  of  the  Klebs-Loeffler  Bacillus  in,  Non-membranous  Angina 
and  in  Healthy  Throats. — The  bacillus  has  been  isolated  from  cases  which 
show  nothing  more  than  a  simple  catarrhal  angina,  of  a  mild  type 
without  any  membrane,  with  diffuse  redness,  and  perhaps  huskiness  and 
signs  of  catarrhal  laryngitis.  In  other  cases  the  anatomical  picture  may  be 
that  of  a  lacunar  tonsillitis.  The  organisms  may  be  met  with  in  perfectly 
healthy  throats  (diphtheria  carriers),  particularly  in  persons  in  the  same 
house,  or  the  ward  attendants  and  nurses  in  fever  hospitals.  Following  an 
attack  of  diphtheria  the  bacilli  may  persist  in  the  throat  or  nose  after  all 
the  membrane  has  disappeared  for  weeks  or  months — even  15  months.  In 
explanation  of  this  persistence  Councilman  has  called  attention  to  the  fre- 
quency with  which  the  antrum  is  affected. 

Toxins  of  the  Klebs-Loeffler  Bacillus. — Roux  and  Yersin  showed  that  a 
fatal  result  following  the  inoculation  with  the  bacillus  was  not  caused 
by  any  extension  of  the  micro-organisms  within  the  body;  and  they  were 
enabled  in  bouillon  cultures  to  separate  the  bacilli  from  the  poison.  The  toxin 
so  separated  killed  with  very  much  the  same  effects  as  those  caused  by  the 
inoculation  of  the  bacilli;  the  pseudo-membrane,  however,  is  not  formed. 

Susceptible  animals  may  be  rendered  immune  from  diphtheritic  infection 
by  injecting  weakened  cultures  of  the  bacillus  or,  what  is  better,  suitable  doses 
of  the  diphtheria  toxin.  The  result  of  the  injections  is  a  febrile  reaction 
which  soon  passes  away  and  leaves  the  animal  less  susceptible  to  the  poison  or 
the  living  bacilli.  By  repeating  and  gradually  increasing  the  quantity  of 
poison  injected  a  high  degree  of  immunity  can  be  produced  in  large  animals 
(goat,  horse). 

The  Bacteria  Associated  with  the  Diphtheria  Bacillus. — The  most  com- 
mon is  the  streptococcus  pyogenes.  Others,  in  addition  to  the  organisms 
constantly  found  in  the  mouth,  are  the  micrococcus  lanceolatus,  the  bacillus 
coli,  and  the  staphylococcus  aureus  and  albus.  Of  these,  probably  the  strepto- 
coccus pyogenes  is  the  most  important,  as  cases  of  general  infection  with  this 
organism  have  been  found  in  diphtheria.  The  suppuration  in  the  lymph- 
glands  and  the  broncho-pneumonia  are  usually  (though  not  always)  caused  by 
this  organism. 

Pseudo-Diphtheria  Bacillus;  Bacillus  Xerosis. — As  mentioned  above,  the 
Klebs-Loeffler  bacillus  varies  very  much  in  its  virulence,  and  it  exists  in  a 
form  entirely  devoid  of  pathogenic  properties.  This  organism  should  not, 
however,  be  designated  pseudo-diphtheria  bacillus.  The  name  should  be  con- 
fined to  bacilli,  which,  though  resembling  the  diphtheria  bacillus,  differ  from 
it  not  only  by  abscence  of  virulence,  but  also  by  cultural  peculiarities.  A 
similar  bacillus,  showing,  however,  certain  cultural  differences  from  the 


60  SPECIFIC    INFECTIOUS    DISEASES 

pseudo-diphtheria  bacillus,  has  heen  repeatedly  found  in  the  coiijunctival  sac 
in  health  and  disease  (B.  xerosis} .  Hoffmann's  Bacillus,  which  is  also  spoken 
of  as  psieudo-diphtheria  bacillus,  is  a  common  organism  in  the  throats  of 
healthy  persons  and  is  found  also  in  cases  of  diphtheria;  but  how  far  it  is 
responsible  for  pathological  conditions  is  not  yet  settled.  Vincent's  Bacillus 
is  a  fusiform  organism  associated  with  a  diphtheroid  angina  (Vincent's  an- 
gina), which  occurs  in  iwo  forms:  a  membranous  and  an  ulcerative  and  de- 
structive. The  fusiform  bacilli  have  been  found  in  healthy  throats  and  also 
in  association  with  true  diphtheria. 

Diphtheroid  Inflammations. — Under  the  term  diphtheroid  may  be  grouped 
those  membranous  inflammations  which  are  not  associated  with  the  Klebs- 
Loeffler  bacillus.  It  is  perhaps  a  more  suitable  designation  than  pseudo-diph- 
theria or  secondary  diphtheria.  As  in  a  great  majority  of  cases  the  strepto- 
coccus pyogenes  is  the  active  organism,  the  term  "streptococcus  diphtheritis" 
is  often  employed.  The  name  "diphtheritis"  is  best  used  in  an  anatomical 
sense  to  designate  an  inflammation  of  a  mucous  membrane  or  integumentary 
surface  characterized  by  necrosis  and  a  fibrinous  exudate,  whereas  the  term 
"diphtheria"  should  be  limited  to  the  disease  caused  by  the  Klebs-Loeffler 
bacillus.  The  proportion  of  cases  of  diphtheroid  inflammation  varies  greatly 
in  the  different  statistics.  Of  the  large  number  of  observations  made  by  Park 
and  Beebe  (5,611)  in  New  York,  40  per  cent,  were  diphtheroid.  Figures  from 
other  sources  do  not  show  3o  high  a  percentage. 

CONDITIONS  UNDER  WHICH  THE  DIPHTHEROID  AFFECTION  OCCURS. — Of 
450  cases  (Park  and  Beebe),  300  occurred  in  the  autumn  months  and  150  in 
the  spring;  198  occurred  in  children  from  the  first  to  the  seventh  year.  In  a 
large  proportion  of  all  the  cases  the  disease  develops  in  children,  and  can  be 
differentiated  from  diphtheria  proper  only  by  the  bacteriological  examination. 
It  may  be  simply  an  acute  catarrhal  angina  with  lacunar  tonsillitis.  Some 
of  the  cases  are  due  to  Hoffmann's  bacillus,  a  few  to  Vincent's  fusiform 
bacillus.  The  diphtheroid  inflammations  are  particularly  prone  to  develop  in 
connection  with  the  acute  fevers. 

(a)  Scarlet  Fever. — In  a  large  proportion  of  the  cases  of  angina  in  scar- 
let fever  the  Klebs-Loeffler  bacillus  is  not  present.  Booker  has  reported  11 
cases  complicating  scarlet  fever,  in  all  of  which  the  streptococci  were  the  pre- 
dominant organisms.  Of  the  450  cases  of  Park  and  Beebe,  42  complicated 
scarlet  fever.  The  angina  of  this  disease  is  not  always,  however,  due  to  the 
streptococcus.  Where  diphtheria  is  prevalent  and  opportunities  are  favorable 
for  exposure,  a  large  proportion  of  the  cases  of  membranous  throats  in  scarlet 
fever  may  be  genuine  diphtheria. 

(6)  Measles. — Membranous  angina  is  much  less  common  in  this  disease. 
It  occurred  in  6  of  the  450  diphtheroid  cases  in  New  York.  Of  4  cases  with 
severe  membranous  angina  at  the  Boston  City  Hospital,  1  only  presented  the 
Klebs-Loeffler  bacillus. 

(c)  Whooping-cough  may  also  be  complicated  with  membranous  angina, 
Escherich  records  4  cases,  in   all  of  which  the  Klebs-Loeffler  bacillus  was 
found. 

(d)  Typhoid  Fever. — Membranous  inflammations  in  this  disease  are  not 
very  infrequent;  they  may  occur  in  the  throat,  the  pelvis  of  the  kidney,  the 
bladder,  or  the  intestines.    The  complication  may  be  caused  by  the  Klebs-Loef-  . 


DIPHTHERIA  61 

fler  bacillus,  but  it  is  frequently  a  streptococcus  infection.  Ernst  Wagner  has 
remarked  upon  the  greater  frequency  of  these  membranous  inflammations  in 
typhoid  fever  when  diphtheria  is  prevailing. 

Clinical  Features  of  the  Diphtheroid  Affection. — The  cases,  as  a  rule,  are 
milder,  and  the  mortality  is  low,  only  2.5  per  cent,  in  the  450  cases  of  Park 
and  Beebe.  The  diphtheroid  inflammations  complicating  the  specific  fevers 
are,  however,  often  very  fatal,  and  a  general  streptococcus  infection  is  by  no 
means  infrequent.  As  in  the  Klebs-Loeffler  angina,  there  may  be  only  a 
simple  catarrhal  process.  In  other  instances  the  tonsils  are  covered  with  a 
creamy,  pultaceous  exudate,  without  any  actual  membrane.  An  important 
group  may  begin  as  a  simple  lacunar  tonsillitis,  while  in  others  the  entire 
fauces  and  tonsils  are  covered  by  a  continuous  membrane,  and  there  is  a  foul 
sloughing  angina  with  intense  constitutional  disturbance. 

Are  the  diphtheroid  cases  contagious?  General  clinical  experience  war- 
rants the  statement  that  the  membranous  angina  associated  with  the  fevers 
is  rarely  communicated  to  other  patients.  The  health  department  of  New 
York  does  not  keep  the  diphtheroid  cases  under  supervision.  Their  inves- 
tigation of  the  450  diphtheroid  cases  seems  to  justify  this  conclusion.  Park 
and  Beebe  say  that  "it  did  not  seem  that  the  secondary  cases  were  any  less 
liable  to  occur  when  the  primary  case  was  isolated  than  when  it  was  not." 

Sequelae  of  the  Diphtheroid  Angina. — The  usual  mildness  of  the  disease 
is  in  part,  no  doubt,  due  to  the  less  frequent  systemic  invasion.  Some  of  the 
worst  forms  of  general  streptococcus  infection  are,  however,  seen  in  this  dis- 
ease. There  are  no  peculiarities,  local  or  general,  which  can  be  in  any  way 
regarded  as  distinctive;  and  even  the  most  extensive  paralysis  may  follow  an 
angina  caused  by  it. 

Morbid  Anatomy. — DISTRIBUTION  OF  MEMBRANE. — A  definite  membrane 
was  found  in  127  of  the  220  fatal  Boston  cases,  distributed  as  follows:  tonsils, 
65  cases;  epiglottis,  60;  larynx,  75;  trachea,  66;  pharynx,  51;  mucous  mem- 
brane of  nares,  43;  bronchi,  42;  soft  palate,  including  uvula,  13;  oesophagus, 
12 ;  tongue,  9 ;  stomach,  5 ;  duodenum,  1 ;  vagina,  2 ;  vulva,  1 ;  skin  of  ear,  1 ; 
conjunctiva,  1.  An  interesting  point  in  the  Boston  investigation  was  the  great 
frequency  with  which  the  accessory  sinuses  of  the  nose  were  found  to  be  in- 
fected. In  the  fatal  cases,  the  exudation  is  very  extensive,  involving  the 
uvula,  the  soft  palate,  the  posterior  nares,  and  the  lateral  and  posterior  walls  of 
the  pharynx.  These  parts  are  covered  with  a  dense  pseudo-membrane,  in 
places  firmly  adherent,  in  others  beginning  to  separate.  In  extreme  cases 
the  necrosis  is  advanced  and  there  is  a  gangrenous  condition  of  the  parts. 
The  membrane  is  of  a  dirty  greenish  or  gray  color,  and  the  tonsils  and  palate 
may  be  in  a  state  of  necrotic  sloughing.  The  erosion  may  be  deep  enough  in 
the  tonsils  to  open  the  carotid  artery,  or  a  false  aneurism  may  be  produced 
in  the  deep  tissues  of  the  neck.  The  nose  may  be  completely  blocked  by  the 
false  membrane,  which  may  also  extend  into  the  conjunctiva?  and  through  the 
Eustachian  tubes  into  the  middle  ear.  In  cases  of  laryngeal  diphtheria  the 
exudate  in  the  pharynx  may  be  extensive.  In  many  cases,  however,  it  is  slight 
upon  the  tonsils  and  fauces  and  abundant  upon  the  epiglottis  and  the  larynx, 
which  may  be  completely  occluded  by  false  membrane.  In  severe  cases  the 
exudate  extends  into  the  trachea  and  to  the  bronchi  of  the  third  or  fourth 
dimension. 


62  SPECIFIC    INFECTIOUS    DISEASES 

In  all  these  situations  the  membrane  varies  very  much  in  consistence,  de- 
pending greatly  upon  the  stage  at  which  death  has  taken  place.  If  death 
has  occurred  early,  it  is  firm  and  closely  adherent;  if  late,  it  is  soft,  shreddy, 
and  readily  detached.  When  firmly  adherent  it  is  torn  off  with  difficulty  and 
leaves  an  abraded  mucosa.  In  the  most  extreme  cases,  in  which  there  is 
extensive  necrosis,  the  parts  look  gangrenous.  In  fatal  cases  the  lymphatic 
glands  of  the  neck  are  enlarged,  and  there  is  a  general  infiltration  of  the 
tissues  with  serum;  the  salivary  glands,  too,  may  be  swollen.  In  rare  in- 
stances the  membrane  extends  to  the  gullet  and  stomach. 

On  inspection  of  the  larynx  of  a  child  dead  of  membranous  croup  the  rima 
is  seen  filled  with  mucus  or  with  a  shreddy  material  which,  when  washed  off 
carefully,  leaves  the  mucosa  covered  by  a  thin  grayish-yellow  membrane, 
which  may  be  uniform  or  in  patches.  It  covers  the  ary-epiglottic  folds  and 
the  true  cords,  and  may  be  continued  into  the  ventricles  or  even  into  the 
trachea.  Above,  it  may  involve  the  epiglottis.  It  varies  much  in  consistency. 
I  have  seen  fatal  cases  in  which  the  exudation  was  not  actually  membranous, 
but  rather  friable  and  granular.  It  may  form  a  thick,  even  stratified  mem- 
brane, which  fills  the  entire  glottis.  The  exudation  may  extend  down  the 
trachea  and  into  the  bronchi,  and  may  pass  beyond  the  epiglottis  to  the  fauces. 
Usually  it  is  readily  stripped  off  from  the  mucous  membrane  of  the  larynx 
and  leaves  exposed  the  swollen  and  injected  mucosa.  On  examination  it  is 
seen  that  the  fibrinous  material  has  involved  chiefly  the  epithelial  lining  and 
has  not  greatly  infiltrated  the  subjacent  tissues. 

We  owe  largely  to  the  labors  of  Wagner,  Weigert,  and  more  particularly 
to  the  splendid  work  of  Oertel,  our  knowledge  of  the  histological  changes 
which  take  place  in  diphtheria.  The  beginning  of  the  lesion  is  due  to  the 
toxic  action  of  the  bacilli  growing  in  the  throat.  The  primary  lesion  is  a 
necrosis  and  degeneration  of  the  epithelial  tissues.  The  organisms  grow,  not 
in  the  living,  but  in  the  necrotic  tissues.  The  first  step  is  necrosis  of  the 
epithelium,  often  preceded  by  active  proliferation  of  the  nuclei  of  the  cells, 
which  become  changed  into  refractive  hyaline  masses.  From  the  structures 
below  an  inflammatory  exudate  rich  in  fibrin  factors  is  poured  out,  and 
fibrin  is  formed  when  this  comes  in  contact  with  the  necrotic  epithelium. 

The  following  are  the  important  changes  in  the  other  organs : 

HEART. — Fatty  degeneration  is  found  in  a  majority  of  the  cases.  It  may 
precede  the  more  advanced  degeneration,  in  which  the  sarcous  elements  become 
swollen  and  converted  into  hyaline  masses.  There  is  a  primary,  acute,  inter- 
stitial myositis,  and  also  a  form  secondary  to  degeneration  of  the  heart  muscle, 
to  which  it  is  possible  that  some  of  the  cases  of  fibrous  myocarditis  are  due. 
Pericarditis  and  endocarditis  are  rare;  endocarditis  was  present  in  7  of  220 
cases  at  the  Boston  City  Hospital.  The  diphtheria  bacilli  have  been  found  in 
the  vegetations. 

The  PULMONARY  COMPLICATIONS  are  the  most  important,  and  death  is  due 
to  them  as  often  as  to  the  throat  lesion.  Broncho-pneumonia,  or,  as  Council- 
man terms  it,  acinous  pneumonia,  is  the  most  common,  and  was  present  in  131 
of  the  220  Boston  cases.  Acute  lobar  pneumonia  is  rare.  The  pneumococcus 
is  the  principal  agent  in  producing  the  lung  infection.  The  streptococci  and 
the  diphtheria  bacilli  are  frequently  met  with. 

KIDNEYS. — The  lesions,  which  are  due  to  the  action  of  the  toxins,  not  to 


DIPHTHERIA  63 

the  presence  of  bacteria,  vary  from  simple  degeneration  to  an  intense  nephritis. 
There  is  no  specific  type  of  lesion.  Interstitial  and  glomerular  nephritis  are 
most  common  in  the  older  subjects.  Degenerative  changes  are  present  in  a 
large  proportion  of  all  the  fatal  cases. 

The  liver  and  the  spleen  show  the  degenerative  lesions  of  the  acute  in- 
fections. 

General  infection  is  common,  and  is  about  equal  with  the  streptococcus 
and  the  diphtheria  bacillus.  It  occurs  generally  in  the  grave  septic  cases,  in 
which  type  of  cases  the  former  organism  is  more  frequently  met  with. 

Symptoms. — The  period  of  incubation  is  "from  two  to  seven  days,  often- 
est  two." 

The  initial  symptoms  are  those  of  an  ordinary  febrile  attack — slight  chilli- 
ness, fever,  and  aching  pains  in  the  back  and  limbs.  In  mild  cases  these  symp- 
toms are  trifling,  and  the  child  may  not  feel  ill  enough  to  go  to  bed.  Usually 
the  temperature  rises  within  the  first  twenty-four  hours  to  102.5°  or  103°  F. ; 
in  severe  cases  to  104°  F.  In  young  children  there  may  be  convulsions  at  the 
outset. 

PHARYNGEAL  DIPHTHERIA. — In  a  typical  case  there  is  at  first  redness  of 
the  fauces,  and  the  child  complains  of  slight  difficulty  in  swallowing.  The 
membrane  first  appears  upon  the  tonsils,  and  it  may  be  a  little  difficult  to  dis- 
tinguish a  patchy  diphtheritic  pellicle  from  the  exudate  of  the  tonsillar  crypts. 
The  pharyngeal  mucous  membrane  is  reddened,  and  the  tonsils  themselves  are 
swollen.  By  the  third  day  the  membrane  has  covered  the  tonsils,  the  pillars  of 
the  fauces,  and  perhaps  the  uvula,  which  is  thickened  and  oadematous,  and 
may  fill  completely  the  space  between  the  swollen  tonsils.  The  membrane 
may  extend  to  the  posterior  wall  of  the  pharynx.  At  first  grayish-white  in 
color,  it  changes  to  a  dirty  gray,  often  to  a  yellow-white.  It  is  firmly  ad- 
herent, and  when  removed  leaves  a  bleeding,  slightly  eroded  surface,  which  is 
soon  covered  by  fresh  exudate.  The  glands  in  the  neck  are  swollen,  and 
may  be  tender.  The  general  condition  of  a  patient  in  a  case  of  moderate 
severity  is  usually  good;  the  temperature  not  very  high,  in  the  absence  of 
complications  ranging  from  102°  to  103°  F.  The  pulse  range  is  from  100 
to  120.  The  local  condition  of  the  throat  is  not  of  great  severity,  and  the 
constitutional  depression  is  slight.  The  symptoms  gradually  abate,  the  swell- 
ing of  the  neck  diminishes,  the  membranes  separate,  and  from  the  seventh  to 
the  tenth  day  the  throat  becomes  clear  and  convalescence  sets  in. 

Clinically  atypical  forms  are  extremely  common,  and  I  follow  here  Koplik's 
division : 

(a)  There  may  be  no  local  manifestation  of  membrane,  but  a  simple  catar- 
rhal  angina  associated  sometimes  with  a  croupy  cough.  The  detection  in 
these  cases  of  the  Klebs-Loeffler  bacillus  can  alone  determine  the  diagnosis. 
Such  cases  are  of  great  moment,  inasmuch  as  they  may  communicate  the 
severer  disease  to  other  children. 

(&)  There  are  cases  in  which  the  tonsils  are  covered  by  a  pultaceous  exu- 
date, not  a  consistent  membrane. 

(c)  Cases  presenting  a  punctate  form  of  membrane,  isolated,  and  usually 
on  the  surface  of  the  tonsils. 

(d)  Cases  which  begin  and  often  run  their  entire  course  with  the  local 
picture  of  a  typical  lacunar  amygdalitis.     They  may  be  mild,  and  the  local 


64  SPECIFIC   INFECTIOUS    DISEASES 

exudate  may  not  extend,  but  in  other  cases  there  are  rapid  development  of 
membrane,  and  extension  of  the  disease  to  the  pharynx  and  the  nose,  with 
severe  septic  and  constitutional  symptoms. 

(e)  Under  the  term  "latent  diphtheria"  Heubner  has  described  cases, 
usually  secondary,  occurring  chiefly  in  hospital  practice,  in  young  persons  the 
subject  of  wasting  affections,  such  as  rickets  and  tuberculosis.  There  are 
fever,  naso-pharyngeal  catarrh,  and  gastro-intestinal  disturbances.  Diphtheria 
may  not  be  suspected  until  severe  laryngeal  complications  develop,  or  the 
condition  may  not  be  determined  until  auptosy.  ' 

SYSTEMIC  INFECTION. — The  constitutional  disturbance  in  mild  diphtheria 
is  very  slight.  There  are  instances,  too,  of  extensive  local  disease  without 
grave  systemic  symptoms.  As  a  rule,  the  general  features  of  a  case  bear  a 
definite  relation  to  the  severity  of  the  local  disease.  There  are  rare  instances 
in  which  from  the  outset  the  constitutional  prostration  is  extreme,  the  pulse 
frequent  and  small,  the  fever  high,  and  the  nervous  phenomena  are  pro- 
nounced; the  patient  may  sink  in  two  or  three  days  overwhelmed  by  the  in- 
tensity of  the  toxaemia.  There  are  cases  of  this  sort  in  which  the  exudate  in 
the  throat  may  be  slight,  but  usually  the  nasal  symptoms  are  pronounced. 
The  temperature  may  be  very  slightly  raised  or  even  subnormal.  More  com- 
monly the  severe  systemic  symptoms  appear  at  a  later  date  when  the  pharyn- 
geal  lesion  is  at  its  height.  They  are  constantly  present  in  extensive  disease, 
and  when  there 'is  a  sloughing,  fetid  condition.  The  lymphatic  glands  be- 
come greatly  enlarged;  the  pallor  is  extreme;  the  face  has  an  ashen-gray 
hue;  the  pulse  is  rapid  and  feeble,  and  the  temperature  sinks  below  normal. 
In  the  most  aggravated  forms  there  are  gangrenous  processes  in  the  throat, 
and  in  rare  instances,  when  life  is  prolonged,  extensive  sloughing  of  the 
tissues  of  the  neck. 

Escherich  accounts  for  the  discrepancy  sometimes  observed  between  the 
severity  of  the  constitutional  disturbance  and  the  intensity  of  the  local 
process,  by  assuming  varying  degrees  of  susceptibility  to  the  diphtheria  bacillus 
on  the  one  hand,  and  to  its  poison  on  the  other  hand.  With  high  local  sus- 
ceptibility of  a  part  to  the  action  of  the  bacillus,  with  little  general  suscepti- 
bility to  the  toxin,  there  is  extensive  local  exudate  with  mild  constitutional 
symptoms,  or  vice  versa,  severe  systematic  disturbance  with  limited  local  in- 
flammation. 

A  leucocytosis  is  present  in  diphtheria.  Morse  does  not  think  it  of  any 
prognostic  value,  since  it  is  present  and  may  be  pronounced  in  mild  cases. 

NASAL  DIPHTHERIA. — In  cases  of  pharyngeal  diphtheria  the  Klebs-Loef- 
fler  bacillus  is  found  on  the  mucous  membrane  of  the  nose  and  in  the  secre- 
tions, even  when  no  membrane  is  present,  but  it  may  apparently  produce  two 
affections  similar  enough  locally  but  widely  differing  in  their  general  features. 

In  membranous  or  fibrinous  rjiinitis,  a  very  remarkable  affection  seen  usu- 
ally in  children,  the  nares  are  occupied  by  thick  membranes,  but  there  is  an 
entire  absence  of  any  constitutional  disturbance.  The  condition  has  been 
studied  very  carefully  by  Park,  Abbott,  Gerber  and  Podack,  and  others. 
Eavenel  has  collected  77  cases,  in  41  of  which  a  bacteriological  examination 
was  made,  in  33  the  Klebs-Loeffler  bacillus  being  present.  All  the  cases  ran 
a  benign  course,  and  in  all  but  a  few  the  membrane  was  limited  to  the  nose, 
and  the  constitutional  symptoms  were  either  absent  or  very  slight.  Remark- 


DIPHTHERIA  65 

able  and  puzzling  features  are  that  the  disease  runs  a  benign  course,  and  that 
infection  of  other  children  in  the  family  is  extremely  rare. 

On  the  other  hand,  nasal  diphtheria  is  apt  to  present  a  most  malignant 
type  of  the  disease.  The  infection  may  be  primary  in  the  nose,  and  in  a  case 
in  my  wards  there  was  otitis  media,  and  the  Klebs-Loeffler  bacillus  was  sepa- 
rated from  the  discharge  before  the  condition  of  nasal  diphtheria  was  sus- 
pected. While  some  cases  are  of  mild  character,  others  are  very  malignant, 
and  the  constitutional  symptoms  most  profound.  The  glandular  inflammation 
is  usually  very  intense,  owing,  as  Jacobi  points  out,  to  the  great  richness  of  the 
nasal  mucosa  in  lymphatics.  From  the  nose  the  inflammation  may  extend 
through  the  tear-ducts  to  the  conjunctiva?  and  into  the  antra. 

LARYXGEAL  DIPHTHERIA  (Membranous  Croup). — With  a  very  large  pro- 
portion of  all  the  cases  of  membranous  laryngitis  the  Klebs-Loeffler  bacillus  is 
associated ;  in  a  much  smaller  number  other  organisms,  particularly  the  strep- 
tococcus, are  found.  Membranous  croup,  then,  may  be  said  to  be  either  genu- 
ine diphtheria  or  diphtheroid  in  character.  Of  286  cases  in  which  the  disease 
was  confined  to  the  larynx  or  bronchi,  in  229  the  Klebs-Loeffler  bacilli  were 
found.  In  57  they  were  not  present,  but  17  of  these  cultures  were  unsatis- 
factory (Park  and  Beebe).  The  streptococcus  cases  are  more  likely  to  be  sec- 
ondary to  other  acute  diseases. 

Symptoms. — Xaturally,  the  clinical  symptoms  are  almost  identical  in  the 
non-specific  and  specific  forms  of  membranous  laryngitis. 

The  affection  begins  like  an  acute  laryngitis  with  slight  hoarseness  and 
rough  cough,  to  which  the  term  croupy  has  been  applied.  After  these  symp- 
toms have  lasted  for  a  day  or  two  with  varying  intensity,  the  child  suddenly 
becomes  worse,  usually  at  night,  and  there  are  signs  of  impeded  respiration. 
At  first  the  difficulty  in  breathing  is  paroxysmal,  due  probably  to  more  or  less 
spasm  of  the  muscles  of  the  glottis.  Soon  the  dyspncea  becomes  continuous, 
inspiration  and  expiration  become  difficult,  particularly  the  latter,  and  with 
the  inspiratory  movement  the  epigastrium  and  lower  intercostal  spaces  are 
retracted.  The  voice  is  husky  and  may  be  reduced  to  a  whisper.  The  color 
gradually  changes  and  the  imperfect  aeration  of  the  blood  is  shown  in  the 
lividity  of  the  lips  and  finger-tips.  Restlessness  comes  on  and  the  child  tosses 
from  side  to  side,  vainly  trying  to  get  breath.  Occasionally,  in  a  severer  par- 
oxysm, portions  of  membrane  are  coughed  out.  The  fever  in  membranous 
laryngitis  is  rarely  very  high  and  the  condition  of  the  child  is  usually  very 
good  at  the  time  of  the  onset.  The  pulse  is  always  increased  in  frequency  and 
if  cyanosis  be  present  is  small.  In  favorable  cases  the  dyspncea  is  not  very 
urgent,  ftie  color  of  the  face  remains  good,  and  after  one  or  two  paroxysms  the 
child  goes  to  sleep  and  wakes  in  the  morning,  perhaps  without  fever  and  feel- 
ing comfortable.  The  attack  may  recur  the  following  night  with  greater 
severity.  In  unfavorable  cases  the  dyspnoea  becomes  more  and  more  urgent, 
the  cyanosis  deepens,  the  child,  after  a  period  of  intense  restlessness,  sinks!  into 
a  semi-comatose  state,  and  death  finally  occurs  from  poisoning  of  the  nerve 
centres.  In  other  cases  the  onset  is  less  sudden  and  is  preceded  by  a  longer 
period  of  indisposition.  As  a  rule,  there  are  pharyngeal  symptoms.  The 
constitutional  disturbance  may  be  more  severe,  the  fever  higher,  and  there 
may  be  swelling  of  the  glands  of  the  neck.  Inspection  of  the  fauces  may 
show  the  presence  of  false  membranes  on  the  pillars  or  on  the  tonsils-  Bac- 


66  SPECIFIC   INFECTIOUS    DISEASES 

teriological  examination  can  alone  determine  whether  these  are  due  to  the 
Klebs-Loffler  bacillus  or  to  the  streptococcus.  Fagge  held  that  non-contagious 
membranous  croup  may  spread  upward  from  the  larynx  just  as  diphtheritic 
inflammation  is  in  the  habit  of  spreading  downward  from  the  fauces.  Ware, 
of  Boston,  whose  essay  on  croup  is  one  of  the  most  solid  contributions  to  the 
subject,  reported  the  presence  of  exudate  in  the  fauces  in  74  out  of  75  cases 
of  croup.  These  observations  were  made  prior  to  1840,  during  periods  in 
which  diphtheria  was  not  epidemic  to  any  extent  in  Boston.  In  protracted 
cases  pulmonary  symptoms  may  occur,  which  are  sometimes  due  to  the  diffi- 
culty in  expelling  the  muco-pus  from  the  tubes ;  in  others,  the  false  membrane 
extends  into  the  trachea  and  even  into  the  bronchial  tubes.  During  the 
paroxysm  the  vesicular  murmur  is  scarcely  audible,  but  the  laryngeal  stridor 
may  be  loudly  communicated  along  the  bronchial  tubes. 

DIPHTHERIA  or  OTHER  PARTS. — Primary  diphtheria  occurs  occasionally 
in  the  conjunctiva.  It  follows  in  some  instances  the  affection  of  the  nasal 
mucous  membrane.  Some  of  the  cases  are  severe  and  serious,  but  it  has  been 
shown  by  C.  Frankel  and  others  that  the  diphtheria  bacilli  may  be  present  in 
a  conjunctivitis  catarrhal  in  character,  or  associated  with  only  slight  croupous 
deposits. 

Diphtheria  of  the  external  auditory  meatus  is  seen  in  rare  instances  in 
which  a  diphtheritic  otitis  media  has  extended  through  the  tympanic  mem- 
brane. 

Diphtheria  of  the  skin  is  most  frequently  seen  in  the  severer  forms  of 
pharyngeal  diphtheria,  in  which  the  membrane  extends  to  the  mouth  and 
lips,  and  invades  the  adjacent  portions  of  the  skin  of  the  face.  The  skin  about 
the  anus  and  genitals  may  also  be  attacked.  Pseudo-membranous  inflamma^ 
tion  is  not'  uncommon  on  ulcerated  surfaces  and  wounds.  In  very  many 
of  these  cases  it  is  a  streptococcus  infection,  but  in  a  majority,  perhaps,  in 
which  the  patient  is  suffering  with  diphtheria,  the  Klebs-Loeffler  bacillus  will 
be  found  in  the  fibrinous  exudate.  As  proposed  by  Welch,  the  term  "wound 
diphtheria"  should  be  limited  to  infection  of  a  wound  by  the  Klebs-Loeffler 
bacillus.  This  "may  manifest  itself  as  a  simple  inflammation,  or  inflammation 
with  superficial  necrosis,  or  inflammation  with  more  or  less  adherent  pseudo- 
membrane.  The  conditions  as  regards  varying  intensity  and  character  of 
the  infection,  association  with  other  bacteria,  particularly  streptococci,  and 
the  necessity  of  a  bacteriological  examination  to  establish  the  diagnosis,  are 
in  no  way  different  in  the  diphtheria  of  wounds  from  those  in  diphtheria 
of  mucous  membranes.  Wound  diphtheria  may  occur  without  demonstrable 
connection  with  cases  of  diphtheria  and  without  affection  of  the  tfiroat  in 
the  individual  attacked,  but  such  occurrences  are  rare"  (Welch).  Paralysis 
may  follow  wound  diphtheria.  Pseudo-membranous  inflammations  of  wounds 
are  caused  more  frequently  by  other  micro-organisms,  particularly  the  strepto- 
coccus pyogenes,  than  by  the  Klebs-Loeffler  bacillus.  The  fibrinous  membrane 
so  common  in  the  neighborhood  of  the  tracheotomy  wound  in  diphtheria  is 
rarely  associated  with  the  Klebs-Loeffler  bacillus.  Diphtheria  of  the  genitals 
is  occasionally  seen. 

Complications  and  Sequelae. — Of  local  complications,  haemorrhage  from 
the  nose  or  throat  may  occur  in  the  severe  ulcerative  cases.  Skin  rashes  are 
not  infrequent,  particularly  the  diffuse  erythema.  Occasionally  there  is  urti- 


DIPHTHERIA  67 

caria  and  in  the  severe  cases  purpura.  Fatal  cases  almost  invariably  show 
capillary  bronchitis  with  broncho-penumonia  and  large  patches  of  collapse,  or 
the  septic  particles  may  reach  the  bronchi  and  excite  gangrenous  processes 
which  may  lead  to  severe  and  fatal  hemorrhage.  Jaundice,  usually  a  feature 
of  the  toxaemia,  is  rarely  of  serious  import.  Local  gangrene  may  occur. 

Albuminuria,  present  in  all  severe  cases,  is  alarming  only  when  the  albu- 
min is  in  considerable  quantity  and  associated  with  epithelial  or  blood  casts. 
Nephritis  may  appear  quite  early  in  the  disease,  setting  in  occasionally  with 
complete  suppression  of  the  urine.  In  comparison  with  scarlet  fever  the  renal 
changes  lead  less  frequently  to  general  dropsy.  In  rare  instances  there  may 
be  coma,  and  even  convulsions,  without  albumin  in  the  urine,  and  without 
drops}r. 

Of  the  sequele,  paralysis  is  by  far  the  most  important.  It  can  be  experi- 
mentally produced  in  animals  by  the  inoculation  of  the  toxins.  The  disease  is 
a  toxic  neuritis,  due  to  the  absorption  of  the  poison.  The  proportion  of  the 
cases  in  which  it  occurs  ranges  from  10  to  15  and  even  to  20  per  cent.  It  is 
strictly  a  sequel,  coming  on  usually  in  the  second  or  third  week  of  convales- 
cence. It  may  follow  very  mild  cases;  indeed,  the  local  lesion  may  be  so 
trifling  that  the  onset  of  the  paralysis  alone  calls  attention  to  the  true  nature 
of  the  trouble.  It  is  proportionately  less  frequent  in  children  than  in  adults. 
L.  W.  Rolleston's  recent  study  of  the  subject  indicates  that  the  early  use  of 
antitoxin  diminishes  the  liability  to  paralysis.  In  494  cases  collected,  by 
Woodhead,  the  palate  was  involved  in  155,  the  ocular  muscles  in  197,  in  10 
other  muscles.  Ninety-one  of  the  patients  died. 

Of  the  local  paralyses  the  most  common  is  that  which  affects  the  palate. 
This  gives  a  nasal  character  to  the  voice,  and,  owing  to  a  return  of  liquids 
through  the  nose,  causes  a  difficulty  in  swallowing.  The  palate  is  seen  to  be 
relaxed  and  motionless,  and  the  sensation  in  it  is  also  much  impaired.  The 
affection  may  extend  to  the  constrictors  of  the  pharynx,  and  deglutition  become 
embarrassed.  Within  two  or  three  weeks  or  even  a  shorter  time  the  paralysis 
disappears.  In  many  cases  the  affection  of  the  palate  is  only  part  of  a  general 
neuritis.  Of  other  local  forms  perhaps  the  most  common  are  paralyses  of  the 
eye-muscles,  intrinsic  and  extrinsic.  There  may  be  strabismus,  ptosis,  and 
loss  of  power  of  accommodation.  Facial  paralysis  is  rare.  The  neuritis  may 
be  confined  to  the  nerves  of  one  limb,  though  more  commonly  the  legs  or  the 
arms  are  affected  together.  Very  often  with  the  palatal  paralysis  is  associated 
a  weakness  of  the  legs  without  definite  palsy  but  with  loss  of  the  knee-jerk. 

The  multiple  form  of  diphtheritic  neuritis  may  begin  with  the  palatal 
affection,  or  with  loss  of  power  of  accommodation  and  loss  of  the  tendon 
reflexes.  This  last  is  an  important  sign,  which,  as  Bernard,  Buzzard,  and 
R.  L.  MacDonnell  have  shown,  may  occur  early,  but  is  not  necessarily  fol- 
lowed by  other  symptoms  of  neuritis.  There  is  paraplegia,  which  may  be 
complete  or  involve  only  the  extensors  of  the  feet.  The  paralysis  may  extend 
and  involve  the  arms  and  face  and  render  the  patient  entirely  helpless.  The 
muscles  of  respiration  may  be  spared. 

Heart. — Irregularity  of  the  heart  is  common.  It  was  present  in  60  per 
cent,  of  the  Boston  cases  of  White  and  Smith.  A  murmur  at  the  apex  or 
base  of  the  heart  is  present  in  94  per  cent,  of  all  cases.  This  means,  of  course, 
that  a  majority  of  all  young  children  with  fever  have  a  heart  murmur.  Onty 


68  SPECIFIC    INFECTIOUS   DISEASES 

a  few  cases  of  diphtheria  have  serious  heart  symptoms,  36  out  of  the  946 
cases  specially  studied.  Eapid  action  of  the  heart  with  gallop  rhythm  and 
epigastric  pain  and  tenderness  are  the  most  serious  symptoms.  The  cases  in 
which  the  pulse  drops  from  110  to  40  or  30  are  usually  very  serious.  Some 
are  due  to  heart  block.  The  heart  S}'mptoms  are  more  common  in  the  second 
or  third  week  of  the  disease,  and  fatal  dilatation  of  the  heart  may  come  on  as 
late  as  the  sixth  or  seventh  week.  It  seems  probable  that  the  heart  weakness  is 
due  to  degeneration  of  the  muscle.  Possibly  in  some  of  the  cases  there  is 
degeneration  of  the  vagus,  a  view  which  is  supported  by  the  frequency  of 
paralysis  of  the  palate  with  vomiting  and  epigastric  pain  and  tenderness. 

Diagnosis. — The  presence  of  the  Klebs-Loeffler  bacillus  is  regarded  by  bac- 
teriologists as  the  sole  criterion  of  true  diphtheria,  and  as  this  organism  may 
be  associated  with  all  grades  of  throat  affections,  from  a  simple  catarrh  to  a 
sloughing,  gangrenous  process,  it  is  evident  that  in  many  instances  there  will 
be  a  striking  discrepancy  between  the  clinical  and  the  bacteriological  diagnosis. 

The  bacteriological  diagnosis  is  simple.  The  plan  adopted  by  the  New 
York  Health  Department  is  a  model  which  may  be  followed  with  advantage  in 
other  cities.  Outfits  for  making  cultures,  consisting  of  a  box  containing  a 
tube  of  blood-serum  and  a  sterilized  swab  in  a  test-tube,  are  distributed  to 
stations  at  convenient  points  in  the  city.  A  list  of  these  places  is  published, 
and  a  physician  can  obtain  the  outfit  free  of  cost.  The  directions  are  as 
follows :  "The  patient  should  be  placed  in  a  good  light,  and,  if  a  child,  prop- 
erly held.  In  cases  where  it  is  possible  to  get  a  good  view  of  the  throat,  depress 
the  tongue  and  rub  the  cotton  swab  gently  but  freely  against  any  visible 
exudate.  In  other  cases,  including  those  in  which  the  exudate  is  confined 
to  the  larynx,  avoiding  the  tongue,  pass  the  swab  far  back  and  rub  it  freely 
against  the  mucous  membrane  of  the  pharynx  and  tonsils.  Without  laying  the 
swab  down,  withdraw  the  cotton  plug  from  the  culture-tube,  insert  the  swab, 
and  rub  that  portion  of  it  which  has  touched  the  exudate  gently  but  thoroughly 
all  over  the  surface  of  the  blood-serum.  Do  not  push  the  swab  into  the 
blood-serum,  nor  break  the  surface  in  any  way.  Then  replace  the  swab  in 
its  own  tube,  plug  both  tubes,  put  them  in  the  box,  and  return  the  culture 
outfit  at  once  to  the  station  from  which  it  was  obtained."  The  culture-tubes 
which  have  been  inoculated  are  kept  in  an  incubator  at  37°  C.  for  twelve 
hours  and  are  then  ready  for  examination.  Some  prefer  a  method  by  which 
the  material  from  the  throat  collected  on  a  sterile  swab,  or,  as  recommended 
by  von  Esmarch,  on  small  pieces  of  sterilized  sponge,  is  sent  to  the  laboratory 
where  the  cultures  and  microscopic  examination  are  made  by  a  bacteriologist. 

An  immediate  diagnosis  without  the  use  of  cultures  is  often  possible  by 
making  a  smear  preparation  of  the  exudate  from  the  throat.  The  Klebs-Loef- 
fler bacilli  may  be  present  in  sufficient  numbers,  and  may  be  quite  character- 
istic to  an  expert.  In  this  connection  may  be  given  the  following  statement 
by  Park,  who  has  had  such  an  exceptional  experience:  "The  examination  by 
a  competent  bacteriologist  of  the  bacterial  growth  in  a  blood-serum  tube  which 
has  been  properly  inoculated  and  kept  for  fourteen  hours  at  the  body  tem- 
perature can  be  thoroughly  relied  upon  in  cases  where  there  is  visible  mem- 
brane in  the  throat,  if  the  culture  is  made  during  the  period  in  which  the 
membrane  is  forming,  and  no  antiseptic,  especially  no  mercurial  solution,  has 
lately  been  applied.  In  cases  in  which  the  disease  is  confined  to  the  larynx  or 


DIPHTHEEIA  69 

bronchi,  surprisingly  accurate  results  can  be  obtained  from  cultures,  but  in  a 
certain  proportion  of  cases  no  diphtheria  bacilli  will  be  found  in  the  first 
culture,  and  yet  will  be  abundantly  present  in  later  cultures.  We  believe, 
therefore,  that  absolute  reliance  for  a  diagnosis  can  not  be  placed  upon  a  single 
culture  from  the  pharynx  in  purely  laryngeal  cases." 

Where  a  bacteriological  examination  can  not  be  made,  the  practitioner  must 
regard  as  suspicious  all  forms  of  throat  affections  in  children,  and  carry  out 
measures  of  isolation  and  disinfection.  In  this  way  alone  can  serious  errors 
be  avoided.  It  is  not,  of  course,  in  the  severer  forms  of  membranous  angina 
that  mistake  is  likely  to  occur,  but  in  the  various  lighter  forms,  many  of  which 
are  in  reality  due  to  the  Klebs-Loeffler  bacillus. 

A  large  proportion  of  the  cases  of  diphtheroid  inflammation  of  the  throat 
are  due  to  the  streptococcus  pyogenes.  They  are  usually  milder,  and  the  lia- 
bility to  general  infection  is  less  intense ;  still,  in  scarlet  fever  and  other  spe- 
cific fevers  some  of  the  most  virulent  cases  of  throat  disease  which  we  see, 
with  intense  systemic  infection,  are  caused  by  this  micro-organism.  These 
streptococcus  cases  are  probably  much  less  numerous  than  the  figures  given 
would  indicate.  The  more  careful  examinations  in  the  diphtheria  pavilions 
of  hospitals,  particularly  in  Europe,  have  shown  that  in  the  large  majority 
of  cases  admitted  the  Klebs-Loeffler  bacillus  is  present.  The  question  of  the 
diagnosis  between  scarlet  fever  with  severe  angina  and  diphtheria  is  dis- 
cussed in  the  section  on  scarlet  fever. 

Prognosis. — The  outlook  in  any  case  depends  on  the  promptness  and  thor- 
oughness with  which  antitoxin  treatment  is  carried  out.  In  hospital  practice 
the  mortality  was  formerly  from  30  to  50  per  cent.  In  the  Boston  City  Hos- 
pital the  death-rate  between  1888  and  1894  was  only  once  below  40  per  cent., 
and  in  1892  and  1893  rose  to  nearly  50  per  cent.  Following  the  introduction 
of  antitoxin  from  1895  to  1912  the  death-rate  has  not  once  been  above  15  per 
cent.,  and  in  6,080  recent  cases  has  been  7.8  per  cent.  (McCollom).  In  coun- 
try places  the  disease  may  display  an  appalling  virulence.  In  cases  of  ordinary 
severity  the  outlook  is  usually  good.  Death  results  from  involvement  of 
the  larynx,  septic  infection,  sudden  heart-failure,  diphtheritic  paralysis,  occa- 
sionally from  uraemia,  and  sometimes  from  broncho-pneumonia  occurring 
during  convalescence.  In  England  and  Wales  in  1909  there  were  5,476  deaths, 
compared  with  9,130,  the  average  number  in  the  previous  decennium 
(Tatham).  Of  late  years  the  mortality  has  been  steadily  falling.  In  Boston 
during  the  twenty  years  ending  1894  the  mortality  per  10,000  of  the  living 
averaged  14.46.  The  mortality  has  greatly  decreased,  from  18.03  per  10,000 
living  in  1894  to  1.5  in  1912  (McCollom). 

Prophylaxis. — Isolation  of  the  sick,  disinfection  of  the  clothing  and  of 
everything  that  has  come  in  contact  with  the  patient,  careful  scrutiny  of  the 
milder  cases  of  throat  disorder,  and  more  stringent  surveillance  in  the  period 
of  convalescence  are  the  essential  measures  to  prevent  the  spread  of  the  dis- 
ease. Suspected  cases  in  families  or  schools  should  be  at  once  isolated  or  re- 
moved to  a  hospital  for  infectious  disorders.  When  a  death  has  occurred  from 
diphtheria,  the  body  should  be  wrapped  in  a  sheet  which  has  been  soaked  in 
a  corrosive-sublimate  solution  (1  to  2,000),  and  placed  in  a  closely  sealed 
coffin.  The  funeral  should  always  be  private. 

In  cases  of  well-marked  diphtheria  these  precautions  are  usually  carried 


70  SPECIFIC   INFECTIOUS    DISEASES 

out,  but  the  chief  danger  is  from  the  milder  cases,  particularly  the  ambulatory 
form,  in  which  the  disease  has  perhaps  not  been  suspected.  But  from  such 
patients  mingling  with  susceptible  children  the  disease  is  often  conveyed.  The 
healthy  children  in  a  family  in  which  diphtheria  exists  may  carry  the  disease 
to  their  school-fellows.  The  question  of  the  influence  of  isolation  hospitals 
on  the  spread  of  the  disease  has,  I  think,  been  solved  in  Boston,  a  city  which 
has  suffered  terribly  from  diphtheria.  The  ratio  of  mortality  per  10,000  living 
in  1893  was  11+,  and  in  1894  it  was  19+.  In  1895  the  infectious  pavilion 
was  opened.  Prior  to  that  year  only  about  10  per  cent,  of  the  reported  cases 
were  treated  in  hospital ;  in  succeeding  years  50  per  cent,  were  treated  in  hos- 
pital. In  1898  the  mortality  per  10,000  had  fallen  to  3,  and  in  1899  it 
was  4.9. 

A  very  important  matter  in  the  prophylaxis  relates  to  the  period  of  con- 
valescence. It  has  been  shown  by  numerous  observations  that,  after  all  the 
membrane  has  cleared  away,  virulent  bacilli  may  persist  in  the  throat  from 
periods  ranging  from  six  weeks  to  six  months,  or  even  longer.  The  disease 
may  be  communicated  by  these  carriers  and  they  should  be  isolated  and  the 
throat  carefully  treated,  but  there  are  cases  very  resistant  to  all  forms  of 
throat  antiseptics.  Antitoxin  may  be  applied  locally  to  the  throat  and  spray- 
ing the  throat  and  nose  with  a  bouillon  culture  of  staphylococcus  pyogenes 
aureus  is  stated  to  be  an  efficient  measure. 

It  cannot  be  too  strongly  emphasized  that  the  important  elements  in  the 
prophylaxis  of  diphtheria  are  the  rigid  scrutiny  of  the  milder  types  of  throat 
affection,  and  the  thorough  isolation  and  disinfection  of  the  individual 
patients.  During  an  epidemic  there  should  be  repeated  examinations  made  of 
all  those  exposed  to  infection. 

Careful  attention  should  be  given  to  the  throats  and  mouths  of  childen, 
particularly  to  the  teeth  and  tonsils,  as  Caille  has  urged.  Swollen  and  en- 
larged tonsils  should  be  removed.  Cats  and  dogs  may  carry  infection  and 
should  be  excluded  from  coming  in  contact  with  patients.  In  persons  exposed, 
the  antiseptic  mouth  washes,  such  as  corrosive  sublimate  (1  to  10,000),  hydro- 
gen peroxide,  or  swabbing  the  throat  with  a  diluted  Loeffler's  solution,  should 
be  employed.  Physicians  and  nurses  should  wear  gowns  and  caps,  and  cover 
the  nose  and  mouth  with  gauze. 

IMMUNIZATION. — The  giving  of  antitoxin  as  a  preventive  measure  has  an 
important  place.  Its  value  is  well  shown  in  the  children's  hospitals  in  which 
it  is  given  as  a  routine  prophylactic  measure.  The  usual  dose  for  adults  is 
1,000  units,  for  older  children  750  units,  and  for  children  under  two  years 
of  age  500  units.  The  immunity  lasts  about  three  weeks.  The  same  precau- 
tions should  be  taken  as  in  giving  antitoxin  to  those  with  the  disease. 

Treatment. — The  important  points  are  hygienic  measures  to  prevent  the 
spread  of  the  malady,  local  treatment  of  the  throat  to  destroy  the  bacilli, 
medication,  general  or  specific,  to  counteract  the  effects  of  the  toxins,  and, 
lastly,  to  meet  the  complications  and  sequels. 

(a)  HYGIENIC  MEASURES. — The  patient  should  be  in  a  room  from  which 
the  carpets,  curtains,  and  superfluous  furniture  have  been  removed.  The  tem- 
perature should  be  about  68°,  and  thorough  ventilation  should  be  secured. 
The  air  may  be  kept  moist  by  a  kettle  or  a  steam-atomizer.  If  possible,  only 
the  irvse,  the  child's  mother,  and  the  doctor  should  come  in  contact  with  the 


DIPHTHERIA  71 

patient.  During  the  visit  the  physician  should  wear  a  gown  and  cap,  and  on 
leaving  the  room  he  should  thoroughly  wash  his  hands  and  face  in  a  corrosive- 
sublimate  solution.  The  strictest  quarantine  should  be  employed  against 
other  members  in  the  house. 

(&)  LOCAL  TREATMENT. — In  mild  cases  the  throat  symptoms  are  alone 
prominent.  Vigorous  local  treatment  from  the  outset  should  be  carried  out, 
taking  especial  care  in  all  instances  to  avoid  mechanical  injury  to  the  tissues. 
A  very  large  number  of  solutions  have  been  recommended.  They  are  best 
employed  with  a  swab  of  cotton-wool  or  a  soft  sponge,  or  irrigation  with  hot 
antiseptic  solutions  may  be  used.  The  direct  application  with  a  swab  of  cot- 
ton-wool or  sponge  is,  as  a  rule,  effective.  In  many  young  children  it  is  really 
a  most  trying  procedure  to  carry  out  the  treatment,  and  sometimes  one  is 
compelled  to  desist.  In  infants  the  disinfecting  fluids  are  sometimes  better 
applied  through  the  nostrils,  but  the  irrigating  stream  should  be  allowed  to 
flow  very  gently.  The  following  solutions  may  be  employed : 

Loeffler's  solution :  Menthol,  10  grams  dissolved  in  toluol  to  36  c.  c. ;  Liq. 
Ferri  sesquichlorati,  4  c.  c. ;  alcohol  absol.,  60  c.  c. 

Corrosive  sublimate,  1  to  1,000,  either  alone  or  with  tartaric  acid,  5 
grams  to  the  litre. 

Carbolic  acid,  3  per  cent,  in  30  per  cent,  alcohol  solution, is  much  employed; 
some  prefer  to  touch  the  small  spots  of  exudate  with  pure  carbolic  acid. 

Another  solution  is:  The  tincture  of  the  perchloride  of  iron,  a  drachm 
and  a  half,  in  glycerine,  one  ounce,  water,  one  ounce,  with  from  15  to  20 
minims  of  carbolic  acid.  Chlorine  water,  boric  acid,  peroxide  of  hydrogen, 
iodoform,  lactic  acid,  trypsin,  and  papain  are  also  recommended. 

In  many  cases  the  use  of  an  alkaline  solution  or  even  of  a  saline  solution 
is  more  satisfactory  than  antiseptics. 

Nasal  diphtheria  requires  prompt  and  thorough  disinfection  of  the  pas- 
sages. Jacobi  recommends  chloride  of  sodium,  saturated  boric  acid,  or  1  part 
of  bichloride  of  mercury,  35  of  chloride  of  sodium,  and  1,000  of  water, 
or  the  1-per-cent.  solution  of  carbolic  acid.  Loeffler's  solution  may  be  diluted 
and  applied  with  a  syringe  or  spray.  To  be  effectual  the  injection  must  be 
properly  given.  The  nurse  should  be  instructed  to  pass  the  nozzle  of  the 
syringe  horizontally,  not  vertically ;  otherwise  the  fluid  will  return  through  the 
same  nostril. 

When  the  larynx  becomes  involved,  a  steam  tent  may  be  arranged  upon 
the  bed,  so  that  the  child  may  breathe  an  atmosphere  saturated  with  moisture. 
When  the  signs  of  obstruction  are  marked  there  should  be  no  delay  in  the  per- 
formance of  intubation  or  tracheotomy.  The  choice  between  these  must  depend 
on  the  circumstances  in  each  case.  Intubation  may  be  regarded  as  the  opera- 
tion of  choice  in  the  majority  of  cases.  Tracheotomy  is  preferable  in  adults 
and  may  be  the  operation  of  necessity.  The  patient  requires  more  skillful  care 
after  intubation  than  after  tracheotomy. 

Hot  applications  to  the  neck  are  usually  very  grateful,  particularly  to 
young  children,  though  in  the  case  of  older  children  and  adults  the  ice  poul- 
tices are  to  be  preferred. 

(c)  GENE^VL  MEASURES. — Every  effort  should  be  made  to  nourish  the 
patient.  The  food  should  be  liquid — milk,  beef  juices,  barley  water,  ice 
cream,  albumen  water,  and  soups.  The  patient  should  be  encouraged  to  drink 


72  SPECIFIC   INFECTIOUS   DISEASES 

water  freely.  If  there  is  difficulty  in  taking  it  by  mouth,  it  should  be  given 
by  the  bowel  or  by  infusion.  The  bowels  should  be  freely  opened,  for  which  a 
calomel  and  saline  purge  is  usually  best.  When  the  pharyngeal  involvement 
is  very  great  and  swallowing  painful,  nutritive  enemata  should  be  used.  In 
cases  with  severe  constitutional  symptoms  stimulants  should  be  given  early. 

Medicines  given  internally  are  of  very  little  avail,  but  there  is  still  a  wide- 
spread belief  in  the  profession  that  forms  of  mercury  are  beneficial.  The 
tincture  of  the  perchloride  of  iron  is  also  very  warmly  recommended.  We 
must  rely  on  general  measures  of  feeding  and  stimulation  to  support  the 
strength. 

(d)  ANTITOXIN  TREATMENT. — As  the  years  go  on  additional  experience 
has  shown  that,  thoroughly  carried  out,  this  method  of  treatment  is  both 
safe  and  efficacious.  There  are  no  reasonable  grounds  for  skepticism  on  the 
part  of  intelligent  practitioners,  and  still  less  on  the  part  of  those  in  charge 
of  the  hospitals  for  infectious  diseases. 

The  principle  of  action  depends  on  the  circumstance  that  the  blood-serum 
of  an  animal  rendered  immune,  when  introduced  into  another  animal,  protects 
it  from  infection  with  the  diphtheria  bacilli,  and  has  also  an  important  cura- 
tive influence  upon  diphtheria,  whether  artificially  given  to  animals,  or  spon- 
taneously acquired  by  man.  In  the  preparation  of  the  blood-serum  a  uniform 
standard  strength  is  procured.  The  antitoxin  unit  is  the  amount  of  antitoxin, 
which,  injected  into  a  guinea-pig  of  250  grams  in  weight,  neutralizes  100 
times  the  minimum  fatal  dose  of  toxin  of  standard  strength. 

Dosage. — This  is  one  of  the  most  important  questions  relating  to  the  use 
of  the  antitoxin.  J.  H.  McCollom,  of  the  Boston  City  Hospital,  who  prob- 
ably had  a  richer  experience  with  the  disease  than  any  man  in  the  United 
States,  insisted  that  the  guiding  practice  in  the  use  of  the  antitoxin  is  to  give 
it  until  the  characteristic  effects  are  produced,  whether  4,000  or  70,000  units 
be  required  for  this  result.  He  very  rightly  remarks  that  in  the  case  of  a 
patient  ill  with  diphtheria  there  is  no  way  of  estimating  the  quantity  of  toxin 
generated  by  the  membrane,  and  therefore  one  must  administer  the  agent  until 
the  characteristic  effect  is  produced — viz.,  the  shriveling  of  the  membrane, 
the  diminution  of  the  nasal  discharge,  the  correction  of  the  fetid  odor,  and  a 
general  improvement  in  the  condition  of  the  patient.  No  case,  he  says,  in  the 
acute  stage  should  be  considered  hopeless.  "When  one  sees  a  patient  with 
membrane  covering  the  tonsils  and  uvula,  profuse  sanious  discharge  from  the 
nose,  spots  of  ecchymosis  on  the  body  and  extremities,  cold,  clammy  hands 
and  feet,  a  feeble  pulse,  and  the  nauseous  odor  of  diphtheria,  and  finds  that 
after  the  administration  of  10,000  units  of  antitoxin  in  two  doses  the  condi- 
tion of  the  patient  improves  slightly;  that  after  10,000  units  more  have  been 
given  there  is  a  marked  abatement  in  the  severity  of  the  symptoms ;  that  when 
an  additional  10,000  units  have  been  given  the  patient  is  apparently  out  of 
danger,  and  eventually  recovers — one  must  believe  in  the  curative  power  of 
antitoxin.  When  one  sees  a  patient  in  whom  the  intubation  tube  has  been 
repeatedly  clogged,  when  the  hopeless  condition  of  the  patient  changes  for  the 
better  after  the  administration  of  50.000  units,  one  can  not  help  but  be  con- 
vinced of  the  importance  of  giving  large  doses  of  antitoxin  in  the  very  severe 
and  apparently  hopeless  cases.  In  the  majority  of  instances  these  large  do00," 
are  not  required,  particularly  if  the  patients  are  seen  early  ift  the  attack,  4,00 J 


DIPHTHERIA  73 

to  6,000  units  being  enough  to  produce  the  characteristic  effect  on  the  mem- 
brane." The  initial  dose  in  ordinary  cases  should  be  from  3,000  to  5,000 
units  and  the  result  must  determine  the  frequency  of  repetition.  In  severe 
cases  and  in  laryngeal  diphtheria  the  first  dose  should  be  from  5,000  to  10,000 
units,  repeated  in  six  hours.  The  danger  is  in  giving  too  small  and  not  too 
large  a  dose. 

Administration. — Antitoxin  may  be  injected  subcutaneously,  intramuscu- 
larly or  intravenously.  The  two  last  are  advisable  in  severe  cases.  Intramus- 
cular is  usually  better  than  subcutaneous  injection.  The  skin  and  needle 
should  be  thoroughly  clean. 

Favorable  effects  are  seen  in  the  improvement  in  both  the  local  and  general 
condition.  The  swelling  of  the  fauces  subsides,  the  membrane  begins  to 
disappear,  the  temperature  falls,  and  the  pulse  becomes  slower. 

Untoward  Effects. — "Serum  Disease." — This  may  appear  in  any  normal 
individual  and  is  due  to  the  serum  and  not  to  the  antitoxin.  Following  the 
injection  after  a  varying  interval,  which  varies  from  one  to  eighteen  days,  but 
is  usually  between  seven  and  ten  days,  a  local  reaction  appears  which  may  be 
accompanied  by  general  symptoms.  The  site  of  injection  shows  cedema,  urti- 
caria or  erythema,  which  may  become  more  or  less  general.  Malaise,  vomiting, 
fever,  adenitis,  albuminuria,  and  arthralgia  may  accompany  this.  The  symp- 
toms are  usually  not  severe  and  disappear  in  three  or  four  days.  Calcium 
lactate  (gr.  xv,  1  gm.  three  times  a  day)  may  be  given  as  a  prophylactic  or 
when  the  symptoms  have  appeared.  There  is  another  reaction  which  is  much 
more  serious.  In  individuals  who  have  been  given  antitoxin  previously,  even 
at  a  long  interval — who  have  been  sensitized — in  some  who  have  had  asthma 
and  in  some  of  those  who  are  affected  by  the  smell  or  proximity  of  horses,  an 
acute  dangerous  condition  may  be  caused  by  the  injection  of  serum — anaphy- 
laxis.  This  comes  on  very  suddenly  and  with  acute  symptoms,  among  which 
are  extreme  distress,  dyspnoea,  cyanosis,  cedema,  collapse,  respiratory  failure 
and  convulsions;  death  may  follow  rapidly.  Fortunately  this  occurs  rarely, 
but  its  possibility  should  be  kept  in  mind,  and  before  giving  antitoxin  the 
patient  should  be  asked  as  to  a  history  of  asthma,  an  idiosyncrasy  to  horses 
and  previous  administration  of  antitoxin;  If  there  is  any  reason  to  suspect 
the  possibility  of  a  reaction,  the  patient  should  be  tested  by  the  administration 
of  two  or  three  drops  of  antitoxin,  which  will  not  give  a  dangerous  reaction. 
If  he  is  susceptible  a  reaction  usually  occurs  in  an  hour,  but  it  is  safer  to 
wait  three  hours.  The  skin  reaction  may  also  be  tried  (Moss),  but  this  de- 
mands twenty-four  hours,  too  long  to  wait  if  the  diphtheria  is  severe.  If  the 
patients  are  sensitive  and  the  need  of  antitoxin  is  great,  small  doses  should  be 
given  at  short  intervals.  In  the  absence  of  reaction  it  is  safe  to  give  the  usual 
dose,  for  a  sensitized  individual,  after  receiving  a  small  dose,  is  refractory  to 
larger  doses  some  hours  later.  This  must  be  kept  in  mind  in  the  case  of 
patients  who  have  a  relapse,  as  if  seven  days  have  elapsed  since  the  first  dose 
the  patient  may  be  sensitized.  Children  seem  to  be  much  less  liable  to  sensi- 
tization  than  adults.  If  anaphylaxis  should  occur,  morphia  (gr.  y±)  and 
atropine  (gr.  1-100)  hypodermically  should  be  given  at  once.  Artificial 
respiration  should  be  done  if  there  is  respiratory  failure. 

Results. — Of  183,256  cases  treated  in  150  cities  previous  to  the  serum 
period,  the  mortality  was  38.4  per  cent.  Since  the  introduction  of  serum- 
7 


74  SPECIFIC    INFECTIOUS    DISEASES 

among  132,548  cases,  there  was  a  mortality  of  14.6  per  cent.  Leaving  out 
those  not  treated  with  the  serum,  the  mortality  was  9.8  per  cent.  (Edwin 
Eosenthal).  The  figures  of  the  Boston  City  Hospital  are  of  special  value,  aa 
the  number  of  cases  is  large,  the  character  severe,  and  the  Director  of  the 
South  Department,  Dr.  McCollom,  had  faith  in  the  treatment  and  courage 
in  carrying  it  out. 

In  Chicago,  for  fifteen  years  before  antitoxin  treatment,  the  death  rate 
was  144,  for  the  fifteen  years  after  its  introduction  it  was  38  (G.  B.  Young). 

Convalescence. — This  demands  special  care,  particularly  if  there  are  signs 
of  cardiac  disturbance.  In  this  event  the  patient  should  be  kept  absolutely 
at  rest  and  this  may  be  necessary  for  a  long  period.  Nourishment  should  be 
given  freely,  strychnine  administered  in  full  doses,  and  iron  with  arsenic  if 
there  is  anaemia.  If  swallowing  becomes  difficult  it  is  wise  to  use  the  stomach 
tube  for  feeding.  With  the  post-diphtheritic  paralysis  the  patients  should  be 
kept  in  bed,  fed  liberally  and  given  strychnine  hypodermically.  Antitoxin 
is  valuable  in  doses  of  1,000  to  3,000  units  daily.  In  the  chronic  forms  with 
muscular  wasting,  electricity  and  massage  should  be  used.  The  patient  should 
not  be  discharged  from  quarantine  until  two  successive  cultures  from  the 
throat  and  nose,  two  days  apart,  have  been  negative. 


VI.    THE   PNEUMONIAS   AND   PNEUMOCOCCIC   INFECTIONS 

A  variety  of  diseases  are  caused  by  the  pneumococcus,  among  which  lobar 
and  lobular  pneumonia  are  the  most  important.  Various  inflammatory  affec- 
tions of  the  lungs  may  be  caused  by  other  organisms,  but  the  pneumococcus 
plays  the  important  role  in  the  common  fibrinous  pneumonia  and  in  the  ordi- 
nary broncho-pneumonia.  It  may  set  up  also  many  local  affections  and  is  the 
cause  of  many  terminal  infections  in  chronic  diseases. 

A.     LOBAE  PNEUMONIA, 
(Croupous  or  Fibrinous  Pneumonia,  Lung  Fever) 

Definition. — An  infection  caused  by  the  pneumococcus  of  Fraenkel,  char- 
acterized by  inflammation  of  the  lungs,  a  toxemia  of  varying  intensity  and 
a  fever  which  usually  terminates  by  crisis.  Secondary  infective  processes  are 
common. 

History. — The  disease  was  known  to  Hippocrates  and  the  old  Greek  physi- 
cians, by  whom  it  was  confounded  with  pleurisy.  Among  the  ancients,  Are- 
taeus  gave  a  remarkable  description.  "Buddy  in  countenance,  but  especially 
the  cheeks ;  the  white  of  the  eyes  very  bright  and  fatty ;  the  point  of  the  nose 
flat;  the  veins  in  the  temples  and  neck  distended;  loss  of  appetite;  pulse,  at 
first,  large,  empty,  very  frequent,  as  if  forcibly  accelerated ;  heat  indeed,  exter- 
nally, feeble,  and  more  humid  than  natural,  but,  internally,  dry  and  very  hot, 
by  means  of  which  the  breath  is  hot;  there  is  thirst,  dryness  of  the  tongue, 
desire  of  cold  air,  aberration  of  mind ;  cough  mostly  dry,  but  if  anything  be 
brought  up  it  is  a  frothy  phlegm,  or  slightly  tinged  with  bile,  or  with  a  very 
florid  tinge  of  blood.  The  blood-stained  is  of  all  others  the  worst."  At  the 
end  of  the  seventeenth  and  the  beginning  of  the  eighteenth  century  Morgagni 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS          75 

4 

and  Yalsalva  made  many  accurate  clinical  and  anatomical  observations  on  the 
disease.  Our  modern  knowledge  dates  from  Laennec  (1819),  whose  masterly 
description  of  the  physical  signs  and  morbid  anatomy  left  very  little  for  subse- 
quent observers  to  add  or  modify. 

Incidence. — One  of  the  most  widespread  and  fatal  of  all  acute  diseases, 
pneumonia  has  become  the  "Captain  of  the  Men  of  Death,"  to  use  the  phrase 
applied  by  John  Bunyan  to  consumption.  In  England  and  Wales  in  1913 
there  were  37,350  deaths  from  this  cause;  8,055  were  attributed  to  lobar 
pneumonia,  17,580  to  broncho-pneumonia,  while  11,715  were  registered  as 
from  pneumonia  without  further  qualification.  In  the  United  States  in  the 
registration  area  in  1913  there  were  83,778  deaths.  It  is  a  disease  of  cities,  in 
the  overcrowded  districts  of  which  there  has  been  an  increase  of  late,  particu- 
larly in  America. 

Careful  studies  of  tropical  pneumonia  have  been  made  at  Panama.  At  the 
Ancon  Hospital  among  574  cases  the  mortality  was  37  per  cent. ;  among  the 
mixed  races,  natives  of  the  Isthmus,  from  50  to  60  per  cent.  The  same  high 
death  rate  prevails  at  the  Colon  Hospital.  Among  the  natives  employed  in  the 
Transvaal  mines  the  disease  is  very  fatal,  killing  a  larger  number  than  any 
other  disease,  tuberculosis  coming  second.  It  is  more  particularly  among  the 
natives  during  the  first  month  of  work  in  the  mines,  443  per  thousand  of  all 
deaths  during  this  period.  There  is  a  marked  decline  in  succeeding  periods  of 
six  months — from  16  per  thousand  in  the  first  six  months  to  9.24  per  thousand 
in  the  second  six  months,  and  5.5  per  thousand  in  the  third  six  months.  Of 
a  total  of  6,333  deaths  in  1909-1910  in  the  labor  area,  2,264,  more  than  one- 
third,  were  due  to  pneumonia  (G.  D.  Maynard).  The  case  mortality  is  not 
extraordinarily  high.  In  Johannesburg  the  deaths  among  the  colored  people 
fell  from  1,196  in  1912-13  (a  rate  of  10.79  per  1,000  population)  to  325  in 
1913-14  (a  rate  of  3.09  per  1,000)  coincident  with  improvement  in  the  sani- 
tary condition  of  the  dwellings. 

Etiology. — AGE. — To  the  sixth  year  the  predisposition  to  pneumonia  is 
marked;  it  diminishes  to  the  fifteenth  year,  but  then  for  each  subsequent 
decade  it  increases.  For  children  Holt's  statistics  of  500  cases  give:  First 
year,  15  per  cent.;  from  the  second  to  the  sixth  year,  62  per  cent;  from  the 
seventh  to  the  eleventh  year,  21  per  cent. ;  from  the  twelfth  to  the  fourteenth 
year,  2  per  cent.  Lobar  pneumonia  has  been  met  with  in  the  new-born.  The 
relation  to  age  is  well  shown  in  the  U.  S.  Census  Eeport  for  1900.  The  death- 
rate  in  persons  from  fifteen  to  forty-five  years  was  100.05  per  100,000* of  popu- 
lation; from  forty-five  to  sixty-five  years  it  was  263.12;  and  in  persons 
sixty-five  years  of  age  and  over  it  was  733.77.  Pneumonia  may  well  be  called 
the  friend"  of  the  aged.  Taken  off  by  it  in  an  acute,  short,  not  often  painful 
illness,  the  old  escape  those  "cold  gradations  of  decay"  that  make  the  last 
stage  of  all  so  distressing. 

SEX. — Males  are  more  frequently  affected  than  females — 533  to  125  in 
the  Johns  Hopkins  Hospital  series. 

RACE. — in  the  United  States  pneumonia  is  more  fatal  in  negroes  than 
among  the  whites.  This  was  not  so  marked  in  our  figures  at  the  Johns  Hop- 
kins Hospital,  but  at  the  Charite  Hospital,  New  Orleans,  and  at  the  Ancon 
and  Colon  hospitals  of  the  Canal  Zone  the  death  rate  among  the  negroes  is 
much  higher,  Jt  is  rare  among  the  Chinese. 


76  SPECIFIC    INFECTIOUS    DISEASES 

SOCIAL  CONDITION. — The  disease  is  more  common  in  the  cities.  Indi« 
viduals  who  are  much  exposed  to  hardship  and  cold  are  particularly  liable  to 
the  disease.  Newcomers  and  immigrants  are  stated  to  be  less  susceptible  than 
native  inhabitants. 

PERSONAL  CONDITION. — Debilitating  causes  of  all  sorts  render  individuals 
more  susceptible.  Alcoholism  is  perhaps  the  most  potent  predisposing  factor. 
Robust,  healthy  men  are,  however,  often  attacked. 

PREVIOUS  ATTACK. — No  other  acute  disease  recurs  in  the  same  individual 
with  such  frequency.  Instances  are  on  record  of  individuals  who  have  had 
ten  or  more  attacks.  The  percentage  of  recurrences  has  been  placed  as  high 
as  50.  Netter  gives  it  as  31,  and  he  has  collected  the  statistics  of  eleven 
observers  who  place  the  percentage  at  26.8.  Among  the  highest  figures  for 
recurrences  are  those  of  Benjamin  Rush,  28,  and  Andral,  16. 

TRAUMA — CONTUSION-PNEUMONIA. — Pneumonia  may  follow  directly  upon 
injury,  particularly  of  the  chest,  without  necessarily  any  lesion  of  the  lung. 
Litten  gives  4.4  per  cent.,  Stern  2.8  per  cent.  Stern  describes  three  clinical 
varieties:  first,  the  ordinary  lobar  pneumonia  following  a  contusion  of  the 
chest  wall;  secondly,  atypical  cases,  with  slight  fever  and  not  very  character- 
istic physical  signs;  thirdly,  cases  with  the  physical  signs  and  features  of 
broncho-pneumonia.  The  last  two  varieties  have  a  favorable  prognosis.  Ac- 
cording to  Ballard,  workers  in  certain  phosphate  factories,  where  they  breathe 
a  very  dusty  atmosphere,  are  particularly  prone  to  pneumonia. 

COLD  has  been  for  years  regarded  as  an  important  etiological  factor.  The 
frequent  occurrence  of  an  initial  chill  has  been  one  reason  for  this  widespread 
belief.  As  to  the  close  association  of  pneumonia  with  exposure  there  can  be 
no  question.  We  see  the  disease  occur  either  promptly  after  a  wetting  or  a 
chilling  due  to  some  unusual  exposure,  or  come  on  after  an  ordinary  catarrh 
of  'one  or  two  days'  duration.  Cold  is  now  regarded  simply  as  a  factor  in 
lowering  the  resistance  of  the  bronchial  and  pulmonary  tissues. 

CLIMATE  AND  SEASON. — Climate  does  not  appear  to  have  very  much  influ- 
ence, as  pneumonia  prevails  equally  in  hot  and  cold  countries.  It  is  stated  to 
be  more  prevalent  in  the  Southern  than  in  the  Northern  States,  but  an  exam- 
ination of  the  Census  Reports,  shows  that  there  is  very  little  difference  in  the 
various  State  groups. 

The  disease  is  less  prevalent  in  England  than  in  the  United  States,  where 
the  dry,  overheated  air  of  the  houses  favors  catarrhal  processes  in  the  air 
passages,  though  I  know  of  no  figures  which  show  a  greater  incidence  of  pneu- 
mococci  in  the  mouths  and  throats  of  the  inhabitants  of  the  latter  country. 

Much  more  important  is  the  influence  of  season.  Statistics  are  almost 
unanimous  in  placing  the  highest  incidence  of  the  disease  in  the  winter  and 
spring  months.  In  Montreal,  January,  the  coldest  month  of  the  year,  but  with 
steady  temperature,  has  usually  a  comparatively  low  death-rate  from  pneu- 
monia. The  large  statistics  of  Seitz  from  Munich  and  of  Seibert  of  New 
York  give  the  highest  percentage  in  February  and  March. 

Bacteriology  of  Acute  Lobar  Pneumonia. — (a)  MICROCOCCUS  LANCEOLA- 
TUS,  PNEUMOCOCCUS  OR  DIPLOCOCCUS  PNEUMONIA  OF  FRAENKEL  AND  WEICH- 
SELBAUM. — In  September,  1880,  Sternberg  inoculated  rabbits  with  his  own 
saliva  and  isolated  a  micrococcus.  The  publication  was  not  made  until  April, 
1881.  Pasteur  discovered  the  same  organism  in  the  saliva  of  a  child  dead 


PNBUMOK1AS   AXD   PXEUMOCOCCIC   INFECTIONS         77 

of  hydrophobia  in  December,  1880,  and  the  priority  of  the  discovery  belongs 
to  him,  as  his  publication  is  dated  January,  1881.  There  was,  however,  no 
suspicion  that  this  organism  was  concerned  in  the  etiology  of  lobar  pneumo- 
nia, and  it  was  not  really  until  April,  1884,  that  Fraenkel  determined  that  the 
organism  found  by  Sternberg  and  Pasteur  in  the  saliva,  and  known  as  the 
coccus  of  sputum  septicnemia,  was  the  most  frequent  germ  in  pneumonia. 

The  organism  is  a  somewhat  elliptical,  lance-shaped  coccus,  usually  occur- 
ring in  pairs ;  hence  the  term  diplococcus.  About  the  organism  in  the  sputum 
a  capsule  can  always  be  demonstrated.  Its  kinship  to  Streptococcus  pyogenes 
is  regarded  by  many  as  very  close.  R.  Cole  and  his  co-workers  recognize  four 
groups  based  upon  well  defined  immunological  differences.  The  numerous 
strains  conform  to  one'  or  other  of  these  types  but  until  they  are  worked  out 
thoroughly  we  shall  not  have  a  rational  basis  for  immunotherapy  in  the  various 
pneumococcal  infections.  They  differ  in  virulence,  and  Type  IV  which  is 
responsible  for  only  one-fifth  of  the  cases  is  the  commonest  form  found  in 
the  mouths  of  healthy  individuals.  A  fifth  well-marked  strain  has  been  deter- 
mined in  South  Africa  by  Lister. 

Distribution  in  tlte  Body. — In  the  bronchial  secretions  and  in  the  affected 
lung  the  pneumococcus  is  readily  demonstrated  in  smears,  and  in  the  latter 
in  sections.  With  the  more  recent  methods  it  is  possible  to  isolate  the  pneu- 
mococcus from  the  blood  in  a  large  proportion  of  all  cases. 

(6)  PNEUMOCOCCUS  UNDER  XORMAL  CONDITIONS. — (1)  In  the  Mouth. — 
The  pneumococcus  is  present  in  the  mouths  of  a  large  proportion  of  healthy 
individuals,  the  various  observers  giving  80  to  90  per  cent,  of  positive  results. 
The  virulence  is  not  always  uniform,  and  Longcope  and  Fox  were  able  to 
show  that  the  saliva  of  the  same  individual  increased  in  virulence  during  the 
winter  months.  Some  persons  always  harbor  a  virulent  variety.  Buerger  at 
the  Mt.  Sinai  Hospital  studied  the  communicability  of  the  organism  from  one 
person  to  another  "and  it  was  found  repeatedly  that  normal  individuals — 
i.  e.,  persons  in  whose  mouths  the  pneumococcus  was  proved  by  repeated  exam- 
inations to  be  absent — acquired  the  organisms  by  association  with  cases  of 
pneumonia,  or  with  healthy  persons  in  whose  saliva  pneumococci  were  present. 

(2)  Outside  the  Body. — The  viability  of  the  pneumococcus  is  not  great. 
It  has  been  found  occasionally  in  the  dust  and  sweepings  of  rooms,  but  Wood 
has  shown  (Xew  York  Commission  Report)  that  the  germs  exposed  to  sun- 
light die  in  a  very  short  time — an  hour  and  a  half  being  the  limit.  In  moist 
sputum  kept  in  a  dark  room  the  germs  lived  ten  days,  and  in  a  badly  venti- 
lated room  in  which  a  person  with  pneumonia  coughed,  the  germs  suspended 
in  the  air  retained  their  vitality  for  several  hours. 

(c)  BACILLUS  PNEUMONIA  OF  FRIEDLANDER. — This  is  a  larger  organism 
than  the  pneumococcus,  and  appears  in  the  form  of  plump,  short  rods.    It  also 
shows  a  capsule,  but  presents  marked  biological  and  cultural  differences  from 
Fraenkel's  pneumococcus.     It  may  cause  broncho-pneumonia  and  other  affec- 
tions, and  is  not  a  cause  of  genuine  lobar  pneumonia.    The  exudate  caused  by 
this  bacillus  is  usually  more  viscid  and  poorer  in  fibrin  than  that  in  diplo- 
coccus pneumonia. 

(d)  OTHER  ORGANISMS. — Various  bacteria  may  be  associated  with  the 
pneumococcus  in  lobar  pneumonia,  the  most  common  of  these  being  Strep- 
tococcus pyogenes,  the  pyogenic  staphylococci.   and   Friedlander's  pneumo- 


78  SPECIFIC    INFECTIOUS    DISEASES 

bacillus;  but  while  these  latter  may  cause  broncho-pneumonia,  they  have 
not  been  satisfactorily  demonstrated  to  be  other  than  secondary  invaders  in 
lobar  pneumonia.  Likewise  the  pneumonias  caused  by  Bacillus  iypliosus, 
Bacillus  diphtheria?,  and  the  influenza  bacillus  are  not  to  be  identified  with 
true  lobar  pneumonia. 

Clinically,  the  infectious  nature  of  pneumonia  was  recognized  long  before 
we  knew  anything  of  the  pneumococcus.  It  may  occur  in  endemic  form,  local- 
ized in  certain  houses,  in  barracks,  jails,  and  schools.  As  many  as  ten  occu- 
pants of  one  house  have  been  attacked.  I  have  seen  three  members  of  a  family 
consecutively  attacked  with  a  most  malignant  type  of  pneumonia.  Among 
the  more  remarkable  endemic  outbreaks  is  that  reported  by  W.  B.  Eodman,  of 
Frankfort,  Ky.  In  a  prison  with  a  population  of  735"  there  occurred  in  one 
year  118  cases  of  pneumonia  with  25  deaths.  The  disease  may  assume  epi- 
demic proportions.  In  the  Mid'dlesborough  epidemic,  so  carefully  studied  by 
Ballard,  there  were  682  persons  attacked,  with  a  mortality  of  21  per  cent. 
During  some  years  pneumonia  is  so  prevalent  that  it  is  practically  pandemic. 
Direct  contagion  is  suggested  by  the  fact  that  a  patient  in  the  next  bed  to  a 
pneumonia  case  may  take  the  disease,  or  2  or  3  cases  may  follow  in  rapid  suc- 
cession in  a  ward.  It  is  very  exceptional,  however,  for  nurses  or  doctors  to  be 
attacked. 

Infection,  the  Symptoms  and  Immunity. — A  majority  of  persons  harbor  the 
germ  in  mouth,  nose,  or  throat,  but  the  virulence  of  the  ordinary  mouth 
form  is  low  and  varies  with  the  season.  A  virulent  germ  may  be  constant  and 
such  persons  are  true  carriers  and  play  an  important  role  in  the  spread  of  the 
disease.  Some  individuals  are  less  resistant,  and  in  no  other  acute  disease 
may  so  many  successive  attacks  occur  in  the  same  person.  The  negro  race  in 
the  United  States,  in  the  Canal  Zone,  and  in  South  Africa  shows  an  extreme 
susceptibility;  on  the  other  hand  the  Chinese  workmen,  when  in  South  Africa, 
showed  an  extraordinary  resistance  to  the  disease. 

There  are  three  phases  in  the  infection — a  period  of  incubation  and  onset, 
the  clinical  manifestations,  and  the  immunization  characterized  by  the  crisis. 
The  attack  is  usually  attributed  to  lowered  general  resistance,  but  experimen- 
tally there  is  basis  for  the  view  that  local  conditions  in  the  lung,  such  as  the 
catarrhal  processes,  favor  the  development  of  pneumococci.  Changes  leading 
to  lobar  consolidation  may  be  regarded  as  local  defensive  reactions.  The 
explosive  onset  bears  a  certain  resemblance  to  the  anaphylactic  reaction. 

The  clinical  features  are  a  toxaemia,  plus  disturbances  of  respiratory  and 
circulatory  functions.  The  intoxication  bears  no  proportion  to  the  local  lesion. 
There  are  profound  general  infections  with  little  or  no  pulmonary  involvement. 
Some  of  the  most  toxic  cases,  particularly  in  the  aged,  have  very  slight  lesions, 
while  a  lung  may  be  solid  and  the  patient  show  no  signs  of  poisoning.  The 
nature  of  the  toxa?mia  is  unknown,  nor  whether  due  to  absorption  of  the 
products  of  digestion  of  the  local  exudate,  which  does  not  seem  likely,  as  the 
symptoms  abate  after  crisis  when  this  absorption  is  most  active.  To  regard 
the  symptoms  as  due  to  absorption  of  a  toxin  is  natural  but  no  special  sub- 
stance has  been  discovered  in  the  culture  fluids  of  pneumococci ;  the  problem 
is  still  under  discussion.  Metabolic  studies  on  the  oxygen  and  carbon  dioxide 
contents  of  the  blood  by  Peabody  show  no  change  in  the  reaction  of  the  body 
tissues  beyond  the  mild  grade  of  acidosis  present  in  all  fevers.  Probably,  as 


PXEUMOXIAS    AXD    PXEUMOCOCCIC    IXFECTIOXS          79 

Pfeifer  suggests,  it  is  an  endotoxin  produced  from  the  bodies  of  the  pneumo- 
coeci. 

The  explanation  of  the  crisis  is  obscure.  Immune  bodies  are  not  constantly 
increased  after  it,  or  they  may  not  appear  for  several  days.  Upon  what  the 
neutralization  of  the  toxins  depends  is  doubtful. 

The  serum  of  a  horse  actively  immunized  will  protect  a  mouse  against  a 
million  lethal  doses  when  injected  together;  but  if  injected  only  a  few  hours 
after  the  lethal  dose  it  is  not  possible  to  save  the  animal  (Cole).  Insufficient 
dosage  may  account  for  the  common  failure  and  in  each  case  the  special  strain 
must  be  determined.  A  univalent  serum  was  efficient  to  protect  animals 
against  about  40  per  cent,  of  cultures  obtained  from  the  blood  of  patients. 
Up  to  the  present  serums  have  been  found  useful  in  the  treatment  of  infec- 
tions with  Types  I  and  II.  No  effective  serum  has  been  obtained  for  Type  III 
(Pxaeumococcus  Mucosus). 

Morbid  Anatomy. — Since  the  time  of  Laennec,  pathologists  have  recog- 
nized three  stages  in  the  inflamed  lung:  engorgement,  red  hepatization,  and 
gray  hepatization. 

In  the  stage  of  engorgement  the  lung  tissue  is  deep  red  in  color,  firmer 
to  the  touch,  and  more  solid,  and  on  section  the  surface  is  bathed  with  blood 
and  serum.  It  still  crepitates,  though  not  so  distinctly  as  healthy  lung,  and 
excised  portions  float.  The  air-cells  can  be  dilated  by  insufflation  from  the 
bronchus.  The  capillary  vessels  are  greatly  distended,  the  alveolar  epithelium 
swollen,  and  the  air-cells  occupied  by  a  variable  number  of  blood  corpuscles 
and  detached  alveolar  cells.  In  the  stage  of  red  hepatization  the  lung  tissue 
is  solid,  firm,  and  airless.  If  the  entire  lobe  is  involved  it  looks  voluminous, 
and  shows  indentations  of  the  ribs.  On  section,  the  surface  is  dry,  reddish- 
brown  in  color,  and  has  lost  the  deeply  congested  appearance  of  the  first  stage. 
One  of  the  most  remarkable  features  is  the  friability;  in  striking  contrast 
to  the  healthy  lung,  which  is  torn  with  difficulty.  The  surface  has  a  granu- 
lar appearance  due  to  the  fibrinous  plugs  filling  the  air-cells.  The  distinctness 
of  this  appearance  varies  greatly  with  the  size  of  the  alveoli,  which  are  about 
0.10  mm.  in  diameter  in  the  infant,  0.15  or  0.16  in  the  adult,  and  from  0.20 
to  0.25  in  old  age.  On  scraping  the  surface  with  a  knife  a  reddish  viscid 
serum  is  removed,  containing  small  granular  masses.  The  smaller  bronchi 
often  contain  fibrinous  plugs.  If  the  lung  has  been  removed  before  the  heart,, 
it  is  not  uncommon  to  find  solid  moulds  of  clot  filling  the  blood-vessels. 
Microscopically,  the  air-cells  are  seen  to  be  occupied  by  coagulated  fibrin  in 
the  meshes  of  which  are  red  blood-corpuscles,  mononuclear  and  polynuclear 
leucocytes, '  and  alveolar  epithelium.  The  alveolar  walls  are  infiltrated  and 
leucocytes  are  seen  in  the  interlobular  tissues.  Cover-glass  preparations  from 
the  exudate,  and  thin  sections  show,  as  a  rule,  the  diplococci  already  referred 
to,  many  of  which  are  contained  within  cells.  Staphylococci  and  strepto- 
cocci may  also  be  seen  in  some  cases.  In  the  stage  of  gray  hepatization  the 
tissue  has  changed  from  a  reddish-brown  to  a  grayish-white  color.  The  surface 
is  moister,  the  exudate  obtained  on  scraping  is  more  turbid,  the  granules  in 
the  acini  are  less  distinct,  and  the  lung  tissue  is  still  more  friable.  The  air- 
cells  are  densely  filled  with  leucocytes,  the  fibrin  network  and  the  red  blood- 
corpuscles  have  largely  disappeared.  A  more  advanced  condition  of  gray 
hepatization  is  that  known  as  purulent  infiltration,  in  which  the  lung  tissue 


80  SPECIFIC    INFECTIOUS    DISEASES 

is  softer  and  bathed  with  a  purulent  fluid.  Small  abscess  cavities  may  form, 
and  by  their  fusion  larger  ones,  though  this  is  a  rare  event  in  ordinary 
pneumonia. 

RESOLUTION. — The  changes  in  the  exudate  which  lead  to  its  resolution  are 
due  to  an  autolytic  digestion  by  proteolytic  enzymes  which  are  present  much 
more  abundantly  in  gray  hepatization  than  in  the  preceding  stage.  The  dis- 
solved exudate  is  for  the  most  part  excreted  by  the  kidneys.  By  following  the 
nitrogen  excess  in  the  urine  the  progress  of  resolution  may  be  followed  and 
even  an  estimate  formed  of  the  amount  of  the  exudate  thus  eliminated.  In 
a  study  from  my  clinic  H.  W.  Cook  found  in  cases  of  delayed  resolution  that 
the  nitrogen  excess  in  the  urine  (which  persisted  until  the  lung  was  clear) 
was  very  large,  and  he  suggests  that  delayed  resolution  may  really  be  a  matter 
of  continued  exudation. 

GENERAL  DETAILS  OF  THE  MORBID  ANATOMY. — In  100  autopsies,  made 
by  me  at  the  General  Hospital,  Montreal,  in  51  cases  the  right  lung  was 
affected,  in  32  the  left,  in  17  both  organs.  In  27  cases  the  entire  lung,  with 
the  exception,  perhaps,  of  a  narrow  margin  at  the  apex  and  anterior  border, 
was  consolidated.  In  34  cases,  the  lower  lobe  alone  was  involved ;  in  13  cases, 
the  upper  lobe  alone.  When  double,  the  lower  lobes  were  usually  affected 
together,  but  in  three  instances  the  lower  lobe  of  one  and  the  upper  lobe  of  the 
other  were  attacked.  In  3  cases,  also,  both  upper  lobes  were  affected.  Occa- 
sionally the  disease  involves  the  greater  part  of  both  lungs;  thus,  in  one  in- 
stance the  left  organ  with  the  exception  of  the  anterior  border  was  uniformly 
hepatized,  while  the  right  was  in  the  stage  of  gray  hepatization,  except  a  still 
smaller  portion  in  the  corresponding  region.  In  a  third  of  the  cases,  red 
and  gray  hepatization  existed  together.  In  22  instances  there  was  gray  hepati- 
zation. As  a  rule  the  unaffected  portion  of  the  lung  is  congested  or  cedema- 
tous.  When  the  greater  portion  of  a  lobe  is  attacked,  the  uninvolved  part 
may  be  in  a  state  of  almost  gelatinous  oedema.  The  unaffected  lung  is  usually 
congested,  particularly  at  the  posterior  part.  This,  it  must  be  remembered, 
may  be  largely  due  to  post  mortem  subsidence.  Thef  uninflamed  portions  are 
not  always  congested  and  cedematous.  The  upper  lobe  may  be  dry  and  blood- 
less when  the  lower  lobe  is  uniformly  consolidated.  The  average  weight  of  a 
normal  lung  is  about  600  grams,  while  that  of  an  inflamed  organ  may  be 
1,500,  2,000,  or  even  2,500  grams. 

The  bronchi  contain,  as  a  rule,  at  the  time  of  death  a  frothy  serous  fluid, 
rarely  the  tenacious  mucus  so  characteristic  of  pneumonic  sputum.  The 
mucous  membrane  is  usually  reddened,  rarely  swollen.  In  the  affected  areas 
the  smaller  bronchi  often  contain  fibrinous  plugs,  which  may  extend  into  the 
larger  tubes,  forming  perfect  casts.  The  bronchial  glands  are  swollen  and 
may  even  be  soft  and  pulpy.  The  pleural  surface  of  the  inflamed  lung  is 
invariably  involved  when  the  process  becomes  superficial.  Commonly,  there 
is  only  a  thin  sheeting  of  exudate,  producing  slight  turbidity  of  the  mem- 
brane. The  pleura  was  not  involved  in  only  two  of  the  hundred  instances. 
In  some  cases  the  fibrinous  exudate  may  form  a  creamy  layer  an  inch  in  thick- 
ness. A  serous  exudation  of  variable  amount  is  not  uncommon. 

LESIONS  IN  OTHER  ORGANS. — The  heart,  particularly  its  right  chamber,  is 
distended  with  firm,  tenacious  coagula,  which  can  be  withdrawn  from  the 
vessels  as  dendritic  moulds.  In  no  other  acute  disease  do  we  meet  with  coagula 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS         81 

of  such  solidity.  The  spleen  is  often  enlarged,  though  in  only  35  of  the  100 
cases  was  the  weight  above  200  grams.  The  kidneys  show  parenchymatous 
swelling,  turbidity  of  the  cortex,  and,  in  a  very  considerable  proportion  of  the 
cases — 25  per  cent. — chronic  interstitial  changes. 

Pericarditis  was  present  in  35  of  658  cases  in  my  series  (Chatard).  Endo- 
carditis occurred  in  16  of  my  100  post  mortems.  In  5  of  these  the  endocar- 
ditis was  of  the  simple  character;  in  11  the  lesions  were  ulcerative.  Of  209 
cases  of  malignant  endocarditis  which  I  collected  from  the  literature,  54 
occurred  in  pneumonia.  Kanthack  found  an  antecedent  pneumonia  in  14.2 
per  cent,  of  cases  of  infective  endocarditis.  In  the  recent  figures  collected  by 
E.  F.  Wells,  of  517  fatal  cases  of  acute  endocarditis,  22.3  per  cent,  were  in 
pneumonia.  It  is  more  common  on  the  left  than  on  the  right  side  of  the 
heart.  Among  658  cases  of  pneumonia  in  the  Johns  Hopkins  Hospital  endo- 
carditis occurred  in  15  (Marshall).  Myocarditis  and  fatty  degeneration  of 
the  heart  may  be  present  in  protracted  cases. 

Meningitis,  which  is  not  infrequent,  may  be  associated  with  malignant 
endocarditis.  It  was  present  in  8  of  the  100  autopsies.  Of  20  cases  of  menin- 
gitis in  ulcerative  endocarditis  15  occurred  in  pneumonia.  The  meningitis  is 
usually  of  the  convex. 

Croupous  or  diphtheritic  inflammation  may  occur  in  other  parts.  A 
croupous  colitis,  as  pointed  out  by  Bristowe,  is  not  very  uncommon.  It  oc- 
curred in  5  of  my  100  post  mortems.  It  is  usually  a  thin,  flaky  exudation, 
most  marked  on  the  tops  of  the  folds  of  the  mucous  membrane.  In  one  case 
there  was  a  patch  of  croupous  gastritis,  covering  an  area  2  by  8  cm.,  situated 
to  the  left  of  the  cardiac  orifice. 

The  liver  shows  parenchymatous  changes,  and  often  extreme  engorgement 
of  the  hepatic  veins. 

Symptoms. — COURSE  OF  THE  DISEASE  IN  TYPICAL  CASES. — We  know  but 
little  of  the  incubation  period  in  lobar  pneumonia.  It  is  probably  very  short. 
There  are  sometimes  slight  catarrhal  symptoms  for  a  day  or  two.  As  a  rule, 
the  disease  sets  in  abruptly  with  a  severe  chill,  which  lasts  from  fifteen  to 
thirty  minutes  or  longer.  In  no  acute  disease  is  an  initial  chill  so  constant 
or  so  severe.  The  patient  may  be  taken  abruptly  in  the  midst  of  his  work, 
or  may  awaken  out  of  a  sound  sleep  in  a  rigor.  The  temperature  taken  during 
the  chill  shows  that  the  fever  has  already  begun.  If  seen  shortly  after  the 
onset,  the  patient  has  usually  features  of  an  acute  fever,  and  complains  of 
headache  and  general  pains.  Within  a  few  hours  there  is  pain  in  the  side, 
often  of  an  agonizing  character;  a  short,  dry,  painful  cough  begins,  and  the 
respirations  are  increased  in  frequency.  When  seen  on  the  second  or  third 
day,  the  picture  in  typical  pneumonia  is  more  distinctive  than  that  presented 
by  any  other  acute  disease.  The  patient  lies  flat  in  bed,  often  on  the  affected 
side;  the  face  is  flushed,  particularly  one  or  both  cheeks;  the  breathing  is 
hurried,  accompanied  often  with  a  short  expiratory  grunt;  the  ala?  nasi  dilate 
with  each  inspiration;  herpes  is  usually  present  on  the  lips  or  nose;  the  eyes 
are  bright,  the  pupils  are  often  unequal,  the  expression  is  anxious,  .and  there 
is  a  frequent  short  cough  which  makes  the  patient  wince  and  hold  his  side. 
The  expectoration  is  blood-tinged  and  extremely  tenacious.  The  temperature 
may  be  104°  or  105°.  The  pulse  is  full  and  bounding  and  the  pulse-respira- 
tion ratio  much  disturbed.  Examination  of  the  lungs  shows  the  physical  signs 


82 


SPECIFIC    INFECTIOUS    DISEASES 


of  consolidation  with  blowing  breathing  and  fine  rales.     After  persisting  for 
from  seven  to  ten  days  the  crisis  occurs,  and  with  a  fall  in  the  temperature 


Reap. 


70 


Temp. 


86 
Temp 


Pulse 


Resp. 
Stool 


)ayof 

Hscasc 


j       I       i       j       |       1       i 


BLACK,  TEMPERATURE; 


BLUE,      RESPIRATION 


CHART  III. — FEVER,  PULSE  AND  KESPIRATION  IN  LOBAR  PNEUMONIA 

the  patient  passes  from  the  condition  of  extreme  distress  and  anxiety  to  one 
of  comparative  comfort. 

SPECIAL  FEATURES. — The  fever  rises  rapidly,  and  the  height  may  be  104° 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS          83 

F.  or  105°  F.  within  twelve  hours.  Having  reached  the  fastigium,  it  is 
remarkably  constant.  Often  the  two-hour  temperature  chart  will  not 
show  for  two  days  more  than  a  degree  of  variation.  In  children  and 
in  cases  without  chill  the  rise  is  more  gradual.  In  old  persons  and  in 
drunkards  the  temperature  range  is  lower  than  in  children  and  in 
healthy  individuals;  indeed,  one  occasionally  meets  with  an  afebrile  pneu- 
monia. 

The  Crisis. — After  the  fever  has  persisted  for  from  five  to  nine  or  ten 
days  there  is  an  abrupt  drop,  known  as  the  crisis,  which  is  one  of  the  most 
characteristic  features  of  the  disease.  The  day  of  the  crisis  is  variable.  It 
is  very  uncommon  before  the  third  day,  and  rare  after  the  twelfth.  I  have 
seen  it  as  early  as  the  third  day.  From  the  time  of  Hippocrates  it  has  been 
thought  to  be  more  frequent  on  the  uneven  days,  particularly  the  fifth  and 
seventh;  the  latter  has  the  largest  number  of  cases  (Musser  and  Norris).  A 
precritical  rise  of  a  degree  or  two  may  occur.  In  one  case  the  temperature 
rose  from  105°  to  nearly  107°,  and  then  in  a  few  hour's  fell  to  normal.  Not 
even  after  the  chill  in  malarial  fever  do  we  see  such  a  prompt  and  rapid  drop 
in  the  temperature.  The  usual  time  is  from  five  to  twelve  hours,  but  often 
in  an  hour  there  may  occur  a  fall  of  six  or  eight  degrees  (S.  West).  The 
temperature  may  be  subnormal  after  the  crisis,  as  low  as  96°  or  97°.  Usually 
there  is  an  abundant  sweat,  and  the  patient  sinks  into  a  comfortable  sleep. 
The  day  after  the  crisis  there  may  be  a  slight  post-critical  rise.  A  pseudo- 
crisis  is  not  very  uncommon,  in  which  on  the  fifth  or  sixth  day  the  tempera- 
ture drops  from  104°  or  105°  to  102°,  and  then  rises  again.  When  the  fall 
takes  place  gradually  within  twenty-four  hours  it  is  called  a  protracted  crisis. 
If  the  fever  persists  beyond  the  twelfth  day,  the  fall  is  likely  to  be  by  lysis. 
In  children  this  mode  of  termination  is  common,  and  occurred  in  one-third 
of  a  series  of  183  cases  reported  by  Morrill.  Occasionally  in  debilitated  indi- 
viduals the  temperature  drops  rapidly  just  before  death;  more  frequently 
there  is  an  ante-mortem  elevation.  In  cases  of  delayed  resolution  the  fever 
may  persist  for  six  or  eight  weeks.  The  crisis,  the  most  remarkable  phenom- 
enon of  pneumonia,  appears  to  represent  the  stage  of  active  immunity  to  the 
toxin  of  the  pneumococcus.  The  fever,  dyspnoea  and  the  general  symptoms 
disappear  when  the  immunity  reaches  a  certain  stage.  With  the  fall  in  the 
fever  the  respirations  become  reduced  almost  to  normal,  the  pulse  slows,  and 
the  patient  passes  from  perhaps  a  state  of  extreme  hazard  and  distress  to  one 
of  safety  and  comfort,  and  yet,  so  far  as  the  physical  examination  indicates, 
there  is  with  the  crisis  no  special  change  in  the  local  condition  in  the  lung. 
For  a  study  of  the  problem  see  Emerson,  The  Johns  Hopkins  Hospital  Ee- 
ports,  Vol.  XV. 

Pain. — There  is  early  a  sharp,  agonizing  pain,  generally  referred  to  the 
region  of  the  nipple  or  lower  axilla  of  the  affected  side,  and  much  aggravated 
on  deep  inspiration  and  on  coughing.  It  is  associated,  as  Areta?us  remarks, 
with  involvement  of  the  pleura.  It  is  absent  in  central  pneumonia,  and  much 
less  frequent  in  apex  pneumonia.  The  pain  may  be  severe  enough  to  require 
a  hypodermic  injection  of  morphia.  As  has  been  recognized  for  many  years, 
the  pain  may  be  altogether  abdominal,  either  central  or  in  the  right  iliac 
fossa,  suggesting  appendicitis.  Crozer  Griffith,  calling  attention  to  the  fre- 
quency of  the  simulation  in  children,  reports  8  cases,  and  has  collected  34  cases 


84  SPECIFIC    INFECTIOUS   DISEASES 

from  the  literature,  many  in  adults.     The  operation  for  appendicitis  has 
been  performed. 

Dyspnoea  is  an  almost  constant  feature.  Even  early  in  the  disease  the 
respirations  may  be  30  in  the  minute,  and  on  the  second  or  third  day  between 
40  and  50.  The  movements  are  shallow,  evidently  restrained,  and  if  the 
patient  is  asked  to  draw  a  deep  breath  he  cries  out  with  the  pain.  Expiration 
is  frequently  interrupted  by  an  audible  grunt.  At  first  with  the  increased 
respiration  there  may  be  no  sensation  of  distress.  Later  this  may  be  present 
in  a  marked  degree.  In  children  the  respirations  may  be  80  or  even  100. 
Many  factors  combine  to  produce  the  shortness  of  breath — the  pain  in  the 
side,  the  toxaemia,  the  fever,  and  the  loss  of  function  in  a  considerable  area 
of  the  lung  tissue.  Sometimes  there  appear  to  be  nervous  factors  at  work. 
That  it  does  not  depend  upon  the  consolidation  is  shown  by  the  fact  that 
after  the  crisis,  without  any  change  in  the  local  condition  of  the  lung,  the 
number  of  respirations  may  drop  to  normal.  The  ratio  between  the  respira- 
tions and  the  pulse  may  be  1  to  2  or  even  1  to  1.5,  a  disturbance  rarely  so 
marked  in  any  other  disease. 

Cough. — This  usually  comes  on  with  the  pain  in  the  side,  and  at  first  is 
dry,  hard,  and  without  any  expectoration.  Later  it  becomes  very  character- 
istic— frequent,  short,  restrained,  and  associated  with  great  pain  in  the  side. 
In  old  persons,  in  drunkards,  in  the  terminal  pneumonias,  and  sometimes  in 
young  children,  there  may  be  no  cough.  After  the  crisis  the  cough  usually 
becomes  much  easier  and  the  expectoration  more  easily  expelled.  The  cough 
is  sometimes  persistent,  continuous,  and  by  far  the  most  aggravated  and  dis- 
tressing symptom  of  the  disease.  Paroxysms  of  coughing  of  great  intensity 
after  the  crisis  suggest  a  pleural  exudate. 

Sputum. — A  brisk  haemoptysis  may  be  the  initial  symptom.  At  first  the 
sputum  may  be  mucoid,  but  usually  after  twenty-four  hours  it  becomes  blood- 
tinged,  viscid,  and  very  tenacious.  At  first  quite  red  from  the  unchanged 
blood,  it  gradually  becomes  rusty  or  of  an  orange  yellow.  The  tenacious 
viscidity  of  the  sputum  is  remarkable;  it  often  has  to  be  wiped  from  the  lips 
of  the  patient.  When  jaundice  is  present  it  may  be  green  or  yellow.  In  low 
types  of  the  disease  the  sputum  may  be  fluid  and  of  a  dark  brown  color, 
resembling  prune  juice.  The  amount  is  very  variable,  ranging  from  100  to 
300  c.  c.  in  the  twenty-four  hours.  In  100  cases  in  my  clinic  studied  by  Emer- 
son, in  16  there  was  little  or  no  sputum;  in  32  it  was  typically  rusty;  in  33 
blood-streaked ;  in  3  cases  the  sputum  was  very  bloody.  In  children  and  very 
old  people  there  may  be  no  sputum  whatever.  After  the  crisis  the  quantity 
is  variable,  abundant  in  some  cases,  absent  in  others. 

Microscopically,  the  sputum  consists  of  leucocytes,  mucus  corpuscles,  red 
blood-corpuscles  in  all  stages  of  degeneration,  and  bronchial  and  alveolar 
epithelium.  Haematoidin  crystals  are  occasionally  met  with.  Of  micro- 
organisms the  pneumococcus  is  usually  present,  and  sometimes  Friedliinder's 
bacillus,  the  influenza  bacillus,  streptococci,  both  pyogenes  and  mucosus,  and 
the  colon  bacillus.  Very  interesting  constituents  are  small  cell  moulds  of 
the  alveoli  and  the  fibrinous  casts  of  the  bronchioles;  the  latter  may  be 
plainly  visible  to  the  naked  eye,  and  sometimes  may  form  good-sized  dendritic 
casts.  Chemically,  the  expectoration  is  particularly  rich  in  calcium  chloride. 
PHYSICAL  SIGNS. — Inspection. — The  position  of  the  patient  is  not  con- 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS          85 

slant.  He  usually  rests  more  comfortably  on  the  affected  side,  or  he  is  propped 
up  with  the  spine  curved  toward  it.  Orthopncea  is  rare. 

In  a  small  lesion  no  differences  may  be  noted  between  the  sides;  as  a 
rule,  movement  is  much  less  on  the  affected  side,  which  may  look  larger. 
With  involvement  of  a  lower  lobe,  the  apex  on  the  same  side  may  show  greater 
movement.  The  compensatory  increased  movement  on  the  sound  side  is 
sometimes  very  noticeable  even  before  the  patient's  chest  is  bared.  The  inter- 
costal spaces  are  not  usually  obliterated.  When  the  cardiac  lappet  of  the  left 
upper  lobe  is  involved  there  may  be  a  marked  increase  in  the  area  of  visible 
cardiac  pulsation.  Pulsation  of  the  affected  lung  may  cause  a  marked  move- 
ment of  the  chest  wall  (Graves).  Other  points  to  be  noticed  in  the  inspec- 
tion are  the  frequency  of  the  respiration,  the  action  of  the  accessory  muscles, 
such  as  the  sterno-cleido-mastoids  and  scaleni,  and  the  dilatation  of  the  nos- 
trils with  each  inspiration. 

Mensuration  may  show  a  definite  increase  in  the  volume  of  the  side 
affected,  rarely  more,  however,  than  1  or  l1/^  cm. 

Palpation. — The  lack  of  expansion  on  the  affected  side  is  sometimes  more 
readily  perceived  by  touch  than  by  sight.  The  pleural  friction  may  be  felt. 
On  asking  the  patient  to  count,  the  voice  fremitus  is  greatly  increased  in  com- 
parison with  the  corresponding  point  on  the  healthy  side.  It  is  to  be  remem- 
bered that  if  the  bronchi  are  filled  with  thick  secretion,  or  if,  in  what  is 
known  as  massive  pneumonia,  they  are  filled  with  fibrinous  exudate,  the  tac- 
tile fremitus  may  be  diminished.  It  is  always  well  to  ask  the  patient  to 
cough  before  testing  the  fremitus. 

Percussion. — In  the  stage  of  engorgement  the  note  is  higher  pitched  and 
may  have  a  somewhat  tympanitic  quality,  the  so-called  Skoda's  resonance. 
This  can  often  be  obtained  over  the  lung  tissue  just  above  a  consolidated  area. 
L.  A.  Conner  calls  attention  to  a  point  which  all  observers  must  have  noticed, 
that,  when  the  patient  is  lying  on  his  side,  the  percussion  at  the  dependent 
base  is  "deeper  and  more  resonant  than  that  of  the  upper  side,"  which  by 
contrast  may  seem  abnormal,  and  there  may  even  be  a  faint  tubular  element 
added  to  the  vesicular  breathing  on  the  compressed  side.  When  the  lung  is 
hepatized,  the  percussion  note  is  dull,  the  quality  varying  a  good  deal  from  a 
note  which  has  in  it  a  certain  tympanitic  quality  to  one  of  absolute  flatness. 
There  is  not  the  wooden  flatness  of  effusion  and  the  sense  of  resistance  is  not 
so  great.  During  resolution  the  tympanitic  quality  of  the  percussion  note 
usually  returns.  For  weeks  or  months  after  convalescence  there  may  be  a 
higher-pitched  note  on  the  affected  side.  Wintrich's  change  in  the  percussion 
note  when  the  mouth  is  open  may  be  very  well  marked  in  pneumonia  of  the 
upper  lobe.  Occasionally  there  is  an  almost  metallic  quality  over  the  consol- 
idated area,  and  when  this  exists  with  a  very  pronounced  amphoric  quality 
in  the  breathing  the  presence  of  a  cavity  may  be  suggested.  In  deep-seated 
pneumonias  there  may  be  for  several  days  no  change  in  the  percussion  note. 

Auscultation. — Quiet,  suppressed  breathing  in  the  affected  part  is  often 
a  marked  feature  in  the  early  stage,  and  is  always  suggestive.  Only  in  a  few 
cases  is  the  breathing  harsh  or  puerile.  Very  early  there  is  heard  at  the  end 
of  inspiration  the  fine  crepitant  rale,  a  series  of  minute  cracklings  heard  close 
to  the  ear,  and  perhaps  not  audible  until  a  full  breath  is  drawn.  This  is  pos- 
sibly a  fine  pleural  crepitus,  as  J.  B.  Learning  maintained;  it  is  usually 


86  SPECIFIC    INFECTIOUS   DISEASES 

believed  to  be  produced  in  the  air-cells  and  finer  bronchi  by  the  separation 
of  the  sticky  exudate.  In  the  stage  of  red  hepatization  and  when  dulness  is 
well  defined,  the  respiration  is  tubular.  It  is  heard  first  with  expiration  (a 
point  noted  by  James  Jackson,  Jr.),  and  is  soft  and  of  low  pitch.  Gradually 
it  becomes  more  intense,  and  finally  presents  an  intensity  unknown  in  any 
other  pulmonary  affection — of  high  pitch,  perfectly  dry,  and  of  equal  length 
with  inspiration  and  expiration.  It  is  simply  the  propagation  of  the  laryngeal 
and  tracheal  sounds  through  the  bronchi  and  the  consolidated  lung  tissue. 
The  permeability  of  the  bronchi  is  essential  to  its  production.  Tubular 
breathing  is  absent  in  the  excessively  rare  cases  of  massive  pneumonia  in 
which  the  larger  bronchi  are  completely  filled  with  exudation.  When  resolu- 
tion begins  mucous  rales  of  all  sizes  can  be  heard.  At  first  they  are  small  and 
have  been  called  the  redux-crepitus.  The  voice-sounds  and  the  expiratory 
grunt  are  transmitted  through  the  consolidated  lung  with  great  intensity. 
This  bronchophony  may  have  a  curious  nasal  quality,  to  which  the  term  sego- 
phony  has  been  given.  There  are  cases  in  which  the  consolidation  is  deeply 
seated — so-called  central  pneumonia,  in  which  the  physical  signs  are  slight 
or  even  absent,  yet  the  cough,  the  rusty  expectoration,  and  general  features 
make  the  diagnosis  certain. 

CIRCULATORY  SYMPTOMS. — During  the  chill  the  pulse  is  small,  but  in  the 
succeeding  fever  it  becomes  full  and  bounding.  In  cases  of  moderate  severity 
it  ranges  from  100  to  116.  It  is  not  often  dicrotic.  In  strong,  healthy  indi- 
viduals and  in  children  there  may  be  no  sign  of  failing  pulse  throughout  the 
attack.  With  extensive  consolidation  the  left  ventricle  may  receive  a  very 
much  diminished  amount  of  blood  and  the  pulse  in  consequence  may  be  small. 
In  the  old  and  feeble  it  may  be  small  and  rapid  from  the  outset.  The  pulse 
may  be  full,  soft,  very  deceptive,  and  of  no  value  whatever  in  prognosis. 

Blood  Pressure. — During  the  first  few  days  there  is  no  change.  The 
extent  of  involvement  seems  to  have  no  effect  upon  the  peripheral  blood  pres- 
sure. In  the  toxic  cases  the  pressure  may  begin  to  fall  early;  a  drop  of  15-20 
mm.  Hg.  is  perfectly  safe,  but  a  progressive  fall  indicates  the  need  of  stim- 
ulation. A  sudden  drop  is  rarely  seen  except  just  before  death.  A  slow,  grad- 
ual fall  of  more  than  20  mm.  Hg.  means  cardio-vascular  asthenia,  and  calls 
for  an  increase  in  the  stimulation.  The  crisis  has  no  effect  on  the  blood 
pressure.  The  opinion  commonly  held,  that  when  the  blood  pressure  as  ex- 
pressed in  millimeters  of  Hg.  does  not  fall  below  the  pulse  rate  expressed  in 
beats  per  minute,  the  outlook  is  good,  and  vice  versa,  is  by  no  means  always 
correct.  The  heart  sounds  are  usually  loud  and  clear.  During  the  intensity 
of  the  fever,  particularly  in  children,  bruits  are  not  uncommon  both  in  the 
mitral  and  in  the  pulmonic  areas.  The  second  sound  over  the  pulmonary 
artery  is  accentuated.  Attention  to  this  sign  gives  a  valuable  indication  as 
to  the  condition  of  the  lesser  circulation.  With  distention  of  the  right  cham- 
bers and  failure  of  the  right  ventricle  to  empty  itself  completely,  the  pulmo- 
nary second  sound  becomes  much  less  distinct.  When  the  right  heart  is 
engorged  there  may  be  an  increase  in  the  dulness  to  the  right  of  the  sternum. 
With  gradual  heart  weakness  and  signs  of  dilatation  the  long  pause 
is  greatly  shortened,  the  sounds  approach  each  other  in  tone  and  have  a  fetal 
character  ( embryocardia ) . 

There  may  be  a  sudden  early  collapse  of  the  heart  with  very  feeble,  rapid 


PNEUMONIAS   AND   PNEUMOCOCCIC    INFECTIONS         87 

pulse  and  increasing  cyanosis.  I  have  known  this  to  occur  on  the  third  day. 
Even  when  these  symptoms  are  very  serious  recovery  may  take  place.  In 
other  instances  without  any  special  warning  death  may  occur  even  in  robust, 
previously  healthy  men.  The  heart  weakness  may  be  due  to  paralysis  of  the 
vaso-motor  centre  and  consequent  lowering  of  the  general  arterial  pressure. 
The  soft,  easily  compressed  pulse,  with  the  gray,  ashy  facies,  cold  hands  and 
feet,  the  clammy  perspiration,  and  the  progressive  prostration  tell  of  a  toxic 


CH^ 

f- 

3 

Number-1 
of  Cases 

0 
0 

o 

0 

o 

0 

0 

o 

0 

O 

o 

0 

0 

o 

0 

O 
0 

o 

0 

o 

0 

0 
O 
0 

0 

0 

o 

0 

o 

0 

0 

o 

0 

o 

0 

o 

o 

0 
0 

o 

0 

o 

0 
0 

o 

o 

0 

o 

0 
O 

0 

o 

0 

o 

0 
0 

o 

0 
0 

o 

o 

0 

o 

Mortality  % 

in 
i 
o 

o 

in 

in 

1 

o 

0 
CM 
1 

in 

CM 

I 

o 

CM 

o 

CO 

1 

m 

CM 

CO 

1 

0 

cj 

1 

in 
co 

l' 

o 

0 

ID 

in 

in 
i 

0 

in 

o 

10 

in 

in 

ID 

0 

ID 

o 

K 

in 

35 

0 

o 

CD 

in 

CO 

1 

0 
CO 

0 

en 
in 

CO 

o 
01 

o 

0 

in 

01 

o 

o 

o 

100-105 

100-105 

95  -100 

f 

\ 

95-100 

90-  95 

, 

1 

1 

90-  95 

85  -  90 

J 

1 

85  -  90 

80-  85 

1 

1 

80-  85 

75  -  80 

/ 

75  -  80 

70-  75 

/ 

i 

70-  75 

65  -  70 

l 

l 

65  -  70 

60  -  65 

\ 

! 

', 

60-  65 

55  -  60 

x 

•*.  f 

\ 

i 

1 

i 

55  -  60 

50  -  55 

' 

J 

I 
I 

I 

50-  55 

45  -  50 

I 

45-  50 

40  -  45 

\ 

* 

; 

40  -  45 

35  -  40 

I 

\ 

\ 

; 

i 

; 

35  -  40 

30  -  35 

< 

'  ~\ 

,j 

i 

i 

30-  35 

25  -  30 

v 

v 

f 

\ 

k- 

• 

25  -  30 

20  -  25 

f 

\ 

I 

V 

A 

20  -  25 

15-  20 

\ 

j 

N 

15-  20 

10  -  15 

3 

\ 

10  -  15 

5-10 

7 

V 

-\ 

5-10 

0-5 

\ 

. 

. 

0-5 

•w. 

UJ 

o 

00 

CO 

o 

co 

0 

~ 

CO 

0 

t 

- 

in 

in 

0 

0 

0 

Recovered 

Recovered 

8 

in 
m 

CM 
CO 

in 

CM 

en 

01 

CO 
CM 

CO 

0 
CO 

0 

CO 

CO 

CO 
CM 

CO 
CM 

0 

in 

0 
0 

0 

in 

uj  z 

in 

* 

CO 

S 

CO 

CO 

CO 

CTl 

o 

o 

ID 

CT) 

0 

CM 

CO 
CM 

0 

- 

- 

CM 

CM 

CM 

« 

•*; 

IRT  IV.  —  BLOOD  COUNT  IN  PNEUMONIA  AND    COMPARATIVE    MORTALITY.      CONTINU- 
OUS LINE  REPRESENTS  NUMBER  OF  CASES    OF    PNEUMONIA.      BROKEN    LINE 
REPRESENTS   MORTALITY  PERCENTAGE  OF  SAME. 

action  on  the  vaso-motor  centres.     Endocarditis  and  pericarditis  will  be  con- 
sidered under  complications. 

Blood. — Pneumococci  are  present  in  the  blood  in  a  large  proportion  of  all 
cases.  Anaemia  is  rare.  A  decrease  in  the  red  cells  may  occur  at  the  time 
of  the  crisis.  There  is  in  most  cases  a  leucocytosis,  which  appears  early,  per- 
sists, and  disappears  with  the  crisis.  The  leucocytes  may  number  from  12,000 
to  40,000  or  even  100,000  per  cubic  millimetre.  The  fall  in  the  leucocytes  is 
often  slower  than  the  drop  in  the  fever,  particularly  when  resolution  is  delayed 
or  complications  are  present.  The  annexed  chart  gives  a  study  of  the  leuco- 


8$  SPECIFIC   INFECTIOUS   DISEASES 

cytes  in  582  cases  at  the  Johns  Hopkins  Hospital  by  Chatard.  More  than 
half  of  the  patients,  about  350,  had  a  leucocytosis  of  between  15,000  and 
35,000,  and  nearly  one-third  (198)  between  20,000  and  30,000.  The  broken 
line  represents  the  mortality  which  is  high  when  the  leucocytes  are  below 
10,000,  but  steadily  decreases  and  is  lowest  when  they  are  between  20,000  and 
30,0000.  With  the  leucocytes  between  30,000  and  60,000  the  mortality  is 
again  higher.  The  two  patients  with  the  highest  leucocytosis  of  the  series, 
95,000  and  105,000  respectively,  recovered.  A  striking  feature  in  the  blood- 
slide  is  the  richness  and  density  of  the  fibrin  network.  This  corresponds  to 
the  great  increase  in  the  fibrin  elements,  the  proportion  rising  from  4  to  10 
parts  per  thousand.  The  blood-plates  are  greatly  increased. 

DIGESTIVE  ORGANS. — The  tongue  is  white  and  furred,  and  in  severe  toxic 
cases  rapidly  becomes  dry.  Vomiting  is  not  uncommon  at  the  onset  in  chil- 
dren. The  appetite  is  lost.  Constipation  is  more  common  than  diarrhoea. 
A  distressing  and  sometimes  dangerous  symptom  is  meteorism.  Fibrinous, 
pneumococcic  exudates  may  occur  in  the  conjunctivas,  nose,  mouth,  prepuce, 
and  anus  (Gary).  The  liver  may  be  depressed  by  the  large  right  lung,  or 
enlarged  from  the  engorged  right  heart  or  as  a  result  of  the  infection.  The 
spleen  is  usually  enlarged,  and  the  edge  can  be  felt  during  a  deep  inspiration. 

SKIN. — Among  cutaneous  symptoms  one  of  the  most  interesting  is  the 
association  of  herpes  with  pneumonia.  Not  excepting  malaria,  we  see  labial 
herpes  more  frequently  in  this  than  in  any  other  disease,  occurring,  as  it 
does,  in  from  12  to  40  per  cent,  of  the  cases.  It  is  supposed  to  be  of  favorable 
prognosis,  and  figures  have  been  quoted  in  proof  of  this  assertion.  It  may 
also  occur  on  the  nose,  genitals,  and  anus.  Its  significance  and  relation  to 
the  disease  are  unknown.  At  the  height  of  the  disease  sweats  are  not  com- 
mon, but  at  the  crisis  they  may  be  profuse.  Eedness  of  one  cheek  is  a  phe- 
nomenon long  recognized  in  connection  with  pneumonia,  and  is  usually  on 
the  same  side  as  the  disease.  A  diffuse  erythema  is  occasionally  seen,  and 
in  rare  cases  purpura.  Jaundice  is  referred  to  among  the  complications. 

URINE. — Early  in  the  disease  it  presents  the 'usual  febrile  characters  of 
high  color,  high  specific  gravity,  and  increased  acidity.  A  trace  of  albumin 
is  very  common.  There  may  be  tube-casts,  and  in  a  few  instances  the  exist- 
ence of  albumin,  tube-casts,  and  blood  indicates  the  presence  of  an  acute 
nephritis.  The  urea  and  uric  acid  are  usually  increased  at  first,  but  may  be 
much  diminished  before  the  crisis,  to  increase  greatly  with  its  onset.  Eobert 
Hutchison's  researches  show  that  a  true  retention  of  chlorides  within  the 
body  takes  place,  the  average  amount  being  about  2  grams  daily.  It  is  a  more 
constant  feature  of  pneumonia  than  of  any  other  febrile  disease,  and  this 
being  the  case,  a  diminution  of  the  chlorides  in  the  urine  may  be  of  value  in 
the  diagnosis  from  pleurisy  with  effusion  or  empyema.  It  is  to  be  remem- 
bered that  in  dilatation  of  the  stomach  chlorides  may  be  absent.  Haematuria 
is  a  rare  complication. 

CEREBRAL  SYMPTOMS. — Headache  is  common.  In  children  convulsions 
occur  frequently  at  the  outset.  Apart  from  meningitis,  which  will  be  consid- 
ered separately,  one  may  group  the  cases  with  marked  cerebral  features  into : 

First,  the  so-called  cerebral  pneumonias  of  children,  in  which  the  disease 
gets  in  with  a  convulsion,  and  there  are  high  fever,  headache,  delirium,  great 
irritability,  muscular  tremor,  and  perhaps  retraction  of  the  head  and  neck. 


PNEUMONIAS   AND   PNETJMOCOCCIC   INFECTIONS        89 

The  diagnosis  of  meningitis  is  usually  made,  and  the  local  affection  may  be 
overlooked. 

Secondly,  the  cases  with  maniacal  symptoms.  These  may  occur  at  the 
very  outset,  and  there  may  be  no  suspicion  whatever  that  the  disease  is  other 
than  acute  mania. 

Thirdly,  alcoholic  cases  with  the  features  of  delirium  tremens.  It  should 
be  an  invariable  rule,  even  if  fever  be  not  present,  to  examine  the  lungs  in  a 
case  of  mania  a  potu. 

Fourthly,  cases  with  toxic  features,  rather  resembling  those  of  uraemia. 
Without  a  chill  and  without  cough  or  pain  in  the  side,  a  patient  may  have 
fever,  a  little  shortness  of  breath,  and  then  gradually  grow  dull  mentally,  and 
within  three  days  be  in  profound  toxaemia  with  low,  muttering  delirium. 

It  is  stated  that  apex  pneumonia  is  more  often  accompanied  with  severe 
delirium.  Occasionally  the  cerebral  symptoms  occur  immediately  after  the 
crisis.  Mental  disturbance  may  persist  during  and  after  convalescence,  and 
in  a  few  instances  delusional  insanity  follows,  the  outlook  in  which  is  favorable. 

Hemiplegia  may  be  due  to  thrombosis,  embolism,  abscess  or  cedema.  With- 
ington  has  called  attention  to  a  form  associated  with  encephalitis.  It  may  be 
transient  and  recovery  complete.  Transient  aphasia,  with  or  without  hemi- 
plegia,  may  also  occur  and  there  are  cases  in  which  no  gross  lesions  have  been 
found,  so  that  it  has  been  suggested  that  it  is  due  to  cedema  or  to  a  relative 
ischaemia. 

Complications. — Compared  with  typhoid  fever,  pneumonia  has  but  few 
complications  and  still  fewer  sequelae.  The  most  important  are  the  following : 

Pleurisy  is  an  inevitable  event  when  the  inflammation  reaches  the  surface 
of  the  lung,  and  thus  can  scarcely  be  termed  a  complication.  But  there  are 
cases  in  which  the  pleuritic  features  take  the  first  place.  The  exudation  may 
be  sero-fibrinous  with  copious  effusion,  differing  from  that  of  an  ordinary 
acute  pleurisy  in  the  greater  richness  of  the  fibrin,  which  may  form  thick, 
tenacious,  curdy  layers.  Pneumonia  on  one  side  vith  extensive  pleurisy  on  the 
other  is  sometimes  a  puzzling  complication  to  diagnose,  and  an  aspirating 
needle  may  be  required  to  settle  the  question.  Empyema  is  a  most  common 
complication  occurring  in  2.2  per  cent,  of  clinical  cases  collected  by  Musser 
and  Norris  and  in  3.6  per  cent,  of  the  Johns  Hopkins  Hospital  series.  During 
the  eight  years,  1S83-'90,  there  were  at  Guy's  Hospital  7  cases  of  empyema 
among  445  cases  of  pneumonia,  while  in  the  eight  years,  1891-'98,  there  were 
38  cases  among  896  cases  of  pneumonia  (Hale  White).  Influenza  may  be 
responsible  for  the  increase.  The  pneumococcus  is  usually  present;  in  a  few 
the  streptococcus,  in  which  case  the  prognosis  is  not  so  good.  Eecurrence  of 
the  fever  after  the  crisis  or  persistence  of  it  after  the  tenth  day,  with  sweats, 
leucocytosis,  and  an  aggravation  of  the  cough,  are  suspicious  symptoms.  The 
dulness  persists  at  the  base,  or  may  extend.  The  breathing  is  feeble  and  there 
are  no  rales.  Such  a  condition  may  be  closely  simulated,  of  course,  by  a 
thickened  pleura.  Exploratory  aspiration  may  settle  the  question  at  once. 
There  are  obscure  cases  in  which  the  pus  has  been  found  only  after  operation, 
as  the  collection  may  be  very  small.  The  X-rays  often  give  aid. 

Pericarditis,  one  of  the  most  serious  of  complications  was  present  in  35  of 
658  patients  in  my  wards  at  the  Johns  Hopkins  Hospital   (Chatard).     It  is 
often  a  terminal  affair  and  overlooked.     The  mortality  is  very  high;  31  of  the 
8 


90  SPECIFIC   INFECTIOUS   DISEASES 

35  patients  died.  It  was  most  frequently  associated  with  pneumonia  of  the 
right  lung.  In  only  three  instances  was  the  amount  of  fluid  above  500  c.  c. 
Pleurisy  is  an  almost  constant  accompaniment,  being  present  in  28  of  the  29 
autopsies  in  my  series. 

Endocarditis. — The  valves  on  the  left  side  are  more  commonly  attacked, 
and  particularly  if  the  seat  of  arterio-sclerosis.  It  is  especially  liable  to 
attack  persons  with  old  valvular  disease.  There  may  be  no  symptoms  indica- 
tive of  this  complication  even  in  very  severe  cases.  It  may,  however,  be  sus- 
pected in  cases  (1)  in  which  the  fever  is  protracted  and  irregular;  (2)  when 
signs  of  septic  mischief  arise,  such  as  chills  and  sweats;  (3)  when  embolic 
phenomena  appear.  The  frequent  complication  of  meningitis  with  the  endo- 
carditis of  pneumonia,  which  has  already  been  mentioned,  gives  prominence 
to  the  cerebral  symptoms  in  these  cases.  The  physical  signs  may  be  very 
deceptive.  There  are  instances  in  which  no  cardiac  murmurs  have  been  heard. 
In  others  the  occurrence  under  observation  of  a  loud,  rough  murmur,  particu- 
larly if  diastolic,  is  extremely  suggestive. 

Ante-mortem  clotting  in  the  heart,  upon  which  the  old  writers  laid  great 
stress,  is  very  rare.  Thrombosis  in  the  peripheral  veins  is  also  uncommon. 
Three  cases  occurred  at  my  clinic,  which  have  been  reported  by  Steiner,  who 
was  able  to  collect  only  54  cases  from  the  literature.  In  35  out  of  44  cases 
which  were,  fully  reported,  the  thrombosis  occurred  during  convalescence.  It 
is  almost  always  in  the  femoral  veins.  A  rare  complication  is  embolism  of 
one  of  the  larger  arteries.  I  saw  in  Montreal  an  instance  of  embolism  of 
the  femoral  artery  at  the  height  of  pneumonia,  which  necessitated  amputation 
at  the  thigh.  The  patient  recovered.  Aphasia  has  been  met  with  in  a  few 
instances,  setting  in  abruptly  with  or  without  hemiplegia. 

Meningitis  is  perhaps  the  most  serious  complication  of  pneumonia.  It 
varies  very  much  at  different  times  and  in  different  regions.  My  Montreal 
experience  is  rather  exceptional,  as  8  per  cent,  of  the  fatal  cases  had  this  com- 
plication. In  twenty  years  at  the  Johns  Hopkins  Hospital  there  were  25 
cases  of  pneumococcus  meningitis,  in  18  of  which  pn6umonia  was  present.  In 
16  of  the  cases  the  organism  was  demonstrated  in  the  cerebro-spinal  fluid.  En- 
docarditis was  present  in  7  of  the  18  cases.  The  percentage  of  meningitis  in 
,the  pneumonia  cases  was  2.4,  which  is  lower  than  the  figures  of  Musser  and 
Norris  of  3.5  per  cent,  in  4,883  autopsies.  It  usually  comes  on  at  the  height 
of  the  fever,  and  in  the  majority  of  the  cases  is  not  recognized  unless,  as  before 
mentioned,  the  base  is  involved,  which  is  not  common.  Occurring  later  in  the 
disease,  it  is  more  easily  diagnosed.  The  prognosis  is  bad;  all  of  our  patients 
died.  A  few  instances  of  recovery  are  on  record. 

Peripheral  neuritis  is  a  rare  complication,  of  which  several  cases  have 
been  described. 

Gastric  complications  are  rare.  Fussell  has  recently  drawn  attention  to 
the  occurrence  of  acute  dilatation  of  the  stomach.  Persistent  vomiting,  sud- 
den abdominal  distention  and  collapse  are  the  most  common  features.  A 
croupous  gastritis  has  already  been  mentioned.  The  croupous  colitis  may  in- 
duce severe  diarrhoea. 

It  is  by  no  means  uncommon  to  have  early  pain,  either  in  the  region  of 
the  umbilicus  or  in  the  right  iliac  fossa,  and  a  suspicion  of  appendicitis  is 
Aroused ;  indeed,  a  catarrhal  form  of  this  disease  may  occur  coincidently  with 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS          91 

the  pneumonia.  In  other  instances  so  localized  may  the  pain  be  in  the  region 
of  the  pancreas,  associated  with  meteorism  and  high  fever,  that  the  diagnosis 
of  acute  haemorrhagic  pancreatitis  is  made.  Such  a  case  occurred  in  February, 
1905,  in  the  wards  of  my  colleague  Dr.  Halsted.  The  patient  was  admitted 
in  a  desperate  condition,  all  the  symptoms  were  abdominal,  and  the  apex 
pneumonia  was  not  discovered.  Peritonitis  is  a  rare  complication,  of  which 
we  have  had  only  two  or  three  instances.  It  is  sometimes  in  the  upper  peri- 
toneum, and  a  direct  extension  through  the  diaphragm.  It  is  usually  in  the 
severer  cases  and  not  easy  to  recognize.  In  one  case,  indeed,  in  which  there 
was  a  friction  along  the  costal  border,  which  we  thought  indicated  a  peritonitis; 
it  was  communicated  from  the  diaphragmatic  pleura.  Meteorism  is  not  in- 
frequent, and  is  sometimes  serious.  In  some  cases  it  may  be  due  to  a  defect  in 
the  mechanical  action  of  the  diaphragm,  in  others  to  an  acute  septic  catarrh 
of  the  bowels,  or  to  a  toxic  paresis  of  the  walls,  occasionally  to  peritonitis. 
Jaundice  occurs  with  curious  irregularity  in  different  outbreaks  of  the  dis- 
ease. In  Baltimore  it  was  more  common  among  the  negro  patients.  It  sets 
in  early,  is  rarely  very  intense,  and  has  not  the  characters  of  obstructive  jaun- 
dice. There  are  cases  in  which  it  assumes  a  very  serious  form.  The  mode 
of  production  is  not  well  ascertained.  It  does  not  appear  to  bear  any  definite 
relation  to  the  degree  of  hepatic  engorgement,  and  it  is  not  always  due  to 
catarrh  of  the  ducts.  Possibly  it  may  be,  in  great  part,  haematogenous. 

Parotitis  occasionally  occurs,  commonly  in  association  with  endocarditis. 
In  children,  middle-ear  disease  is  not  an  infrequent  complication. 

Bright's  disease  does  not  often  follow  pneumonia. 

Arthritis  occurred  in  5  of  658  cases  at  the  Johns  Hopkins  Hospital  (How- 
ard). It  may  precede  the  onset,  and  the  pneumonia,  possibly  with  endocarditis 
and  pleurisy,  may  occur  as  a  complication.  In  other  instances  at  the  height 
of  an  ordinary  pneumonia  one  or  two  joints  may  become  red  and  sore.  On 
the  other  hand,  after  the  crisis  has  occurred  pain  and  swelling  may  come  on  in 
the  joints.  It  is  a  serious  complication  as  recovery  is  often  slow  and  a  stiff 
joint  may  follow. 

Relapse. — There  are  cases  in  which  from  the  ninth  to  the  eleventh  day  the 
fever  subsides,  and  after  the  temperature  has  been  normal  for  a  day  or  two  a 
rise  occurs  and  fever  may  persist  for  another  ten  days  or  even  two  weeks. 
Though  this  might  be  termed  a  relapse,  it  is  more  correct  to  regard  it  as  an 
instance  of  an  anomalous  course  or  delayed  resolution.  Wagner,  who  has 
studied  the  subject  carefully,  says  that  in  his  large  experience  of  1,100  cases 
he  met  with  only  3  doubtful  cases.  When  it  does  occur,  the  attack  is  usually 
abortive  and  mild.  In  the  case  of  Z.  E.  (Medical  No.  J.  H.  H.,  4223),  with 
pneumonia  of  the  right  lower  lobe,  crisis  occurred  on  the  seventh  day,  and 
after  a  normal  temperature  for  thirteen  days  he  was  discharged.  That  night 
he  had  a  shaking  chill,  followed  by  fever,  and  he  had  recurring  chills  with 
reappearance  of  the  pneumonia.  In  a  second  case  (Medical  No.  J.  H.  H., 
4538)  crisis  occurred  on  the  third  day,  and  there  was  recurrence  of  pneumonia 
on  the  thirteenth  day. 

Recurrence  is  more  common  in  pneumonia  than  in  any  other  acute  disease. 
Rush  gives  an  instance  in  which  there  were  28  attacks.  Other  authorities  nar- 
rate cases  of  8,  10,  and  even  more  attacks. 

Convalescence  in  pneumonia  is  usually  rapid,  and  sequelae  are  rare.    After 


92  SPECIFIC    INFECTIOUS    DISEASES 

the  crisis,  sudden  death  has  occurred  when  the  patient  has  got  up  too  soon. 
With  the  onset  of  fever  and  persistence  of  the  leucocytosis  the  affected  side 
should  be  very  carefully  examined  for  pleurisy.  With  a  persistence  of  the 
dulness  the  physical  signs  may  be  obscure,  but  the  use  of  a  small  exploratory 
needle  or  the  X-rays  will  help  to  clear  the  diagnosis. 

Clinical  Varieties. — Local  variations  are  responsible  for  some  of  the  most 
marked  deviations  from  the  usual  type. 

Apex  pneumonia  is  said  to  be  more  often  associated  with  adynamic  fea- 
tures and  with  marked  cerebral  symptoms.  The  expectoration  and  cough  may 
be  slight. 

Migratory  or  creeping  pneumonia,  a  form  which  successively  involves  one 
lobe  after  the  other. 

Double  pneumonia  has  no  peculiarities  other  than  the  greater  danger  con- 
nected with  it. 

Massive  pneumonia,  is  a  rare  form,  in  which  not  alone  the  air-cells  but 
the  bronchi  of  an  entire  lobe  or  even  of  a  lung  are  filled  with  the  fibrinous  exu- 
date.  The  auscultatory  signs  are  absent;  there  is  neither  fremitus  nor  tubu- 
lar breathing,  and  on  percussion  the  lung  is  absolutely  flat.  It  closely  resem- 
bles pleurisy  with  effusion.  The  moulds  of  the  bronchi  may  be  expectorated 
in  violent  fits  of  coughing. 

Central  Pneumonia. — The  inflammation  may  be  deep-seated  at  the  root 
of  the  lung  or  centrally  placed  in  a  lobe,  and  for  several  days  the  diagnosis 
may  be  in  doubt.  It  may  not  be  until  the  third  or  fourth  day  that  a  pleural 
friction  is  detected,  or  that  dulness  or  blowing  breathing  and  rales  are  recog- 
nized. I  saw  in  1898  with  Drs.  H.  Adler  and  Chew  a  young,  thin-chested  girl 
in  whom  at  the  end  of  the  fourth  day  all  the  usual  symptoms  of  pneumonia 
were  present  without  any  physical  signs  other  than  a  few  clicking  rales  at  the 
left  apex  behind.  The  thinness  of  the  patient  greatly  facilitated  the  examina- 
tion. The  general  features  of  pneumonia  continued,  and  the  crisis  occurred 
on  the  seventh  day. 

PNEUMONIA  IN  INFANTS. — It  is  sometimes  seen  in  the  new-born.  In  in- 
fants it  very  often  sets  in  with  a  convulsion.  The  apex  of  the  lung  seems 
more  frequently  involved  than  in  adults,  and  the  cerebral  symptomo  are  more 
marked.  The  torpor  and  coma,  particularly  if  they  follow  convulsions,  and 
the  preliminary  stage  of  excitement,  may  lead  to  the  diagnosis  of  meningitis. 
Pneumonic  sputum  is  rarely  seen  in  children. 

PNEUMONIA  IN  THE  AGED. — The  disease  may  be  latent,  and  set  in  with- 
out a  chill ;  the  cough  and  expectoration  are  slight,  the  physical  signs  ill- 
defined  and  changeable,  and  the  constitutional  symptoms  out  of  all  propor- 
tion to  the  extent  of  the  local  lesion. 

PNEUMONIA  IN  ALCOHOLIC  SUBJECTS. — The  onset  is  insidious,  the  symp- 
toms masked,  the  fever  slight,  and  the  clinical  picture  usually  that  of  delirium 
tremens.  The  thermometer  alone  may  indicate  the  presence  of  an  acute  dis- 
ease. Often  the  local  condition  is  overlooked,  as  the  patient  makes  no  com- 
plaint of  pain,  and  there  may  be  very  little  shortness  of  breath,  no  cough,  and 
no  sputum. 

TERMINAL  PNEUMONIA. — The  wards  and  the  post  mortem  room  show 
a  very  striking  contrast  in  their  pneumonia  statistics,  owing  to  the  occur- 
rence of  what  may  be  called  terminal  pneumonia.  During  the  winter  months 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS          93 

patients  with  chronic  pulmonary  tuberculosis,  arterio-sclerosis,  heart  disease, 
Bright's  disease,  and  diabetes  are  not  infrequently  carried  off  by  a  pneu- 
monia which  may  give  few  or  no  signs  of  its  presence.  In  the  Johns  Hopkins 
Hospital  series  of  658  cases,  there  were  35  cases  of  this  variety,  20  of  which 
were  associated  with  cardio-vascular  and  14  with  renal  disease.  It  is  nearly 
always  of  the  lobar  form.  There  may  be  a  slight  elevation  of  temperature, 
with  increase  in  the  respirations,  but  the  patient  is  near  the  end  and  perhaps 
not  in  a  condition  in  which  a  thorough  physical  examination  can  be  made.  In 
our  series  the  right  lung  was  involved  in  19  cases  and  9  had  a  low  leucocyte 
count.  In  diabetic  patients  the  disease  often  runs  a  rapid  and  severe  course, 
and  may  end  in  abscess  or  gangrene. 

SECONDARY  PNEUMONIA. — These  are  met  with  chiefly  in  the  specific  fevers, 
particularly  diphtheria,  typhoid  fever,  typhus,  influenza,  and  the  plague.  Ana- 
tomically, they  rarely  present  the  typical  form  of  red  or  gray  hepatization.  The 
surface  is  smoother,  not  so  dry,  and  it  is  often  a  pseudo-Lobar  condition,  a  con- 
solidation caused  by  closely  set  areas  of  lobular  involvement.  Histologically, 
they  are  characterized  in  many  instances  by  a  more  cellular,  less  fibrinous  exu- 
date,  which  may  also  infiltrate  the  alveolar  walls.  Bacteriologically,  the  pneu- 
mococcus  may  be  the  dominant  organism;  but  Friedlander's  bacillus,  strepto- 
cocci, staphylococci,  the  influenza  and  colon  bacillus  have  been  found. 

The  symptoms  of  the  secondary  pneumonias  often  lack  the  striking  defi- 
niteness  of  the  primary  croupous  pneumonia.  The  pulmonary  features  may 
be  latent  or  masked  altogether.  There  may  be  no  cough  and  only  a  slight  in- 
crease in  the  number  of  respirations.  The  lower  lobe  of  one  lung  is  most  com- 
monly involved,  and  the  physical  signs  are  obscure  and  rarely  amount  to 
more  than  impaired  resonance,  feeble  breathing,  and  a  few  crackling  rales. 

EPIDEMIC  PNEUMONIA  has  already  been  referred  to.  It  is,  as  a  rule,  more 
fatal,  and  often  displays  minor  complications  which  differ  in  different  out- 
breaks. In  some  the  cerebral  manifestations  are  very  marked;  in  others,  the 
cardiac;  in  others  again,  the  gastro-intestinal. 

LARVAL  PNEUMONIA. — Mild,  abortive  types  are  seen,  particularly  in  insti- 
tutions when  pneumonia  is  prevailing  extensively.  A  patient  may  have  the 
initial  symptoms  of  the  disease,  a  slight  chill,  moderate  fever,  a  few  indefi- 
nite local  signs,  and  herpes.  The  whole  process  may  only  last  for  two  or  three 
days ;  some  authors  recognize  even  a  one-day  pneumonia. 

ASTHENIC,  Toxic,  OR  TYPHOID  PNEUMONIA. — The  toxffimic  features 
dominate  the  scene  throughout.  The  local  lesions  may  be  slight  in  extent 
and  the  subjective  phenomena  of  the  disease  absent.  The  nervous  symptoms 
usually  predominate.  There  are  delirium,  prostration,  and  early  weakness. 
Very  frequently  there  is  jaundice.  Gastro-intestinal  symptoms  may  be  pres- 
ent, particularly  diarrhoea  and  meteorism.  In  such  a  case,  seen  about  the  end 
of  the  first  week,  it  may  be  difficult  to  say  whether  the  condition  is  one  of 
asthenic  pneumonia  or  one  of  typhoid  fever  which  has  set  in  with  early  local- 
ization in  the  lung.  Here  the  Widal  reaction  and  cultures  from  the  blood  are 
important  aids.  The  pneumococcus  may  sometimes  be  isolated  from  the  blood. 
Possibly,  too,  there  is  a  mixed  infection,  and  the  streptococcus  pyogenes  may 
be  in  large  part  responsible  for  the  toxic  features  of  the  disease. 

ASSOCIATION  OF  PNEUMONIA  WITH  OTHJR  DISEASES. —  (a)  With  Malaria. 
< — A  malarial  pneumonia  is  described  by  many  observers  and  thought  to  be 


94  SPECIFIC    INFECTIOUS    DISEASES 

particularly  prevalent  in  some  parts  of  the  United  States.  One  hears  of  it, 
indeed,  even  where  true  malaria  is  rarely  seen.  Pneumonia  is  a  common  dis- 
ease in  the  tropics  and  often  attacks  the  subjects  of  malaria.  The  prognosis 
is  bad  in  the  aestivo-autumnal  infections.  A  special  form  of  pneumonia  due 
to  the  malarial  parasite  is  unknown.  Yet  there  are  cases  reported  by  Craig 
and  others  in  which  in  an  acute  malarial  infection  the  features  suggest  pneu- 
monia at  the  onset,  but  the  parasites  are  found  in  the  blood,  and  under  the 
use  of  quinine  the  fever  drops  rapidly  and  the  pneumonia  symptoms  clear  up. 
Such  a  case  as  the  following  we  see  occasionally:  A  patient  was  admitted, 
March  16,  1894,  with  tertian  malarial  fever.  The  lungs  were  clear.  A  pneu- 
monia began  thirty-six  hours  after  admission.  Quinine  was  given  that  even- 
ing, and  the  malarial  organisms  rapidly  disappeared  from  the  blood.  There 
was  successive  involvement  of  the  right  lower,  the  middle,  and  the  left  lower 
lobe.  The  temperature  fell  by  crisis  on  the  24th,  and  there  were  no  features 
in  the  disease  whatever  suggestive  of  malaria.  In  other  instances  we  have 
found  a  chill  in  the  course  of  an  ordinary  pneumonia  to  be  associated  with  a 
malarial  infection,  and  quinine  has  rapidly  and  promptly  caused  the  disap- 
pearance of  the  parasites  from  the  blood. 

(&)  Pneumonia  and  Acute  Arthritis. — We  have  already  spoken  under 
complications  of  this  association,  which  is  more  frequently  seen  in  children. 

(c)  Pneumonia  and  Tuberculosis. — Many  subjects  of  chronic  pulmonary 
tuberculosis  die  of  an  acute  croupous  pneumonia.  A  point  to  be  specially 
borne  in  mind  is  the  fact  that  acute  tuberculous  pneumonia  may  set  in  with 
all  the  features  and  physical  signs  of  fibrinous  pneumonia. 

For  the  consideration  of  the  association  of  pneumonia  with  typhoid  fever 
and  influenza,  the  reader  is  referred  to  the  sections  on  those  diseases. 

POST-OPERATION  PNEUMONIA. — Before  the  days  of  anesthesia,  lobar  pneu- 
monia was  a  well-recognized  cause  of  death  after  surgical  injuries  and  opera- 
tions. Norman  Cheevers,  in  an  early  number  of  the  Guy's  Hospital  Eeports, 
calls  attention  to  it  as  one  of  the  most  frequent  causes  of  death  after  surgical 
procedures,  and  Erichsen  states  that  of  41  deaths  after  surgical  injuries  23 
cases  showed  signs  of  pneumonia.  In  the  statistics  collected  by  Romans  the 
mortality  due  to  lung  complications  after  laparotomies  ranged  from  0.56  to 
12.5.  Operations  on  the  stomach  seem  to  be  peculiarly  liable  to  be  followed 
by  pneumonia.  The  low  figure,  0.56,  in  Kronlein's  clinic  may  be  attributed 
to  the  use  of  ether  by  the  open  method,  to  the  absence  of  all  preparation  on 
the  table  and  to  shortening  as  much  as  possible  the  period  of  anaesthesia.  The 
cases  may  be  divided  into  three  groups:  (1)  Inhalation  or  anaesthesia  pneu- 
monia, characterized  by  areas  of  broncho-pneumonia  or  a  lobar  pneumonia. 
(2)  Hypostatic  pneumonia  due  to  enfeebled  circulation.  (3)  Embolic 
cases  with  sudden  onset.  The  route  may  be  lymphatic  or  through  the 
veins. 

ANESTHESIA  PNEUMONIA. — The  cases  appear  to  be  quite  as  frequent  after 
chloroform  as  after  ether.  The  vapor  of  the  anaesthetic  may  itself  have  a 
damaging  influence  on  the  bronchial  and  alveolar  epithelium,  but  a  more  im- 
portant influence  is  the  aspiration  of  mucus  and  saliva  into  the  air  passages  dur- 
ing the  anaesthesia.  Neuwerck,  and  subsequently  Whitney,  have  suggested  thor- 
ough disinfection  of  the  mouth  and  throat  before  operation.  Pneumonia  is 
the  most  frequent  complication,  next  a  diffuse  bronchitis.  W.  Pasteur  has 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS          95 

called  attention  to  a  condition  of  massive  collapse  of  the  lungs  due  to  deflation 
of  the  lower  lobes,  owing  to  imperfect  action  or  paralysis  of  the  diaphragm. 
He  has  published  the  statistics  of  lung  complications  at  the  Middlesex  Hospi- 
tal; following  3,559  abdominal  operations  there  were  201  pulmonary  com- 
plications, with  45  deaths.  Among  these  pneumonia  heads  the  list  with  88 
cases  and  31  deaths.  The  complications  are  much  more  numerous  in  opera- 
tions above  the  umbilicus.  The  pneumonia  is  usually  patchy,  involving  both 
lungs;  sometimes  it  is  lobar,  and  as  a  rule  the  signs  are  well  marked  within 
the  first  two  days  after  operation.  The  collapse,  to  which  Pasteur  calls  atten- 
tion, may  involve  both  lower  lobes  or  only  one  lung,  and  it  may  simulate  pneu- 
monia very  closely,  or  may  initiate  it.  When  unilateral,  the  mediastinum  and 
heart  are  drawn  towards  the  affected  side.  It  may  come  on  with  great  sud- 
denness, and  when  widespread  it  may  prove  fatal. 

DELAYED  BESOLUTION  IN  PNEUMONIA. — The  lung  is  restored  to  its  nor- 
mal state  by  the  liquefaction  and  absorption  of  the-  exudate.  There  are 
cases  in  which  resolution  takes  place  rapidly  without  any  increase  in  (or, 
indeed,  without  any)  expectoration;  on  the  other  hand,  during  resolution  it  is 
not  uncommon  to  find  in  the  sputum  the  little  plugs  of  fibrin  and  leucocytes 
which  have  been  loosened  from  the  air-cells  and  expelled  by  coughing.  A 
variable  time  is  taken  in  the  restoration  of  the  lung.  Sometimes  within  a 
week  or  ten  days  the  dulness  is  greatly  diminished,  the  breath-sounds  become 
clear,  and,  so  far  as  physical  signs  are  any  guide,  the  lung  seems  perfectly 
restored.  Delayed  resolution  occurs  in  from  3  to  4  per  cent,  of  cases.  Of  40 
cases  at  the  Johns  Hopkins  Hospital  studied  by  McCrae,  33  were  males  and  7 
females;  23  of  the  patients  were  negroes,  a  very  high  incidence.  The  lower 
lobe  is  most  frequently  involved,  37  cases  in  this  series,  usually  the  right  one 
and  as  a  rule  only  one  lobe.  The  duration  was  to  the  fourth  week  5  cases, 
fifth  week  10  cases,  sixth  week  4  cases,  ninth  week  3  cases,  tenth,  eleventh  and 
twelfth  weeks  each  one  case.  I  saw  a  patient  in  whom  the  left  lung,  except 
a  small  portion  of  the  upper  lobe,  remained  solid  for  eleven  weeks  and  then 
cleared  perfectly. 

Clinically,  there  are  several  groups  of  cases:  First,  those  in  which  the 
crisis  occurs  naturally,  the  temperature  falls  and  remains  normal;  but  the 
local  features  persist — well-marked  flatness  with  tubular  breathing  and  rales. 
Kesolution  may  occur  very  slowly  and  gradually,  taking  from  two  to  three 
weeks.  In  a  second  group  of  cases  the  temperature  falls  by  lysis,  and  with  the 
persistence  of  the  local  signs  there  is  slight  fever,  sometimes  sweats  and  rapid 
pulse.  The  condition  may  persist  for  three  or  four  weeks  and  during  all 
this  time  there  may  be  little  or  no  sputum.  The  practitioner  is  naturally 
much  exercised,  and  he  dreads  lest  tuberculosis  should  supervene.  In  a  third 
group  the  crisis  occurs  or  the  fever  falls  by  lysis;  but  the  consolidation  persists, 
and  there  may  be  intense  bronchial  breathing,  with  few  or  no  rales,  or  the  fever 
may  recur  and  the  patient  may  die  exhausted. 

TERMINATION  IN  CHRONIC  PNEUMONIA, — The  exudate  may  organize  and 
the  alveolar  walls  thicken  with  the  production  gradually  of  a  chronic  inter- 
stitial or  fibroid  pneumonia.  In  one  of  my  pneumonia  autopsies  on  a 
patient  aged  58,  dead  on  the  thirty-second  day  from  the  initial  chill,  the  right 
lung  was  solid  and  the  cut  surface  grayish  in  color  with  a  smooth,  translucent 
appearance.  This  termination  is  most  frequently  seen  as  a  sequence  of  delayed 


96  SPECIFIC    INFECTIOUS    DISEASES 

resolution  in  debilitated  subjects.  In  a  recent  study  Milne  found  10  instances 
of  organization  of  the  exudate  among  150  fatal  cases.  The  shortest  duration 
in  the  series  was  twenty-three  days. 

Ordinary  fibrinous  pneumonia  never  terminates  in  tuberculosis.  The  in- 
stances of  caseous  pneumonia  and  softening  which  have  followed  an  acute 
pneumonic  process  have  been  from  the  outset  tuberculous. 

TERMINATION  IN  ABSCESS. — This  occurred  in  4  of  my  100  autopsies. 
Usually  the  lung  breaks  down  in  limited  areas  and  the  abscesses  are  not 
large,  but  they  may  fuse  and  involve  a  considerable  proportion  of  a  lobe. 
The  condition  is  recognized  by  the  sputum,  which  is  usually  abundant  and 
contains  pus  and  elastic  tissue,  sometimes  cholesterin  crystals  and  hsema- 
toidin  crystals.  The  cough  is  often  paroxysmal  and  of  great  severity;  usu- 
ally the  fever  is  remittent,  or  in  protracted  cases  intermittent  in  character, 
and  there  may  be  pronounced  hectic  symptoms.  When  a  case  is  seen  for  the 
first  time  it  may  be  difficult  to  determine  whether  it  is  one  of  abscess  of  the 
lung  or  a  local  empyema  which  has  perforated  the  lung. 

GANGRENE. — This  is  most  commonly  seen  in  old  debilitated  persons.  It 
was  present  in  3  of  my  100  autopsies.  It  very  often  occurs  with  abscess. 
The  gangrene  is  associated  with  the  growth  of  the  saprophytic  bacteria  on 
a  soil  made  favorable  by  the  presence  of  the  pneumococcus  or  the  strepto- 
coccus. Clinically,  the  gangrene  is  rendered  very  evident  by  the  horribly 
fetid  odor  of  the  expectoration  and  its  characteristic  features.  In  some  in- 
stances the  gangrene  may  be  found  post  mortem  when  clinically  there  has  not 
been  any  evidence  of  its  existence. 

Prognosis. — Pneumonia  is  one  of  the  most  fatal  of  all  acute  diseases,  kill- 
ing more  than  diphtheria,  and  outranking  even  consumption  as  a  cause  of 
death.  In  America  the  mortality  appears  to  be  increasing. 

The  statistics  of  my  clinic  at  the  Johns  Hopkins  Hospital  from  1889  to 
1905  have  been  analyzed  by  Chatard.  There  were  658  cases  with  200  deaths, 
a  mortality  of  30.4  per  cent.  Excluding  35  cases  of  terminal  pneumonia  the 
percentage  is  26.4.  The  death  rate  among  245  negroes  was  very  little  above 
that  of  the  whites.  Greenwood  and  Candy  in  a  study  of  the  pneumonia  sta- 
tistics at  the  London  Hospital  from  1854-1903,  a  total  of  5,097  cases,  conclude 
that  the  fatality  of  the  disease  has  not  appreciably  changed  in  this  period.  In 
comparing  the  collected  figures  of  these  authors  with  those  from  other  in- 
stitutions, there  is  an  extraordinary  uniformity  in  the  mortality  rate.  Be- 
tween the  ages  of  21-30  the  mortality  is  everywhere  about  20  per  cent. ;  be- 
tween the  ages  of  31-40,  30  per  cent.;  and  then  after  each  decade  it  rises,  until 
above  the  age  of  60  more  than  one-half  of  the  persons  attacked  die. 

The  mortality  in  private  practice  varies  greatly.  E.  P.  Howard  treated 
170  cases  with  only  6  per  cent,  of  deaths.  Fussell  has  reported  134  cases  with 
a  mortality  of  17.9  per  cent.  The  mortality  in  children  is  sometimes  very  low. 
Morrill  has  reported  6  deaths  in  123  cases  of  frank  pneumonia.  On  the  other 
hand,  Goodhart  had  25  deaths  in  120  cases. 

The  following  are  among  the  circumstances  which  influence  the  prog- 
nosis : 

Age. — As  Sturges  remarks,  the  old  are  likely  to  die,  the  young  to  recover. 
Under  one  year  it  is  more  fatal  than  between  two  and  five.  Of  50  cases  under 
10  years  of  age  4  died;  of  119  cases  under  20,  16  died  (Chatard).  Above  sixty 


PNEUMONIAS   AND   PNETJMOCOCCIC    INFECTIONS         97 

the  death  rate  is  very  high,  amounting  to  60  or  80  per  cent. ;  33  of  44  cases  in 
my  series.  From  the  reports  of  its  fatality  in  some  places,  one  may  say  that 
to  die  of  pneumonia  is  almost  the  natural  end  of  old  people. 

Previous  habits  of  life  and  the  condition  of  bodily  health  at  the  time  of 
the  attack  form  the  most  important  factors  in  the  prognosis  of  pneumonia. 
In  analyzing  a  series  of  fatal  cases  one  is  very  much  impressed  with  the  num- 
ber of  cases  in  which  the  organs  show  signs  of  degeneration.  In  25  of  my 
100  autopsies  at  the  Montreal  General  Hospital  the  kidneys  showed  extensive 
interstitial  changes.  Individuals  debilitated  from  sickness  or  poor  food,  hard 
drinkers,  and  that  large  class  of  hospital  patients,  composed  of  robust-looking 
laborers  between  the  ages  of  forty-five  and  sixty,  whose  organs  show  signs  of 
wear  and  tear,  and  who  have  by  excesses  in  alcohol  weakened  the  reserve  power, 
fall  an  easy  prey  to  the  disease.  Very  few  fatal  cases  occur  in  robust,  healthy 
adults.  Some  of  the  statistics  given  by  army  surgeons  show  better  than  any 
others  the  low  mortality  from  pneumonia  in  healthy  picked  men.  The  death 
rate  in  the  German  army  in  over  40,000  cases  was  only  3.6  per  cent. 

Certain  complications  and  terminations  are  particularly  serious.  The 
meningitis  of  pneumonia  is  almost  always  fatal.  Endocarditis  is  extremely 
grave,  much  more  so  than  pericarditis.  Much  stress  has  been  laid  of  late 
upon  the  factor  of  leucocytosis  as  an  element  in  the  prognosis.  A  very  slight 
or  complete  absence  of  a  leucocytosis  is  rightly  regarded  as  very  unfavorable. 

Toxcemia  is  the  important  prognostic  feature  in  the  disease,  to  which  in 
a  majority  of  the  cases  the  degree  of  pyrexia  and  the  extent  of  consolidation 
are  entirely  subsidiary.  It  is  not  at  all  proportionate  to  the  degree  of  lung 
involved.  A  severe  and  fatal  toxaemia  may  occur  with  the  consolidation  of 
only  a  small  part  of  one  lobe.  On  the  other  hand,  a  patient  with  complete 
solidification  of  one  lung  may  have  no  signs  of  a  general  infection.  The 
question  of  individual  resistance  seems  to  be  the  most  important  one,  and 
one  sees  robust-looking  individuals  fatally  stricken  within  a  few  days. 

Death  is  rarely  due  to  direct  interference  with  the  function  of  respira- 
tion, even  in  double  pneumonia.  Sometimes  it  seems  to  be  caused  by  the 
extensive  involvement  with  oedema  of  the  other  parts  of  the  lungs,  an  engorge- 
ment with  progressive  weakness  of  the  right  heart.  But  death  is  most  fre- 
quently due  to  the  action  of  the  poisons  on  the  vaso-motor  centres,  with  pro- 
gressive lowering  of  the  blood  pressure.  This  is  a  much  more  serious  factor 
than  direct  weakness  of  the  heart  muscle  itself. 

Diagnosis. — No  disease  is  more  readily  recognized  in  a  large  majority  of 
the  cases.  The  external  characters,  the  sputum,  and  the  physical  signs  combine 
to  make  one  of  the  clearest  of  clinical  pictures.  The  ordinary  lobar  pneumonia 
of  adults  is  rarely  overlooked.  Errors  are  particularly  liable  to  occur  in  the 
intercurrent  pneumonias,  in  those  complicating  chronic  affections,  and  in  the 
disease  as  met  with  in  children,  the  aged,  and  drunkards.  Tuberculo- 
pneumonic  phthisis  is  frequently  confounded  with  pneumonia.  Pleurisy  with 
effusion  is  not  often  mistaken  except  in  children.  The  diagnostic  points  will 
be  referred  to  under  pleurisy. 

In  diabetes,  Bright's  disease,  chronic  heart-disease,  pulmonary  phthisis, 
and  cancer,  an  acute  pneumonia  often  ends  the  scene,  and  is  frequently  over- 
looked. In  these  cases  the  temperature  is  perhaps  the  best  index,  and  should, 
more  particularly  if  cough  occurs,  lead  to  a  careful  examination  of  the  lungs. 


98  SPECIFIC   INFECTIOUS   DISEASES 

The  absence  of  expectoration  and  of  pulmonary  symptoms  may  make  the  diag- 
nosis very  difficult. 

In  children  there  are  two  special  sources  of  error;  the  disease  may  be 
entirely  masked  by  the  cerebral  symptoms  and  the  case  mistaken  for  one  of 
meningitis.  It  is  remarkable  in  these  cases  how  few  indications  there  are  of 
pulmonary  trouble.  The  other  condition  is  pleurisy  with  effusion,  which  in 
children  often  has  deceptive  physical  signs.  The  breathing  may  be  intensely 
tubular  and  tactile  fremitus  may  be  present.  The  exploratory  needle  is  some- 
times required  to  decide  the  question.  In  the  old  and  debilitated  a  knowledge 
that  the  onset  of  pneumonia  is  insidious,  and  that  the  symptoms  are  ill- 
defined  and  latent,  should  put  the  practitioner  on  his  guard  and  make  him 
very  careful  in  the  examination  of  the  lungs  in  doubtful  cases.  In  chronic 
alcoholism  the  cerebral  symptoms  may  completely  mask  the  local  process.  As 
mentioned,  the  disease  may  assume  the  form  of  violent  mania,  but  more  com- 
monly the  symptoms  are  those  of  delirium  tremens.  In  any  case,  rapid  pulse, 
rapid  respiration,  and  fever  are  symptoms  which  should  invariably  excite 
suspicion  of  inflammation  of  the  lungs.  Under  cerebro-spinal  meningitis  will 
be  found  the  points  of  differential  diagnosis  between  pneumonia  and  that 
disease. 

Pneumonia  is  rarely  confounded  with  pulmonary  tuberculosis,  but  to  dif- 
ferentiate acute  tuberculo-pneumonic  phthisis  is  often  difficult.  The  attack 
may  set  in  with  a  chill.  It  may  be  impossible  to  determine  which  condition  is 
present  until  softening  occurs  and  elastic  tissue  and  tubercle  bacilli  appear 
in  the  sputum.  A  similar  mistake  is  sometimes  made  in  children.  With 
typhoid  fever,  pneumonia  is  not  infrequently  confounded.  There  are  in- 
stances of  pneumonia  with  the  local  signs  well  marked  in  which  the  patient 
rapidly  sinks  into  what  is  known  as  the  typhoid  state,  with  dry  tongue,  rapid 
pulse,  and  diarrhoea.  Unless  the  case  is  seen  from  the  outset  it  may  be  very 
difficult  to  determine  the  true  nature  of  the  malady.  On  the  other  hand, 
there  are  cases  of  typhoid  fever  which  set  in  with^  symptoms  of  lobar  pneu- 
monia— the  so-called  pneumo-typhus.  It  may  be  impossible  to  make  a  differ- 
ential diagnosis  in  such  a  case  unless  the  characteristic  eruption  occurs,  a  blood 
culture  is  positive,  or  the  Widal  reaction  is  given. 

Prophylaxis. — We  do  not  know  the  percentage  of  individuals  who  harbor 
the  pneumococcus  normally  in  the  secretions  of  the  mouth  and  throat.  In  a 
great  majority  of  cases  it  is  an  auto-infection,  and  the  lowered  resistance  due 
to  exposure  or  to  alcohol,  or  a  trauma  or  anesthetization,  simply  furnishes 
conditions  which  favor  the  spread  and  growth  of  an  organism  already  present. 
Individuals  who  have  already  had  pneumonia  should  be  careful  to  keep  the 
teeth  in  good  condition,  and  the  mouth  and  throat  in  as  healthy  a  state  as  pos- 
sible. Antiseptic  mouth  washes  may  be  used. 

We  know  practically  nothing  of  the  conditions  under  which  the  pneumo- 
coccus lives  outside  the  body,  or  how  it  gains  entrance  in  healthy  individuals. 
The  sputum  of  each  case  should  be  very  carefully  disinfected.  In  institutions 
the  patients  should  be  isolated. 

Treatment. — Pneumonia  is  a  self-limited  disease,  which  can  neither  be 
aborted  nor  cut  short  by  any  known  means  at  our  command.  Even  under 
the  most  unfavorable  circumstances  it  may  terminate  abruptly  and  naturally. 
So  alsOj,  under  the  favoring  circumstances  of  good  nursing  and  careful  diet, 


PNEUMONIAS    AND    PXEUMOCOCCIC    INFECTIONS          99 

the  experience  of  many  physicians  in  different  lands  has  shown  that  pneu- 
monia runs  its  course  in  a  definite  time,  terminating  sometimes  spontaneously 
on  the  third  or  the  fifth  day,  or  continuing  until  the  tenth  or  twelfth. 

Morgenroth  and  Levy  claim  for  optochin,  a  quinine  derivative,  a  specific 
action  on  the  pneumococcus.  It  has  a  well-marked  protective  action  against 
experimental  infection  in  mice;  encouraging,  but  scarcely  good  enough  results 
to  use  the  term  specific  have  been  reported  clinically. 

(a)  GENERAL  MANAGEMENT  OF  A  CASE. — The  same  careful  hygiene  of  the 
bed  and  of  the  sick-room  should  be  carried  out  as  in  typhoid  fever.  Everything 
should  be  done  to  make  the  patient  comfortable  and  to  save  him  exer- 
tion. Whenever  possible  the  patient  should  be  in  the  open  air.  In  cold 
weather  he  should  have  sufficient  covering  to  keep  him  warm,  but  should  not 
be  overburdened  by  a  heavy  weight  of  clothes.  A  blanket  and  rubber  sheet, 
under  the  mattress,  which  can  be  folded  up  over  the  bed  prevent  chilling  from 
below.  A  hot-water  bag  should  be  kept  at  the  feet.  The  patient  is  brought 
indoors  when  necessary  for  hydrotherapy.  For  the  heavy  flannel  undershirts 
should  be  substituted  a  thin,  light  flannel  jacket,  open  in  front,  which  enables 
the  physician  to  make  his  examinations  without  unnecessarily  disturbing  the 
patient.  If  the  patient  is  indoors  the  room  should  be  bright  and  light,  letting 
in  the  sunshine  if  possible,  and  thoroughly  well  ventilated.  Only  one  or  two 
persons  should  be  allowed  in  the  room  at  a  time.  Even  when,  not  called  for 
on  account  of  the  high  fever,  the  patient  should  be  carefully  sponged  each  day 
with  tepid  water.  This  should  be  done  with  as  little  disturbance  as  possible. 
Special-  care  should  be  taken  to  keep  the  mouth  and  nose  clean. 

(6)  DIET. — Plain  water,  a  pleasant  table  water,  or  lemonade  should  be 
given  freely.  When  the  patient  is  delirious  the  water  should  be  given  at 
fixed  intervals  and  by  the  bowel  or  by  infusion  if  it  is  not  taken  by  mouth. 
The  food  should  be  liquid,  consisting  chiefly  of  milk,  either  alone  or,  better, 
mixed  with  food  prepared  from  some  one  of  the  cereals,  and  eggs,  either  soft 
boiled  or  raw.  Carbohydrate,  as  milk  sugar,  can  be  added  to  each  feeding  of 
milk,  and  as  cane  sugar  to  lemonade. 

(c)  BOWELS. — At  the  onset  it  is  well  to  give  a  calomel  and  saline  purge. 
The  bowels  can  be  kept  open  by  salines  or  enemata.    Drastic  purgation  is  not 
advisable.     It  is  important  to  prevent  meteorism,  if  possible,  by  care  in  the 
diet,  giving  water  freely  and  preventing  constipation.     If  present,  measures 
for  relief  should  be  begun  at  once.     Turpentine  stupes,  turpentine    (§  ss, 
15  c.  c.)  added  to  an  enema,  and  the  use  of  the  rectal  tube,  are  helpful.  Strych- 
nine and  pituitary  extract  hypodermically  are  also  useful.     If  the  stomach  is 
distended  a  stomach  tube  should  be  passed. 

(d)  BLEEDING. — The  reproach  of  Van  Helmont,  that  "a  bloody  Moloch 
presides  in  the  chairs  of  medicine,"  can  not  be  brought  against  this  genera- 
tion of  physicians.     Before  Louis'  iconoclastic  paper  on  bleeding  in  pneu- 
monia it  would  have  been  regarded  as  almost  criminal  to  treat  a  case  without 
venesection.    We  employ  it  nowadays  much  more  than  we  did  a  few  years  ago, 
but  more  often  late  in  the  disease  than  early.     To  bleed  at  the  very  onset 
in  robust,  healthy  individuals  in  whom  the  disease  sets  in  with  great  intensity 
and  high  fever  is,  I  believe,  a  good  practice.     Late  in  the  course  marked 
dilatation  of  the  right  heart  is  the  common  indication.    The  quantity  of  blood 
removed  must  be  decided  by  the  effect ;  small  amounts  are  often  sufficient. 


100  SPECIFIC    INFECTIOUS    DISEASES 

(e)  ANTIPNEUMOCOCCIC  SERUM. — The  value  of  this  method  of  treatment 
is  on  trial.     With  prompt  and  accurate  means  to  determine  the  variety  of 
pneumococcus  causing  the  attack  much  may  be  expected.     Good  results  have 
been  obtained  by  the  early  use  of  large  doses,  particularly  in  Type  I. 

(f)  HYDROTHERAPY. — This — internal    and    external — is    our    principal 
means  of  combatting  toxemia  and  circulatory  failure.    Cold  sponging  is  usu- 
ally the  best  measure,  done  every  three  hours  and  with  the  least  possible  di?r 
turban.ce  of  the  patient.    With  marked  toxsemia  or  hyperpyrexia  a  bath  at  80° 
with  constant  friction  may  be  given  for  five  minutes  if  it  does  not  increase 
distress  or  dyspnoea.    The  application  of  linen  compresses  covered  by  flannel 
is  an  excellent  measure.     They  should  be  cut  to  the  size  of  the  body,  in  the 
shape  of  a  jacket,  with  the  opening  at  one  side  instead  of  in  the  front,  which 
can  be  applied  from  the  side  of  the  body  with  the  patient  turned,  and  fastened 
over  the  other  shoulder  and  in  the  axilla.    They  should  be  wrung  out  of  water 
at  50°  to  60°  and  be  changed  every  hour.     The  compress  should  cover  the 
thorax  and  upper  abdomen.    A  large  flat  ice  bag  may  be  kept  to  the  side  or 
back  constantly,  unless  it  causes  distress.     Probably  the  best  effect  of  hydro- 
therapy  is  its  effect  on  the  vaso-motor  system. 

(g)  SYMPTOMATIC  TREATMENT. — (1)  To  Relieve  the  Pain. — The  stitch  in 
the  side  at  onset,  which  is  sometimes  so  agonizing,  is  best  relieved  by  a  hypo- 
dermic injection  of  a  quarter  of  a  grain  of  morphia.    When  the  pain  is  less 
intense  and  diffuse  over  one  side,  the  Paquelin  cautery  applied  lightly  is  very 
helpful,    but    the    ice    bag    is    usually    efficacious.      When    the    disease    is 
fairly  established  the  pain  is  not,  as  a  rule,  distressing,  except  when  the 
patient  coughs,  and  for  this  codeia  may  be  used  in  half-grain  doses,   or 
morphia  given  hypodermically  (gr.  1/12  to  1/6),  according  to  the  patient's 
needs.    Hot  poultices,  formerly  so  much  in  use,  relieve  the  pain,  though  not 
more  than  the  cold  applications.    For  children  they  are  often  preferable. 

(2)  To  Combat  the  Toxaemia. — Abundance  of  water  should  be  given  to 
promote  the  flow  of  urine,  and  the  saline  infusion  seems  to  act  helpfully  in 
this  way,  but  care  must  be  taken  not  to  give  too  large  an  amount  if  the  cir- 
culation is  failing ;  500  c.  c.   is  usually  sufficient.     External  hydrotherapy 
should  be  kept  up  actively.    Alcohol  is  generally  advisable,  best  as  whisky  in 
amounts  of  four  to  twelve  ounces  in  the  twenty-four  hours.    The  bowels  should 
be  kept  freely  open  by  saline  laxatives. 

(3)  An  all-important  indication  is  to  support  the  circulation.     Hydro- 
therapy  and  keeping  the  patient  out  of  doors  are  of  great  value  for  this. 
Mechanical  disturbance,  as  from  meteorism,  shpuld  be  prevented  if  possible. 
Drugs  should  not  be  given  in  any  routine  way  and  not  until  they  are  required. 
Strychnine  is  useful  (also  for  its  effects  on  the  respiratory  centre).     It  should 
be  given  hypodermically  and  in  full  doses  (gr.  1/40  to  1/20  and  even  gr. 
1/10  for  short  periods)  every  two  or  three  hours.     Digitalis  can  be  given  by 
mouth  as  the  infusion  (3  ii,  8  c.  c.),  the  tincture  (H\  xv,  1  c.  c.),  or  digitalin 
intramuscularly  (gr.  1/30)  every  four  hours.     For  severe  circulatory  failure, 
camphor  gr.  ii,  0.13  gm.  (dissolved  in  TTt  x  of  olive  oil)  hypodermically,  digi- 
talin (gr.  1/30)  hypodermically,  and  caffeine  (sodiobenzoate)  gr.  v  (0.3  gm.) 
hypodermically  may  be  tried.     Pituitary  extract   (posterior  lobe)    has  been 
warmly  recommended.     An  injection  of  hot  saline  solution  given  high  in  the 
bowel  or  a  saline  infusion  is  helpful. 

(4)  Respiratory  Tract.— The  most  comfortable  position,  avoidance  of  ex- 


PNEUMONIAS   AND   PNEUMOCOCCIC    INFECTIONS        101 

ertion,  and  abundance  of  fresh  air  are  important  aids  in  preventing  dyspnoea. 
Pain  should  be  relieved  as  much  as  possible.  The  value  of  the  administration 
of  oxygen  is  doubtful.  If  used,  it  should  be  given  very  slowly  and  through  a 
funnel  held  over  the  mouth  and  nose.  The  effect  is  the  best  guide  as  to  its 
continuance.  Expectorant  drugs  are  not  indicated  and  often  upset  the  stom- 
ach. When  the  cough  is  severe  it  is  well  to  give  sedatives,  of  which  codeia 
(gr.  1/4  to  1/2)  or  heroin  (gr.  1/20  to  1/10)  are  the  best.  Morphia  in  small 
doses  may  be  required,  but  these  drugs  should  be  given  only  when  necessary. 
For  oedema  of  the  lungs  strychnine  (gr.  1/20)  and  atropine  (gr.  1/100) 
should  be  given  hypodermically.  Venesection  is  advisable  if  the  right  heart 
be  dilated. 

(5)  Nervous  System. — The  patient  with  delirium  should  be  constantly 
watched.    An  ice  bag  to  the  head  and  frequent  ice  packs  or  cold  sponges  are 
useful.     Sleep  is  important  for  every  patient  and  the  need  for  this  is  often 
forgotten.     While  such  drugs  as  the  bromides  and  chlpral  hydrate  may  be 
effectual,  it  is  wiser,  as  a  rule,  to  give  morphia  hypodermically  in  a  sufficient 
dose  (gr.  1/6  to  1/4)  to  secure  rest  and  sleep. 

(6)  Crisis. — As  this  approaches  constant  watch  should  be  kept  for  signs 
of  collapse.     If   sweating  is   profuse  and  the  patient  feeble,   atropine    (gr. 
1/100)   should  be  given  hypodermically. 

(h)  TREATMENT  OF  COMPLICATIONS. — If  the  fever  persists  it  is  important 
to  look  out  for  pleurisy,  particularly  for  the  meta-pneumonic  empyema.  The 
exploratory  needle  should  be  used  if  necessary.  A  sero-fibrinous  effusion 
should  be  aspirated,  a  purulent  opened  and  drained.  In  a  complicating  peri- 
carditis with  a  large  effusion  aspiration  may  be  necessary.  Delayed  resolution 
is  a  difficult  condition  to  treat.  Fibrolysin,  2.5  c.  c.  every  other  day,  has  been 
used  successfully  in  a  few  cases  (Crofton).  The  use  of  the  X-rays  is  per- 
haps the  most  effective  treatment. 

(i)  CONVALESCENCE. — The  diet  should  be  increased  as  rapidly  as  possible, 
the  patient  kept  out  of  doors  and  after  an  ordinary  attack  allowed  up  in  about 
a  week.  If  the  heart  has  suffered  rest  should  be  more  prolonged. 

B.     BRONCHO-PNEUMONIA 
(Lobular  Pneumonia,  Capillary  Bronchitis) 

Definition. — A  bacterial  infection  of  the  finer  bronchi  and  their  related 
lobules. 

The  process  begins  with  inflammation  of  the  bronchioles  and  smaller  bron- 
chi, a  capillary  bronchitis,  which  extends  to  the  alveoli  and  the  whole  lobule 
or  a  group  of  lobules  becomes  filled  with  exudate,  cellular  and  hsemorrhagic 
but  distinctly  less  fibrinous  than  in  lobar  pneumonia. 

Etiology. — Broncho-pneumonia  occurs  either  as  a  primary  or  as  a  sec- 
ondary affection.  The  relative  frequency  in  443  cases  is  thus  given  by  Holt : 
Primary,  without  previous  bronchitis,  154;  secondary  to  bronchitis  of  the 
larger  tubes,  41;  to  measles,  89;  to  whooping-cough,  66;  to  diphtheria,  47; 
to  scarlet  fever,  7;  to  influenza,  6;  to  varicella,  2;  to  erysipelas,  2;  and  to 
acute  ileo-colitis,  19.  The  proportion  of  primary  to  secondary  forms  as  shown 
in  this  list  is  probably  too  low. 

PRIMARY  ACUTE  BRONCHO-PNEUMONIA,  like  the  lobar  form,  attacks  chil- 


102  SPECIFIC   INFECTIOUS   DISEASES 

dren  in  good  health,  usually  under  two  years  but  is  not  uncommon  in  adults. 
The  etioiogical  factors  are  very  much  those  of  ordinary  pneumonia,  and  prob- 
ably the  pneumococcus  is  more  often  associated  with  it. 

SECONDARY  BRONCHO-PNEUMONIA  occurs  in  two  great  groups:  (a)  As  a 
sequence  of  the  infectious  fevers — measles,  diphtheria,  influenza,  whooping- 
cough,  scarlet  fever,  and,  less  frequently  smallpox,  erysipelas,  and  typhoid 
fever.  In  children  it  forms  the  most  serious  complication  of  these  diseases, 
and  in  reality  causes  more  deaths  than  are  due  directly  to  the  fevers.  In  large 
cities  it  ranks  next  in  fatality  to  infantile  diarrhoea.  Following,  as  it  does,  the 
contagious  diseases  which  principally  affect  children,  we  find  that  a  large 
majority  of  cases  occur  during  early  life.  According  to  Merrill's  Boston  sta- 
tistics, it  is  most  fatal  during  the  first  two  years  of  life.  The  number  of  cases 
in  a  community  increases  or  decreases  with  the  prevalence  of  measles,  scarlet 
fever,  and  diphtheria.  It  is  most  prevalent  in  the  winter  and  spring  months. 
In  the  febrile  affections  of  adults  broncho-pneumonia  is  not  very  common. 
Thus  in  typhoid  fever  it  is  not  so  frequent  as  lobar  pneumonia,  though  isolated 
areas  of  consolidation  at  the  bases  are  by  no  means  rare  in  protracted  cases 
of  this  disease.  In  old  people  it  may  follow  debilitating  causes  of  any  sort, 
and  is  met  with  in  the  course  of  chronic  Bright's  disease  and  various  acute 
and  chronic  maladies. 

(6)  In  the  second  division  of  this  affection  are  embraced  the  cases  of 
so-called  aspiration  or  deglutition  pneumonia.  Whenever  the  sensitiveness  of 
the  larynx  is  benumbed,  as  in  the  coma  of  apoplexy  or  urasmia,  minute  par- 
ticles of  food  or  drink  are  allowed  to  pass  the  rima,  and,  reaching  finally  the 
smaller  tubes,  excite  an  intense  inflammation  similar  to  the  vagus  pneumonia 
•which  follows  the  section  of  the  pneumogastrics  in  the  dog.  Cases  are  very 
common  after  operations  about  the  mouth  and  nose,  after  tracheotomy,  and 
in  cancer  of  the  larynx  and  oesophagus.  The  aspirated  particles  in  some 
instances  induce  such  an  intense  broncho-pneumonia  that  suppuration  or  even 
gangrene  supervenes.  The  ether  pneumonia,  already  described,  is  often  lobu- 
lar  in  type. 

An  aspiration  broncho-pneumonia  may  follow  haemoptysis,  the  aspiration 
of  material  from  a  bronchiectatic  cavity,  and  occasionally  the  material  from 
an  empyema  which  has  ruptured  into  the  lung.  A  common  and  fatal  form  of 
broncho-pneumonia  is  that  excited  by  the  tubercle  bacillus. 

Among  general  predisposing  causes  may  be  mentioned  age.  As  just  noted, 
it  is  prone  to  attack  infants,  and  a  majority  of  cases  of  pneumonia  in  chil- 
dren under  five  years  of  age  are  of  this  form.  Of  370  cases  in  children  under 
five  years  of  age,  75  per  cent,  were  broncho-pneumonia  (Holt).  At  the  oppo- 
site extreme  of  life  it  is  also  common,  in  association  with  influenza  and  with 
various  debilitating  circumstances  and  with  the  chronic  diseases  incident  to 
the  old.  In  children,  rickets  and  diarrhoea  are  marked  predisposing  causes, 
and  broncho-pneumonia  is  one  of  the  most  frequent  post  mortem  lesions 
in  infants'  homes  and  foundling  asylums.  The  disease  prevails  most  exten- 
sively among  the  poorer  classes. 

Morbid  Anatomy. — On  the  pleural  surfaces,  particularly  toward  the  base, 
are  seen  depressed  bluish  or  blue-brown  areas  of  collapse,  between  which  the 
lung  tissue  is  of  a  lighter  color.  Here  and  there  are  projecting  portions  over 
.which  the  pleura  may  be  slightly  turbid  «r  oranular.  The  lung  is  fuller 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS        103 

firmer  than  normal,  and,  though  in  great  part  crepitant,  there  can  be  felt 
in  places  throughout  the  substance  solid,  nodular  bodies.  The  dark  depressed 
areas  may  be  isolated  or  a  large  section  of  one  lobe  may  be  in  the  condition 
of  collapse.  Gradual  inflation  by  a  blow-pipe  inserted  in  the  bronchus  will 
distend  a  great  majority  of  these  collapsed  areas.  On  section,  the  general 
surface  has  a  dark  reddish  color  and  usually  drips  blood.  Projecting  above 
the  level  of  the  section  are  lighter  red  or  reddish-gray  areas  representing  the 
patches  of  broncho-pneumonia.  These  may  be  isolated  and  separated  from, 
each  other  by  tracts  of  uninflamed  tissue  or  they  may  be  in  groups;  or  the 
greater  part  of  a  lobe  may  be  involved.  Study  of  a  favorable  section  of  an 
isolated  patch  shows:  (a)  A  dilated  central  bronchiole  full  of  tenacious. puru- 
lent mucus.  A  fortunate  section  parallel  to  the  long  axis  may  show  a  racemose 
arrangement — the  alveolar  passages  full  of  muco-pus.  (&)  Surrounding  the 
bronchus  for  from  3  to  5  mm.  or  even  more,  an  area  of  grayish-red  consoli- 
dation, usually  elevated  above  the  surface  and  firm  to  the  touch.  Unlike  the 
consolidation  of  lobar  pneumonia,  it  may  present  a  perfectly  smooth  sur- 
face, though  in  some  instances  it  is  distinctly  granular.  In  a  late  stage  of 
the  disease  small  grayish-white  points  may  be  seen,  which  on  pressure  may  be 
squeezed  out  as  purulent  droplets.  A  section  in  the  axis  of  the  lobule  may 
present  a  somewhat  grape-like  arrangement,  the  stalks  and  stems  represent- 
ing the  bronchioles  and  alveolar  passages  filled  with  a  yellowish  or  grayish- 
white  pus,  while  surrounding  them  is  a  reddish-brown  hepatized  tissue,  (c) 
In  the  immediate  neighborhood  of  this  peribronchial  inflammation  the  tissue 
is  dark  in  color,  smooth,  airless,  at  a  somewhat  lower  level  than  the  hepatized 
portion,  and  differs  distinctly  in  color  and  appearance  from  the  other  por- 
tions of  the  lung.  This  is  the  condition  to  which  the  term  splenization  has 
been  given.  It  really  represents  a  tissue  in  the  early  stage  of  inflammation, 
and  it  perhaps  would  be  as  well  to  give  up  the  use  of  this  term  and  also  that 
of  carnification,  which  is  only  a  more  advanced  stage. 

There  are  three  groups  of  cases:  (1)  Those  in  which  the  bronchitis  and 
bronchiolitis  are  most  marked,  and  in  which  there  may  be  no  definite  con- 
solidation, and  yet  on  microscopic  examination  many  of  the  alveolar  passages 
and  adjacent  air-cells  appear  filled  with  inflammatory  products.  (2)  The 
disseminated  broncho-pneumonia,  in  which  there  are  scattered  areas  of  peri- 
bronchial  hepatization  with  patches  of  collapse,  while,  a  considerable  propor- 
tion of  the  lobe  is  still  crepitant.  This  is  by  far  the  most  common  condition. 
(3)  The  pseudo-lobar  form,  in  which  the  greater  portion  of  the  lobe  is  con- 
solidated, but  not  uniformly,  for  intervening  strands  of  dark  congested  lung 
tissue  separate  the  groups  of  hepatized  lobules. 

Microscopically,  the  centre  of  the  bronchus  is  seen  filled  with  a  plug  of 
exudation,  consisting  of  leucocytes  and  swollen  epithelium.  Section  in  the 
long  axis  may  show  irregular  dilatations  of  the  tube.  The  bronchial  wall  is 
swollen  and  infiltrated  with  cells.  Under  a  low  power  it  is  readily  seen  that 
the  air-cells  next  the  bronchus  are  mostly  densely  filled,  while  toward  the  per- 
iphery the  alveolar  exudation  becomes  less.  The  contents  of  the  air-cells  are 
made  up  of  leucocytes  and  swollen  epithelial  cells  in  varying  proportions. 
Red  corpuscles  are  not  often  present  and  a  fibrin  network  is  rarely  seen, 
though  it  may  be  present  in  some  alveoli.  In  the  swollen  walls  are  seen  dis- 
tended capillaries  and  numerous  leucocytes.  As  Delafield  has  pointed  out, 


104  SPECIFIC    INFECTIOUS    DISEASES 

the  interstitial  inflammation  of  the  bronchi  and  alveolar  walls  is  tlie  special 
feature  of  broncho-pneumonia. 

The  histological  changes  in  the  aspiration  or  deglutition  broncho-pneu- 
monia differ  from  the  ordinary  post-febrile  form  in  a  more  intense  infiltra- 
tion of  the  air-cells  with  leucocytes,  producing  suppuration  and  foci  of  soften- 
ing; even  gangrene  may  be  present. 

Bacteriology. — The  organisms  most  commonly  found  in  broncho-pneumo- 
nia are  Micrococcus  lanceolatus,  Streptococcus  pyogenes  (either  alone  or  with 
the  pneumococcus),  Stapliylococcus  aureus  et  albus,  Friedlander's  Bacillus 
pneumonia,  and  the  influenza  bacillus.  The  Klebs-Loeffler  bacillus  is  not 
infrequently  found  in  the  secondary  lesions  of  diphtheria.  Except  the  pneu- 
mococcus these  microbes  are  rarely  found  in  pure  cultures.  In  the  lobular 
type  the  streptococcus  is  the  most  constant  organism,  in  the  pseudo-lobar  the 
pneumococcus.  Mixed  infections  are  almost  the  rule  in  broncho-pneumonia. 

Terminations  of  Broncho-pneumonia. —  (a)  In  resolution,  which  when  it 
once  begins  goes  on  more  rapidly  than  in  fibrinous  pneumonia.  Broncho- 
pneumonia  of  the  apices,  in  a  child,  persisting  for  three  or  more  weeks, 
particularly  if  it  follow  measles  or  diphtheria,  is  often  tuberculous.  In  these 
instances,  when  resolution  is  supposed  to  be  delayed,  caseation  has  in  reality 
taken  place.  (b)  In  suppuration,  which  is  rarely  seen  apart  from  the  aspira- 
tion and  deglutition  forms,  in  which  it  is  extremely  common,  (c)  In  gan- 
grene, which  occurs  under  the  same  conditions,  (d)  In  fibroid  changes — 
chronic  broncho-pneumonia — a  rare  termination  in  the  simple,  a  common 
sequence  of  the  tuberculous,  disease.  Formerly  it  was  thought  that  one  of 
the  most  common  changes  in  broncho-pneumonia,  particularly  in  children, 
was  caseation ;  but  this  is  really  a  tuberculous  process,  the  natural  termination 
of  an  originally  specific  broncho-pneumonia.  It  is  of  course  quite  possible 
that  a  broncho-pneumonia,  simple  in  its  origin,  may  subsequently  be  the  seat 
of  infection  by  Bacillus  tuberculosis. 

Symptoms. — The  primary  form  sets  in  abruptly  with  a  chill  or  a  con- 
vulsion. The  child  has  not  had  a  previous  illness",  but  there  may  have  been 
slight  exposure.  The  temperature  rises  rapidly  and  is  more  constant;  the 
physical  signs  are  more  local  and  there  is  not  the  widespread  diffuse  catarrh 
of  the  smaller  tubes.  Many  cases  are  mistaken  for  lobar  pneumonia.  In 
others  the  pulmonary  features  are  in  the  background  or  are  overlooked  in 
the  intensity  of  the  general  or  cerebral  symptoms.  The  termination  is  often 
by  crisis,  and  the  recovery  is  prompt.  The  mortality  of  this  form  is  slight. 
S.  West  has  called  attention  to  the  importance  of  recognizing  these  primary 
cases  and  to  their  resemblance  in  clinical  features  to  acute  lobar  pneumonia. 
The  secondary  form  begins  usually  as  a  bronchitis  of  the  smaller  tubes.  Much 
confusion  has  arisen  from  the  description  of  capillary  bronchitis  as  a  sepa- 
rate affection,  whereas  it  is  only  a  part,  though  a  primary  and  important  one, 
of  broncho-pneumonia.  At  the  outset  it  may  be  said  that  if  in  convalescence 
from  measles  or  whooping-cough  a  child  has  an  accession  of  fever  with 
cough,  rapid  pulse,  and  rapid  breathing,  and  if,  on  auscultation,  fine  rales 
are  heard  at  the  bases,  or  widely  spread  throughout  the  lungs,  even  though 
neither  consolidation  nor  blowing  breathing  can  be  detected,  the  diagnosis 
of  broncho-pneumonia  may  safely  be  made.  I  have  never  seen  in  a  fatal  case 
after  diphtheria  or  measles  a  capillary  bronchitis  as  the  sole  lesion.  The  onset 


PNEUMONIAS    AND    PNEUMOCOCCIC    INFECTIONS        105 

is  rarely  sudden,  or  with  a  distinct  chill;  but  after  a  day  or  so  of  indisposi- 
tion the  child  becomes  feverish  and  begins  to  cough  and  be  short  of  breath. 
The  fever  is  extremely  variable;  a  range  of  from  102°  to  104°  F.  is  common. 
The  skin  is  very  dry  and  hot.  The  cough  is  hard,  distressing,  and  may 
be  painful.  Dyspnoaa  gradually  becomes  a  prominenl;  feature.  Expiration 
may  be  jerky  and  grunting.  The  respirations  may  rise  as  high  as  60  or  even 
80  per  minute.  Within  the  first  forty-eight  hours  the  percussion  resonance  is 
not  impaired;  the  note,  indeed,  may  be  very  full  at  the  anterior  borders  of 
the  lungs.  On  auscultation,  many  rales  are  heard,  chiefly  the  fine  subcrepitant 
variety,  with  sibilant  rhonchi.  There  may  really  be  no  signs  indicating  that 
the  parenchyma  of  the  lung  is  involved,  and  yet  even  at  this  early  stage,  within 
forty-eight  hours  of  the  onset  of  the  pulmonary  symptoms,  I  have  repeatedly, 
after  diphtheria,  found  scattered  nodules  of  lobular  hepatization.  Northrup, 
in  a  case  in  which  death  occurred  within  the  first  twenty-four  hours,  in  addi- 
tion to  the  extensive  involvement  of  the  smaller  bronchi,  found  the  intra- 
lobular  tissue  also  involved  in  places.  The  dyspnoea  is  constant  and  progres- 
sive and  soon  signs  of  deficient  aeration  of  the  blood  are  noted.  The  face 
becomes  a  little  suffused  and  the  finger-tips  bluish.  The  child  has  an  anxious 
expression  and  gradually  enters  upon  the  most  distressing  stage  of  asphyxia. 
At  first  the  urgency  of  the  symptoms  is  marked,  but  soon  the  influence 
of  the  toxins  on  the  nerve-centres  is  seen  and  the  child  no  longer  makes  stren- 
uous efforts  to  breathe.  The  cough  subsides,  and,  with  a  gradual  increase 
in  lividity  and  a  drowsy  restlessness,  the  right  ventricle  becomes  more  and 
more  distended,  the  bronchial  rales  become  more  liquid  as  the  tubes  fill  with 
mucus,  and  death  follows.  These  are  symptoms  of  a  severe  case  of  broncho- 
pneumonia,  or  what  the  older  writers  called  suffocative  catarrh. 

The  PHYSICAL  SIGNS  may  at  first  be  those  of  capillary  bronchitis,  as  indi- 
cated by  the  absence  of  dulness  and  the  presence  of  fine  subcrepitant  and 
whistling  rales.  In  many  cases  death  takes  place  before  any  definite  pneu- 
monic signs  are  detected.  When  these  exist  they  are  much  more  frequent  at 
the  bases,  where  there  may  be  areas  of  impaired  resonance  or  even  of  positive 
dulness.  When  numerous  foci  involve  the  greater  part  of  a  lobe  the  breathing 
may  become  tubular,  but  in  the  scattered  patches  of  ordinary  broncho-pneu- 
monia, following  the  fevers,  the  breathing  is  more  commonly  harsh  than 
blowing.  In  grave  cases  there  is  retraction  of  the  base  of  the  sternum  and 
of  the  lower  costal  cartilages  during  inspiration,  pointing  to  deficient  lung 
expansion. 

Diagnosis. — With  lobar  pneumonia  it  may  readily  be  confounded  if  the 
areas  of  consolidation  are  large  and  merged  together.  It  is  to  be  remembered, 
as  Holt's  figures  well  show,  that  broncho-pneumonia  occurs  chiefly  in  children 
under  one  year,  whereas  lobar  pneumonia  is  more  common  after  the  third 
year.  No  writer  has  so  clearly  brought  out  the  difference  between  pneumonia 
at  these  periods  as  Gerhard,*  of  Philadelphia,  whose  papers  on  this  subject 
have  the  freshness  and  accuracy  which  characterized  all  the  writings  of  that 
eminent  physician.  Between  lobar  pneumonia  and  the  secondary  form  of 
broncho-pneumonia  the  diagnosis  is  easy.  The  mode  of  onset  is  essentially 
different  in  the  two  infections,  the  one  developing  insidiously  in  the  course 
or  at  the  conclusion  of  another  disease,  the  other  setting  in  abruptly  in  a 

*   American   Journal    of   Medical   Sciences,    vols.    xiv    and   xv. 
9 


106  SPECIFIC    INFECTIOUS    DISEASES 

child  in  good  health.  In  lobar  pneumonia  the  disease  is  usually  unilateral, 
in  broncho-pneumonia  bilateral.  The  chief  trouble  arises  in  cases  of  primary 
broncho-pneumonia,  which  by  aggregation  of  the  foci  involves  the  greater 
part  of  one  lobe.  Here  the  difficulty  is  very  great,  and  the  physical  signs 
may  be  practically  identical,  but  in  broncho-pneumonia  it  is  much  more  likely 
that  a  lesion,  however  slight,  will  be  found  on  the  other  side. 

A  still  more  difficult  question  to  decide  is  whether  an  existing  broncho- 
pneumonia  is  simple  or  tuberculous.  In  many  instances  the  decision  cannot 
be  made,  as  the  circumstances  under  which  the  disease  occurs,  the  mode  of 
onset,  and  the  physical  signs  may  be  identical.  It  has  often  been  my  expe- 
rience that  a  case  has  been  sent  down  from  the  children's  ward  to  the  dead 
house  with  the  diagnosis  of  post-febrile  broncho-pneumonia  in  which  there 
was  no  suspicion  of  the  existence  of  tuberculosis;  but  on  section  there  were 
found  tuberculous  bronchial  glands  and  scattered  areas  of  broncho-pneumonia, 
some  of  which  were  distinctly  caseous,  while  others  showed  signs  of  softening. 
It  is  well  to  emphasize  the  fact  that  there  are  many  cases  of  broncho-pneu- 
monia in  children  which  time  alone  enables  us  to  distinguish  from  tubercu- 
losis. The  existence  of  extensive  disease  at  the  apices  or  central  regions  is  a 
suggestive  indication,  and  signs  of  softening  may  be  detected.  In  the  vomited 
matter,  which  is  brought  up  after  severe  spells  of  coughing,  sputum  may  be 
picked  out  and  elastic  tissue  and  tubercle  bacilli  detected. 

It  must  not  be  forgotten  that,  as  in  lobar  pneumonia,  cerebral  symptoms 
may  mask  the  true  nature  of  the  disease,  and  may  even  lead  to  the  diagnosis 
of  meningitis.  I  recall  more  than  one  instance  in  which  it  could  not  be  sat- 
isfactorily determined  whether  the  infant  had  tuberculous  meningitis  or  a 
cerebral  complication  of  an  acute  pulmonary  affection. 

Prognosis. — In  the  primary  form  the  outlook  is  good.  In  children  en- 
feebled by  constitutional  disease  and  prolonged  fevers  broncho-pneumonia  is 
terribly  fatal,  but  in  cases  coming  on  in  connection  with  whooping-cough  or 
after  measles  recovery  may  take  place  in  the  most  desperate  cases.  It  is  in 
this  disease  that  the  truth  of  the  old  maxim  is  shown — "Never  despair  of 
a  sick  child."  The  death  rate  in  children  under  five  has  been  variously  esti- 
mated at  from  30  to  50  per  cent.  After  diphtheria  and  measles  thin,  wiry 
children  seem  to  stand  broncho-pneumonia  much  better  than  fat,  flabby  ones. 
In  adults  the  aspiration  or  deglutition  pneumonia  is  a  very  fatal  disease. 

Prophylaxis. — Much  can  be  done  to  reduce  the  probability  of  attack  after 
febrile  affections.  Thus,  in  the  convalescence  from  measles  and  whooping- 
cough,  it  is  very  important  that  the  child  should  not  be  exposed  to  cold,  par- 
ticularly at  night,  when  the  temperature  of  the  room  naturally  falls.  The 
use  of  light  flannel  "combinations"  obviates  this  nocturnal  chill,  which  is, 
I  am  sure,  an  important  factor  in  the  colds  and  pulmonary  affections  of 
young  children.  The  catarrhal  troubles  of  the  nose  and  throat  should  be 
carefully  attended  to,  and  during  fevers  the  mouth  should  be  washed  two  or 
three  times  a  day  with  an  antiseptic  solution. 

Treatment. — The  frequency  and  the  seriousness  of  broncho-pneumonia 
render  it  a  disease  which  taxes  to  the  utmost  the  resources  of  the  practitioner. 
There  is  no  acute  pulmonary  affection  over  which  he  at  times  so  greatly 
despairs.  On  the  other  hand,  there  is  not  one  in  which  he  will  be  more 
gratified  in  saving  patients  who  have  seemed  past  all  succor.  The  general 


measures  are  much  as  in  lobar  pneumonia.  The  patient  should  be  in  the  open 
air  if  possible;  if  indoors,  the  windows  should  be  wide  open  with  the  patient 
nrotected  from  drafts. 

(a)  DIET. — As  much  food  as  possible  should  be  given.     Milk  and  its 
modifications,  ice  cream,  eggs,  broths,  cocoa,  and  gruels  are  suitable.     Water 
should  be  given  freely  by  mouth  and  if  this  is  not  possible  by  the  bowel  or 
by  infusion.    Alcohol  is  usually  indicated  and  best  given  as  whisky  to  adults 
and  brandy  to  young  children.     The  bowels  should  be  opened  by  castor  oil 
or  calomel  and  care  taken  to  secure  a  daily  movement. 

(b )  HYDROTHEEAPY. — This  may  be  given  by  various  methods  to  be  chosen 
for  each  patient,  depending  on  the  condition  and  results.     Sponges  may  be 
given  to  any  patient.     Packs  are  useful,  hot  if  there  is  much  restlessness  or 
cold  if  the  temperature  is  high,  or  baths  may  be  given  to  children  for  short 
periods,  using  water  at  95°    F.  and  gradually  reducing  to  75°   or  80°    P. 
Applying  small  amounts  of  cold'  water  to  the  chest  during  the  bath  is  some- 
times useful,  particularly  if  the  respirations  are  shallow.     Compresses,  made 
out  of  linen  covered  by  flannel  or  of  flannel  alone,  wrung  out  of  water  at  60° 
to  70°,  are  particularly  indicated  and  should  be  changed  every  one  or  two 
hours.    They  should  not  be  covered  by  oiled  silk.    A  mustard  bath  is  of  value 
for  children,  especially  early  in  the  attack.     Alternate  douches  of  hot  and 
cold  water  are  useful,  particularly  in  children,  when  the  condition  is  severe. 
Hydrotherapy  is  especially  indicated  for  patients  with  high  fever,  delirium 
or  stupor,  severe  toxaemia,  or  circulatory  failure. 

(c)  LOCAL  APPLICATIONS. — Poultices  have  gone  out  of  fashion  but  are 
sometimes  of  value.    They  should  be  light  and  are  best  kept  in  place  by  being 
slipped  in  pockets  in  a  flannel  jacket  which  is  constantly  worn  so  that  the  poul- 
tice can  be  replaced  without  disturbing  the  patient.     The  use  of  dry  cups  is 
often  advised ;  they  should  be  applied  frequently.    The  ice  bag  should  be  used 
if  it  gives  comfort. 

(d)  MEDICINAL. — The  indications  must  be  carefully  studied  and  drugs 
which  may  disturb  the  stomach  given  with  care.    If  cough  is  distressing  the 
use  of  the  compound  tincture  of  benzoin  in  an  inhalation  should  be  tried.   The 
expectorant  drugs  may  aid  and  of  these  ammonium  chloride  (gr.  ii  to  v,  0.13 
to  0.3  gm.)   and  the  wine  of  ipecacuanha  (""I  x  to  xx,  0.6  to  1.3  c.  c.)  are 
the  most  useful.    To  these  a  sedative,  such  as  paregoric  (3  i,  4  c.  c.),  codeia 
(gr.  ^  0.016  gm.)  or  heroin  (gr.  1-20,  0.0032  gm.)  should  be  added  if  the 
cough  is  very  distressing.    Strychnine  hypodermically  (gr.  1-40  to  1-20,  0.0016 
to  0.0032  gm.)   is  an  aid  to  the  respiratory  centre  and  to  the  circulation. 
For  circulatory  failure  the  treatment  is  the  same  as  described  under  lobar 
pneumonia.    With  increasing  difficulty  in  getting  up  the  secretions  an  emetic 
may  be  given,  but  only  to  robust  patients.    Ipecacuanha  or  apomorphine  hypo- 
dermically should  be  employed.     Inhalations  of  oxygen  are  advisable  if  they 
give  relief  to  the  dyspnoea  and  lessen  cyanosis. 

In  old  persons  early  stimulation  is  usually  advisable  and  every  effort 
should  be  made  to  persuade  them  to  take  nourishment.  Cold  applications  or 
sponges  must  be  used  with  caution  and  the  use  of  heat  is  generally  better. 
At  all  ages  frequent  change  in  position  is  advisable  and  in  young  chil- 
dren this  may  be  done  by  taking  them  out  of  bed  and  holding  them  in  the 
arms. 


108  SPECIFIC    INFECTIOUS    DISEASES 

C.     OTHEE   PNEUMOCOCCIC   INFECTIONS 

The  organism  is  widely  distributed  and  causes  a  number  of  important 
affections  other  than  pulmonary,  of  which  the  following  are  the  most  im- 
portant : 

1.  Acute  Septicaemia. — A  few  instances  have  been  reported  in  which  with- 
out any  recognized  local  lesion  there  has  been  a  general  infection  with  the 
pneumococcus.    In  Townsend's  case,  a  girl,  aged  six,  had  pain  in  the  abdomen, 
vomiting  and  a  temperature  of  104.2°  F.  without  any  throat  affection.    Death 
occurred  in  thirty  hours,  and  a  general  infection  with  the  organism  was  found 
in  the  blood,  spleen,  lungs  and  kidneys. 

2.  Local  Affections. — The  local  affections  caused  by  the  pneumococcus  are 
very  numerous  and  will  be  described  under  their  appropriate  sections.    In  the 
mouth,  erosions,  gingivitis  and  glossitis;  in  the  pharynx.,  inflammation  and 
tonsillitis ;  in  the  ear,  acute  and  chronic  suppuration ;  in  the  accessory  sinuses, 
of  which  it  is  a  common  habitat,  inflammation  and  suppuration ;  in  the  mem- 
brane of  the  brain  it  is  a  common  cause  of  primary  and  secondary  meningitis ; 
in  the  bronchi  it  has  been  found  associated  with  acute  and  chronic  bronchitis, 
and  bronchiectasis ;  in  the  lungs,  in  addition  to  the  two  important  diseases 
already  considered,  it  may  cause  acute  oedema  and  is  associated  with  tuber- 
culosis and  many  chronic  affections.    It  has  been  found  in  acute  pleurisy  and 
it  is  one  of  the  common  causes  of  empyema;  acute  arthritis,  primary  and 
secondary   forms;   acute   peritonitis,   particularly   in   children;   appendicitis; 
endocarditis ;  pyelitis  and  local  abscesses  in  various  parts  may  be  caused  by  it. 

VII.    CEREBRO-SPINAL   FEVER 

Definition. — An  infectious  disease,  occurring  sporadically  and  in  epidem- 
ics, caused  by  the  Diplococcus  intracellularis,  characterized  by  inflammation  of 
the  cerebro-spinal  meninges  and  a  clinical  course  of  great  irregularity. 

The  affection  is  also  known  by  the  names  of  malignant  purpuric  fever, 
petechial  fever,  spotted  fever  and  epidemic  cerebro-spinal  meningitis. 

History. — Vieusseux  first  described  a  small  outbreak  in  Geneva  in  1805. 
In  1806  L.  Danielson  and  E.  Mann  (Medical  and  Agricultural  Register,  Bos- 
ton) gave  an  account  of  "a  singular  and  very  mortal  disease  which  lately 
made  its  appearance  in  Medfield,  Mass."  The  Massachusetts  Medical  Society, 
in  1809,  appointed  James  Jackson,  Thomas  Welch,  and  J.  C.  Warren  to 
investigate  it.  Elisha  North's  little  book  (1811)  gives  a  full  account  of  the 
early  epidemics.  Stille's  monograph  (1867)  and  the  elaborate  section  in  vol. 
i  of  Joseph  Jones'  works  contain  details  of  the  later  American  outbreaks.  In 
his  Geographical  Pathology,  Hirsch  divides  the  outbreaks  into  four  periods: 
From  1805  to  1830,  in  which  the  disease  was  most  prevalent  throughout  the 
United  States;  a  second  period,  from  1837  to  1850,  when  the  disease  pre- 
vailed extensively  in  France,  and  there  were  a  few  outbreaks  in  the  United 
States;  a  third  period,  from  1854  to  1874,  when  there  were  outbreaks  in 
Europe  and  several  extensive  epidemics  in  America.  During  the  Civil  War 
there  were  comparatively  few  cases.  It  prevailed  extensively  in  the  Ottawa 
Valley  early  in  the  seventies.  In  the  fourth  period,  from  1875  to  the  present 
time,  the  disease  has  broken  out  in  a  great  many  regions.  In  the  United 


CEREBRO-SPINAL    FEVER  109 

States,  during  1898-1899,  it  prevailed  in  mild  form  in  27  states.  Since  1899 
there  have  been  extensive  outbreaks  in  Silesia,  and  in  the  cities  of  the  United 
States  on  the  Atlantic  coast.  In  New  York  in  1904-5  there  were  6,755  cases 
and  3,455  deaths.  In  Glasgow  in  1907  there  were  nearly  1,000  cases  with  595 
deaths  (Chalmers).  In  Belfast  in  the  eighteen  months  ending  June,  1908, 
there  were  725  cases  with  548  deaths  (Robb).  There  were  only  130  deaths 
in  England  and  Wales  in  1909,  but  there  has  been  a  rapid  rise  during  the  war. 
In  the  winter  of  1914-15  the  disease  appeared  among  the  Canadian  troops  and 
was  carried  by  them  to  England.  It  broke  out  in  many  home  camps  and, 
spreading  to  the  civil  population,  for  the  first  time  in  its  history  the  disease 
prevailed  widely  in  England. 

Etiology. — Cerebro-spinal  fever  occurs  in  epidemic  and  in  sporadic  form?. 
The  epidemics  are  localized  and  are  rarely  very  widespread.  Only  in  the 
tropics  have  there  been  extensive  killing  pandemics.  As  a  rule,  country  dis- 
tricts have  been  more  afflicted  than  cities.  Mining  districts  and  seaports  have 
suffered  most  severely.  The  outbreaks  have  occurred  most  frequently  in  the 
winter  and  spring.  The  concentration  of  individuals,  as  of  troops  in  large 
barracks,  is  a  special  factor ;  recruits  and  young  soldiers  are  specially  liable. 
In  civil  life  children  and  }roung  adults  are  most  susceptible.  Over-exertion, 
long  marches  in  the  heat,  depressing  mental  and  bodily  surroundings,  and 
the  misery  and  squalor  of  the  large  tenement  houses  in  cities  are  predisposing 
cause's.  The  disease  is  not  highly  contagious,  and  is  probably  not  transmitted 
by  clothing  or  the  excretions.  It  is  very  rare  to  have  more  than  one  or  two 
cases  in  a  house,  and  in  a  city  epidemic  the  distribution  of  the  cases  is  very 
irregular.  Meningitis  carriers  play  an  important  role  in  transmitting  the 
disease.  They  are  found  also  when  the  disease  is  not  epidemic. 

Sporadic  cerebro-spinal  fever. — The  disease  lingers  indefinitely  after  an 
outbreak,  and  in  all  large  cities  cases  occur.  There  are  two  types,  one  the 
posterior  basic  meningitis  of  Gee  and  Barlow,  which  has  very  distinctive  fea- 
tures, and  the  other  the  meningococcus  meningitis  of  young  adults  met  with 
in  periods  during  which  the  disease  is  not  specially  prevalent ;  two,  three,  and 
even  five  cases  may  occur  in  succession  in  one  family.  The  meningitis  in 
children,  known  as  the  simple  or  posterior  basic,  is  the  sporadic  form.  It  has 
two  suggestive  features  of  similarity  in  the  seasonal  incidence  and  in  the  fact 
that  patients  recover.  Still  determined  the  identity  of  the  organism  with  the 
meningococcus,  and  the  view  has  been  confirmed  by  Koplik  and  many  others. 

Bacteriology. — In  1877  Weichselbaum  described  the  meningococcus  or 
Diplococcus  intracellularis  meningitidis.  In  the  tissues  the  organism  is  al- 
most constantly  within  the  polynuclear  leucocytes.  Recent  investigations  have 
shown  that  there  are  two  distinct  types  distinguishable  from  one  another  by 
immune  reactions.  In  the  recent  outbreak  both  types  were  found  widely 
distributed.  The  so-called  parameningococcus  is  not,  as  was  thought,  a  rare 
cause  but  it  and  the  ordinary  forms  are  equally  responsible  as  causative  agents 
and  correspond  exactly  to  the  different  types  of  pneumococci  causing  pneumonia 
(Ellis).  The  organism  is  found  in  the  blood  and  in  the  various  lesions  of  the 
disease.  Three  important  facts  have  been  brought  out — the  presence  of  the 
germ  in  fully  half  the  cases  in  the  naso-pharynx,  the  existence  of  it  in  healthy 
contacts,  and  the  preparation  of  a  curative  serum. 

Morbid  Anatomy. — In  malignant  cases  there  may  be  no  characteristic 


110  SPECIFIC    INFECTIOUS   DISEASES 

changes,  the  brain  and  spinal  cord  showing  only  extreme  congestion,  which 
was  the  lesion  described  by  Vieusseux.  In  a  majority  of  the  acutely  fatal 
cases  death  occurs  within  the  first  week.  There  is  intense  injection  of  the 
pia-arachnoid.  The  exudate  is  usually  fibrino-purulent,  most  marked  at  the 
base  of  the  brain,  where  the  meninges  may  be  greatly  thickened  and  plastered 
over  with  it.  On  the  cortex  there  may  be  much  lymph  along  the  larger  fissures 
and  in  the  sulci;  sometimes  the  entire  cortex  is  covered  with  a  thick,  puru- 
lent exudate.  It  deserves  to  be  recorded  that  Danielson  and  Mann  made  five 
autopsies  and  were  the  first  to  describe  "a  fluid  resembling  pus  between  the 
dura  and  pia  mater."  The  cord  is  always  involved  with  the  brain.  The 
exudate  is  more  abundant  on  the  posterior  surface,  and  involves,  as  a  rule, 
the  dorsal  and  lumbar  regions  more  than  the  cervical  portion. 

In  the  more  chronic  cases  there  is  general  thickening  of  the  meninges  and 
scattered  yellow  patches  mark  where  the  exudate  has  been.  The  ventricles 
in  the  acute  cases  are  dilated  and  contain  a  turbid  fluid,  or  in  the  posterior 
cornua  pure  pus.  In  the  chronic  cases  the  dilatation  may  be  very  great.  The 
brain  substance  is  usually  a  little  softer  than  normal  and  has  a  pinkish  tinge ; 
foci  of  haemorrhage  and  of  encephalitis  may  be  found.  The  cranial  nerves  are 
usually  involved,  particularly  the  second,  fifth,  seventh,  and  eighth.  The 
spinal  nerve  roots  are  also  found  imbedded  in  the  exudate. 

Microscopically,  the  exudate  consists  largely  of  polynuclear  leucocytes 
closely  packed  in  a  fibrinous  material.  In  some  instances  there  are  foci  of 
purulent  infiltration  and  haemorrhage.  The  neuroglia  cells  are  swollen,  with 
large,  clear,  and  vesicular  nuclei.  The  ganglion  cells  show  less  marked 
changes.  Diplococci  are  found  in  variable  numbers  in  the  exudate,  being  more 
numerous  in  the  brain  than  in  the  cord. 

The  nasal  secretion  during  life  may  show  diplococci.  The  sphenoidal 
sinuses  may  be  full  of  pus  and  the  surrounding  bone  inflamed.  The  frequency 
of  catarrhal  and  other  changes  in  the  naso-pharynx  and  sinuses  suggests  that 
the  infection  reaches  the  meninges  through  this  route., 

Pneumonia  and  pleurisy  have  been  described  in  the  disease.  Councilman 
reports  that  in  13  cases  there  was  congestion  with  oedema,  in  7  broncho-pneu- 
monia, in  2  characteristic  croupous  pneumonia  with  pneumococci;  in  8 
pneumonia  due  to  the  diplococcus  intracellularis  was  present. 

The  spleen  varies  a  good  deal  in  size.  In  only  three  of  the  Boston  fatal 
cases  was  it  found  much  enlarged.  The  liver  is  rarely  abnormal.  Acute 
nephritis  is  sometimes  present.  The  intestines  show  sometimes  swelling  of 
the  follicles. 

Symptoms. — Cases  differ  remarkably  in  their  characters.  Many  different 
forms  have  been  described.  These  are  perhaps  best  grouped  into  three  classes : 
(a)  MALIGNANT  FORM. — This  fulminant  or  apoplectic  type  is  found  with 
variable  frequency  in  epidemics.  It  may  occur  sporadically.  The  onset  is 
sudden,  usually  with  violent  chills,  headache,  somnolence,  spasms  in  the  mus- 
cles, great  depression,  moderate  elevation  of  temperature,  and  feeble  pulse, 
which  may  fall  to  fifty  or  sixty  in  the  minute.  Usually  a  purpuric  rash  de- 
velops. In  a  Philadelphia  case,  in  1888,  a  young  girl,  apparently  quite  well, 
died  within  twenty  hours  of  this  form.  There  are  cases  on  record  in  which 
death  has  occurred  within  a  shorter  time.  Stille  tells  of  a  child  of  five  years, 
in  whom  death  occurred  after  an  illness  of  ten  hours;  and  refers  to  a  case 


CEREBRO-SPINAL   FEVER  111 

reported  by  Gordon,  in  which  the  entire  duration  of  the  illness  was  only  five 
hours.     Two  of  Vieusseux's  cases  died  within  twenty-four  hours. 

(&)  ORDINARY  FORM. — The  stage  of  incubation  is  not  known.  The  dis- 
ease usually  sets  in  suddenly.  There  may  be  premonitory  s^'mptoms:  head- 
ache, pains  in  the  back,  and  loss  of  appetite.  More  commonly,  the  onset  is 
with  headache,  severe  chill,  and  vomiting.  The  temperature  rises  to  101°  or 
102°.  The  pulse  is  full  and  strong.  An  early  and  important  symptom  is  a 
painful  stiffness  of  the  muscles  of  the  neck.  The  headache  increases,  and 
there  are  photophobia  and  great  sensitiveness  to  noises.  Children  become 
very  irritable  and  restless.  In  severe  cases  the  contraction  of  the  muscles  of 
the  neck  sets  in  early,  the  head  is  drawn  back,  and  when  the  muscles  of  the 
back  are  also  involved,  there  is  orthotonos,  which  is  more  common  than 
opisthotonos.  The  pains  in  the  back  and  in  the  limbs  may  be  very  severe. 
The  motor  symptoms  are  most  characteristic.  Tremor  of  the  muscles  may 
be  present,  with  tonic  or  clonic  spasms  in  the  arms  or  legs.  Rigidity  of  the 
muscles  of  the  back  or  neck  is  very  common,  and  the  patient  lies  with  the 
body  stiff  and  the  head  drawn  so  far  back  that  the  occiput  may  be  between 
the  shoulder-blades.  Except  in  early  childhood  convulsions  are  not  common. 
Strabismus  is  a  frequent  and  important  symptom.  Spasm  of  the  muscles -of 
the  face  may  also  occur.  Cases  have  been  described  in  which  the  general 
rigidity  and  stiffness  was  such  that  the  body  could  be  moved  like  a  statue. 
Paralysis  of  the  trunk  muscles  is  rare,  but  paralysis  of  the  muscles  of  the  eye 
and  the  face  is  not  uncommon. 

Of  sensory  symptoms,  headache  is  the  most  dominant  and  persists  from 
the  outset.  It  is  chiefly  in  the  back  of  the  head,  and  the  pain  extends  into 
the  neck  and  back.  There  may  be  great  sensitiveness  along  the  spine,  and  in 
many  cases  there  is  general  hyperassthesia. 

The  psychical  symptoms  are  pronounced.  Delirium  occurs  at  the  onset, 
occasionally  of  a  furious  and  maniacal  kind.  The  patient  may  display 
marked  erotic  symptoms  at  the  onset.  The  delirium  gives  place  in  a  few  days 
to  stupor,  which,  as  the  effusion  increases,  deepens  to  coma. 

The  temperature  is  irregular  and  variable.  Remissions  occur  frequently, 
and  there  is  no  uniform  or  typical  curve  during  the  disease.  In  some  in- 
stances there  has  been  little  or  no  fever.  In  others  the  temperature  may 
reach  105°  or  106°  F.,  or,  before  death,  108°  F.  The  pulse  may  be  very 
rapid  in  children;  in  adults  it  is  at  first  usually  full  and  strong.  In  some 
cases  it  is  remarkably  slow,  and  may  not  be  more  than  fifty  or  sixty  in  the 
minute.  Sighing  respirations  and  Cheyne-Stokes  breathing  are  met  with  in 
some  instances.  Unless  there  is  pneumonia  the  respirations  are  not  often 
increased  in  frequency. 

The  cutaneous  symptoms  of  the  disease  are  important.  Herpes  occurs 
with  a  frequency  almost  equal  to  that  in  pneumonia  or  intermittent  fever. 
The  petechial  rash,  which  has  given  the  name  spotted  fever  to  the  disease,  is 
very  variable.  •  Stille  states  that  of  98  cases  in  the  Philadelphia  Hospital,  no 
eruption  was  observed  in  37.  In  the  Montreal  cases  petechia?  and  purple 
spots  were  common.  They  appear  to  have  been  more  frequent  in  the  epidemics 
in  America  than  in  Europe.  The  petechiae  may  be  numerous  and  cover  the 
entire  skin.  An  erythema  or  dusky  mottling  may  be  present.  In  some  in- 
stances there  have  been  rose-colored  hyperaemic  spots  like  the  typhoid  rash. 


112  SPECIFIC   INFECTIOUS   DISEASES 

Urticara  or  erythema  nodosum,  ecthyma,  pemphigus,  and  in  rare  instances 
gangrene  of  the  skin  have  been  noted. 

Leucocytosis  is  an  early  and  constant  feature,  and  ranges  from  25,000  to 
40,000  per  cubic  millimetre.  It  persists  even  in  the  most  protracted  cases. 
The  diplococcus  intracellularis  has  been  isolated  from  the  blood  during  life 
and  demonstrated  in  the  leucocytes. 

As  already  stated,  vomiting  may  be  a  special  feature  at  the  onset ;  but,  as 
a  rule,  it  gradually  subsides.  In  some  instances,  however,  it  persists  and 
becomes  the  most  serious  and  distressing  of  the  symptoms.  Diarrhoea  is  not 
common,  the  bowels  being  usually  constipated.  The  abdomen  is  not  tender. 
In  the  acute  form  the  spleen  is  usually  enlarged. 

The  urine  is  sometimes  albuminous  and  the  quantity  may  be  increased. 
Glycosuria  has  been  noted  in  some  instances,  and  in  the  malignant  types 
haematuria. 

The  duration  of  the  disease  is  extremely  variable.  Hirsch  rightly  states 
that  it  may  range  between  a  few  hours  and  several  months.  More  than  half 
of  the  deaths  occur  within  the  first  five  days.  In  favorable  cases,  after  the 
symptoms  have  persisted  for  five  or  six  days,  improvement  is  indicated  by  a 
lessening  of  the  spasm,  reduction  of  the  fever,  and  a  return  of  the  intelli- 
gence. A  sudden  fall  in  the  temperature  is  of  bad  omen.  Convalescence  is 
extremely  tedious,  and  may  be  interrupted  by  complications  and  sequelae  to 
be  noted. 

(c)  ANOMALOUS  ForxMS. —  (1)  Abortive  Type. — The  attack  sets  in  with 
great  severity,  but  in  a  day  or  two  the  symptoms  subside  and  convalescence  is 
rapid.  Striimpell  would  distinguish  between  this  abortive  variety,  which  be- 
gins with  such  intensity,  and  the  mild  ambulant  cases  described  by  certain 
writers.  He  reports  a  case  in  which  the  meningeal  symptoms  set  in  with  the 
greatest  intensity  and  persisted  for  four  days,  the  temperature  rising  to  105.6° 
F.  On  the  fifth  day  the  patient  entered  upon  a  rapid  and  satisfactory  con- 
valescence. In  the  mild  cases,  as  distinguished  from  the  abortive,  the  patients 
complain  of  headache,  nausea,  sensations  of  discomfort  in  the  back  and  limbs, 
and  stiffness  in  the  neck.  There  is  little  or  no  fever,  and  only  moderate  vomit- 
ing. These  cases  could  be  recognized  only  during  the  prevalence  of  an  epi- 
demic. 

(2)  An  intermittent  type  has  been  observed  in  many  epidemics,  and  is 
recognized  by  von  Ziemssen  and  Stille.     It  is  characterized  by  exacerbations 
of  fever,  which  may  recur  daily  or  every  second  day,  or  follow  a  curve  of  an 
intermittent  or  remittent  character.     The  pyrexia  resembles  that  of  pyaemia 
rather  than  malaria. 

(3)  Chronic  Form. — Heubner  states  that  this  is  a  relatively  frequent 
form,  though  it  does  not  seem  to  be  recognized  by  many  writers  on  the  sub- 
ject.    An  attack  may  be  protracted  for  from  two  to  five  or  even  six  months, 
and  may  cause  the  most  intense  marasmus.     It  is  characterized  by  a  series  of 
recurrences  of  the  fever,  and  may  present  the  most  complex  symptomatology. 
It  is  not  improbable  that  .in  these  protracted  cases  chronic  hydrocephalus  or 
abscess  of  the  brain  is  present.     This  form  differs  distinctly  from  the  inter- 
mittent type.     Three  cases  in  our  series  were  of  this  chronic  form;  in  one 
the  disease  persisted  for  ninety  days. 

Complications. — Pleurisy,  pericarditis,  and  parotitis  are  not  uncommon. 


CEREBRO-SPINAL   FEVER  113 

Pneumonia  is  described  as  frequent  in  certain  outbreaks.  Immennann 
found,  during  the  Erlangen  epidemic,  many  instances  of  the  combination  of 
pneumonia  with  meningitis,  but  it  does  not  seem  possible  to  determine  whether, 
in  such  cases,  pneumonia  is  the  primary  disease  and  the  meningitis  secondary, 
or  vice  versa.  The  frequency  with  which  inflammation  of  the  meninges  of 
the  brain  complicates  pneumonia  is  well  known.  Councilman  suggests  that 
the  pneumonia  of  the  disease  is  not  the  true  croupous  form,  but  due  to  the 
diplococcus  meningitidis.  This  was  found  in  eight  of  the  Boston  cases,  and 
in  one  it  was  so  extensive  that  it  could  have  been  mistaken  for  the  ordinary 
croupous  pneumonia.  Cerebro-spinal  fever  sometimes  prevails  extensively  with 
ordinary  pneumonia,  as  in  New  York  in  the  winter  of  1903-'04.  Arthritis 
has  been  the  most  frequent  complication  in  certain  epidemics.  Many  joints 
are  affected  simultaneously,  and  there  are  swelling,  pain,  and  exudation,  some- 
times serous,  sometimes  purulent.  This  was  first  observed  by  James  Jack- 
son, Sr.,  in  the  epidemic  which  he  described.  Enteritis  is  rare. 

Headache  may  persist  for  months  or  years  after  an  attack.  Chronic  hydro- 
cephalus  occurs  in  certain  instances  in  children.  The  symptoms  of  this  are 
"paroxysms  of  severe  headache,  pains  in  the  neck  and  extremities,  vomiting, 
loss  of  consciousness,  convulsions,  and  involuntary  discharges  of  faeces  and 
urine"  (von  Ziemssen).  Mental  feebleness  and  aphasia  have  occasionally 
been  noted. 

Paralysis  of  individual  cranial  nerves  or  of  the  lower  extremities  may  per- 
sist for  some  time.  In  some  of  these  cases  there  may  be  peripheral  neuritis, 
as  Mills  suggested. 

SPECIAL  SENSES. — Eye. — Optic  neuritis  may  follow  involvement  of  the 
nerve  in  the  exudation  at  the  base.  Acute  papillitis  was  found  in  6  out  of  40 
cases  examined  by  Randolph.  The  inflammation  may  extend  directly  into  the 
eye  along  the  pia-arachnoid  of  the  optic  nerve,  causing  purulent  choroido-iritis 
or  even  keratitis.  A  neuritis  of  the  fifth  nerve  may  be  followed  by  keratitis 
and  purulent  conjunctivitis. 

Ear. — Deafness  very  often  follows  inflammation  of  the  labyrinth.  Otitis 
media,  with  mastoiditis,  may  occur  from  direct  extension.  In  64  cases  of 
meningitis  which  recovered,  Moos  found  that  55  per  cent,  were  deaf.  He  sug- 
gests that  the  abortive  form  of  the  disease  may  be  responsible  for  many  cases 
of  early  acquired  deafness.  In  children  this  not  infrequently  leads  to  deaf- 
mutism.  Von  Ziemssen  states  that  in  the  deaf  and  dumb  institutions  of  Bam- 
berg  and  Nuremberg,  in  1874,  a  majority  of  the  pupils  had  become  deaf  from 
epidemic  cerebro-spinal  meningitis. 

Nose. — Coryza  is  not  infrequent  early  in  the  disease,  and  Striimpell  says 
that  in  many  of  his  cases  nasal  catarrh  preceded  the  meningitis.  He  suggests 
that  the  latter  may  be  caused  by  infection  from  the  nose.  Certainly  the  nasal 
secretion  appears  frequently  to  contain  the  diplococci — in  18  cases  examined  by 
Scherrer,  and  in  10  out  of  15  of  the  Boston  cases. 

Diagnosis. — Much  has  been  done  of  late  to  enable  the  practitioner  to 
recognize  definitely  the  existence  of  meningitis  and  of  the  various  forms. 

(a)  GENERAL  FEATURES. — The  fever,  headache,  delirium,  retraction  of  the 
neck,  tremor,  and  rigidity  of  the  muscles  are  most  important  signs.  As  al- 
ready mentioned,  in  the  meningitis  of  cerebro-spinal  fever  the  spinal  symptoms 
are  very  much  more  marked  than  in  the  other  forms.  One  has  constantly  to 


114  SPECIFIC    INFECTIOUS    DISEASES 

bear  in  mind  that  certain  cases  of  typhoid  fever  and  of  pneumonia  closely  simu- 
late cerebro-spinal  meningitis. 

(6)  Among  the  SPECIAL  DIAGNOSTIC  FEATURES  may  be  mentioned: 

Kernig's  Sign. — When  the  thigh  is  flexed  at  right  angles  to  the  abdomen, 
the  leg  can  be  extended  upon  the  thigh  nearly  in  a  straight  line.  If  menin- 
gitis be  present,  strong  contractures  of  the  flexors  prevent  the  full  extension 
of  the  leg  on  the  thigh. 

Brudzinski's  Sign. — Flexing  the  head  on  the  chest  causes  flexion  of  the 
legs  at  the  hip  and  knee  joints,  and  flexing  one  leg  on  the  trunk  produces  the 
same  movement  in  the  other  leg. 

Lumbar  Puncture. — The  procedure  is  quite  harmless,  and  in  a  majority 
of  the  cases  can  be  done  without  general  anaesthesia,  with  the  aid  of  a  local 
freezing  mixture.  As  a  rule,  it  is  best  in  children  to  give  a  whiff  or  two  of 
chloroform.  The  patient  is  turned  on  the  side  with  the  back  bowed  and  the 
knees  drawn  up.  As  a  rule,  there  is  no  difficulty  in  finding  the  spinal  pro- 
cesses, and  with  the  thumb  or  index  finger  of  the  left  hand  as  a  guide,  a  small 
aspirator  needle  is  inserted  slightly  to  one  side  of  the  median  line  and  thrust 
deeply  into  the  third  lumbar  interspace  in  an  upward  and  inward  direction. 
At  a  variable  distance,  according  to  the  age  and  musculature,  the  needle  enters 
the  spinal  canal — about  two  and  a  half  centimetres  in  infants  and  from  four 
to  six  centimetres  in  adults.  The  fluid  runs,  as  a  rule,  drop  by  drop,  and 
when  meningitis  is  present  it  is  usually  turbid,  sometimes  purulent,  occasion- 
ally bloody.  Meningitis  may  be  present  with  a  clear  fluid.  The  pressure 
under  which  the  fluid  flows  may  reach  250-300  mm.,  the  normal  being  about 
120  mm.  The  cytology  of  the  fluid  is  important.  The  polymorphonuclear 
leucocytes  are  in  great  excess  while  in  the  tuberculous  form  the  lympho- 
cytes are  the  more  abundant.  In  the  late  stages  and  throughout  the  course  of 
the  posterior  basic  form  the  formula  may  be  reversed.  There  is  rarely  any 
difficulty  in  determining  between  the  pneumococcus  and  the  diplococcus  intra- 
cellularis.  Careful  search  will  usually  show  tubercle  bacilli  in  cases  of  tuber- 
culous meningitis  or  a  guinea-pig  may  be  inoculated. 

Prognosis. — Hirsch  states  that  the  mortality  has  ranged  in  various  epi- 
demics from  20  to  75  per  cent.  In  children  the  death  rate  is  much  higher 
than  in  adults.  The  earlier  the  serum  is  given  the  better  the  outlook. 

Prophylaxis. — The  patient  should  be  isolated,  seen  only  by  the  doctor, 
nurses,  and  one  or  two  special  members  of  the  family.  Cultures  from  the  naso- 
pharynx of  those  in  immediate  contact  should  be  taken  and,  if  possible,  carriers 
should  be  isolated.  The  throats  of  carriers  should  be  thoroughly  treated,  irri- 
gated with  salt  solution,  and  sprayed  with  a  1  per  cent,  solution  of  peroxido 
or  with  a  solution  of  iodine  and  glycerine.  Some  carriers  prove  very  resist- 
ant; in  others  the  germs  disappear  after  a  few  days.  Hexamine,  30  to  50 
grains  daily,  may  be  given.  Protective  vaccination  has  been  tried  extensively 
in  the  last  English  epidemic. 

Treatment. — The  patient  should  be  kept  as  quiet  as  possible,  handled 
gently,  and  all  causes  of  irritation  removed.  Special  attention  should  be  given 
to  the  care  of  the  skin  owing  to  the  danger  of  bedsores.  The  hair  should 
be  clipped  close  and  an  ice-bag  applied  to  the  head.  The  diet  should  be  liquid, 
as  concentrated  as  possible,  and  given  at  short  intervals.  If  swallowing  is 
difficult  the  patient  can  be  fed  through  a  tube.  Water  should  be  given  freely. 


115 

The  bowels  are  to  be  opened  by  a  calomel  and  saline  purge,  and  laxatives  or 
enemata  used  later  if  necessary.  For  severe  headache,  general  pains  or  vomit- 
ing, morphia  hypodermically  is  usually  best.  The  administration  of  hexa- 
methylenamine,  sixty  grains  (4  gm.)  a  day,  is  worthy  of  a  trial. 

SERUM  THERAPY. — The  serum  should  be  given  as  early  as  possible  and 
also  in  doubtful  cases.  Whenever  the  fluid  obtained  by  lumbar  puncture  is 
purulent  the  serum  should  be  given,  but  repeated  only  if  the  meningococcus 
is  found.  Before  giving  the  serum  as  much  cerebro-spinal  fluid  as  possible 
should  be  withdrawn.  If  this  has  been  large  in  amount  (over  40  c.  c.)  and 
in  severe  cases,  45  c.  c.  of  the  serum  should  be  introduced  through  the  needle. 
In  ordinary  cases  30  c.  c.  of  the  serum  should  be  given.  In  all  cases  with 
abnormal  resistance  to  the  injection  of  serum  after  an  amount  equal  to  the 
fluid  removed  has  been  injected,  it  is  well  to  stop.  If  the  symptoms  are  very 
severe  or  increasing,  the  injection  should  be  repeated  in  twelve  hours.  Other- 
wise the  usual  dose  (30  c.  c.)  should  be  given  daily  for  four  days.  If  diplococci 
are  found  after  this,  daily  injections  should  be  continued.  Continuance  or 
exacerbation  of  the  symptoms  demands  further  injections.  If  the  condition 
remains  stationary  after  four  days'  interval,  the  four  daily  injections  should 
be  given  again  and  this  repeated  until  the  diplococci  disappear  and  the 
symptoms  abate.  The  failure  of  the  serum  in  many  hands  during  the  recent 
epidemic  may  have  been  due  to  its  preparation  from  different  strains.  In  the 
chronic  forms  the  serum  should  be  given  if  diplococci  are  present  and  in  the 
posterior  basic  form  in  the  hope  of  benefit. 

HYDROTHERAPY. — This  may  give  relief  to  the  symptoms.  Hot  baths  or 
hot  packs  may  be  given  for  fifteen  minutes  every  three  hours. 

LUMBAR  PUNCTURE. — Done  for  injection  of  the  serum  it  is  often  of  value 
in  itself.  Severe  headache  and  marked  cerebral  features  are  indications.  As 
much  fluid  as  possible  should  be  removed  and  if  it  escapes  under  high  pressure 
ea^ly  repetition  is  advisable.  It  should  be  done  early  and  frequently  with  signs 
of  accumulation  of  fluid  in  the  ventricles. 

COMPLICATIONS. — Conditions  due  to  extension  to  the  cranial  nerves  are 
not  influenced  by  treatment.  Oiiiis  requires  early  incision  and  arthritis  rest, 
local  applications  and  incision  if  suppuration  occurs.  With  signs  of  dilatation 
of  the  ventricles,  drainage  with  injection  of  serum  may  be  tried.  In  the 
chronic  cases  every  effort  should  be  made  to  nourish  the  patient  well  and 
especial  precautions  taken  against  bed-sores.  For  the  pain  and  stiffness  some- 
times occurring  in  convalescence,  hot  baths  and  massage  are  useful. 


VIII.     INFLUENZA 

(La  Grippe) 

Definition. — A  pandemic  disease,  appearing  at  irregular  intervals,  charac- 
terized by  extraordinary  rapidity  of  extension  and  the  large  number  of  people 
attacked.  Following  the  pandemic  there  are,  as  a  rule,  for  several  years 
endemic,  epidemic,  or  sporadic  outbreaks  in  different  regions.  Clinically,  the 
disease  has  protean  aspects,  but  a  special  tendency  to  attack  the  respiratory 
mucous  membranes.  A  special  organism,  Bacillus  influenza,  is  found. 


116  SPECIFIC    INFECTIOUS    DISEASES 

History. — Great  pandemics  have  been  recognized  since  the  sixteenth  cen- 
tury. There  were  four  \vith  their  succeeding  epidemics  during  the  last  cen- 
tury—1830-'33,  1836-'37,  1847-'48,  and  1889-'90.  The  last  pandemic  seems 
to  have  begun,  as  many  others  had  before,  in  the  far  East.  It  may  have  started 
in  May,  1889,  in  Buchara,  reaching  Moscow  in  September,  the  Caucasus  and 
St.  Petersburg  in  October.  By  the  middle  of  November  Berlin  was  attacked. 
By  the  middle  of  December  it  was  in  London,  and  by  the  end  of  the  montK 
it  had  invaded  New  York,  and  was  widely  distributed  over  the  entire  con- 
tinent. Within  a  year  it  had  visited  nearly  all  parts  of  the  earth. 

The  duration  of  an  epidemic  in  any  one  locality  is  from  six  to  eight  weeks. 
With  the  exception,  perhaps,  of  dengue,  there  is  no  disease  which  attacks  in- 
discriminately so  large  a  portion  of  the  inhabitants,  about  40  per  cent.,  as 
a  rule.  Fortunately,  as  in  dengue,  the  rate  of  mortality  is  very  low.  Of 
55,263  cases  reported  in  the  German  army,  GO  died,  or  about  0.1  per  cent. 
As  might  be  expected,  in  the  civil  population  the  mortality  is  somewhat  higher, 
reaching  133,  or  about  0.5  per  cent,  of  the  22,972  cases  reported  in  Munich. 
Over  one-half  of  these  deaths  were  due  to  pneumonia.  In  1909  the  deaths  in 
England  and  Wales  numbered  8,992.  The  opportunity  for  studying  the  dis- 
ease in  the  last  epidemic  has  thrown  much  light  upon  many  problems.  Among 
the  most  notable  productions  were  the  work  of  Pfeiffer  on  the  etiology  of  the 
disease,  the  -elaborate  Berlin  report  by  von  Leyden  and  Senator,  and  the  Local 
Government  Board's  report  by  Parsons.  Leichtenstern's  article  in  Nothnagel's 
Handbuch  is  the  most  masterly  and  systematic  consideration  of  the  disease  in 
the  literature. 

Etiology. — What  relation  has  the  epidemic  influenza  to  the  ordinary  influ- 
enza cold  or  catarrhal  fever  (commonly  also  called  the  grippe),  which  is  con- 
stantly present  in  the  community?  Leichtenstern  answers  this  question  by 
making  the  following  divisions:  (<z)  Epidemic  influenza  vera,  caused  by 
Pfeiffer's  bacillus;  (&)  endemic-epidemic  influenza  vera,  which  often  occurs 
for  several  years  in  succession  after  a  pandemic,  also  caused  by  the  same 
bacillus;  (c)  endemic  influenza  nostras,  pseudo-influenza  or  catarrhal  fever, 
commonly  called  the  grippe,  is  caused  by  various  organisms,  alone  or  in  com- 
bination, and  bears  the  same  relation  to  the  true  influenza  as  cholera  nostras 
does  to  Asiatic  cholera. 

Since  the  last  pandemic  we  have  not  been  free  from  local  outbreaks  in 
some  part  of  the  world.  In  some  places  the  disease  seems  to  have  been  con- 
tinually present. 

Euhemann  reports  1,979  cases  of  typical  grippe  between  1895  and  1902. 
In  115  he  demonstrated  the  influenza  bacillus.  Lord  (in  Boston)  demon- 
strated influenza  bacilli  in  about  30  per  cent,  of  100  unselected  cases  of  acute 
and  chronic  bronchitis.  Yet  during  this  period  there  was  no  epidemic  of  in- 
fluenza in  the  city.  The  reports  are  sufficiently  numerous  to  show  that  the 
influenza  bacillus  is  probably  constantly  with  us.  Many  observations  show 
that  it  is  a  frequent  invader  of  the  respiratory  tract  in  the  inter-epidemic 
periods  and  is  probably  responsible  for  many  of  the  cases  of  Leichtenstern's 
influenza  nostras.  Indeed,  it  seems  to  bear  a  similar  relation  to  the  acute 
infections  of  the  respiratory  tract  as  other  common  organisms.  It  is  still 
unexplained  why  it  should  stand  in  a  different  relation  to  the  epidemics  of 
influenza  as  the  sole  cause  of  the  disease. 


INFLUENZA  117 

The  disease  is  highly  contagious;  it  spreads  with  remarkable  rapidity, 
which,  however,  is  not  greater  than  modern  methods  of  conveyance.  In  the 
great  pandemic  of  1889-'90  some  of  the  large  prisons  escaped  entirely.  The 
outbreak  of  epidemics  is  independent  of  all  seasonal  and  meteorological  con- 
ditions, except  perhaps  sunshine.  The  worst  have  been  in  the  colder  seasons 
of  the  year.  One  attack  does  not  necessarily  protect  from  a  subsequent  one. 
A  few  persons  appear  not  to  be  liable  to  the  disease. 

Bacteriology. — In  1892  Pfeiffer  isolated  a  bacillus  from  the  nasal  and 
bronchial  secretions,  which  is  recognized  as  the  cause  of  the  disease.  It  is  a 
small,  non-motile  organism,  which  stains  well  in  Loeffler's  methylene  blue,  or 
in  a  dilute,  pale-red  solution  of  carbol-fuchsin  in  water.  The  bacilli  are 
present  in  enormous  numbers  in  the  nasal  and  bronchial  secretions  of  patients, 
in  the  latter  almost  in  pure  cultures.  They  persist  often  after  the  severe 
symptoms  have  subsided. 

The  much-discussed  question  whether  during  the  presence  of  an  epidemic 
human  influenza  attacks  animals  must  be  answered  in  the  negative.  In  great 
pandemics  of  influenza  the  general  rule  seems  to  hold  that  other  diseases  do 
not  prevail  to  the  same  extent,  but  it  may  be  that  other  diseases  are  wrongly 
included  under  influenza. 

Symptoms. — The  incubation  period  is  "from  one  to  four  days;  oftenest 
three  to  four  days."  The  onset  is  usually  abrupt,  with  fever  and  its  associated 
phenomena. 

Types  of  the  Disease. — The  manifestations  are  so  extraordinarily  complex 
that  it  is  best  to  describe  them  under  types  of  the  disease. 

(a)  KESPIRATORI  . — The  mucous  membrane  of  the  respiratory  tract  from 
the  nose  to  the  air-cells  of  the  lungs  may  be  regarded  as  the  seat  of  election 
of  the  influenza  bacilli.  In  the  simple  forms  the  disease  sets  in  with  coryza, 
and  presents  the  features  of  an  acute  catarrhal  fever,  with  perhaps  rather 
more  prostration  and  debility  than  is  usual.  In  other  cases  after  catarrhal 
symptoms  bronchitis  occurs,  the  fever  increases,  there  is  delirium  and  much 
prostration,  and  the  picture  may  even  be  that  of  severe  typhoid  fever.  The 
graver  respiratory  conditions  are  bronchitis,  pleurisy,  and  pneumonia.  The 
bronchitis  has  really  no  special  peculiarities.  The  sputum  is  supposed  by 
many  to  be  distinctive.  Sometimes  it  is  in  extraordinary  amounts,  very  thin, 
and  containing  purulent  masses.  Pfeiffer  regards  sputum  of  a  greenish-yellow 
color  and  in  coin-like  lumps  as  almost  characteristic  of  influenza.  In  other 
cases  there  may  be  a  dark  red,  bloody  sputum.  It  occasionally  happens  that 
the  bronchitis  is  of  great  intensity  and  reaches  the  finer  tubes,  so  that  the 
patient  becomes  cyanosed  or  even  asphyxiated. 

Influenza  pneumonia  is  one  of  the  most  serious  manifestations,  and  may 
depend  upon  Pfeiffer's  bacillus  itself,  or  is  the  result  of  a  mixed  infection. 
The  true  influenza  pneumonia  is  most  commonly  lobular  or  catarrhal,  prob- 
ably, never  croupous.  Much  of  the  mortality  of  the  disease  depends  upon  the 
fatal  character  of  this  complication.  The  clinical  course  of  the  cases  is  often 
irregular  and  the  symptoms  are  obscure  or  masked. 

Influenza  pleurisy  is  more  rare,  but  cases  of  primary  involvement  of  the 
pleura  are  reported.  It  is  very  apt  to  lead  to  empyema.  Pulmonary  tubercu- 
losis is  usually  much  aggravated  by  an  attack  of  influenza. 

(6)    NERVOUS  FORM. — Without  any  catarrhal  symptoms  there  are  severe 


118  SPECIFIC    INFECTIOUS    DISEASES 

headache,  pain  in  the  back  and  joints,  with  profound  prostration.  Among  the 
more  serious  complications  may  be  mentioned  meningitis  and  encephalitis,  the 
latter  leading  to  hemiplegia  or  monoplegia.  Abscess  of  the  brain  has  followed 
in  acute  cases.  Myelitis,  with  symptoms  like  an  acute  Landry's  paralysis,  has 
occurred,  and  spastic  paraplegia  or  a  pseudo-tabes  may  follow  an  attack. 

The  influenza  bacillus  has  been  demonstrated  by  lumbar  puncture  during 
life  and  in  the  meninges  after  death.  All  forms  of  neuritis  are  not  uncom- 
mon, and  in  some  cases  are  characterized  by  marked  disturbance  of  motion 
and  sensation.  Judging  from  the  accounts  in  the  literature,  almost  every 
form  of  disease  of  the  nervous  system  may  follow  influenza. 

Among  the  most  important  of  the  nervous  sequela?  are  depression  of  spirits, 
melancholia,  and  in  some  cases  dementia. 

(c)  G ASTRO-INTESTINAL  FORM. — With  the  onset  of  the  fever  there  may  be 
nausea  and  vomiting,  or  the  attack  may  set  in  with  abdominal  pain,  profuse 
diarrhoea,  and  collapse.     In  some  epidemics  jaundice  'has  been  a  common 
symptom.     In  a  considerable  number  of  the  cases  there  is  enlargement  of  the 
spleen,  depending  chiefly  upon  the  intensity  of  the  fever.     This  was  a  very 
rare  form  in  the  United  States. 

(d)  FEBRILE  FORM. — The  fever  in  influenza  is  very  variable,  but  it  is  im- 
portant to  recognize  that  it  may  be  the  only  manifestation  of  the  disease.    It 
is  sometimes  markedly  remittent,  with  chills;  or  in  rare  cases  there  is  a  pro- 
tracted, continued  fever  of  several  weeks'  duration,  which  simulates  typhoid 
closely.     Sometimes  the  fever  resembles  that  of  a  tertian  malaria. 

Complications. — The  pericarditis  is  apt  to  be  latent.  Of  endocarditis,  a 
number  of  cases  have  been  reported  in  which  micro-organisms  morphologically 
like  influenza  bacilli  have  been  isolated  from  the  vegetations.  The  malignant 
form  may  occur.  Myocarditis  may  follow,  and  has  been  a  cause  of  sudden 
death.  Functional  disturbances  are  common,  palpitation,  bradycardia,  tachy- 
cardia, and  angina-like  attacks.  Phlebitis  and  thrombosis  of  various  vessels 
have  been  described. 

Septicaemia  has  been  demonstrated  in  a  number  of  cases  by  the  cultivation 
of  influenza  bacilli  from  the  circulating  blood. 

Peritonitis  is  rare.  Cholelithiasis  may  follow  an  attack.  The  increased 
prevalence  of  appendicitis  has  been  attributed  to  influenza. 

Various  renal  affections  have  been  noted.  G.  Baumgarten  has  called  at- 
tention to  the  frequency  of  nephritis.  Orchitis  has  been  also  seen.  Herpes 
is  common.  A  diffuse  erythema  sometimes  occurs,  occasionally  purpura.  Ca- 
tarrhal  conjunctivitis  is  a  frequent  event.  Iritis,  and  in  rare  instances  optic 
neuritis,  have  been  met  with.  Acute  otitis  media  is  a  common  complication. 
I  have  seen  severe  and  persistent  vertigo  follow  influenza,  probably  from 
involvement  of  the  labyrinth.  Bronchiectasis  may  follow.  I  have  seen  sev- 
eral cases;  in  a  fatal  one  of  three  years'  duration  the  influenza  bacilli  were 
present  in  the  sputum. 

Since  the  late  severe  epidemics  it  has  been  the  fashion  to  date  various 
ailments  or  chronic  ill  health  from  influenza.  In  many  cases  this  is  correct. 
It  is  astonishing  the  number  of  people  who  have  been  crippled  in  health  for 
years  after  an  attack. 

Diagnosis. — During  a  pandemic  the  cases  offer  but  slight  difficulty.  The 
nrofoundness  of  the  prostration,  out  of  all  proportion  to  the  intensity  of  the 


WHOOPING   COUGH  119 

disease,  is  one  of  the  most  characteristic  features.  In  the  respiratory  form 
the  diagnosis  may  be  made  by  the  bacteriological  examination  of  the  sputum, 
a  procedure  which  should  be  resorted  to  early  in  a  suspected  epidemic.  The 
differentiation  of  the  various  forms  has  been  already  sufficiently  considered. 

Treatment. — Isolation  should  be  practised  when  possible,  and  old  people 
should  be  guarded  against  all  possible  sources  of  infection.  The  secretions, 
nasal  and  bronchial,  should  be  thoroughly  disinfected.  In  every  case  the 
disease  should  be  regarded  as  serious,  and  the  patient  should  be  confined  to 
bed  until  the  fever  has  completely  disappeared.  In  this  way  alone  can  serious 
complications  be  avoided.  From  the  outset  the  treatment  should  be  support- 
ing, and  the  patient  should  be  carefully  fed  and  well  nursed.  The  bowels 
should  be  opened  by  a  dose  of  calomel  or  a  saline  draught.  At  night  10  grains 
of  Dover's  powder  may  be  given.  At  the  onset  a  warm  bath  is  sometimes 
grateful  in  relieving  the  pain  in  the  back  and  limbs,  but  great  care  should  be 
taken  to  have  the  bed  well  warmed,  and  the  patient  should  be  given  after  it 
a  drink  of  hot  lemonade.  If  the  fever  is  high  and  there  is  delirium,  small 
doses  of  antipyrin  or  aspirin  (gr.  x,  0.6  gm.)  may  be  given  and  an  ice-cap 
applied  to  the  head.  The  medicinal  antiypyretics  should  be  used  with  cau- 
tion, as  profound  prostration  sometimes  occurs  after  their  employment.  Too 
much  stress  should  not  be  laid  upon  the  mental  features.  Delirium  may  be 
marked  even  with  slight  fever.  In  the  cases  with  great  cardiac  weakness  stimu- 
lants should  be  given  freely,  and  during  convalescence  strychnia  in  full  doses. 

The  intense  bronchitis,  pneumonia,  and  other  complications  should  re- 
ceive their  appropriate  treatment.  The  convalescence  requires  careful  man- 
agement, and  it  may  be  weeks  or  months  before  the  patient  is  restored  to  full 
health.  A  good  nutritious  diet,  change  of  air,  and  pleasant  surroundings  are 
essential.  The  depression  of  spirits  following  this  disease  is  one  of  its  most 
unpleasant  and  obstinate  features. 


IX.     WHOOPING   COUGH 

Definition. — A  specific  affection  due  in  all  probability  to  the  Bordet  bacil- 
lus, characterized  by  catarrh  of  the  respiratory  passages  and  a  series  of  con- 
vulsive coughs  which  end  in  a  long-drawn  inspiration  or  "whoop." 

History. — Ballonius,  in  his  Ephemerides,  describes  the  disease  as  it  ap- 
peared in  1578.  Glisson  and  Sydenham  in  the  following  century  gave  brief 
accounts.  Willis  (Pharmaceutice  Eationalis,  second  part,  1674)  gave  a  much 
better  description  and  called  it  an  "epidemical  disorder." 

Etiology. — The  disease  occurs  in  epidemic  form,  but  sporadic  cases  appear 
in  a  community  from  time  to  time.  It  is  directly  contagious  from  person  to 
person;  but  dwelling-rooms,  houses,  school-rooms,  and  other  localities  may  be 
infected  by  a  sick  child.  It  is,  however,  in  this  way  less  contagious  than  other 
diseases,  and  is  probably  most  often  taken  by  direct  contact.  Epidemics  pre- 
vail for  two  or  three  months,  usually  during  the  winter  and  spring,  and  have 
a  curious  relation  to  other  diseases,  often  preceding  or  following  epidemics  of 
measles,  less  frequently  of  scarlet  fever. 

Children  between  the  first  and  second  dentitions  are  most  liable  to  be 
attacked.  Sucklings  are,  however,  not  exempt,  and  I  have  seen  very  severe 


120  SPECIFIC   INFECTIOUS   DISEASES 

attacks  in  infants  under  six  weeks.  Congenital  cases  are  described.  It  is 
stated  that  girls  are  more  subject  to  the  disease  than  boys.  Adults  and  old 
people  are  sometimes  attacked,  and  in  the  aged  it  may  be  a  very  serious  affec- 
tion. It  appears  to  be  most  contagious  in  the  catarrhal  period.  A  natural 
immunity  has  been  mentioned,  but  it  must  be  remembered  that  a  child  may 
have  the  disease  in  a  very  mild  form.  As  a  rule,  one  attack  protects ;  second 
attacks  are  rare.  The  disease  is  more  than  twice  as  fatal  in  the  negro  race 
as  in  others.  There  were  7,182  deaths  from  it  in  1909  in  England. 

An  organism  has  been  described  by  Bordet  and  Gengou,  Bacillus  pertussis, 
resembling  in  certain  features  the  influenza  bacillus.  In  convalescents  the 
deviation  of  complement  reaction  is  present  and  the  serum  is  stated  to  agglu- 
tinate the  organism.  Apes  have  been  inoculated  with  the  production  of  a 
characteristic  pertussis. 

Morbid  Anatomy. — Whooping  cough  itself  has  no  special  pathological 
changes.  In  fatal  cases  pulmonary  complications,  particularly  broncho-pneu- 
monia, are  usually  present.  Collapse  and  compensatory  emphysema,  vesicular 
and  interstitial,  are  found,  and  the  tracheal  and  bronchial  glands  are  enlarged. 
There  is  a  constant  lesion  of  the  trachea  with  the  presence  of  bacilli  between 
the  columnar  cells. 

Symptoms. — There  is  a  variable  period  of  incubation  of  from  seven  to  ten 
days.  Catarrhal  and  paroxysmal  stages  can  be  recognized.  In  the  catarrhal 
stage  the  child  has  the  symptoms  of  an  ordinary  cold,  which  may  begin  with 
slight  fever,  running  at  the  nose,  injection  of  the  eyes,  and  a  bronchial  cough, 
usually  dry,  and  sometimes  giving  indications  of  a  spasmodic  character. 
Trousseau  calls  attention  to  the  incessant  character  of  the  early  cough.  The 
fever  is  usually  not  high,  and  slight  attention  is  paid  to  the  symptoms,  which 
are  thought  to  be  those  of  a  simple  catarrh.  After  lasting  for  a  week  or  ten 
days,  instead  of  subsiding,  the  cough  becomes  worse  and  more  convulsive  in 
character. 

The  paroxysmal  stage,  marked  by  the  characteristic  cough,  dates  from  the 
first  appearance  of  the  "whoop."  The  fit  begins  with  a  series  of  from  fifteen 
to  twenty  forcible  short  coughs  of  increasing  intensity,  between  which  no 
inspiratory  effort  is  made.  The  child  gets  blue  in  the  face,  and  then  with  a 
deep  inspiration  the  air  is  drawn  into  the  lungs,  making  the  "whoop,"  which 
may  be  heard  at  a  distance,  and  from  which  the  disease  takes  its  name.  A 
deep  inspiration  may  precede  the  series  of  spasmodic  expiratory  efforts.  Sev- 
eral coughing  fits  may  succeed  each  other  until  a  tenacious  mucus  is  ejected, 
usually  small  in  amount,  but  after  a  series  of  coughing  spells  a  considerable 
quantity  may  be  expectorated.  Vomiting  often  takes  place  at  the  end  of  a  par- 
oxysm, and  may  recur  so  frequently  in  the  day  that  the  child  does  not  get 
enough  food  and  becomes  emaciated.  There  may  be  only  four  or  five  attacks 
in  the  day,  or  in  severe  cases  they  may  recur  every  half-hour.  In  severe  and 
fatal  cases  the  paroxysms  may  exceed  one  hundred  daily.  During  the  par- 
oxysm the  thorax  is  very  strongly  compressed  by  the  powerful  expiratory 
efforts,  and,  as  very  little  air  passes  in  through  the  glottis,  there  are  signs  of 
defective  aeration  of  the  blood ;  the.  face  becomes  swollen  and  congested,  the 
veins  are  prominent,  the  eyeballs  protrude,  and  the  conjunctiva?  become  deeply 
engorged.  Suffocation  indeed  seems  imminent,  when  with  a  deep,  crowing 
inspiration  air  enters  the  lungs  and  the  color  is  quickly  restored.  The  child 


WHOOPIXG    COUGH  121 

knows  for  a  few  moments  when  the  attack  is  coming  on,  and  tries  in  every 
way  to  check  it,  but  failing  to  do  so,  runs  terrified  to  the  nurse  or  mother  to 
be  supported,  or  clutches  anything  near  by.  Few  diseases  are  more  painful  to 
witness.  In  severe  paroxysms  the  sphincters  may  be  opened.  The  urine  is 
said  to  be  of  high  specific  gravity  (1022-1032),  pale  yellow,  and  to  contain 
much  uric  acid. 

An  ulcer  may  form  under  the  tongue  from  rubbing  on  the  teeth  (Riga's 
disease). 

During  the  attack,  if  the  chest  be  examined,  the  resonance  is  defective  in 
the  expiratory  stage,  full  and  clear  during  the  deep,  crowing  inspiration;  but 
on  auscultation  during  the  latter  there  may  be  no  vesicular  murmur  heard, 
owing  to  the  slowness  with  which  the  air  passes  the  narrowed  glottis.  Bron- 
chial rales  are  occasionally  heard. 

Among  circumstances  which  precipitate  a  paroxysm  are  emotion,  such  as 
crying,  and  any  irritation  about  the  throat.  Even  the  act  of  swallowing 
sometimes  seems  sufficient.  In  a  close  dusty  atmosphere  the  coughing  fits  are 
more  frequent.  After  lasting  for  three  or  four  weeks  the  attacks  become 
lighter  and  finally  cease.  In  cases  of  ordinary  severity  the  course  of  the  dis- 
ease is  rarely  under  six  weeks. 

Complications  and  Sequelae. — The  complications  and  sequelae  of  whooping 
cough  are  important.  During  the  extensive  venous  congestion,  haemorrhages 
are  very  apt  to  occur  in  the  form  of  petechiae,  particularly  about  the  fore- 
head, ecchymosis  of  the  conjunctivas,  and  even  bleeding  tears  of  blood  (Trous- 
seau) from  the  rupture  of  the  vessels,  epistaxis,  bleeding  from  the  ears,  and 
occasionally  haemoptysis.  Haemorrhage  from  the  bowels  is  rare.  Convulsions 
are  not  very  uncommon,  due  perhaps  to  the  extreme  engorgement  of  the 
cerebral  cortex.  Death  has  occurred  from  spasm  of  the  glottis.  Sudden 
death  has  been  caused  by  extensive  subdural  haemorrhage.  Paralysis  is  a  rare 
event.  It  was  associated  with  3  of  my  series  of  120  cases,  but  in  none  of 
them  did  the  hemiplegia  come  on  during  the  paroxysm,  as  in  a  case  reported 
by  S.  West.  Valentine  (1901)  has  collected  79  cases,  chiefly  hemiplegias.  A 
spastic  paraplegia  may  follow.  Acute  polyneuritis  is  a  rare  sequel. 

The  persistent  vomiting  may  induce  marked  anaemia  and  wasting.  The 
pulmonary  complications  are  extremely  serious.  During  the  severe  coughing 
spells  interstitial  emphysema  may  be  induced,  more  rarely  pneumothorax.  I 
saw  one  instance  in  which  rupture  occurred,  evidently  near  the  root  of  the 
lung,  and  the  air  passed  along  the  trachea  and  reached  the  subcutaneous  tis- 
sues of  the  neck,  a  condition  which  has  been  known  to  become  general. 
Capillary  bronchitis,  lobular  and  pseudo-lobar  pneumonia  are  the  dangerous 
complications,  responsible  for  nine  out  of  ten  deaths  in  the  disease.  In  some 
cases  the  process  is  tuberculous.  Pleurisy  is  sometimes  met  with  and  occa- 
sionally lobar  pneumonia.  Enlargement  of  the  bronchial  glands  is  very  com- 
mon in  whooping  cough,  and  has  been  thought  to  cause  the  disease.  It  may 
sometimes  be  sufficient  to  produce  dulness  over  the  manubrium.  During  the 
spasm  the  radial  pulse  is  small,  the  right  heart  engorged,  and  during  and 
after  the  attack  the  cardiac  action  is  very  much  disturbed.  Serious  damage 
may  result,  and  possibly  some  of  the  cases  of  severe  valvular  disease  in  chil- 
dren who  have  had  neither  rheumatic  nor  scarlet  fever  may  be  attributed 
to  the  terrible  heart  strain  during  a  prolonged  attack.  Koplik  regards  the 
10 


122  SPECIFIC    INFECTIOUS   DISEASES 

swelling  about  the  face  and  eyes  as  an  important  sign  of  the  heart  strain. 
Serious  renal  complications  are  very  uncommon,  but  albumin  sometimes  and 
sugar  frequently  are  found  in  the  urine.  A  distressing  sequel  in  adults  is 
asthma,  which  may  recur  at  intervals  for  a  year  or  more.  An  unusually 
marked  leucocytosis  appears  early,  chiefly  of  the  lymphocytes  (Meunier). 

Diagnosis. — So  distinctive  is  the  "whoop"  of  the  disease  that  the  diag- 
nosis is  very  easy;  but  occasionally  there  are  doubtful  cases,  particularly  dur- 
ing epidemics,  in  which  a  series  of  expiratory  coughs  occurs  without  any 
inspiratory  crow.  The  spasmodic  cough  due  to  enlarged  bronchial  glands 
may  cause  difficulty. 

Prognosis. — If  we  include  its  complications,  whooping  cough  is  a  very 
fatal  affection,  ranking  one  of  the  first  among  the  acute  infections  as  a  cause 
of  death  in  children  under  five  years  of  age. 

Prophylaxis. — The  disease  should  be  placed  on  the  list  of  reportable  infec- 
tions. When  possible  the  sputum  should  be  collected  and  disinfected.  As  the 
organism  usually  disappears  within  two  weeks  from  the  appearance  of  the 
characteristic  cough  it  is  probable  that  there  is  little  danger  of  contagion  in 
the  later  stages.  A  prophylactic  vaccine  has  been  used. 

Treatment. — The  gravity  of  the  disease  is  scarcely  appreciated  by  the  pub- 
lic. Children  with  the  disease  should  not  be  sent  to  school  or  exposed  in 
public  in  any  way.  There  is  more  reprehensible  neglect  in  connection  with 
this  than  with  any  other  disease.  The  patient  should  be  isolated,  and  if 
the  paroxysms  are  at  all  severe,  at  rest  in  bed.  Fresh  air,  night  and  day, 
is  important,  but  in  cities  in  the  winter  this  is  not  easy  to  manage.  The 
treatment  is  notoriously  unsatisfactory.  Stock  vaccine  has  been  used  for 
treatment  with  some  benefit.  A  few  patients  are  promptly  cured.  Antiseptic 
measures  have  been  extensively  tried.  Quinine  holds  its  own  with  many  prac- 
titioners; a  sixth  of  a  grain  may  be  given  three  times  a  day  for  each  month 
of  age,  and  a  grain  and  a  half  for  each  year  in  children  under  five.  The  use 
of  benzoin  inhalations  is  often  helpful.  For  the  catarrhal  symptoms  moderate 
doses  of  ipecac  are  probably  the  most  satisfactory.  '  Sedatives  are  by  far  the 
most  trustworthy  drugs  in  severe  cases,  and  paregoric  may  be  given  freely, 
particularly  to  give  rest  at  night.  Codeia  and  heroin  in  doses  proper  for  the 
age  often  give  much  relief.  Jacobi  advises  belladonna  in  full  doses,  as  much 
as  one-sixth  of  a  grain  of  the  extract  to  a  child  of  six  or  eight  months  three 
times  a  day.  Children  can  often  be  taught  to  inhibit  an  attack. 

Other  remedies,  such  an  antipyrin  and  chloral  hydrate,  may  be  tried.  In 
older  children  and  in  adults  it  would  be  worth  while,  I  think,  to  try  the  intra- 
tracheal  injections  of  olive-oil  and  iodoform,  which  are  sometimes  so  useful 
in  allaying  severe  paroxysmal  cough.  The  wearing  of  a  tight  abdominal 
binder  is  sometimes  of  value. 

After  the  severity  of  the  attack  has  passed  and  convalescence  has  begun, 
the  child  should  be  watched  with  the  greatest  care.  It  is  just  at  this  period 
that  the  fatal  broncho-pneumonias  are  apt  to  develop.  The  cough  sometimes 
persists  for  months  and  the  child  remains  weak  and  delicate.  Change  of  air 
should  lie  tried.  Such  a  patient  should  be  fed  with  care  and  given  tonics  and 
cod-liver  oiJ. 


GONOCOCCUS    INFECTION" 


X.     GONOCOCCUS   INFECTION 

Definition. — An  acute  infection  with  a  primary  lesion,  usually  blennorrha- 
gia.  and  numerous  secondary  and  systemic  manifestations,  of  which  prosta- 
titis  and  epididymitis,  salpingitis,  arthritis,  synovitis  and  endocarditis  are  the 
most  important.  The  Micrococcus  gonorrhoea  (gonococcus)  was  described  by 
Neisser,  in  1879. 

Gonorrhcea,  one  of  the  most  widespread  and  serious  of  infectious  diseases, 
presents  many  features  for  consideration.  It  is  not  a  killing  disease;  only  39 
fatal  cases  are  recorded  in  the  Registrar  General's  Report,  1909,  for  England 
and  Wales,  but  as  a  cause  of  ill-health  and  disability  the  gonococcus  occupies 
a  position  of  the  very  first  rank  among  its  fellows.  While  the  local  lesion  is 
too  often  thought  to  be  trifling,  in  its  singular  obstinacy,  in  the  possibilities 
of  permanent  sexual  damage  to  the  individual  himself  .and  still  more  in  the 
"grisly  troop" 'which  may  follow  in  its  train,  gonorrhoea  does  not  fall  very  far 
short  of  syphilis  in  importance. 

Etiology. — The  organism  is  a  biscuit-shaped  micrococcus,  occurring  in 
pairs,  usually  within  the  leucocytes,  and  is  always  found  in  the  primary  and 
systemic  lesions.  It  is  capable  of  cultivation,  and  the  disease  has  been  repro- 
duced by  inoculation  of  the  pure  culture. 

The  disease  is  seen  in  men  and  women  as  a  result  of  impure  sexual  inter- 
course, and  in  the  new-born  from  vaginal  contamination,  and  in  older  chil- 
dren by  accidental  infection.  Ophthalmia  neonatorum  is  one  of  the  great 
causes  of  blindness,  but  an  active  campaign  of  education  is  rapidly  reducing  the 
number  of  cases. 

The  gonococcus  vaginitis  and  the  ophthalmia  are  very  serious  diseases  in 
children's  hospitals  and  in  infants'  homes.  The  story  of  the  gonococcus 
infection  in  the  Babies'  Hospital,  New  York,  for  eleven  years,  as  told 
by  Holt  (N.  Y.  Med.  Jour.,  March,  1905),  illustrates  the  singular  obstinacy 
of  the  infection.  In  spite  of  the  greatest  care  and  precaution,  there 
were,  in  1903,  65  cases  of  vaginitis,  with  2  of  ophthalmia  and  12  of  arthritis. 
In  1904  there  were  52  cases  of  vaginitis,  only  16  of  which  would  have  been 
recognized  without  the  bacteriological  examination.  In  all,  in  the  eleven 
years,  there  were  273  cases  of  vaginitis,  only  6  with  ophthalmia  and  26  with 
arthritis.  Other  institutions  have  had  equally  sad  experiences.  Isolation  and 
prolonged  quarantine  are  the  only  measures  to  combat  successfully  the  disease. 

The  immediate  and  remote  effects  of  the  gonococcus  may  be  considered 
under — 

I.  The  primary  infection. 

II.  The  spread  in  the  genito-urinary  organs  by  direct  continuity. 

III.  Systemic  gonococcus  infection. 

The  primary  lesion  we  need  not  here  consider,  but  we  may  call  attention 
to  the  frequency  of  the  complications,  such  as  periurethral  abscess,  gonorrhceal 
prostatitis  in  the  male,  and  vaginitis,  endocervicitis,  and  inflammation  of  the 
glands  of  Bartholini  in  the  female. ' 

Perhaps  the  most  serious  of  all  the  sequels  are  those  which  result  from 
the  spread  by  direct  continuity  of  tissue.  Gonococcus  salpingitis  has  been 
shown  to  be  not  infrequent.  Metritis  and  ovaritis  are  also  occasionally  met 


124  SPECIFIC    INFECTIOUS    DISEASES 

with,  and  peritonitis.  The  gonococcus  -has  been  found  in  pure  culture  in  cases 
of  acute  general  peritonitis.  Equally  important  is  the  cystitis,  which  is  proba- 
bly much  more  frequently  the  result  of  a  mixed  infection  than  due  to  the  gono- 
coccus itself.  There  is  some  danger  of  extension  upward  through  the  ureters 
to  the  kidneys.  The  pyelitis,  like  the  cystitis,  is  usually  a  mixed  infection. 

Systemic  Gonococcus  Infection. — -(1)  GONOCOCCUS  SEPTIC^MIA  AND 
PYAEMIA. — Thayer  and  Blumer  first  cultivated  the  gonococci  from  the  blood 
in  a  case  in  my  wards,  and  the  septicaemia  has  been  thoroughly  studied 
by  them  and  by  Cole,  who  has  divided  the  cases  into  four  groups: 
(1)  Those  with  endocarditis,  11  of  the  29  cases  collected  by  him.  The 
clinical  features  are  those  of  malignant  endocarditis ;  two  of  the  cases 
recovered.  (2)  Cases  with  local  suppuration  and  the  general  features  of 
a  pycemia — of  the  six  cases  three  died.  The  septicaemia  associated  with 
a  small  focus  of  suppuration  may  be  very  intense.  I  examined  the 
body  of  a  young  man  who  ten  days  after  the  onset  of  urethritis  had 
chills  and  high  fever;  he  became  profoundly  toxaemic  and  died  on  the  morn- 
ing of  the  fourth  day  from  the  chill.  There  was  a  small  prostatic  abscess  and 
a  dark  tarry  fluid  blood,  unlike  anything  I  have  ever  seen.  (3)  Cases  with 
no  metastatic  local  affections  or  perhaps  only  slight  arthritis.  In  a  remark- 
able case  at  the  Johns  Hopkins  Hospital,  three  months  after  an  acute  gonor- 
rhoea the  patient  had  a  fever  resembling  typhoid,  which  lasted  seven  weeks. 
Gonococci  were  cultivated  from  the  blood.  He  recovered  and,  as  Cole  sug- 
gests, such  cases  are  probably  more  common  than  we  suspect.  (4)  Cases 
of  gonorrheal  puerperal  septiccemia,  of  which  several  instances  have  been  re- 
ported. Of  the  29  cases  in  which  the  septicaemia  was  demonstrated  by  the 
cultivation  of  the  organism  from  the  blood,  12  died.  The  endocarditis  will 
be  considered  later. 

(2)  GONOCOCCUS  ARTHRITIS. — In  many  respects  this  is  the  most  damag- 
ing, disabling,  and  serious  of  all  the  complications  of  gonorrhoea,  occurring  in 
from  2  to  5  -per  cent,  of  the  cases.  It  occurs  more  frequently  in  males  than  in 
females;  43  to  7  in  one  series  at  the  Johns  Hopkins  Hospital  (Cole).  In  a 
series  of  252  cases  collected  by  Northrup,  230  were  in  males;  130  cases  were 
between  twenty  and  thirty  years  of  age.  It  occurs,  as  a  rule,  during  an  acute 
attack  of  gonorrhoea.  In  208  of  Northrup's  series  there  was  a  urethral  dis- 
charge while  in  hospital.  It  may  occur  as  the  attack  subsides,  or  even  when  it 
has  become  chronic.  A  gonorrhreal  arthritis  of  great  intensity  may  occur  in 
a  newly  married  woman  infected  by  an  old  gleet  in  her  husband.  In  women 
it  is  not  always  easy  to  find  evidence  of  local  infection.  As  a  rule,  many 
joints  are  affected.  In  an  analysis  by  Cole  and  McCrae  of  'the  involvement  of 
the  joints  in  gonococcus  arthritis  and  in  rheumatic  fever,  the  average  num- 
ber in  the  former  was  double  that  in  the  latter.  In  Northrup's  series  three 
or  more  joints  were  affected  in  175  cases,  one  joint  in  56  cases.  It  is  pecul- 
iar in  attacking  certain  joints  which  are  rarely  involved  in  rheumatic  fever, 
as  the  sterno-clavicular,  the  inter-vertebral,  the  temporo-maxillary  and  sacro- 
iliac. 

The  anatomical  changes  are  variable.  The  inflammation  is  often  peri- 
articular,  and  extends  along  the  sheaths  of  the  tendons.  When  effusion 
occurs  in  the  joints  it  rarely  becomes  purulent.  It  has  more  commonly  the 
characters  of  a  synovitis.  About  the  wrist  and  hand  suppuration  some- 


GONOCOCCUS   INFECTION"  125 

times  occurs  in  the  sheaths.  The  gonococcus  itself  is  present  in  the  inflamed 
joint  or  in  the  peri-arthritic  exudate,  and  may  often  be  obtained  in  pure  cul- 
ture. Sometimes  the  cultures  are  negative.  Mixed  infection  with  staphylo- 
cocci  or  streptococci  is  very  rare. 

Clinical  Course. — Variability  and  obstinacy  are  the  two  most  distinguish- 
ing features.  The  following  are  the  most  important  clinical  forms: 

(a)  Arthralgic,  in  which  there  are  wandering  pains  about  the  joints, 
without  redness  or  swelling.  These  persist  for  a  long  time. 

(&)  Poly  arthritic,  in  which  several  joints  become  affected.  The  fever  is 
slight;  the  local  inflammation  may  fix  itself  in  one  joint,  but  more  com- 
monly several  become  swollen  and  tender.  In  this  form  cerebral  and  cardiac 
complications  may  occur. 

(c)  Acute  gonococcus  arthritis,  in  which  a  joint,  usually  the  knee,  be- 
comes suddenly  involved.    The  pain  is  severe,  the  swelling  extensive,  and  due 
chiefly  to  peri-articular  oedema.    The  general  fever  is  not  at  all  proportionate 
to  the  intensity  of  the  local  signs.    The  exudate  usually  resolves,  though  sup- 
puration occasionally  supervenes. 

(d)  Chronic  Hydrarthrosis. — This  is  usually  mono-articular,  and  is  par- 
ticularly apt  to  involve  the  knee.     It  comes  on  often  without  pain,  redness, 
or  swelling.     Formation  of  pus  is  rare.     It  occurred  only  twice  in  96  cases 
tabulated  by  Nolen. 

(e)  Bursal  and  Synovial  Form. — This  attacks  chiefly  the  tendons  and 
their  sheaths  and  the  bursa?  and  the  periosteum.     The  articulations  may  not 
be  affected.     The  bursse  of  the  patella,  the  olecranon,  and  the  tendo  Achillis 
are  most  apt  to  be  involved. 

(/)  Septiccemic. — In  which  with  an  acute  arthritis  the  gonococci  invade 
the  blood,  and  the  picture  is  that  of  an  intense  septico-pyasmia,  usually  with 
endocarditis. 

(g)  The  Painful  Heel  of  Gonorrhoea. — This  is  a  remarkable  form  of  podo- 
dynia  due  to  local  periosteal  thickening  and  exostosis  on  the  os  calcis,  causing 
pain  and  great  disability.  Baer  has  demonstrated  the  gonococcus  in  the  peri- 
osteal  lesion. 

Complications. — Iritis  is  not  infrequent  and  may  recur  with  successive 
attacks.  The  visceral  complications  are  serious.  Endocarditis,  pericarditis, 
and  pleurisy  may  occur. 

Treatment. — The  primary  infection — usually  urethritis — should  be  ac- 
tively treated.  Of  special  measures,  the  use  of  anti gonococcus  serum  and 
vaccine  treatment  are  worthy  of  trial;  either  will  help  some  cases,  both  fail 
in  many.  Good  food,  fresh  air,  and  open  bowels  are  important.  Drugs  are 
of  little  value,  especially  sodium  salicylate  and  potassium  iodide.  Phenacetine 
or  aspirin  may  be  given  for  the  pain. 

The  local  treatment  is  very  important.  In  acute  cases,  fixation  of  the 
joints  is  very  beneficial,  and  in  the  chronic  forms,  massage  and  passive  mo- 
tion. Counter-irritation  by  the  cautery  or  blisters,  active  hypersmia  by 
baking  or  passive  by  the  Bier  method  are  all  useful.  A  distended  joint  may 
be  tapped  and  then  tightly  bandaged.  The  surgical  treatment  is.  more  satis- 
factory in  severe  cases  and  good  results  usually  follow  incision  and  irrigation. 


126  SPECIFIC    INFECTIOUS    DISEASES 


XI.     BACILLARY   DYSENTERY 

Definition. — A  form  of  intestinal  flux,  usually  of  an  acute  type,  occurring 
sporadically  and  in  severe  epidemics,  attacking  children  as  well  as  adults, 
characterized  by  pain,  frequent  passages  of  blood  and  mucus,  and  due  to  the 
action  of  a  specific  bacillus,  of  which  there  are  various  strains. 

Etiology. — Owing  to  improved  sanitation,  dysentery  has  become  less  fre- 
quent. In  temperate  climates  sporadic  cases  occur  from  time  to  time,  and  at 
intervals  epidemics  prevail,  particularly  in  overcrowded  institutions.  The  sta- 
tistics of  general  hospitals  for  the  past  twenty  years  show  a  decided  increase 
in  the  number  of  cases  admitted.  Records  of  widespread  epidemics  have  been 
collected  by  Woodward.  The  most  serious  was  that  which  prevailed  from  1847 
to  1856.  In  Great  Britain  and  Ireland  epidemics  of  the  disease  have  become 
less  frequent.  In  institutions,  particularly  in  overcrowded  asylums,  dysen- 
tery is  very  common,  and  this  form  has  been  made  the  subject  of  a  valuable 
report  by  Mott  and  Durham.  In  the  tropics  "dysentery  is  a  destructive  giant 
compared  to  which  strong  drink  is  a  mere  phantom"  (Macgregor).  Dysen- 
tery is  one  of  the  great  camp  diseases,  and  it  has  been  more  destructive  to 
armies  than  powder  and  shot.  In  the  Federal  service  during  the  civil  war, 
according  to  Woodward,*  there  were  259,071  cases  of  acute  and  28,451  cases 
of  chronic  dysentery.  The  disease  prevails  in  Porto  Rico,  the  Philippines, 
and  to  a  less  extent  in  Cuba.  In  the  South  African  campaign  dysentery  pre- 
vailed widely.  For  many  years  a  very  fatal  form  of  dysentery  has  prevailed 
in  Japan,  particularly  in  the  summer  and  autumn  months,  having  a  mortality 
of  from  26  to  27  per  cent.;  in  1899  there  were  125,989  cases,  with  26,709 
deaths  (Eldridge).  It  is  now  generally  conceded  that  the  severe  epidemics 
of  acute  dysentery  occurring  in  the  tropics  are  of  the  bacillary  type,  and  the 
same  form  prevails  in  temperate  climates. 

BACILLUS  DYSENTERIC. — In  1898,  Shiga,  a  Japanese  observer,  found  in 
the  dysentery  prevailing  in  his  country  a  bacillus  with  special  characters, 
which  he  considered  to  be  the  specific  cause  of  the  disease. 

Flexner  and  Barker,  of  the  Johns  Hopkins  Commission  for  the  Study  of 
Tropical  Diseases,  found  in  the  dysentery  in  the  Philippine  Islands  an  iden- 
tical organism,  and  it  has  been  made  the  subject  of  very  careful  study  by  Flex- 
ner, and  also  by  R.  P.  Strong,  Musgrave,  and  Craig,  of  the  United  States 
army.  It  has  also  been  found  in  cases  of  dysentery  from  Porto  Rico.  The 
organism  appears  to  be  constantly  present  in  the  acute  dysentery  of  the 
tropics.  In  Manila,  according  to  Strong  and  Musgrave,  of  1,328  cases,  712 
were  of  the  acute  specific  variety,  55  suspected  specific  cases,  and  561  of 
amoebic  dysentery.  Kruse,  in  an  outbreak  at  Laar,  in  Germany,  in  which 
300  persons  were  attacked,  has  isolated  an  identical  bacillus.  Vedder  and 
Duval  demonstrated  that  sporadic  cases  in  adults  in  Philadelphia,  as  well  as 
epidemics  of  dysentery  in  the  Lancaster  County  Asylum,  Pennsylvania,  and 
in  the  almshouse  at  New  Haven,  were  due  to  this  organism.  Duval  and  Bas- 
sett  demonstrated  that  certain  forms  of  summer  diarrhoeas  of  infants  were 

*  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Medical,  vol.  ii.  The 
most  exhaustive  treatise  extant  on  intestinal  .fluxes — an  enduring  monument  to  the 
industry  and  ability  of  the  author. 


BACILLAKY    DYSENTERY  127 

due  to  infection  with  B.  dysenteries.  The  Rockefeller  Institute  conducted  a 
collective  investigation  into  the  cause  of  infantile  diarrhoeas  in  Boston,  New 
York,  Philadelphia,  and  Baltimore.  Several  observers,  under  Flexner's  direc- 
tion, studied  412  cases  and  found  the  dysentery  bacillus  present  in  279  or 
63.2  per  cent. 

The  strain  of  the  bacillus  most  frequently  found  in  the  United  States  is 
the  "Flexner-Harris"  type.  It  is  now  conceded  that  a  number  of  strains  of 
the  bacillus  occur.  This  fact  has  been  determined  by  the  relative  agglutina- 
tive power  of  immune  serum  upon  the  bacilli  isolated,  as  well  as  by  the  action 
of  the  latter  upon  various  sugars.  The  lesions  produced  by  the  different 
strains  are  identical.  The  organism  agglutinates  with  the  blood  serum  of 
cases  with  acute  dysentery  as  well  as  with  the  serum  of  immunized  animals. 

Infection  takes  place  by  the  mouth.  The  organisms  are  widely  distributed 
by  the  faeces  of  persons  suffering  with  the  disease  and  also  by  dysentery  "car- 
riers." In  institutions  food  and  drink  readily  become  contaminated.  Pos- 
sibly, too,  the  germs  are  distributed  by  flies  and  dust. 

Morbid  Anatomy. — In  the  acute  cases,  when  death  has  occurred  on  the 
fourth  to  the  seventh  day,  the  mucous  membrane  of  the  large  intestine  is 
swollen,  of  a  deep-red  color,  and  presents  elevated,  coarse  corrugations  and 
folds.  In  addition  to  the  intense  hyperaemia  there  are  spots  of  haemorrhage 
scattered  through  the  swollen  mucosa.  Over  the  surface  there  is  usually  a 
superficial  necrotic  layer,  which  can  be  brushed  off  lightly  with  the  finger. 
This  may  be  in  patches,  or  uniform  over  large  areas.  There  is  no  ulceration, 
only  the  superficial,  general  necrosis  of  the  mucosa.  The  solitary  follicles  are 
swollen  and  red,  but  the  prominence  is  obscured  in  the  involvement  of  the 
entire  mucosa.  In  cases  of  great  intensity  the  entire  coats  of  the  colon  may 
be  stiff  and  thick,  and  the  mucous  membrane  enormously  increased  in  thick- 
ness, grayish  black  in  color,  extensively  necrotic,  and,  in  places,  gangrenous. 
The  serous  surface  is  often  deeply  injected.  The  ileum  is,  in  many  cases, 
involved,  having  a  deeply  haemorrhagic  mucosa,  with  a  superficial  necrosis. 
In  the  subacute  cases  there  is  not  the  same  great  thickening  of  the  intestinal 
wall,  the  solitary  follicles  are  more  swollen,  there  is  less  necrosis,  and,  while 
there  are  no  ulcers,  there  are  superficial  erosions. 

Symptoms. — According  to  Strong  and  Musgrave,  the  period  of  incuba- 
tion is  not  more  than  forty-eight  hours.  The  onset,  which  is  usually  sudden, 
is  characterized  by  slight  fever,  pain  in  the  abdomen,  and  frequent  stools. 
At  first  mucus  is  passed,  but  within  twenty-four  hours  blood  appears  with  it, 
or  there  is  pure  blood.  There  is  a  constant  desire  to  go  to  stool,  with  great 
straining  and  tenesmus ;  every  hour  or  half  hour  there  may  be  a  small  amount 
of  blood  and  mucus  passed.  The  temperature  rises,  and  may  reach  103°  or 
10-i°.  The  pulse  increases  in  frequency,  and  in  the  severer  cases  becomes 
very  small.  The  tongue  is  coated  with  a  white  fur,  and  there  is  excessive 
thirst.  In  the  very  acute  cases  the  patient  becomes  seriously  ill  within  forty- 
eight  hours,  the  movements  increase  in  frequency,  the  pain  is  of  great  inten- 
sity, the  patient  becomes  delirious,  and  death  may  occur  on  the  third  or 
fourth  day.  In  cases  of  moderate  severity  the  urgency  of  the  symptoms 
abates,  the  stools  lessen,  the  temperature  falls,  and  within  two  or  three  weeks 
the  patient  is  convalescent.  The  mortality  in  the  severe  forms  is  very  high. 
There  is  a  subacute  form  which  lasts  for  many  weeks  or  months.  The 


128  SPECIFIC    INFECTIOUS    DISEASES 

patients  become  greatly  emaciated,  having  from  three  to  five  stools  in  the 
twenty-four  hours.  The  Bacillus  dysenteries  is  found  in  the  stools,  and  it 
agglutinates  readily  with  the  blood  serum. 

Other  Clinical  Types. — The  foregoing  account  describes  the  essential  fea- 
tures of  bacillary  dysentery  as  seen  in  Japan,  the  Philippines,  and  the  tropics. 
The  clinical  features  of  bacillary  dysentery  in  adults  in  temperate  climates 
differ  in  no  essential  manner  from  those  already  described.  Although  the 
evidence  hardly  warrants  us  at  present  in  making  the  sweeping  statement  that 
all  non-amoebic  cases  of  dysentery  are  bacillary  in  origin,  yet  experience  will 
probably  demonstrate  eventually  that  this  is  the  case.  What  is  known  as  the 
acute  catarrhal  dysentery  is  probably  a  sporadic  form  due  to  the  Bacillus 
dysenteries.  Diphtheritic  dysentery  is  a  type  of  the  bacillary  form  with  great 
necrosis  and  infiltration  of  the  mucosa.  There  may  be  rapid  gangrene  and 
a  fatal  termination  within  twenty-four  hours.  A  secondary  diphtheritic  dys- 
entery is  a  common  terminal  event  in  many  acute  and  chronic  diseases,  and 
a  bacillus  of  the  Shiga  type  has  been  isolated  from  these  cases,  Vedder  and 
Duval  have  demonstrated  that  the  bacillus  is  present  in  them. 

Complications  and  Sequelae. — Peritonitis  is  rare,  due  either  to  extension 
through  the  wall  of  the  bowel  or  to  perforation.  When  this  occurs  about  the 
csecal  region,  perityphlitis  results;  when  low  down  in  the  rectum,  periproc- 
titis.  In  108  autopsies  collected  by  Woodward  perforation  occurred  in  11. 
Abscess  of  the  liver,  so  common  in  the  amoebic  form,  is  very  rare.  It  is  in- 
teresting to  note,  as  illustrating  the  probable  type  of  the  disease,  how  com- 
paratively rare  abscess  of  the  liver  was  during  the  American  civil  war.  Very 
few  cases  occurred  in  the  South- African  War  (Eolleston). 

In  the  tropics  malaria  and  acute  dysentery  very  often  coexist.  With  refer- 
ence to  typhoid  fever,  as  a  complication,  Woodward  mentions  that  the  com- 
bination was  exceedingly  frequent  during  the  civil  war,  and  characteristic 
lesions  of  both  diseases  coexisted.  In  civil  practice  it  is  extremely  rare. 

Sydenham  noted  that  dysentery  was  sometimes  associated  with  rheumatic 
pains,  and  in  certain  epidemics  joint  swellings  have  'been  especially  prevalent. 
They  are  not  of  the  nature  of  rheumatic  fever,  but  rather  analogous  to  those 
of  gonorrhceal  arthritis.  In  severe  cases  there  may  be  pleurisy,  thrombosis, 
pericarditis,  endocarditis,  and  occasionally  pygemic  manifestations,  among 
which  may  be  mentioned  pylephlebitis.  Chronic  nephritis  is  also  an  occasional 
sequel.  In  protracted  cases  there  may  be  an  anaemic  oedema.  An  interesting 
sequel  of  dysentery  is  paralysis.  Woodward  reports  8  cases.  Weir  Mitchell 
mentions  it  as  not  uncommon,  occurring  chiefly  in  the  form  of  paraplegia. 
As  in  other  acute  fevers,  this  is  due  probably  to  a  neuritis.  Remlinger,  in 
two  cases  of  non-amoebic-  dysentery  in  Tunis,  observed  an  epididymitis  during 
convalescence.  Gonorrhoea  was  excluded.  In  a  third  case  the  dysentery  was 
complicated  by  an  abscess  of  the  spleen,  which  ruptured,  causing  death.  In- 
testinal stricture  is  a  rare  sequence — so  rare  that  no  case  was  reported  at  the 
Surgeon-General's  office  during  the  civil  war.  It  appears  to  be  not  uncom- 
mon in  the  East.  Among  the  sequels  of  chronic  dysentery,  in  persons  who 
have  recovered  a  certain  measure  of  health,  may  be  mentioned  persistent  dys- 
pepsia and  irritability  of  the  bowels. 

Diagnosis. — In  the  acute  specific  form  the  blood  serum  agglutinates  the 
dysentery  bacillus.  The  "Flexner-Harris"  type  of  the  organism  agglutinates 


BACILLAEY    DYSENTERY  129 

in  dilutions  of  from  1  to  1,000  up  to  1  to  1,500.  This  is  the  form  of  the 
organism  that  prevails  in  the  United  States.  The  "Shiga"  type  agglutinates 
less  readily.  The  blood  serum  of  a  dysenteric  patient  will  agglutinate  both 
types,  but  the  former  more  readily  than  the  latter.  In  all  non-amcebic 
dysenteries  efforts  should  be  made  to  isolate  the  dysentery  bacillus  from  the 
stools. 

Treatment. — Flint  h&s  shown  that  sporadic  dysentery  is,  in  its  slighter 
grades  at  least,  a  self-limited  disease,  which  runs  its  course  in  eight  or  nine 
days.  Reading  the  report  of  his  cases,  one  is  struck,  however,  with  their  com- 
parative mildness. 

PROPHYLACTIC. — The  same  prophylactic  precautions  should  be  followed 
as  are  adopted  in  typhoid  fever.  Flexner  and  Gay  have  shown  that  animals 
can  be  protected  from  infection  by  a  previous  treatment  with  immune  horse 
serum.  Protective  and  curative  serums  have  been  prepared  and  are  now  on 
the  market. 

I.  ACUTE  DYSENTERY. — The  patient  should  be  absolutely  at  rest  in  bed. 
He  should  be  kept  warm  and  have  a  flannel  abdominal  binder  applied.  The 
diet  should  be  very  simple — whey,  egg  albumen,  barley  or  rice  water,  and 
strained  gruels.  Enough  water  should  be  given  to  relieve  thirst.  If  vomiting 
occurs,  nothing  should  be  given  by  mouth  for  some  hours,  and  if  the  patient 
requires  fluid  this  can  be  given  by  infusion.  Hot  applications  to  the  abdomen 
are  useful.  If  the  patient  is  seen  early  in  the  attack,  free  purgation  is  advisa- 
ble, for  which  sodium  sulphate  and  Rochelle  salts  are  best.  Either  may  be 
given  in  doses  of  two  drachms  (8  gm.^for  two  doses  an  hour  apart  and  later 
half  the  amount  every  three  hours  until  the  bowels  have  moved  freely.  By 
this  treatment  the  course  is  sometimes  cut  short.  If  the  attack  is  well  estab- 
lished, the  use  of  purgatives  must  be  determined  by  the  conditions  present. 
If  solid  faecal  matter  is  being  passed,  a  purgative  is  indicated,  castor  oil  being 
the  best  (5  vi,  25  c.  c.).  Until  the  bowels  have  been  thoroughly  cleared, 
purgation  is  indicated. 

Medicinal. — Bismuth  in  large  doses  often  has  a  beneficial  effect.  Thirty 
to  sixty  grains  (2  to  4  gm.)  should  be  given  every  hour.  Minute  doses  of  bi- 
chloride of  mercury,  one  hundredth  of  a  grain  every  two  hours,  were  recom- 
mended by  Ringer.  For  the  relief  of  pain  and  to  quiet  the  bowel,  morphia 
is  the  most  useful  drug  and  is  to  be  preferred  to  opium  by  mouth.  It  should 
be  given  hypodermically  in  large  doses  (gr.  1-4  to  1-3,  0.016  to  0.022  gm.), 
and  repeated  according  to  the  needs  of  the  patient.  If  tenesmus  is  not 
marked,  opium  can  be  given  as  the  starch  and  laudanum  enema,  in  which 
thirty  minims  (2  c.  c.)  of  laudanum  are  given.  The  ipecacuanha  treatment  is 
not  so  suitable  for  the  bacillary  as  for  the  amcebic  form,  with  which  it  will  be 
considered. 

Local  Treatment. — During  the  acute  stages  this  may  be  out  of  the  ques- 
tion, but  should  be  employed  whenever  possible.  Normal  saline  or  sodium 
bicarbonate  (1  per  cent.)  solution  at  the  body  temperature  can  be  used.  This 
should  be  given  very  gently  and  with  the  hips  elevated.  If  there  is  rectal 
irritation,  a  cocaine  or  morphia  suppository  should  be  given  beforehand. 
As  the  symptoms  lessen,  the  quantity  of  fluid  can  be  increased  and  other 
solutions  used,  such  as  boric  acid  (5  per  cent.),  salicylic  acid  (1  per. cent.)  or 
alum  (1  to  200). 


130  SPECIFIC    INFECTIOUS   DISEASES 

With  convalescence  the  diet  should  be  increased  very  gradually  and  only 
simple  foods  allowed.  The  patient  should  be  kept  quiet  until  all  danger  of  a  re- 
lapse is  over.  This  is  most  important  in  the  prevention  of  a  chronic  dysentery. 

Serum  Therapy. — Shiga  produced  a  polyvalent  serum  by  immunizing 
horses,  by  which  he  claims  to  have  reduced  the  mortality  in  "endemic"  dys- 
entery in  Japan  from  about  35  per  cent,  to  9  per  cent.  Good  results  have 
been  reported  from  the  use  of  the  Pasteur  Institute  and  Lister  Institute 
serums,  which  should  be  given  in  doses  of  20  c.  c.  two  or  three  times  a  day. 

II.  CHRONIC  DYSENTERY. — The  patient  should  be  at  rest  in  bed  and  on 
simple  diet,  milk,  boiled,  peptonized  or  fermented,  whey,  beef  juice,  and  eggs. 
In  some  cases  milk  may  have  to  be  given  well  diluted  or  in  small  amounts, 
but  it  usually  agrees  well.  It  is  well  to  give  an  occasional  purge  (castor  oil, 
§  ss,  15  c.  c.)  to  empty  the  bowels.  Drugs  by  mouth  are  not  of  great  value. 
Bismuth,  if  used,  should  be  in  large  doses  (3  i,  4  gm.)  every  three  hours 
while  the  patient  is  awake.  Opium  should  not  be  given  as  a  routine  measure, 
as  there  is  great  danger  of  forming  a  habit.  If  employed,  it  is  best  given  in 
the  starch  and  laudanum  enema. 

Local  Treatment. — This  is  most  rational  and  should  be  carried  out  thor- 
oughly. If  the  rectum  is  irritable,  a  cocaine  or  morphine  suppository  should 
be  given  half  an  hour  previously.  The  irrigation,  at  the  body  temperature, 
should  be  given  very  gently,  the  patient  encouraged  to  retain  it  as  long  as 
possible,  and  the  amount  gradually  increased  up  to  two  litres  if  possible.  One 
irrigation  a  day  is  usually  enough.  Silver  nitrate  solution  is  probably  the 
best  (1  to  5,000  at  first  and  increased. to  1  to  500).  Boric  acid  (5  per  cent.), 
salicylic  acid  (2  per  cent.),  alum,  or  tannic  acid  (3  per  cent.)  may  also  be 
used.  With  any  of  these  an  occasional  irrigation  of  saline  solution  is  useful. 
With  improvement  the  frequency  of  the  irrigations  should  be  reduced.  In  the 
obstinate  cases  an  appendicostomy  may  be  done  and  the  bowel  irrigated 
through  the  opening. 

XII.    MALTA   FEVER 

(Undulant  Fever,  Mediterranean  Fever] 

Definition. — A  specific  fever,  caused  by  the  Micrococcus  melitensis,  char- 
acterized by  undulatory  pyrexial  relapses,  profuse  sweats,  rheumatic  pains, 
arthritis,  and  an  enlarged  spleen.  It  is  spread,  as  a  rule,  through  the  agency 
of  goat's  milk. 

Distribution. — The  disease  prevails  in  the  Mediterranean  littoral,  and  en- 
demic foci  exist  in  India,  Africa,  China,  and  Manila.  In  the  goat  raising 
sections  of  Texas  the  disease  is  endemic  (Gentry  and  Ferenbaugh).  In  the 
Malta  garrison  in  the  seven  years  1898-1904,  there  were  2,229  cases,  with 
an  average  case  duration  of  one  hundred  and  twenty  days  and  with  77  deaths. 
About  the  same  number  of  cases  occurred  in  the  fleet.  Since  the  introduction 
of  prophylactic  measures  the  disease  has  practically  disappeared  from  the 
Army  and  Navy,  and  has  diminished  greatly  in  the  civil  population. 

Etiology. — The  greater  part  of  our  knowledge  of  this  remarkable  disease 
we  owe  to  the  work  of  British  army  surgeons  stationed  at  Gibraltar  and  Malta, 
particularly  to  Marston,  Bruce,  and  Hughes.  In  1886  Bruce  isolated  an  or- 


MALTA   FEVER  131 

ganism  which  he  called  Micrococcus  melitensis  from  the  spleen  and  blood. 
Hughes,  Wright,  Semple,  and  others  confirmed  this.  In  1904-1905  a  Gov- 
ernment Commission  began  a  study  on  the  island  of  the  problems  of  the  dis- 
ease in  all  its  aspects.  It  was  shown  to  be  a  septicaemia,  due  to  the  above- 
named  organism,  which  had  an  unusually  prolonged  saprophytic  existence. 
Zamit  showed  that  the  goats,  the  most  important  animals  in  the  domestic 
life  of  Malta,  were  largely  infected,  from  10  to  15  per  cent,  having  the  micro- 
coccus  in  their  milk.  Monkeys  were  successfully  infected  with  milk  which 
contained  the  organisms.  Steps  were  at  once  taken  to  stop  the  use  as  far  as 
possible  of  goat's  milk  for  the  troops,  with  the  result  that  the  number  of  cases 
fell  from  750  in  1905  to  145  in  1906,  and  to  7  for  nine  months  of  1907. 
There  were  no  cases  in  1907  in  the  Mediterranean  fleet,  and  since  this  date 
the  disease  has  disappeared  in  the  garrison  and  in  the  fleet. 

The  micrococcus  enters  the  system  through  the  gastro-intestinal  tract. 
Ross  and  Eyre  think  it  may  also  be  transmitted  by  mosquitoes.  It  may  spread 
by  the  infection  of  food  by  flies  or  by  the  fingers. 

Symptoms. — There  is  no  specific  fever  which  presents  the  same  remark- 
able group  of  phenomena.  The  period  of  incubation  is  from  six  to  ten  days. 
"Clinically  the  fever  has  a  peculiar  irregular  temperature  curve,  consisting 
of  intermittent  waves  or  undulations  of  pyrexia,  of  a  distinctly  remittent 
character.  These  pyrexial  waves  or  undulations  last,  as  a  rule,  from  one  to 
three  weeks,  with  an  apyrexial  interval  lasting  for  two  or  more  days.  In  rare 
cases  the  remissions  may  become  so  marked  as  to  give  an  almost  intermittent 
character  to  the  febrile  curve,  clearly  distinguishable,  however,  from  the  par- 
oxysms of  paludic  infection.  This  pyrexial  condition  is  usually  much  pro- 
longed, having  an  uncertain  duration,  lasting  for  even  six  months  or  more. 
Unlike  paludism,  its  course  is  not  markedly  affected  by  the  administration  of 
quinine.  Its  course  is  often  irregular  and  even  erratic  in  nature.  This  py- 
rexia is  usually  accompanied  by  obstinate  constipation,  progressive  anaemia, 
and  debility.  It  is  often  complicated  with  and  followed  by  neuralgic  symp- 
toms referred  to  the  peripheral  or  central  nervous  system,  arthritic  effusions, 
painful  inflammatory  conditions  of  certain  fibrous  structures,  of  a  localized 
nature,  or  swelling  of  the  testicles"  (Hughes).  There  is  a  malignant  type, 
in  which  the  disease  may  prove  fatal  within  a  week  or  ten  days;  an  undulatory 
type — the  common  variety — in  which  the  fever  is  marked  by  intermittent 
waves  or  undulations  of  variable  length,  separated  by  periods  of  apyrexia  and 
freedom  from  symptoms.  In  this  really  lie  the  peculiar  features  of  the  dis- 
ease, and  the  unfortunate  victim  may  suffer  a  series  of  relapses  which  may 
extend  from  three  months,  the  average  time,  to  two  years.  Lastly,  there  is 
an  intermittent  type,  in  which  the  patient  may  simply  have  daily  pyrexia 
toward  evening,  without  any  special  complications,  and  may  do  well  and  be 
able  to  go  about  his  work,  and  yet  at  any  time  the  other  serious  features  of 
the  disease  may  develop. 

The  blood  serum  of  a  patient  with  Malta  fever  agglutinates  the  Micrococ- 
cus melitensis.  For  diagnosis,  cultures  from  the  blood  may  be  made  or,  if 
other  procedures  fail,  from  the  spleen. 

The  mortality  is  slight,  only  about  2  per  cent.  There  are  no  characteristic 
morbid  lesions,  but  the  spleen  is  enlarged,  dark  and  soft.  Malta  fever  ctC 
now  be  readily  differentiated  from  typhoid  fever  and  malaria.  The  prophy- 


132  SPECIFIC    INFECTIOUS    DISEASES 

laxis  is  self-evident,  and  the  brilliant  work  of  the  commission  has  already 
reduced  the  incidence  of  the  disease  to  a  minimum.  The  disease  has  disap- 
peared from  Gibraltar  since  the  importation  of  goats  from  Malta  has  been 
stopped. 

Treatment. — General  measures  suitable  to  typhoid  fever  are  indicated. 
Fluid  food  should  be  given  during  the  febrile  period.  Vaccines  may  be  used 
and  good  results  have  been  reported.  Hydrotherapy,  either  the  bath  or  the 
cold  pack,  should  be  used  every  third  hour  when  the  temperature  is  above 
103°  F.  Otherwise  the  treatment  is  symptomatic.  No  drugs  appear  to  have 
any  special  influence  on  the  fever.  A  change  of  climate  seems  to  promote 
convalescence. 

XIII.    CHOLERA  ASIATICA 

Definition. — A  specific,  infectious  disease,  caused  by  the  comma  bacillus 
of  Koch,  and  characterized  clinically  by  violent  purging  and  rapid  collapse. 

Historical  Summary. — Cholera  has  been  endemic  in  India  from  a  remote 
period,  but  only  within  the  last  century  did  it  make  inroads  into  Europe  and 
America.  An  extensive  epidemic  occurred  in  1832,  in  which  year  it  was 
brought  in  immigrant  ships  from  Great  Britain  to  Quebec.  It  travelled  along 
the  lines  of  traffic  up  the  Great  Lakes,  and  finally  reached  as  far  west  as  the 
military  posts  of  the  upper  Mississippi.  In  the  same  year  it  entered  the 
United  States  by  way  of  New  York.  There  were  recurrences  of  the  disease 
in  1835-'36.  In  1848  it  entered  the  country  through  New  Orleans,  and  spread 
widely  up  the  Mississippi  Valley  and  across  the  continent  to  California.  In 
1849  it  again  appeared.  In  1854  it  was  introduced  by  immigrant  ships  into 
New  York  and  prevailed  widely  throughout  the  country.  In  1866  and  in 
1867  there  were  less  serious  epidemics.  In  1873  it  again  appeared  in  the 
United  States,  but  did  not  prevail  widely.  In  1884  there  was  an  outbreak 
in  Europe,  and  again  in  1892  and  1893.  Although  occasional  cases  have 
been  brought  by  ship  to  the  quarantine  stations  of  Great  Britain  and  the 
United  States,  the  disease  has  not  gained  a  foothold  in  either  country  since 
1873.  It  has  prevailed  continuously  in  the  Philippines  since  1901,  but  is 
now,  1912,  well  under  control.  For  the  past  ten  years  it  has  prevailed  widely 
in  the  near  and  far  East.  Russia  has  suffered  severely  since  1907,  but  last 
year,  1911,  there  were  comparatively  few  cases.  In  1911  cholera  prevailed  in 
Italy,  North  Africa  and  Madeira.  There  were  outbreaks  in  Asia  Minor,  Ara- 
bia and  Turkey,  and  the  usual  prevalence  in  India.  To  the  United  States, 
during  1911,  cholera  was  frequently  conveyed  by  ships  from  Italy,  but  there 
was  no  difficulty  in  controlling  it.  A  number  of  cholera  "carriers"  were 
found. 

Etiology. — In  1884  Koch  announced  the  discovery  of  the  specific  organ- 
ism of  this  disease.  Subsequent  observations  have  confirmed  his  statement 
that  the  comma  bacillus,  as  it  is  termed,  occurs  constantly  in  the  true  cholera, 
and  in  no  other  disease.  It  has  the  form  of  a  slightly  bent  rod,  which  is 
thicker,  but  not  more  than  about  half  the  length  of  the  tubercle  bacillus,  and 
sometimes  occurs  in  corkscrew-like  or  S  forms.  The  organisms  grow  upon 
a  great  variety  of  media  and  display  distinctive  and  characteristic  appear- 
ances. Koch  found  them  in  the  water  tanks  in  India,  and  they  were  isolated 


CHOLEEA    ASIATICA  133 

from  the  Elbe  water  during  the  Hamburg  epidemic  of  1892.  During  epi- 
demics virulent  bacilli  may  be  found  in  the  faeces  of  healthy  persons.  The 
bacilli  are  found  in  the  intestine,  in  the  stools  from  the  earliest  period  of 
the  disease,  and  very  abundantly  in  the  characteristic  rice-water  evacuations, 
in  which  they  may  be  seen  as  an  almost  pure  culture.  They  very  rarely  occur 
in  the  vomit.  Post  mortem,  they  are  found  in  enormous  numbers  in  the 
intestine.  In  acutely  fatal  cases  they  do  not  seem  to  invade  the  intestinal 
wall,  but  in  those  with  a  more  protracted  course  they  are  found  in  the  depths 
of  the  glands  and  in  the  still  deeper  tissues.  Experimental  animals  are  not 
susceptible  to  cholera  germs  administered  per  os.  But  if  introduced  after 
neutralization  of  the  gastric  contents,  and  if  kept  in  contact  with  the  intes- 
tinal mucosa  by  controlling  peristalsis  with  opium,  guinea-pigs  succumb  after 
showing  cholera-like  symptoms.  The  intestines  are  filled  with  thin,  watery 
contents,  containing  comma  bacilli  in  almost  pure  culture. 

CHOLERA  TOXIN. — Koch  in  his  studies  of  cholera  failed  to  find  the  spirilla 
in  the  internal  organs.  He  concluded  that  the  constitutional  symptoms  of 
the  disease  resulted  from  the  absorption  of  toxic  bodies  from  the  intestine. 
E.  Pfeiffer  has  shown  that  the  cholera  toxin  is  intimately  associated  with  the 
proteid  of  the  bacterial  cells,  and,  being  of  a  very  labile  nature,  can  not  be 
separated.  Dead  cultures  are  toxic;  and  the  symptoms  produced  by  the  in- 
troduction of  even  minimal  amounts  are  often  comparable  with  those  of  the 
algid  stage  of  cholera  asiatica.  The  symptoms  occur  very  rapidly,  and  death 
often  results  in  eight  to  twelve  hours;  in  non-fatal  cases  recovery  is  often 
equally  as  rapid.  The  intracellular  cholera  toxin  is  poisonous  to  animals  if 
introduced  into  the  blood,  peritoneal  cavity,  or  subcutaneous  tissues.  No  ab- 
sorption takes  place  from  the  intestine  unless  the  epithelial  layer  has  been 
injured. 

IMMUNITY. — Animals  may  be  immunized  by  repeated  injections  of  non- 
fatal  doses  of  the  dead  and  later  of  the  living  organisms.  The  serum  of  an 
animal  thus  immunized  has  a  protective  power  when  injected  into  a  guinea 
pig  along  with  five  or  ten  times  the  fatal  dose.  This  serum  has  also  agglutina- 
tive and  other  antibacterial  properties.  The  blood  serum  of  convalescent  pa- 
tients also  possesses  these  properties,  and  for  therapeutic  purposes  anti-serums 
have  been  introduced  and  used  widely  in  India,  the  Philippines  and  in  Russia. 

Modes  of  Infection. — As  in  other  diseases,  individual  peculiarities  count 
for  much,  and  during  epidemics  virulent  cholera  bacilli  have  been  isolated 
from  the  normal  stools  of  healthy  men.  Cholera  cultures  have  also  been 
swallowed  with  impunity. 

The  disease  is  not  highly  contagious;  physicians,  nurses,  and  others  in 
close  contact  with  patients  are  not  often  affected.  On  the  other  hand,  washer* 
women  and  those  who  are  brought  into  very  close  contact  with  the  linen  of 
the  cholera  patients,  or  with  their  stools,  are  particularly  prone  to  catch  the 
disease.  There  have  been  several  instances  of  so-called  "laboratory  cholera," 
in  which  students,  having  been  accidentally  infected  while  working  with  the 
cultures,  have  taken  the  disease,  and  at  least  one  death  has  resulted. 

Vegetables  which  have  been  washed  in  the  infected  water,  particularly  let- 
tuces and  cresses,  may  convey  the  disease.  Milk  may  also  be  contaminated. 
The  bacilli  live  on  fresh  bread,  butter,  and  meat,  for  from  six  to  eight  days. 
In  regions  in  which  the  disease  prevails  the  possibility  of  the  infection  of  food 


134  SPECIFIC)    INFECTIOUS   DISEASES 

by  flies  should  be  borne  in  mind,  since  it  has  been  shown  that  the  bacilli 
may  live  for  at  least  three  days  in  their  intestines. 

Infection  through  the  air  is  not  to  be  much  dreaded,  since  the  germs  when 
dried  die  rapidly. 

The  disease  is  propagated  chiefly  by  contaminated  water  used  for  drink- 
ing, cooking,  and  washing.  The  virulence  of  an  epidemic  in  any  region  is  in 
direct  proportion  to  the  imperfection  of  its  water-supply.  In  India  the  dem- 
onstration of  the  connection  between  drinking-water  and  cholera  infection  is 
complete.  The  Hamburg  epidemic  is  a  most  remarkable  illustration.  The 
unfiltered  water  of  the  Elbe  was  the  chief  supply,  although  taken  from  the 
river  in  such  a  situation  that  it  was  of  necessity  directly  contaminated  by 
sewage.  It  is  not  known  accurately  from  what  source  the  contagion  came, 
whether  from  Russia  or  from  France,  but  in  August,  1892,  there  was  a  sud- 
den explosive  epidemic,  and  within  three  months  nearly  18,000  persons  were 
attacked,  with  a  mortality  of  42.3  per  cent.  The  neighboring  city  of  Altona, 
which  also  took  its  water  from  the  Elbe,  but  which  had  a  thoroughly  well- 
equipped  modern  filtration  system,  had  in  the  same  period  only  516  cases. 

Two  main  types  of  epidemics  of  cholera  are  recognized:  the  first,  in  which 
many  individuals  are  attacked  simultaneously,  as  in  the  Hamburg  outbreak, 
and  in  which  no  direct  connection  can  be  traced  between  the  individual  cases. 
In  this  type  there  is  widespread  contamination  of  the  drinking-water.  In  the 
other  the  cases  occur  in  groups,  so-called  cholera  nests;  individuals  are  not 
attacked  simultaneously,  but  successively.  A  direct  connection  between  the 
cases  may  be  very  difficult  to  trace.  Again,  both  these  types  may  be  com- 
bined, and  in  an  epidemic  which  has  started  in  a  widespread  infection  through 
water,  there  may  be  other  outbreaks,  which  are  examples  of  the  second  or 
chain-like  type. 

Cholera  "carriers"  have  no  doubt  an  important  influence.  In  Manila 
nearly  8  per  cent,  of  376  healthy  persons  harbored  the  bacilli.  The  perennial 
outbreaks  of  this  disease  in  the  Manila  prison  were  due  to  carriers,  17  of 
whom  were  found  among  those  who  had  to  do  with  the  preparation  of  the 
food  and  drink  of  3,000  prisoners. 

The  disease  always  follows  the  lines  of  human  travel.  In  India  it  has, 
in  many  notable  cases,  been  widely  spread  by  pilgrims.  It  is  carried  also  by 
caravans  and  in  ships.  It  is  not  conveyed  through  the  atmosphere. 

Places  situated  at  the  sea-level  are  more  prone  to  the  disease  than  inland 
towns.  In  high  altitudes  the  disease  does  not  prevail  so  extensively.  A  high 
temperature  favors  the  development  of  cholera,  but  in  Europe  and  America 
the  epidemics  have  been  chiefly  in  the  late  summer  and  in  the  autumn. 

The  disease  affects  persons  of  all  ages.  It  is  particularly  prone  to  attack 
the  intemperate  and  those  debilitated  by  want  of  food  and  by  bad  surround- 
ings. Depressing  emotions,  such  as  fear,  undoubtedly  have  a  marked  influ- 
ence. It  is  doubtful  whether  an  attack  furnishes  immunity  against  a  second 
one. 

Morbid  Anatomy. — A  post  mortem  diagnosis  of  the  nature  of  the  disease 
could  be  made  by  any  competent  bacteriologist,  as  the  organism  is  distinctive. 
The  body  has  the  appearances  associated  with  profound  collapse.  There  is 
often  marked  post  mortem  elevation  of  temperature.  The  rigor  mortis  sets 
in  early  and  may  produce  displacement  of  the  limbs.  The  lower  jaw  has  been 


CHOLERA    ASIATICA  135 

seen  to  move  and  the  eyes  to  rotate.  Various  movements  of  the  arms  and 
legs  have  also  been  noted.  The  blood  is  thick  and  dark,  and  there  is  a  re- 
markable diminution  in  the  amount  of  its  water  and  salts.  The  peritoneum 
is  sticky,  and  the  coils  of  intestines  are  congested  and  look  thin  and  shrunken. 
The  small  intestine  usually  contains  a  turbid  serum,  similar  in  appearance  to 
that  .which  was  passed  in  the  stools.  The  mucosa  is,  as  a  rule,  swollen,  and  in 
very  acute  cases  slightly  hyperamic;  later  the  congestion,  which  is  not  uni- 
form, is  more  marked,  especially  about  the  Peyer's  patches.  Post  mortem 
the  epithelial  lining  is  sometimes  denuded,  but  this  is  probably  not  a  change 
which  takes  place  freely  during  life.  In  the  stools,  however,  large  numbera 
of  columnar  epithelial  cells  have  been  described  by  Homer  and  others.  The 
bacilli  are  found  in  the  contents  of  the  intestine  and  in  the  mucous  mem- 
brane. The  spleen  is  usually  small.  The  liver  and  kidneys  show  cloudy 
swellings,  and  the  latter  extensive  coagulation-necrosis  and  destruction  of  the 
epithelial  cells. 

Symptoms. — A  period  of  incubation  of  uncertain  length,  probably  not 
more  than  from  two  to  five  days,  precedes  the  onset  of  the  symptoms. 

Three  stages  may  be  recognized  in  the  attack:  the  preliminary  diarrhoea, 
the  collapse  stage,  and  the  period  of  reaction. 

(a)  THE  PRELIMINARY  DIARRHCEA  may  set  in  abruptly  without  any  pre- 
vious indications.  More  commonly  there  are,  for  one  or  two  days,  colicky 
pains  in  the  abdomen,  with  looseness  of  the  bowels,  perhaps  vomiting,  with 
headache  and  depression  of  spirits.  There  may  be  no  fever. 

(&)  COLLAPSE  STAGE. — The  diarrhoea  increases,  or,  without  any  of  the 
preliminary  symptoms,  sets  in  with  the  greatest  intensity,  and  profuse  liquid 
evacuations  succeed  each  other  rapidly.  There  are  in  some  instances  griping 
pains  and  tenesmus.  More  commonly  there  is  a  sense  of  exhaustion  and  col- 
lapse. The  thirst  becomes  extreme,  the  tongue  is  white;  cramps  of  great 
severity  occur  in  the  legs  and  feet.  Within  a  few  hours  vomiting  sets  in  and 
becomes  incessant.  The  patient  rapidly  sinks  into  a  condition  of  collapse, 
the  features  are  shrunken,  the  skin  has  an  ashy-gray  hue,  the  eyeballs  sink 
in  the  sockets,  the  nose  is  pinched,  the  cheeks  are  hollow,  the  voice  becomes 
husky,  the  extremities  are  cyanosed,  and  the  skin  is  shriveled,  wrinkled,  and 
covered  with  a  clammy  perspiration.  The  temperature  sinks.  In  the  axilla 
or  in  the  mouth  it  may  be  from  five  to  ten  degrees  below  normal,  but  in  the 
rectum  and  in  the  internal  parts  it  may  be  103°  or  104°.  The  blood  pressure 
falls  greatly  and  is  often  below  70  mm.  Hg.  The  pulse  becomes  extremely 
feeble  and  flickering,  and  the  patient  gradually  passes  into  a  condition  of 
coma,  though  consciousness  is  often  retained  until  near  the  end. 

The  fa3ces  are  at  first  yellowish  in  color,  from  the  bile  pigment,  but  soon 
they  become  grayish-white  and  look  like  turbid  whey  or  rice-water;  whence 
the  term  "rice-water  stools."  There  are  found  in  them  numerous  small  flakes 
of  mucus  and  granular  matter,  and  at  times  blood.  The  reaction  is  usually 
alkaline.  The  fluid  contains  albumin  and  the  chief  mineral  ingredient  is 
chloride  of  sodium.  Microscopically,  mucus  and  epithelial  cells  and  innu- 
merable bacteria  are  seen,  the  majority  of  the  latter  being  the  comma  bacilli. 

The  condition  of  the  patient  is  largely  the  result  of  the  concentration  of 
the  blood  consequent  upon  the  loss  of  serum  in  the  stools.  The  specific 
gravity  of  the  blood  rises  to  1060  to  1072.  There  is  almost  complete  arrest 


136  SPECIFIC    INFECTIOUS    DISEASES 

of  secretion,  particularly  of  the  saliva  and  the  urine.  On  the  other  hand,  the 
sweat-glands  increase  in  activity,  and  in  nursing  women  it  has  been  stated 
that  the  lacteal  flow  is  unaffected.  This  stage  sometimes  lasts  not  more  than 
two  or  three  hours,  but  more  commonly  from  twelve  to  twenty-four. 

(c)  REACTION  STAGE. — When  the  patient  survives  the  collapse,  the  cyano- 
sis gradually  disappears,  the  warmth  returns  to  the  skin,  which  may  have  for 
a  time  a  mottled  color  or  present  a  definite  erythematous  rash.  The  heart's 
action  becomes  stronger,  the  urine  increases  in  quantity,  the  irritability  of  the 
stomach  disappears,  the  stools  are  at  longer  intervals,  and  there  is  no  abdom- 
inal pain.  In  the  reaction  the  temperature  may  not  rise  above  normal.  Not 
infrequently  this  favorable  condition  is  interrupted  by  a  recurrence  of  severe 
diarrhoea  and  the  patient  is  carried  off  in  a  relapse.  Other  cases  pass  into 
the  condition  of  what  has  been  called  cholera-typhoid,  a  state  in  which  the 
patient  is  delirious,  the  pulse  rapid  and  feeble,  and  the  tongue  dry.  Death 
finally  occurs  with  coma.  These  symptoms  have  been  attributed  to  uraemia. 

During  epidemics  attacks  are  found  of  all  grades  of  severity.  There  are 
cases  of  diarrhoea  with  griping  pains,  liquid,  copious  stools,  vomiting,  and 
cramps,  with  slight  collapse.  To  these  the  term  cholerine  has  been  applied. 
They  resemble  the  milder  cases  of  cholera  nostras.  At  the  opposite  end  of 
the  series  there  are  the  instances  of  cholera  sicca,  in  which  death  may  occur  in 
a  few  hours  after  the  onset,  without  diarrhoea.  There  are  also  cases  in  which 
the  patients  are  overwhelmed  with  the  poison  and  die  comatose,  without  the 
preliminary  stage  of  collapse. 

Complications  and  Sequelae. — The  typhoid  condition  has  already  been  re- 
ferred to.  The  consecutive  nephritis  rarely  induces  dropsy.  Diphtheritic 
colitis  has  been  described.  There  is  a  special  tendency  to  diphtheritic  inflam- 
mation of  the  mucous  membranes,  particularly  of  the  throat  and  genitals. 
Pneumonia  and  pleurisy  may  follow,  and  destructive  abscesses  may  occur  in 
different  parts.  Suppurative  parotitis  is  not  very  uncommon.  In  rare  in- 
stances local  gangrene  may  occur.  A  troublesome  symptom  of  convalescence 
is  cramps  in  the  muscles  of  the  arms  and  legs. 

Diagnosis. — The  only  affection  with  which  Asiatic  cholera  could  be  con- 
founded is  the  cholera  nostras,  the  severe  choleraic  diarrhoea  which  occurs 
during  the  summer  months  in  temperate  climates.  The  clinical  picture  of  the 
two  affections  is  identical.  The  extreme  collapse,  vomiting,  and  rice-water 
stools,  the  cramps,  the  cyanosed  appearance,  are  all  seen  in  the  worst  forms  of 
cholera  nostras.  In  enfeebled  persons  death  may  occur  within  twelve  hours. 
It  is  of  course  extremely  important  to  be  able  to  diagnose  between  the  two 
affections.  This  can  only  be  done  by  one  thoroughly  versed  in  bacteriological 
methods,  and  conversant  with  the  diversified  flora  of  the  intestines. 

Attacks  very  similar  to  Asiatic  cholera  are  produced  in  poisoning  by 
arsenic,  corrosive  sublimate,  and  certain  fungi;  but  a  difficulty  in  diagnosis 
could  scarcely  arise. 

The  prognosis  is  always  uncertain,  as  the  mortality  ranges  in  different 
epidemics  from  30  to  80  per  cent.  Intemperance,  debility,  and  old  age  are 
unfavorable  conditions.  The  more  rapidly  the  collapse  sets  in,  the  greater  is 
the  danger,  and  as  Andral  truly  says  of  the  malignant  form,  "It  begins  where 
other  diseases  end — in  death."  Patients  with  marked  cyanosis  and  very  low 
temperature  rarely  recover. 


CHOLERA    ASIATICA  137 

Prophylaxis. — Preventive  measures  are  all-important,  and  isolation  of 
the  sick  and  thorough  disinfection  have  effectually  prevented  the  disease  enter- 
ing England  or  the  United  States  since  1873.  During  epidemics  the  greatest 
care  should  be  exercised  in  the  disinfection  of  the  stools  and  linen  of  the 
patients.  When  an  epidemic  prevails,  persons  should  be  warned  not  to  drink 
water  unless  previously  boiled.  The  milk  should  be  boiled  and  all  food  and 
drinks  carefully  protected  from  flies.  Errors  in  diet  should  be  avoided.  Un- 
cooked vegetables  and  salads  should  not  be  eaten.  As  the  disease  is  not  more 
contagious  than  typhoid  fever,  the  chance  of  a  person  passing  safely  through 
an  epidemic  depends  very  much  upon  how  far  he  is  able  to  carry  out  thor- 
oughly prophylactic  measures.  Digestive  disturbances  are  to  be  treated 
promptly,  and  particularly  the  diarrhoea,  which  so  often  is  a  preliminary  symp- 
tom. For  this,  opium  and  acetate  of  lead  and  large  doses  of  bismuth  should 
be  given.  Protective  inoculation  has  been  carried  out  extensively  in  India  by 
Haffkine  and  in  the  Philippines  by  Strong,  in  both  places  and  recently  in 
Eussia  with  good  results. 

Treatment. — The  patient  should  be  at  rest  in  bed,  kept  warm,  and  given 
simple  diet,  boiled  milk,  whey  and  egg  albumen.  The  patient  may  be  allowed 
to  take  water  freely.  If  vomiting  occurs  food  should  be  withheld  and  the 
stomach  washed  with  an  alkaline  solution.  Hot  applications  to  the  abdomen 
should  be  used  and  hot  baths  given  if  they  prove  helpful.  Early  in  the  course 
the  bowels  should  be  moved  by  castor  oil  or  calomel.  During  the  initial 
stage,  when  the  diarrhoea  is  not  excessive  but  the  abdominal  pain  is 
marked,  opium  is  the  most  efficient  remedy,  and  it  should  be  given  hypo- 
dermically  as  morphia.  It  is  advisable  to  give  at  once  a  full  dose,  which  may 
be  repeated  on  the  return  of  the  pain.  It  is  best  not  to  attempt  to  give 
remedies  by  the  mouth,  as  they  disturb  the  stomach.  Ice  should  be  given,  and 
brandy  or  hot  coffee.  In  the  collapse  stage,  writers  speak  strongly  against 
the  use  of  opium.  Undoubtedly  it  must  be  given  with  caution,  but,  judging 
from  its  effects  in  cholera  nostras,  I  should  say  that  collapse  per  se  was  not 
a  contraindication. 

Irrigation  of  the  bowel  with  a  solution  of  tannic  acid  (2  per  cent.)  in  hot 
water  (105°)  should  be  used.  With  a  long,  soft-rubber  tube,  as  much  as  two 
litres  may  be  slowly  injected.  Not  only  is  the  colon  cleansed,  but  the  small 
bowel  may  also  be  reached,  as  shown  by  the  fact  that  the  tannic  acid  solutions 
have  been  vomited. 

Owing  to  the  profuse  serous  discharges  the  blood  becomes  concentrated, 
and  absorption  takes  place  rapidly  from  the  lymph-spaces.  To  meet  this, 
intravenous  injections  were  introduced  by  Latta,  of  Leith,  in  the  epidemic 
of  1832.  My  preceptor,  Bovell,  first  practised  the  intravenous  injections  of 
milk  in  Toronto,  in  the  epidemic  of  1854. 

Saline  injections,  intravenous  and  into  the  bowel,  have  been  much  used 
and  with  great  success  by  the  method  introduced  by  Leonard  Eogers.  The 
hypertonic  solution  is  composed  of.  sodium  chloride,  grains  120;  potassium 
chloride,  grains  6 ;  calcium  chloride,  grains  4 ;  water,  1  pint.  It  is  best  given 
intravenously,  particularly  if  the  specific  gravity  of  the  blood  is  over  1063, 
As  much  as  four  pints  may  be  injected  slowly.  It  may  be  repeated  and  ia 
one  case  as  much  as  twenty  pints  were  injected.  In  Calcutta  the  mortality 
has  been  reduced  from  60  to  about  33  per  cent,  in  the  cases  treated  by  this 
11 


138  SPECIFIC    INFECTIOUS    DISEASES 

method  and  Rogers  has  had  equally  good  results  at  Palermo  in  the  summef 
of  1911. 

In  the  stage  of  reaction  special  pains  should  be  taken  to  regulate  the  diet 
and  to  guard  against  recurrences  of  the  severe  diarrhoea. 


XIV.    THE   PLAGUE 

Definition. — A  specific,  infectious  disease,  caused  by  Bacillus  pestis,  and 
occurring  in  two  chief  forms :  a  bubonic,  involving  the  lymphatic  glands,  and 
a  pneumonic,  causing  an 'acute  and  rapidly  fatal  inflammation  of  the  lungs. 

History  and  Geographical  Distribution. — The  disease  was  probably  not 
known  to  the  classical  Greek  writers.  The  earliest  positive  account  dates 
from  the  second  century  of  our  era.  The  plague  of  Athens  and  the  pestilence 
of  the  reign  of  Marcus  Aurelius  were  apparently  not  this  disease  (Payne). 
From  the  great  plague  in  the  days  of  Justinian  (sixth  century)  to  the  middle 
of  the  seventeenth  century  epidemics  of  varying  severity  occurred  in  Europe. 
Among  the  most  disastrous  was  the  famous  "black  death"  of  the  fourteenth 
century,  which  overran  Europe  and  destroyed  a  fourth  of  the  population.  In 
the  seventeenth  century  it  raged  virulently,  and  during  the  great  plague  of 
London,  in  1665,  about  70,000  people  died.  During  the  eighteenth  and  nine- 
teenth centuries  the  ravages  of  the  disease  lessened. 

The  revival  of  the  plague  is  the  most  important  single  fact  in  modern 
epidemiology.  Throughout  the  nineteenth  century  it  waned  progressively, 
outbreaks  of  some  extent  occurring  in  Turkey  and  Asia  Minor  and  Astrakan ; 
but  we  had  begun  to  place  it  with  sweating  sickness  and  typhus  among  the 
diseases  of  the  past.  We  knew  that  it  slumbered  in  parts  of  China,  and  in 
northwest  India,  but  the  outbreak  in  1894  at  Hong-Kong  startled  the  world 
and  showed  that  the  "black  death"  was  still  virulent.  Since  then  it  has 
spread  in  an  ominous  manner,  reaching  India,  China,  French  Indo-China, 
Japan,  Formosa,  Australia,  the  Philippine  Islands,  South  America,  the  West 
Indies,  the  United  States,  Cape  Colony,  Madagascar,  Egypt,  Asia  Minor,  and 
Eussia  in  Asia.  In  Europe,  cases  have  been  carried  to  Marseilles  and  other 
Mediterranean  ports  and  to  Hamburg  and  Glasgow.  In  the  latter  city  there 
was  a  small  outbreak  in  1900,  36  cases.  In  the  next  year  there  were  two  cases 
and  in  1907  two  cases — this  without  fresh  importation.  In  San  Fran- 
cisco there  was  in  1907-1908  a  recrudescence  of  the  disease,  and  to 
March  15,  1908,  there  were  121  cases  with  77  deaths.  The  rats  are  now 
no  longer  affected.  The  disease  spread  to  the  ground  squirrels  of  the  neigh- 
boring countries  from  which  source  eleven  cases  originated.  Cases  have  oc- 
curred in  New  Orleans — the  last  in  October,  1911. 

In  England  there  have  been  four  sets  of  human  cases  in  East  Suffolk; 
at  Shotley  in  1906-07,  8  cases  and  6  deaths;  at  Trimley,  in  December,  1909, 
and  January,  1910,  8  cases  and  5  deaths;  at  Freston  in  the  autumn  of  1910, 
4  fatal  cases;  and  a  fourth  case  occurred  in  the  autumn  of  1911.  The  ma- 
jority of  these  were  of  the  pneumonic  type.  The  serious  feature  is  that  there 
has  been  an  infection  of  the  rats  in  East  Anglia,  beginning  in  the  region 
between  Ipswich  and  the  coast.  The  rats  are  entirely  of  the  species  Mus 
decumanus  except  in  part  of  Ipswich.  The  infection  is  not  very  widespread. 


THE    PLAGUE  139 

as  of  568  rats  examined  only  17  were  found  infected.  The  disease  extended 
to  rabbits,  but  not  to  any  great  extent.  Some  fleas  from  the  rats  were  found 
to  contain  bacilli  indistinguishable  from  plague.  A  much  more  extensive 
investigation  of  the  prevalence  of  the  plague  in  the  rats  of  Suffolk  and  Essex 
was  made  by  Petrie  and  Macalister;  of  6,071  examined  not  one  presented 
the  appearance  of  plague.  The  disease  has  been  introduced  into  Suffolk  by 
ship  rats  from  plague  infected  countries.  More  serious  is  the  fact  that  dur- 
ing the  past  three  years  rats  infected  with  the  plague  have  been  occasionally 
discovered  at  Wapping,  but  there  does  not  seem  to  have  been  any  widespread 
epidemic  among  them. 

The  immunity  of  the  human  population  seems  to  be  due  to  the  fact 
that  50  per  cent,  of  the  rat  fleas  are  of  the  variety  Pulex  cheopis,  which 
rarely  bites  man,  and  the  other  rat  flea,  the  Ceratophyllus  fasciatus,  does  not 
bite  man  very  freely.  Then  the  common  brown  rat  is  not  a  house  resident 
to  any  extent,  so  that  conditions  in  England  are  not  very  favorable  for  epi- 
demic prevalence. 

The  distribution  in  India  is  remarkable,  chiefly  in  the  Punjab,  Bombay, 
and  the  United  Provinces,  which  have  a  combined  population  of  about  100 
millions.  In  these  three  provinces  between  1896  and  the  middle  of  1911, 
about  five  and  a  half  million  deaths  from  plague  have  occurred.  In  the 
remaining  provinces  of  India,  with  a  population  of  some  200  millions,  only 
about  two  millions  of  plague  deaths  have  occurred.  In  the  Presidency  of 
Madras  the  disease  has  not  been  very  severe,  while  Eastern  Bengal  and 
Assam  have  remained  free,  though  cases  have  been  repeatedly  imported.  Dur- 
ing 1911  the  returns  for  India  for  the  first  six  months  show  604,634  deaths. 
There  have  been  recent  outbreaks  in  China,  a  sharp  outbreak  in  Hong-Kong, 
and  the  disease  has  been  reported  in  Egypt,  Japan,  Straits  Settlements,  Java 
and  Sumatra,  Persia,  Turkey  in  Asia,  Astrakan,  the  Mauritius,  and  several 
of  the  South  American  countries.  The  Manchurian  outbreak  of  pneumonic 
plague  in  the  winter  of  1810-11  was  one  of  the  most  virulent  on  record, 
carrying  off  more  than  4,500  persons  in  a  few  months. 

Etiology. — The  specific  organism  of  the  disease  is  a  bacillus  discovered 
by  Kitasato.  It  resembles  somewhat  the  bacillus  of  chicken  cholera,  and 
grows  in  a  perfectly  characteristic  manner.  Bacillus  pestis  occurs  in  the 
blood,  in  the  organs  of  the  body  and  in  the  sputum,  and  has  also  been  found 
in  the  dust  and  in  the  soil  of  houses  in  which  the  patients  have  lived. 

The  disease  prevails  most  frequently  in  hot  seasons,  though  an  outbreak 
may  occur  during  the  coldest  weather.  Persons  of  all  ages  are  attacked.  It 
spreads  chiefly  among  the  poor,  in  the  slums  of  the  great  cities. 

The  following  conclusions  of  the  Plague  Commission  (1908)  relate  to 
bubonic  plague:  (a)  Contagion  occurs  in  less  than  3  per  cent,  of  the  cases, 
playing  a  very  small  part  in  the  general  spread  of  the  disease.  (&)  Bubonic 
plague  in  man  is  entirely  dependent  on  the  disease  in  the  rat.  (c)  The 
infection  is  conveyed  from  rat  to  rat  and  from  rat  to  man  solely  by  means  of 
the  rat-flea,  (d)  A  case  in  man  is  not  in  itself  infectious,  (e)  A  large 
majority  of  cases  occur  singly  in  houses.  When  more  than  one  case  occurs 
in  a  house,  the  attacks  are  generally  nearly  simultaneous.  (/)  Plague  is 
usually  conveyed  from  place  to  place  by  imported  rat-fleas,  which  are  carried 
by  people  on  their  persons  or  in  their  baggage.  The  human  agent  may 


140  SPECIFIC    INFECTIOUS   DISEASES 

himself  escape  infection,  (g)  Insanitary  conditions  have  no  relation  to  ch<s 
occurrence  of  plague,  except  in  so  far  as  they  favor  infestation  by  rats. 
(7i)  The  non-epidemic  season  is  bridged  over  by  acute  plague  in  the  rat, 
accompanied  by  a  few  cases  among  human  beings. 

In  the  pneumonic  form  personal  infection  from  one  person  to  another  is 
the  common  way,  as  the  bacilli  are  sprayed  into  the  air  by  coughing.  The 
possibility  of  the  human  flea  as  a  carrier  must  be  considered. 

Clinical  Forms, — PESTIS  MINOR. — In  this  variety,  also  known  as  the  am- 
bulant, the  patient  has  a  few  days  of  fever,  with  swelling  of  the  glands  of 
the  groin,  and  possibly  suppuration.  He  may  not  be  ill  enough  to  seek 
medical  relief.  These  cases,  often  found  at  the  beginning  and  end  of  an 
epidemic,  are  a  very  serious  danger,  as  the  urine  and  fa3ces  contain  bacilli. 

BUBONIC  PLAGUE. — This  constitutes  the  common  variety,  77.65  per  cent, 
of  11,600  cases  of  plague  treated  in  the  Arthur  Road  Hospital,  Bombay 
(N.  H.  Choksy).  The  stage  of  invasion  is  characterized  by  headache,  back- 
ache, stiffness  of  the  limbs,  a  feeling  of  anxiety  and  restlessness,  and  great 
depression  of  spirits.  There  is  a  steady  rise  in  the  fever  until  the  evening  of 
the  third  or  fourth  day,  when  there  is  a  drop  of  two  or  three  degrees.  There 
is  then  a  secondary  fever,  as  some  writers  describe  it,  in  which  the  tempera- 
ture reaches  a  still  higher  point.  The  tongue  becomes  brown,  collapse  symp- 
toms are  apt  to  supervene,  and  in  very  severe  infections  the  patient  may  die 
at  this  stage.  In  at  least  two-thirds  of  all  cases  there  are  glandular  swellings 
or  buboes.  An  analysis  of  9,500  cases  of  buboes  gave  more  than  54  per  cent, 
with  the  glands  of  the  groin  affected.  The  swelling  appears  usually  from 
the  third  to  the  fifth  day.  Resolution  may  occur,  or  suppuration,  or  in  rare 
cases  gangrene.  Suppuration  is  a  favorable  feature,  as  noted  by  De  Foe  in 
his  graphic  account  of  the  London  plague. 

Petechia?  very  commonly  show  themselves,  and  may  be  very  extensive. 
These  have  been  called  the  "plague  spots,"  or  the  "tokens  of  the  disease,"  and 
gave  to  it  in  the  middle  ages  the  name  of  the  Black  Death.  Hemorrhages 
from  the  mucous  membranes  may  also  occur;  in  some  epidemics  haemoptysis 
has  been  especially  frequent. 

SEPTIC^EMIC  PLAGUE. — In  this,  the  most  rapid  form,  the  patient  suc- 
cumbs in  three  or  four  days  with  a  virulent  infection  before  the  buboes  ap- 
pear. This  form  constituted  14.25  per  cent,  of  the  11,600  cases.  Hgemor- 
rhages  are  common.  The  bacilli  can  be  obtained  from  the  blood. 

PNEUMONIC  PLAGUE. — In  the  ordinary  bubonic  type,  inflammation  of  the 
lungs  is  not  an  uncommon  complication,  but  the  true  pneumonic  plague 
begins  abruptly  with  fever,  shortness  of  breath,  cough,  and  sometimes  pain 
in  the  chest.  The  fever  increases,  the  signs  of  the  involvement  of  the  lung 
occur  early;  there  may  be  impaired  resonance  at  both  bases  with  harsh  and 
tubular  breathing;  the  sputum  becomes  bloody  and  stained  and  more  fluid 
than  in  ordinary  pneumonia.  Cyanosis  is  an  early  feature ;  the  pulse  is  small 
and  rapid,  the  patient  becomes  profoundly  prostrate;  the  spleen  enlarges 
rapidly,  as  early  as  the  second  day,  and  a  fatal  result  follows  in  from  two  to 
four  days.  Recovery  is  very  rare. 

In  other  varieties  the  chief  manifestations  may  be  in  the  skin  and  sub- 
cutaneous tissues,  or  in  the  intestines,  causing  diarrhoea  and  sometimes  the 
features  of  typhoid  fever. 


THE    PLAGUE  141 

Diagnosis. — At  the  early  stage  of  an  outbreak  plague  cases  are  easily 
overlooked,  but  if  the  suspicious  cases  are  carefully  studied  by  a  competent 
bacteriologist,  there  is  no  disease  which  can  be  more  positively  identified. 
The  San  Francisco  epidemic  illustrates  this.  The  nature  of  the  cases  was 
recognized  by  Kellog  and  by  Kinyoun,  but  with  an  amazing  stupidity  (which 
was  shared  by  not  a  few  physicians,  who  should  have  known  better)  the  Gov- 
ernor of  the  State  refused  to  recognize  the  presence  of  plague,  and  the  United 
States  Government  had  to  intervene  and  send  a  board  of  experts  to  settle 
the  question.  In  the  early  Glasgow  cases  Colvin,  while  suspecting  typhoid 
fever,  saw  that  there  was  something  unusual,  and  at  once  took  precautionary 
measures.  Probably,  too,  the  association  of  four  cases  in  one  family  made 
him  suspicious.  The  limitation  of  the  outbreak  was  due  to  the  prompt  and 
effective  measures  taken  by  A.  K.  Chalmers  and  his  associates.  The  wide- 
spread prevalence  of  the  disease  makes  it  the  imperative  duty  of  the  health 
authorities  to  have  on  hand,  in  connection  with'  .large  ports,  skilled  men 
who  can  promptly  make  the  bacteriological  diagnosis.  There  are  dangers 
from  the  cultures  in  laboratories,  as  shown  by  the  experiences  of  Vienna  and 
Ann  Arbor,  but  with  proper  precautions  they  may  be  reduced  to  a  minimum. 
Acute,  rapidly  fatal  pneumonia  should  arouse  suspicion  as  in  the  Suffolk 
cases. 

Prophylaxis. — Wherever  plague  exists  an  organized  staff,  an  intelligent 
policy,  and  a  long  purse  are  needed.  In  India,  where  fifteenth-century  con- 
ditions prevail,  and  where  the  scale  of  the  epidemic  is  so  enormous,  the  prob- 
lem of  prophylaxis  looks  hopeless.  Simpson's  recommendation  of  a  specially 
trained  plague  service,  organized  on  proper  lines  and  on  a  liberal  basis, 
should  be  carried  out.  A  careful  watch  should  be  kept  on  the  mortality  of 
rats.  When  found  infected,  energetic  measures  should  be  taken  to  stamp  out 
the  disease  in  them.  Three  things  are  necessary — the  cleansing  of  premises, 
particularly  stables  and  outhouses,  so  that  the  rats  cannot  find  nesting  places 
or  food;  systematic  rat  destruction;  and  making  houses  rat  proof.  Certain 
measures  prevent  the  access  of  plague  to  healthy  ports;  fumigation  of  ships 
to  destroy  the  rats,  careful  inspection  of  passengers  and  crew,  and  detention 
over  a  period  which  covers  the  incubation  of  the  disease. 

When  a  centre  becomes  infected,  the  sanitary  organization  should  be  ar- 
ranged to  carry  out  the  segregation  of  the  sick  in  hospitals,  the  disinfection 
of  infected  rooms  with  sulphur,  destruction  of  infected  bedding,  and  thorough 
cleansing  of  the  entire  district;  old,  badly  infected  buildings  should  be  de- 
stroyed. 

Treatment. — In  a  disease  the  mortality  of  which  may  reach  as  high  as  80 
or  90  per  cent,  the  question  of  treatment  resolves  itself  into  making  the  patient 
as  comfortable  as  possible,  and  following  out  certain  general  principles  such 
as  guide  us  in  the  care  of  fever  patients.  Cantlie  recommends  purgation  and 
stimulation  from  the  outset,  and  the  use  of  morphia  for  the  pain.  The  local 
treatment  of  the  buboes  is  important.  Ice  may  be  applied  to  them,  and 
good  results  apparently  follow  the  injection  of  the  bichloride  of  mercury. 
The  pyrexia  of  the  disease  is  best  treated  by  systematic  hydrotherapy. 

A  plague  serum,  chiefly  the  Lustig  and  the  Yersin-Eouse,  has  been  used. 
Choksy  concludes  that  a  reduction  of  20-25  per  cent,  in  the  mortality  may  be 
obtained  by  its  use. 


142  SPECIFIC    INFECTIOUS    DISEASES 

Preventive  Inoculation. — With  Haffkine's  serum  in  12  districts,  of 
224,228  persons  inoculated,  3,399  took  the  disease;  of  639,600  uninoculated, 
49,430  were  attacked.  C.  J.  Martin  concludes  that  the  chances  of  subsequent 
infection  are  reduced  four-fifths,  and  the  chances  of  recovery  are  two  and  a 
half  times  as  great  as  in  the  case  of  the  uninoculated.  The  recent  reports  from 
India  are  most  favorable  and  in  South  America  the  value  of  this  plan  has  been 
amply  demonstrated.  It  is  interesting  to  note  that  the  laboratory  staff  at 
Bombay,  116  in  number,  have  remained  immune  though'  in  constant  contact 
with  plague  infested  rats. 

XV.    TETANUS 

(Lockjaw) 

Definition. — An  infectious  malady  characterized  by  tonic  spasms  of  the 
muscles  with  marked  exacerbations.  The  virus  is  produced  by  a  bacillus, 
B.  tetani  of  Nicolaier,  which  occurs  in  earth,  in  putrefying  fluids,  and  man- 
ure, and  is  a  normal  inhabitant  of  the  intestines  of  many  ruminants. 

Etiology. — In  the  United  States,  according  to  Anders  and  Morgan,  it  is 
most  frequent  in  the  Hudson  valley,  in  Long  Island  and  in  the  Atlantic 
States.  In  1909  there  were  1,373  deaths  from  tetanus  among  732,528  deaths 
in  eighteen  states;  of  which  30.7  per  cent,  were  in  children  under  one  year. 
An  extraordinary  number  of  cases  have  followed  the  accidents  of  the  July 
4th  celebrations,  but  the  propaganda  of  the  Journal  of  the  American  Medical 
Association  has  succeeded  in  reducing  these  fatalities  in  a  remarkable  way. 

In  England  the  disease  is  not  very  common,  but  has  increased  of  late 
years.  There  were  only  2,124  deaths  in  the  twenty  year  period  ending  1908. 
It  is  more  prevalent  in  certain  districts,  e.  g.  the  Thames  valley.  It  is  more 
frequent  in  the  Radcliffe  Infirmary,  Oxford,  than  in  any  hospital  with  which 
I  have  been  connected.  It  is  more  common  in  the  summer  months  and  males 
.are  more  frequently  attacked  than  females.  In  E.  W.  Hill's  analysis  of 
3,038  cases  in  temperate  climates  22.31  per  cent,  were  in  children  under  one 
year,  21  per  cent,  in  the  third  and  fourth  decades. 

In  the  tropics  tetanus  is  a  much  more  severe  and  common  disease.  In 
Jamaica  and  Cuba  it  is  from  five  to  six  times  more  frequent  as  a  cause  of 
death  than  in  the  United  States,  and  above  80  per  cent,  of  the  deaths  are  in 
infants.  In  the  Canal  Zone  the  disease  has  not  been  common,  only  25  cases 
have  been  admitted  to  the  Ancon  and  Colon  Hospital  (E.  W.  Hill)  to  1910. 
It  is  not  only  in  the  tropics  that  tetanus  is  a  very  fatal  disease  in  infants.  On 
an  island  near  Iceland  all  the  children  born  died;  and  for  years  the  island  of 
St.  Kilda,  one  of  the  Western  Hebrides,  had  been  scourged  by  the  "eight  days 
sickness"  among  the  new  born.  Of  125  children,  84  died  within  fourteen 
days  of  birth.  Since  the  discovery  of  the  bacillus  and  the  introduction  of 
proper  methods  of  treating  the  umbilical  cord  the  disease  has  practically  dis- 
appeared. 

The  tetanus  bacillus  has  contaminated  vaccines,  and  its  presence  in  com- 
mercial gelatine  is  a  grave  danger.  Owing  to  the  careless  preparation  of  the 
virus  many  cases  of  tetanus  occurred  in  the  neighborhood  of  Philadelphia  in 
1901  among  vaccinated  children.  In  1902  nineteen  persons  who  had  been 


TETANUS  143 

inoculated  against  the  plague  in  the  village  of  Mulkowal  died  of  tetanus 
owing  to  accidental  contamination  of  the  cultures.  Outbreaks  have  occurred 
in  general  hospitals  following  the  use  of  catgut.  The  disease  has  occurred 
after  prolonged  use  of  the  hypodermic  needle  to  inject  morphia  or  quinine,  and 
it  has  followed  the  use  of  gelatine  as  a  haemostatic. 

The  disease  usually  follows  an  injury,  often  of  a  most  trifling  charac- 
ter, and  particularly  lacerated  wounds  of  the  hands  which  have  heen  con- 
taminated by  dirt  and  splinters.  It  may  occur  without  any  recognizable 
wound,  so-called  idiopathic  tetanus. 

THE  TETANUS  BACILLUS, — The  organism  is  widely  diffused  in  nature,  in 
garden  mould,  in  and  about  stables  and  farmyards,  and  is  a  normal  inhabi- 
tant of  the  intestines  of  many  horses  and  of  the  herbivora.  The  disease  has 
been  produced  by  inoculating  animals  with  garden  earth.  Living  bacilli  occur 
in  the  intestines  of  5  per  cent,  of  healthy  men  and  up  to  20  per  cent,  of  ostlers 
and  dairymen.  It  is  a  slender  motile  bacillus,  one  end  Of  which  is  swollen  and 
occupied  by  a  spore.  It  is  anaerobic  and  grows  at  ordinary  temperatures.  The 
spores  are  the  most  resistant  known.  From  two  steel  nibs  dipped  in  a  tetanus 
culture  in  1891  a  growth  of  virulent  bacilli  was  obtained  from  one  in  1902 
and  from  the  other  in  1909  (Semple).  The  toxin  is  perhaps  the  most  virulent 
of  known  poisons.  Whereas  the  fatal  dose  of  strychnine  for  a  man  weighing 
70  kilos  is  from  30  to  100  milligrammes,  that  of  the  tetanus  toxin  is  esti- 
mated at  0.23  milligramme.  Every  feature  of  the  disease  can  be  produced 
by  it  experimentally  without  the  presence  of  the  bacilli.  The  symptoms  do 
not  arise  immediately,  as  in  the  case  of  ordinary  poisons,  but  slowly,  and  it 
has  been  found  to  be  absorbed  by  the  end  plates  in  the  muscles  and  to  pass  up 
the  motor  nerves  to  the  spinal  cord.  What  we  speak  of  as  the  period  of 
incubation  is  the  time  required  for  the  toxins  to  travel  along  the  nerves 
to  the  centres.  A  high  degree  of  antitoxic  immunity  can  be  conferred  on 
animals,  which  then  yield  a  protective  serum.  It  is,  however,  difficult  to 
cure  animals  with  this  serum  on  account  of  the  combination  of  the  toxin 
with  nerve-cells  by  the  time  symptoms  appear. 

Morbid  Anatomy. — ]STo  characteristic  lesions  have  been  found  in  the  cord 
or  in  the  brain.  Congestions  occur  in  different  parts,  and  perivascular  exu- 
dations and  granular  changes  in  the  nerve-cells  have  been  found.  The  con- 
dition of  the  wound  is  variable.  The  nerves  are  often  found  injured,  red- 
dened, and  swollen.  In  tetanus  neonatorum  the  umbilicus  may  be  inflamed. 

Symptoms. — The  incubation  period  is  from  one  to  twenty  days.  Of  1,092 
cases  analyzed  by  E.  W.  Hill,  in  17.49  per  cent,  it  was  from  one  to  five  days 
and  in  55.06  per  cent,  from  five  to  ten  days.  In  only  8  cases  was  the  incu- 
bation as  long  as  twenty  days.  The  patient  complains  at  first  of  slight  stiff- 
ness in  the  neck,  or  a  feeling  of  tightness  in  the  jaws,  or  difficulty  in  mas- 
tication. Occasionally  chilly  feelings  or  actual  rigors  may  precede  these 
symptoms.  Gradually  a  tonic  spasm  of  the  muscles  of  these  parts  produces 
the  condition  of  trismus  or  lockjaw.  The  eyebrows  may  be  raised  and  the 
angles  of  the  mouth  drawn  out,  causing  the  so-called  sardonic  grin — risus 
sardonicus.  In  children  the  spasm  may  be  confined  to  these  parts.  Some- 
times the  attack  is  associated  with  paralysis  of  the  facial  muscles  and  diffi- 
culty in  swallowing — the  head-tetanus  of  Eose,  which  has  most  commonly 
followed  injuries  in  the  neighborhood  of  the  fifth  nerve.  Gradually  the  proc- 


144  SPECIFIC    INFECTIOUS   DISEASES 

ess  extends  and  involves  the  muscles  of  the  body.  Those  of  the  back  are 
most  affected,  so  that  during  the  spasm  the  unfortunate  victim  may  rest  upon 
the  head  and  heels — a  position  known  as  opislhotonos.  The  rectus  abdom- 
inis  muscle  has  been  torn  across  in  the  spasm.  The  entire  trunk  and  limbs 
may  be  perfectly  rigid — orthotonos.  Flexion  to  one  side  is  less  common — 
pleurotkotonos ;  while  spasm  of  the  muscles  of  the  abdomen  may  cause  the 
body  to  be  bent  forward — emprostkotonos.  In  very  violent  attacks  the  thorax 
is  compressed,  the  respirations  are  rapid,  and  spasm  of  the  glottis  may  occur, 
causing  asphyxia.  The  paroxysms  last  for  a  variable  period,  but  even  in  the 
intervals  the  relaxation  is  not  complete.  The  slightest  irritation  is  sufficient 
to  cause  a  spasm.  The  paroxysms  are  associated  with  agonizing  pain,  and 
the  patient  may  be  held  as  in  a  vise,  unable  to  utter  a  word.  Usually  he  is 
bathed  in  a  profuse  sweat.  The  temperature  may  remain  normal  throughout, 
or  show  only  a  slight  elevation  toward  the  close.  In  other  cases  the  pyrexia  is 
marked  from  the  outset;  the  temperature  reaches  105°  or  106°  F.,  and  before 
death  109°  or  110°  F.  In  rare  instances  it  may  go  still  higher.  The  course 
is  sometimes  very  rapid,  with  fever  and  general  spasms ;  death  may  take  place 
on  the  third  day.  Death  either  occurs  during  the  paroxysm  from  heart- 
failure  or  asphyxia,  or  is  due  to  exhaustion. 

The  cephalic  tetanus  (Kopftetanus  of  Eose)  originates  usually  from  a 
wound  of  the  head,  and  is  characterized  by  stiffness  of  the  muscles  of  the 
jaw  and  paralysis  of  the  facial  muscles  on  the  same  side  as  the  wound,  with 
difficulty  in  swallowing.  There  may  be  no  other  symptoms.  This  form  has 
been  called  hydrophobic  because  of  the  spasm  of  the  throat.  The  prognosis 
is  good  in  the  chronic  cases ;  of  those  in  Willard's  table  only  8  of  32  died ;  but 
in  the  acute  form,  of  45  cases,  only  4  recovered. 

Tetanus  neonatorum. — This  is  a  very  common  form,  particularly  in  hot 
climates  and  in  districts  where  the  tetanus  bacillus  is  very  prevalent,  as  in 
the  island  of  St.  Kilda.  The  infection  follows  imperfect  treatment  of  the 
navel.  The  symptoms  may  come  on  in  a  few  days  or  be  delayed  for  ten 
days.  Trismus  and  difficulty  in  crying  and  taking  food  are  the  earliest 
symptoms,  followed  in  a  few  days  by  more  general  spasms.  It  is  a  very  fatal 
form.  A  form  known  as  visceral  tetanus  is  described  by  the  French  in 
which  the  disease  originates  in  the  intestines,  and  the  possibility  of  this  must 
be  considered,  as  the  spores  have  been  found  in  human  faces.  Post-operative 
tetanus  occurs  particularly  after  peritoneal  operations.  Paterson  collected 
150  cases  in  a  large  proportion  of  which  catgut  had  been  used.  It  is  a  very 
fatal  form,  with  a  short  incubation  and  rapid  course. 

Diagnosis. — Well-marked  cases  following  a  trauma  could  not  be  mistaken 
for  any  other  disease.  The  spasms  are  not  unlike  those  of  strychnia-poison- 
ing, and  in  the  celebrated  Palmer  murder  trial  this  was  the  plea  for  the 
defence.  The  jaw-muscles,  however,  are  never  involved  early,  if  at  all,  and 
between  the  paroxysms  in  strychnia-poisoning  there  is  no  rigidity.  In 
tetany  the  distribution  of  the  spasm  at  the  extremities,  the  peculiar  position, 
the  greater  involvement  of  the  hands,  and  the  condition  under  which  it 
occurs  are  sufficient  to  make  the  diagnosis  clear.  In  doubtful  cases  cultures 
should  be  made  from  the  pus  of  the  wound. 

Escherich  has  described  in  children  a  form  of  generalized  tonic  contrac- 
tures  of  the  muscles  of  the  jaw,  neck,  back,  and  limbs,  usually  a  sequel  of 


TETANUS  145 

some  acute  infection,  occasionally  occurring  as  an  independent  malady.  The 
contractures  may  be  either  intermittent  or  persistent.  The  condition  may 
last  from  a  week  to  a  couple  of  months.  .  The  cases  as  a  rule  recover. 

Prognosis. — Two  of  the  Hippocratic  aphorisms  express  tersely  the  general 
prognosis  even  at  the  present  day:  "The  spasm  supervening  on  a  wound  is 
fatal,"  and  "such  persons  as  are  seized  with  tetanus  die  within  four  days, 
or  if  they  pass  these  they  recover."  Of  1,264  cases  analyzed  by  E.  W.  Hill 
only  414  recovered.  If  the  disease  lasts  beyond  the  tenth  day  the  patient 
has  an  even  chance,  and  from  this  time  the  prognosis  improves. 

The  mortality  is  greatest  in  children.  Favorable  indications  are:  late 
onset  of  the  attack,  localization  of  the  spasms  to  the  muscles  of  the  neck  and 
jaw,  and  an  absence  of  fever. 

Prophylaxis. — Suspicious  wounds  should  be  freely  opened,  thoroughly  dis- 
infected by  hydrogen  peroxide  and  cauterized  with  pure  carbolic  acid.  In 
districts  where  the  disease  prevails,  as  in  the  Thames  valley,  special  precau- 
tions should  be  taken  with  all  injuries,  and  a  propliylactic  dose  of  anti- 
tetanic  serum  (500  to  1,000  units)  administered.  The  experience  in  the 
United  States  with  this  treatment  in  the  Fourth  of  July  accidents  has 
been  most  satisfactory.  It  should  be  carried  out  promptly  in  all  street  and 
infected  injuries.  As  the  serum  is  expensive,  Boards  of  Health  should  ar- 
range, if  necessary,  to  provide  it. 

Treatment. — The  patient  should  be  kept  in  a  darkened  room,  absolutely 
quiet,  and  attended  by  only  one  person.  All  possible  sources  of  irritation 
should  be  avoided.  Veterinarians  appreciate  the  importance  of  this  com- 
plete seclusion  in  treating  horses. 

When  the  lockjaw  is  extreme  the  patient  may  not  be  able  to  take  food  by 
the  mouth,  under  which  circumstances  it  is  best  to  use  rectal  injections,  or 
to  feed  by  a  catheter  passed  through  the  nose.  The  spasm  should  be  con- 
trolled by  chloroform,  which  may  be  repeatedly  exhibited  at  intervals.  It  is 
more  satisfactory  to  keep  the  patient  thoroughly  under  the  influence  of  mor- 
phia given  hypodermically.  Chloral  hydrate,  chloretone,  bromide  of  potas- 
sium, Calabar  bean,  curare,  Indian  hemp,  belladonna,  and  other  drugs  have 
been  recommended,  and  recovery  occasionally  follows  their  use.  Intraspinal 
injections  of  a  solution  of  magnesium  sulphate  (25  per  cent.)  have  been  used 
(Meltzer)  ;  1  c.  c.  is  injected  for  every  25  pounds  weight  of  the  patient.  Ee- 
section  of  the  nerve  and  amputation  of  the  limb  have  been  advised.  Although 
tetanus  antitoxin  of  great  strength  can  be  obtained,  its  use  in  the  treatment 
of  human  tetanus  very  often  fails  because  it  is  given  too  late.  Given  at  once 
and  in  sufficient  doses,  it  should  prove  a  specific.  It  may  be  given  in  various 
ways.  The  administration  of  3,000  to  5,000  units  intraspinally  (repeated  in 
24  hours)  and  10,000  units  intravenously  and  10,000  units  subcutaneously 
three  or  four  days  later  has  given  good  results  (Nicoll).  The  best  results 
are  obtained  in  subacute  cases,  but  here  the  prognosis  is  relatively  favorable. 


146  SPECIFIC   INFECTIOUS   DISEASES 

XVI.     GLANDERS 

(Farcy) 

Definition, — An  infectious  disease  of  the  horse  and  ass,  caused  by  Bacillus 
mallei,  communicated  occasionally  to  man.  In  the  horse  it  is  characterized 
by  the  formation  of  nodules,  chiefly  in  the  nares  (glanders)  and  beneath  the 
skin  (farcy). 

Etiology. — The  disease  belongs  to  the  infective  granulomata.  The  local 
manifestations  in  the  nostrils  and  the  skin  of  the  horse  are  due  to  one  and 
the  same  cause.  The  specific  germ  was  discovered  by  Loeffler  and  Schutz. 
It  is  a  short,  non-motile  bacillus,  not  unlike  that  of  tubercle,  but  exhibits  dif- 
ferent staining  reactions.  It  grows  readily  on  the.  ordinary  culture  media. 
For  the  full  recognition  of  glanders  in  man  we  are  indebted  to  the  labors  of 
Eayer,  whose  monograph  remains  one  of  the  best  descriptions  ever  given  of 
the  disease.  Man  becomes  infected  by  contact  with  diseased  animals,  and 
usually  by  inoculation  on  an  abraded  surface  of  the  skin.  The  contagion  may 
also  be  received  on  the  mucous  membrane.  In  a  Montreal  case  a  gentleman 
was  probably  infected  by  the  material  expelled  from  the  nostril  of  his  horse, 
which  was  not  suspected  of  having  the  disease.  It  is  a  rare  disease.  Only  4 
deaths  were  registered  from  this  cause  in  England  and  Wales  in  1909.  Among 
laboratory  workers  the  Bacillus  mallei  has  caused  more  deaths  than  any  other 
germ,  and  in  working  with  it  the  greatest  possible  precautions  should  be 
taken. 

Morbid  Anatomy. — As  in  the  horse,  the  disease  may  be  localized  in  the 
nose  (glanders)  or  beneath  the  skin  (farcy).  The  essential  lesion  is  the 
granulomatous  tumor,  characterized  by  the  presence  of  numerous  lymphoid 
and  epithelioid  cells,  among  and  in  which  are  seen  the  glanders  bacilli.  These 
nodular  masses  tend  to  break  down  rapidly,  and  on  the  mucous  membrane 
result  in  ulcers,  while  beneath  the  skin  they  form'  abscesses.  The  glanders 
nodules  may  also  occur  in  the  internal  organs. 

Symptoms. — An  acute  and  a  chronic  form  of  glanders  may  be  recognized 
in  man,  and  an  acute  and  a  chronic  form  of  farcy. 

ACUTE  GLANDERS. — The  period  of  incubation  is  rarely  more  than  three  or 
four  days.  There  are  signs  of  general  febrile  disturbance.  At  the  site  of 
infection  there  are  swelling,  redness,  and  lymphangitis.  Within  two  or  three 
days  there  is  involvement  of  the  mucous  membrane  of  the  nose,  the  nodules 
break  down  rapidly  to  ulcers,  and  there  is  a  muco-purulent  discharge.  An 
eruption  of  papules,  which  Tapidly  become  pustules,  breaks  out  over  the  face 
and  about  the  joints.  It  has  been  mistaken  for  variola.  In  a  Montreal  case 
this  copious  eruption  led  the  attending  physician  to  suspect  smallpox,  and 
the  patient  was  isolated.  There  is  a  great  swelling  of  the  nose.  The  ulcer- 
ation  may  go  on  to  necrosis,  in  which  case  the  discharge  is  very  offensive. 
The  lymph  glands  of  the  neck  are  usually  much  enlarged.  Suhacute  pneu- 
monia is  very  apt  to  occur.  This  form  runs  its  course  in  about  eight  or  ten 
days,  and  is  invariably  fatal.  Glanders  pneumonia  may  appear  after  sub- 
cutaneous infection  (one  case  from  infection  with  a  hypodermic  syringe  stuck 
into  the  thumb) .  Grossly  the  lung  appeared  like  a  caseous  pneumonia. 


GLANDERS  147 

CHRONIC  GLANDERS  is  rare  and  difficult  to  diagnose,  as  it  is  usually  mis- 
taken for  a  chronic  coryza.  There  are  ulcers  in  the  nose,  and  often  laryn- 
geal  symptoms.  It  may  last  for  months,  or  even  longer,  and  recovery  some- 
times takes  place.  Tedeschi  has  described  a  case  of  chronic  osteomyelitis,  due 
to  the  Bacillus  mallei,  which  was  followed  by  a  fatal  glanders  meningitis. 
The  diagnosis  may  be  extremely  difficult.  In  such  cases  a  suspension  of  the 
secretion,  or  of  cultures  upon  agar-agar  made  from  the  secretion,  should  be 
injected  into  the  peritoneal  cavity  of  a  male  guinea-pig.  At  the  end  of  two 
days,  in  positive  cases,  the  testicles  are  found  to  be  swollen  and  the  skin  of 
the  scrotum  reddened.  The  testicles  continue  to  increase  in  size,  and  finally 
suppurate.  Death  takes  place  after  the  lapse  of  two  or  three  weeks,  and  gen- 
eralized glanders  nodules  are  found  in  the  viscera.  The  use  of  mallein  for 
diagnostic  purposes  is  highly  recommended.  The  principles  and  methods  of 
application  are  the  same  as  for  tuberculin.  McFadyean  and  others  have 
shown  that,  while  the  glanders  bacilli  are  agglutinated  in  a  dilution  of  1  to 
200  by  normal  horse  serum,  that  of  a  glanders  horse  will  agglutinate  at  1 
to  1,000.  The  test  must  be  made  before  mallein  is  given. 

ACUTE  FARCY  in  man  results  usually  from  the  inoculation  of  the  virus 
into  the  skin.  There  is  an  intense  local  reaction  with  a  phlegmonous  inflam- 
mation. The  lymphatics  are  early  affected,  and  along  their  course  there  are 
nodular  subcutaneous  enlargements,  the  so-called  farcy  buds,  which  may 
rapidly  go  on  to  suppuration.  There  are  pains  and  swelling  in  the  joints, 
•and  abscesses  may  form  in  the  muscles.  The  symptoms  are  those  of  an  acute 
infection,  almost  like  an  acute  septicaemia.  The  nose  is  not  involved  and 
the  superficial  skin  eruption  is  not  common.  The  bacilli  have  been  found  in 
the  urine  in  acute  cases  in  man  and  animals. 

The  disease  is  fatal  in  a  large  proportion  of  the  cases,  usually  in  from 
twelve  to  fifteen  days. 

CHRONIC  FARCY  is  characterized  by  the  presence  of  localized  tumors  which 
break  down  into  abscesses,  and  sometimes  form  deep  ulcers,  without  much 
inflammatory  reaction  and  without  special  involvement  of  the  lymphatics. 
The  disease  may  last  for  months  or  even  years.  Death  may  result  from 
pyasmia,  or  occasionally  acute  glanders  develops.  The  celebrated  French 
veterinarian  Bouley  had  it  and  recovered. 

The  disease  is  transmissible  also  from  man  to  man.  Washerwomen  have 
been  infected  from  the  clothes  of  a  patient.  In  the  diagnosis  of  this  affec- 
tion the  occupation  is  very  important.  Nowadays,  in  cases  of  doubt  the 
inoculation  should  be  made  in  animals,  as  in  this  way  the  disease  can  be 
readily  determined.  Mallein,  a  product  of  the  growth  of  the  bacilli,  is  now 
used  for  the  purpose  of  diagnosing  glanders  in  animals.  Several  instances 
of  cured  glanders  have  been  reported  in  animals  treated  with  small  and 
repeated  doses  of  mallein  (Pilavios,  Babes). 

Treatment. — If  seen  early,  the  wound  should  be  either  cut  out  or  thor- 
oughly destroyed  by  caustics  and  an  antiseptic  dressing  applied.  The  farcy 
buds  should  be  ear1}7  opened.  In  the  acute  cases  there  is  very  little  hope.  In 
the  chronic  cases  recovery  is  possible,  though  often  tedious. 


148  SPECIFIC    INFECTIOUS   DISEASES 

XVII.    ANTHRAX 

(Splenic  Fever;  Charbon;  Wool-sorter's  Disease) 

Definition. — An  acute  infectious  disease  caused  by  Bacillus  anthracis, 
occurring  in  three  forms,  cutaneous  (malignant  pustule),  pulmonary,  and 
intestinal.  In  animals,  particularly  in  sheep  and  cattle,  the  disease  has  the 
character  of  an  acute  septicaemia  with  enlargement  of  the  spleen — hence 
the  name  splenic  fever.  In  man  it  occurs  sporadically  or  as  a  result  of  acci- 
dental inoculations  with  the  virus. 

Etiology. — The  infectious  agent  is  a  non-motile,  rod-shaped  organism,  Ba- 
cillus anthracis,  which  has,  by  the  researches  of  Pollender,  Davaine,  Koch, 
and  Pasteur,  become  the  best  known  perhaps  of  all  pathogenic  microbes.  The 
bacillus  has  a  length  of  from  2  to  25  /«.;  the  rods  are  often  united.  The  bacilli 
themselves  are  readily  destroyed,  but  the  spores  are  very  resistant,  and  sur- 
vive after  prolonged  immersion  in  a  5-per-cent.  solution  of  carbolic  acid,  or 
withstand  for  some  minutes  a  temperature  of  212°  F.  They  are  capable 
also  of  resisting  gastric  digestion.  Outside  the  body  the  spores  are  in  all 
probability  very  durable. 

IN  ANIMALS. — Geographically  and  zoologically  the  disease  is  the  most 
widespread  of  all  infections.  It  is  much  more  prevalent  in  Europe  and  in 
Asia  than  in  America.  Its  ravages  among  the  herds  of  cattle  in  Eussia  and 
Siberia,  and  among  sheep  in  certain  parts  of  Europe,  are  not  equalled  by  any 
other  animal  plague.  In  the  United  States  anthrax  is  not  very  widespread. 
In  France  from  6  to  10  per  cent,  of  the  sheep  and  about  5  per  cent,  of  the  cat- 
tle formerly  died  of  it. 

The  disease  is  conveyed  sometimes  by  direct  inoculation,  as  by  the  bites 
and  stings  of  insects,  by  feeding  on  carcasses  of  animals  which  have  died  of 
the  disease,  but  more  commonly  by  grazing  in  pastures  contaminated  by  the 
germs.  Pasteur  thought  that  the  earthworm  played  an  important  part  in 
bringing  to  the  surface  and  distributing  the  bacilli  which  had  been  propa- 
gated in  the  buried  carcass  of  an  infected  animal.  Certain  fields,  or  even 
farms,  may  thus  be  infected  for  an  indefinite  period  of  time.  It  seems  prob- 
able, however,  that,  if  the  carcass  is  not  opened  or  the  blood  spilt,  spores 
are  not  formed  in  the  buried  animal  and  the  bacilli  quickly  die. 

IN  MAN  the  disease  does  not  occur  spontaneously.  It  results  always 
from  infection,  either  through  the  skin  or  intestines,  or  in  rare  instances 
through  the  lungs.  Workers  in  wool  and  hair,  and  persons  whose  occupa- 
tions bring  them  into  contact  with  animals  or  animal  products,  as  stable- 
men, shepherds,  tanners,  and  butchers,  are  specially  liable  to  the  disease.  In 
the  United  States  the  disease  is  usually  found  in  the  workers  in  hides,  in 
butchers,  and  in  veterinarians.  It  is  rare  in  general  hospital  work.  There 
was  only  one  case  in  sixteen  years  at  the  Johns  Hopkins  Hospital.  In  Eng- 
land and  Wales  in  1909  there  were  15  deaths  from  this  cause  in  man. 
Ponder  states  that  40  per  cent,  of  all  the  cases  of  anthrax  in  British  leather 
workers  are  due  to  handling  Chinese  or  East  Indian  goods;  80  per  cent,  of 
the  cases  are  malignant  pustule  from  skin  infection  while  handling  hides  at 
the  docks  or  in  the  tanneries. 


ANTHRAX  149 

Various  forms  of  the  disease  have  been  described,  and  two  chief  groups 
may  be  recognized:  the  external  anthrax  and  the  internal  anthrax,  of  which 
there  are  pulmonary  and  intestinal  forms. 

Symptoms. —  (a)  EXTERNAL  ANTHRAX. —  (1)  Malignant  Pustule. — At  the 
site  of  inoculation,  usually  on  an  exposed  surface — the  hands,  arms,  or  face — 
there  are,  within  a  few  hours,  itching  and  uneasiness,  and  the  gradual  forma- 
tion of  a  small  papule,  which  soon  becomes  vesicular.  Inflammatory  indura- 
tion extends  around  this,  and  within  thirty-six  hours  at  the  site  of  inocula- 
tion there  is  a  dark  brownish  eschar,  at  a  little  distance  from  which  there 
may  be  a  series  of  small  vesicles.  The  brawny  induration  may  be  extreme. 
The  cedema  produces  very  great  swelling  of  the  parts.  The  inflammation 
extends  along  the  lymphatics,  and  the  neighboring  lymph-glands  are  swollen 
and  sore.  The  fever  at  first  rises  rapidly,  and  the  concomitant  phenomena 
are  marked.  Subsequently  the  temperature  falls,  and  in  many  cases  becomes 
subnormal.  Death  may  take  place  in  from  three  to  five  days.  In  cases  which 
recover  the  constitutional  symptoms  are  slighter,  the  eschar  gradually  sloughs 
out,  and  the  wound  heals.  The  cases  vary  much  in  severity.  In  the  mildest 
form  there  may  be  only  slight  swelling.  At  the  site  of  inoculation  a  papule 
is  formed,  which  rapidly  becomes  vesicular  and  dries  into  a  scab,  which 
separates  in  the  course  of  a  few  days. 

(2)  Malignant  Anthrax  (Edema. — This  form  occurs  in  the  eyelid,  and 
also  in  the  head,  hand,  and  arm,  and  is  characterized  by  the  absence  of  the 
papule  and  vesicle  forms,  and  by  the  most  extensive  oedema,  which  may  follow 
rather  than  precede  the  constitutional  symptoms.  The  cedema  reaches  such  a 
grade  of  intensity  that  gangrene  results,  and  may  involve  a  considerable  sur- 
face. The  constitutional  symptoms  then  become  extremely  grave,  and  the 
cases  invariably  prove  fatal. 

The  greatest  fatality  is  seen  in  cases  of  inoculation  about  the  head  and 
face,  where  the  mortality,  according  to  Nasarow,  is  26  per  cent.;  the  least  in 
infection  of  the  lower  extremities,  where  it  is  5  per  cent. 

In  a  case  at  the  Johns  Hopkins  Hospital  in  1895,  in  a  hair-picker,  there 
were  most  extensive  enteritis,  peritonitis,  and  endocarditis,  which  last  lesion 
has  been  described  by  Eppinger. 

A  feature  in  both  these  forms  of  malignant  pustule,  to  which  many  writers 
refer,  is  the  absence  of  feeling  of  distress  or  anxiety  on  the  part  of  the  pa- 
tient, whose  mental  condition  may  be  perfectly  clear.  He  may  be  without 
any  apprehension,  even  though  the  condition  be  most  critical. 

The  diagnosis  in  most  instances  is  readily  made  from  the  character  of  the 
lesion  and  the  occupation  of  the  patient.  When  in  doubt,  the  examination 
of  the  fluid  from  the  pustule  may  show  the  presence  of  the  anthrax  bacilli. 
Cultures  should  be  made,  or  a  mouse  or  guinea-pig  inoculated  from  the  local 
lesion.  It  is  to  be  remembered  that  the  blood  may  not  show  the  bacilli  in 
numbers  until  shortly  before  death. 

(6)    INTERNAL  ANTHRAX. 

(1)  Intestinal  Form,  Mycosis  Intestinalis. — In  these  cases  the  infection 
usually  is  through  the  stomach  and  intestines,  and  results  from  eating  the 
flesh  or  drinking  the  milk  of  diseased  animals ;  it  may,  however,  follow  an 
external  infection  if  the  germs  are  carried  to  the  mouth.  The  symptoms 
are  those  of  intense  poisoning.  The  disease  may  set  in  with  a  chill,,  followed 


150 

by  vomiting,  diarrhoea,  moderate  fever,  and  pains  in  the  legs  and  back.  In 
acute  cases  there  are  dyspncea,  cyanosis,  great  anxiety  and  restlessness,  and 
toward  the  end  convulsions  or  spasms  of  the  muscles.  Hemorrhage  may 
occur  from  the  mucous  membranes.  Occasionally  there  are  on  the  skin  small 
phlegmonous  areas  or  petechiae.  The 'spleen  is  enlarged.  The  blood  is  dark 
and  remains  fluid  for  a  long  time  after  death.  Late  in  the  disease  the  bacilli 
•may  be  found  in  the  blood. 

This  is  one  of  the  forms  of  acute  poisoning  which  may  affect  many  indi- 
viduals together.  Thus,  Butler  and  Karl  Huber  describe  an  epidemic  in 
which  twenty-five  persons  were  attacked  after  eating  the  flesh  of  an  animal 
which  had  had  anthrax.  Six  died  in  from  forty-eight  hours  to  seven 
days. 

(2)  Wool-sorter's  Disease,  Pulmonary  Anthrax,  Anthrac&mia. — This  im- 
portant form  occurs  in  the  large  establishments  in  which  wool  or  hair  is 
sorted  and  cleansed.  The  hair  and  wool  imported  into  Europe  from  Eussia 
and  South  America  appear  to  have  induced  the  largest  number  of  cases. 
Many  of  these  show  no  external  lesion.  The  infective  material  has  been  swal- 
lowed or  inhaled  with  the  dust.  There  are  rarely  premonitory  symptoms. 
The  patient  is  seized  with  a  chill,  becomes  faint  and  prostrated,  has  pains 
in  the  back  and  legs,  and  the  temperature  rises  to  102°  or  103°.  The  breath- 
ing is  rapid,  and  he  complains  of  much  pain  in  the  chest.  There  may  be  a 
cough  and  signs  of  bronchitis.  So  prominent  in  some  instances  are  these 
bronchial  symptoms  that  a  pulmonary  form  of  the  disease  has  been  described. 
The  pulse  is  feeble  and  very  rapid.  There  may  be  vomiting,  and  death  may 
occur  within  twenty-four  hours  with  symptoms  of  profound  collapse  and 
prostration.  Other  cases  are  more  protracted,  and  there  may  be  diarrhoea, 
delirium,  and  unconsciousness.  The  cerebral  symptoms  may  be  most  intense ; 
in  at  least  four  cases  the  brain  seems  to  have  been  chiefly  affected,  and  its 
capillaries  stuffed  with  bacilli  (Merkel).  The  recognition  of  wool-sorter's 
disease  as  a  form  of  anthrax  is  due  to  J.  H.  Bell,  of  Bradford. 

In  certain  instances  these  profound  constitutional  symptoms  of  internal 
anthrax  are  associated  with  the  external  lesions  of  malignant  pustule. 

The  rag-picker's  disease  has  been  made  the  subject  of  an  exhaustive  study 
by  Eppinger  (Die  Hadernkrankheit,  Jena,  1894),  who  has  shown  that  it  is 
a  local  anthrax  of  the  lungs  and  pleura,  with  general  infection. 

Prophylaxis. — This  is  important,  and  should  be  carried  out  by  a  most  rigid 
disinfection  of  the  hides,  hair,  and  rags  before  they  are  placed  in  the  hands 
of  the  workmen.  It  is  suggested  to  soak  the  hides  for  .24  hours  in  a  solution 
of  1  per  cent,  formic  acid  and  0.02  per  cent,  of  mercuric  perchloride.  Animals 
may  be  immunized  against  the  disease  and  Pasteur's  method  of  vaccination 
has  been  extensively  employed  in  France  with  good  results.  The  immunity 
is  lost  within  a  year  in  nearly  50  per  cent,  of  the  animals. 

Treatment. — In  malignant  pustule  the  site  of  inoculation  should  be 
excised  and,  after  the  cautery  or  pure  carbolic  acid  is  applied,  powdered 
bichloride  of  mercury  sprinkled  over  the  exposed  surface.  The  local  develop- 
ment of  the  bacilli  about  the  site  of  inoculation  may  be  prevented  by  the 
subcutaneous  injections  of  solutions  of  carbolic  acid  (3  per  cent.)  or  bichloride 
of  mercury  (1  to  1,000).  The  injections  should  be  made  at  various  points 
around  the  pustule,  and  may  be  repeated  two  or  three  times  a  day.  The 


LEPROSY  151 

internal  treatment  should  be  confined  to  the  administration  of  stimulants  and 
plenty  of  nutritious  food. 

In  malignant  forms,  particularly  the  intestinal  cases,  little  can  be  done. 
Active  purgatives  may  be  given  at  the  outset,  so  as  to  remove  the  infecting 
material.  Quinine  in  large  doses  has  been  recommended. 

An  anti-anthrax  serum  has  been  prepared  by  Sclavo,  for  which  good 
results  are  claimed. 

XVIII.    LEPROSY 

Definition. — A  chronic  infectious  disease  caused  by  Bacillus  leprce,  charac- 
terized by  the  presence  of  tubercular  nodules  in  the  skin  and  mucous  mem- 
branes (tubercular  leprosy)  or  by  changes  in  the  nerves  (anaesthetic  leprosy). 
At  first  these  forms  may  be  separate,  but  ultimately  both  are  combined,  and 
in  the  characteristic  tubercular  form  there  are  disturbances  of  sensation. 

History. — The  disease  appears  to  have  prevailed  in  Egypt  even  so  far 
back  as  three  or  four  thousand  years  before  Christ.  The  Hebrew  writers  make 
many  references  to  it,  but,  as  is  evident  from  the  description  in  Leviticus, 
many  different  forms  of  skin  disease  were  embraced  under  the  term  leprosy. 
Both  in  India  and  in  China  the  affection  was  also  known  many  centuries 
before  the  Christian  era.  The  old  Greek  and  Roman  physicians  were  per- 
fectly familiar  with  its  manifestations.  Evidence  of  a  pre-Columbian  exist- 
ence of  leprosy  in  America  has  been  sought  in  the  old  pieces  of  Peruvian 
pottery  representing  deformities  suggestive  of  this  disease,  but  Ashmead 
denies  their  significance.  Throughout  the  middle  ages  leprosy  prevailed 
extensively  in  Europe,  and  the  number  of  leper  asylums  has  been  estimated 
as  at  least  20,000.  During  the  sixteenth  century  it  gradually  declined. 

Geographical  Distribution. — In  Europe  leprosy  prevails  in  Iceland,  Nor- 
way and  Sweden,  parts  of  Russia,  particularly  about  Dorpat,  Riga,  and  the 
Caucasus,  and  in  certain  provinces  of  Spain  and  Portugal.  In  Great  Britain 
the  cases  are  now  all  imported. 

In  the  United  States  there  were  139  cases  in  1909,  of  which  50  were  in 
Louisiana,  20  in  Florida,  16  in  Minnesota,  and  12  in  Texas.  In  the  Do- 
minion of  Canada  there  are  foci  of  leprosy  in  two  or  three  counties  of  New' 
Brunswick,  settled  by  French  Canadians,  and  in  Cape  Breton,  Nova  Scotia. 
The  disease  appears  to  have  been  imported  from  Normandy  about  the  end 
of  the  18th  century.  The  number  has  gradually  lessened,  and  now  only 
a  few  cases  remain  in  the  lazaretto  at  Tracadie. 

Leprosy  is  endemic  in  the  West  India  Islands.  It  also  occurs  in  Mexico 
and  throughout  the  Southern  States.  In  the  Sandwich  Islands  it  spread 
rapidly  after  1860,  and  strenuous  attempts  have  been  made  to  stamp  it  out 
by  segregating  all  lepers  on  the  island  of  Molokai.  In  the  Philippine  Islands, 
in  a  population  of  over  six  millions,  there  are  2,330  lepers. 

In  British  India,  according  to  the  Leprosy  Commission,  there  are  100,000 
lepers.  This  is  probably  a  low  estimate.  In  China  leprosy  prevails  exten- 
sively. In  South  Africa  it  has  increased  rapidly.  In  Australia,  New 
Zealand,  and  the  Australasian  islands  it  also  prevails,  chiefly  among  the  Chi- 
nese. The  essays  of  Ashburton  Thompson  and  James  Cantlie  deal  fully  with 
leprosy  in  China,  Australia,  and  the  Pacific  islands.  In  Egypt  the  census 
of  1907  gave  6,000  lepers. 


152  SPECIFIC   INFECTIOUS   DISEASES 

Etiology.— Bacillus  lepra,  discovered  by  Hansen,  of  Bergen,  in  1871,  is 
universally  recognized  as  the  cause  of  the  disease.  It  has  many  points  of 
resemblance  to  the  tubercle  bacillus,  but  can  be  readily  differentiated.  It  has 
been  cultivated,  but  with  difficulty,  and  is  stated  to  have  a  pleomorphism  of 
which  the  bacillus  as  seen  in  the  tissues  is  only  one  phase. 

MODES  OF  INFECTION.— (a)  Inoculation.— While  it  is  highly  probable 
that  leprosy  may  be  contracted  by  accidental  inoculation,  the  experimental 
evidence  is  as  yet  inconclusive.  With  one  possible  exception,  negative  results 
have  followed  the  attempts  to  reproduce  the  disease  in  man.  The  Hawaiian 
convict,  under  sentence  of  death,  who  was  inoculated  on  September  30,  1884, 
by  Arning,  four  weeks  later  had  rheumatoid  pains  and  gradual  painful  swell- 
ing of  the  ulnar  and  median  nerves.  The  neuritis  gradually  subsided,  but 
there  developed  a  small  lepra  tubercle  at  the  site  of  the  inoculation.  In  1887 
the  disease  was  quite  manifest,  and  the  man  died  of  it  six  years  after  inocula- 
tion. The  case  is  not  regarded  as  conclusive,  as  he  had  leprous  relatives  and 
lived  in  a  leprous  country. 

(6)  Heredity. — For  years  it  was  thought  that  the  disease  was  transmitted 
from  parent  to  child,  but  the  general  opinion,  as  expressed  in  the  recent 
Leprosy  Congress  in  Berlin,  was  decidedly  against  this  view.  Of  course,  the 
possibility  of  its  transmission  cannot  be  denied,  and  in  this  respect  leprosy 
and  tuberculosis  occupy  very  much  the  same  position,  though  men  with  very 
wide  experience  have  never  seen  a  new-born  leper.  The  youngest  cases  are 
rarely  under  three  or  four  years  of  age. 

(c)  By  Contagion. — The  bacilli  are  given  off  from  the  open  sores;  they 
are  found  in  the  saliva  and  expectoration  of  the  cases  with  leprous  lesions 
in  the  mouth  and  throat,  and  occur  in  very  large  numbers  in  the  nasal  secre- 
tion. Sticker  found  in  153  lepers,  subjects  of  both  forms  of  the  disease, 
bacilli  in  the  nasal  secretion  in  128,  and  herein,  he  thinks,  lies  the  chief 
source  of  danger.  Schaffer  was  able  to  collect  lepra  bacilli  on  clean  slides 
placed  on  tables  and  floors  near  to  lepers  whom  he  had  caused  to  read  aloud. 
The  bacilli  have  also  been  isolated  from  the  urine  and  the  milk  of  patients. 
It  seems  probable  that  they  may  enter  the  body  in  many  ways  through  the 
mucous  membranes  and  through  the  skin.  Sticker  believes  that  the  initial 
lesion  is  in  an  ulcer  above  the  cartilaginous  part  of  the  nasal  septum.  One 
of  the  most  striking  examples  of  the  contagiousness  of  leprosy  is  the  follow- 
ing: "In  1860,  a  girl  who  had  hitherto  lived  at  Holstfershof,  where  no 
leprosy  existed,  married  and  went  to  live  at  Tarwast  with  her  mother-in-law, 
who  was  a  leper.  She  remained  healthy,  but  her  three  children  (1,  2,  3) 
became  leprous,  as  also  her  younger  sister  (4),  who  came  on  a  visit  to  Tar- 
wast  and  slept  with  the  children.  The  younger  sister  developed  leprosy  after 
returning  to  Holstfershof.  At  the  latter  place  a  man  (5),  fifty-two  years  old, 
who  married  one  of  the  'younger  sister's'  children,  acquired  leprosy;  also  a 
relative  (6),  thirty-six  years  old,  a  tailor  by  occupation,  who  frequented  the 
house,  and  his  wife  (7),  who  came  from  a  place  where  no  leprosy  existed. 
The  two  men  last  mentioned  are  at  present  (1897)  inmates  of  the  leper 
asylum  at  Dorpat."  There  is  certain  evidence  to  show  that  the  disease  may 
be  spread  through  infected  clothing,  and  the  high  percentage  of  washerwomen 
among  lepers  is  also  suggestive. 

CONDITIONS  INFLUENCING  INFECTION.— The  disease  attacks  persons  of  all 


LEPEOSY  153 

ages.  We  do  not  yet  understand  all  the  conditions  necessary.  Evidently 
the  closest  and  most  intimate  contact  is  essential.  The  doctors,  nurses,  and 
Sisters  of  Charity  who  care  for  the  patients  are  very  rarely  attacked.  In  the 
lazaretto  at  Tracadie  not  one  of  the  Sisters  who  for  more  than  fifty  years 
have  so  faithfully  nursed  the  lepers  has  contracted  the  disease.  Father 
Damian,  in  the  Sandwich  Islands,  and  Father  Boblioli,  in  New  Orleans, 
both  fell  victims  in  the  discharge  of  their  priestly  duties.  There  has  long 
been  an  idea  that  possibly  the  disease  may  be  associated  with  some  special 
kind  of  food,  and  Jonathan  Hutchinson  believes  that  a  fish  diet  is  the  tertium 
quid,  which  either  renders  the  patient  susceptible  or  with  which  the  poison 
may  be  taken. 

Morbid  Anatomy. — The  leprosy  tubercles  consist  of  granulomatous  tissue 
made  up  of  cells  of  various  sizes  in  a  connective-tissue  matrix.  The  bacilli 
in  extraordinary  numbers  lie  partly  between  and  partly  in  the  cells.  The 
process  gradually  involves  the  skin,  giving  rise  to  tuberous  outgrowths  with 
intervening  areas  of  ulceration  or  cicatrization,  which  in  the  face  may  grad- 
ually produce  the  so-called  fades  leontina.  The  mucous  membranes,  partic- 
ularly the  conjunctiva,  the  cornea,  and  the  larynx,  may  gradually  be  involved. 
In  many  cases  deep  ulcers  form  which  result  in  extensive  loss  of  substance 
or  loss  of  fingers  or  toes,  the  so-called  lepra  mutilans.  In  anesthetic  leprosy 
there  is  a  peripheral  neuritis  due  to  the  development  of  the  bacilli  in  the  nerve- 
fibres.  Indeed,  this  involvement  of  the  nerves  plays  a  primary  part  in  the 
etiology  of  many  of  the  important  features,  particularly  the  trophic  changes 
in  the  skin  and  the  disturbances  of  sensation. 

Clinical  Forms. — (a)  TUBERCULAR  LEPROSY. — Prior  to  the  appearance  of 
the  nodules  there  are  areas  of  cutaneous  erythema  which  may  be  sharply 
defined  and  often  hyperaesthetic.  This  is  sometimes  known  as  macular  leprosy. 
The  affected  spots  in  time  become  pigmented.  In  some  instances  this  super- 
ficial change  continues  without  the  development  of  nodules,  the  areas  become 
anaesthetic,  the  pigment  gradually  disappears,  and  the  skin  gets  perfectly 
white — the  lepra  alba.  Among  the  patients  at  Tracadie  it  was  particularly 
interesting  to  see  three  or  four  in  this  early  stage  presenting  on  the  face  and 
forearms  a  patchy  erythema  with  slight  swelling  of  the  skin.  The  diagnosis 
of  the  condition  is  perfectly  clear,  though  it  may  be  a  long  time  before  any 
other  than  sensory  changes  develop.  The  eyelashes  and  eyebrows  and  the  hairs 
on  the  face  fall  out.  The  mucous  membranes  finally  become  involved,  partic- 
ularly of  the  mouth,  throat,  and  larynx;  the  voice  becomes  harsh  and  finally 
aphonic.  Death  results  not  infrequently  from  the  laryngeal  complications 
and  aspiration  pneumonia.  The  conjunctivas  are  frequently  attacked,  and  the 
sight  is  lost  by  a  leprous  keratitis. 

(&)  ANESTHETIC  LEPROSY. — This  remarkable  form  has,  in  characteristic 
cases,  no  external  resemblance  whatever  to  the  other  variety.  It  usually 
begins  with  pains  in  the  limbs  and  areas  of  hyperaesthesia  or  of  numbness. 
Very  early  there  may  be  trophic  changes,  seen  in  the  formation  of  small  bullae 
(Hillis).  Maculae  appear  upon  the  trunk  and  extremities,  and  after  persist- 
ing for  a  variable  time  gradually  disappear,  leaving  areas  of  anaesthesia,  but 
the  loss  of  sensation  may  come  on  independently  of  the  outbreak  of  maculae. 
The  nerve-trunks,  where  superficial,  may  be  felt  to  be  large  and  nodular.  The 
trophic  disturbances  are  usually  marked.  Pemphigus-like  bullae  develop  in 
12 


154  SPECIFIC   INFECTIOUS   DISEASES 

the  affected  areas,  which  break  and  leave  ulcers  which  may  he  very  destructive 
The  fingers  and  toes  are  liable  to  contractures  and  to  necrosis,  so  that  in 
chronic  cases  the  phalanges  are  lost.  The  course  of  anaesthetic  leprosy  is 
extraordinarily  chronic  and  may  persist  for  years  without  leading  to  much 
deformity.  I  knew  a  prominent  clergyman  who  had  anaesthetic  leprosy  for 
more  than  thirty  years,  which  did  not  seriously  interfere  with  his  usefulness, 
and  not  in  the  slightest  with  his  career. 

Diagnosis.— Even  in  the  early  stage  the  dusky  erythematous  maculae  wit: 
hyperaesthesia  or  areas  of  anaesthesia  are  very  characteristic.    In  an  advanced 
grade  neither  the  tubercular  nor  anaesthetic  forms  could  possibly  be  mistaken 
for  any  other  affection.    In  a  doubtful  case  the  microscopic  examination  of  an 
excised  nodule  is  decisive. 

Treatment.— Vaccines  have  been  prepared  and  good  results  are  claimed 
by  various  observers.  The  Finsen  light,  X-rays,  and  radium  do  good  to  the 
local  lesions.  Nastin,  a  fatty  principle  extracted  from  cultures  of  a  lepra- 
streptothrix  combined  with  benzoyl  chloride,  has  come  into  vogue  and  the 
Calcutta  report  is  favorable.  The  gurjun  and  chaulmoogra  oils  have  been  rec- 
ommended, the  former  in  doses  of  from  5  to  10  minims,  the  latter  in  2-drachm 
doses,  but  their  use  must  be  continued  for  at  least  two  years.  Calmette's  anti- 
venene,  20  to  30  c.  c.,  subcutaneously,  has  been  followed  by  remarkable  results 
in  a  few  cases.  Segregation  should  be  compulsory  in  all  cases  except  where 
the  friends  can  show  that  they  have  ample  provision  in  their  own  home  for 
the  complete  isolation  and  proper  care  of  the  patient. 


XIX.    TUBERCULOSIS 

I.    GENERAL  ETIOLOGY  AND  MORBID  ANATOMY 

Definition. — An  infection  caused  by  Bacillus  tuberculosis,  the  lesions  of 
which  are  characterized  by  nodular  bodies,  tubercles,  and  diffuse  infiltrations, 
which  either  undergo  caseation,  necrosis,  and  ulceration,  or  heal  with  sclerosis 
and  calcification. 

The  very  varied  clinical  features  depend  upon  the  organ  involved,  the 
intensity  of  the  infection,  and  the  degree  of  resistance  offered  by  the  body. 

History. — The  Greek  physicians  made  many  observations  upon  the  clinical 
features  of  pulmonary  tuberculosis,  and  our  description  of  the  symptoms 
and  of  the  consumptive  "type"  dates  from  Hippocrates.  Galen  recognized 
its  contagious  nature.  In  the  17th  century  F.  Sylvius  indicated  the  connec- 
tion between  the  tuberculous  nodule  and  phthisis,  and  Richard  Morton,  a 
friend  and  contemporary  of  Sydenham,  wrote  (1689)  the  first  modern  treatise 
on  the  subject,  in  which  the  clinical  side  of  the  disease  was  well  considered. 
He  regarded  it  as  contagious.  Pierre  Desault,  William  Stark,  and  Matthew 
Baillie  laid  the  foundation  of  our  knowledge  of  the  coarse  characters  of 
tubercle  as  the  anatomical  basis  of  consumption.  Our  real  knowledge  of  the 
disease  is  a  19th  century  contribution,  beginning  with  the  work  of  Bayle  on 
the  structure  of  the  tubercle  and  on  its  identity  in  the  widely  distributed 
lesions.  With  the  TraitS  d' Auscultation  Mediate  (1819)  Laennec  laid  the 
foundation  not  only  of  our  modern  knowledge  of  tuberculosis,  but  of  modern 


TUBEKCULOSIS  155 

clinical  medicine.  This  work  (easily  to  be  had  also  in  an  English  translation) 
should  be  read  from  cover  to  cover  by  every  young  doctor,  and,  when  possible, 
by  every  senior  student.  The  unity  of  the  forms  of  the  tubercle — the  miliary 
granule,  the  infiltration,  and  the  caseous  mass — was  recognized,  and  for  the 
first  time  physical  signs  and  anatomical  features  were  correlated,  and  the 
course  of  the  disease  carefully  studied.  Virchow  led  a  battle  against  the 
unity  of  tuberculous  lesions,  and  held  that  the  products  of  any  simple  inflam- 
mation might  become  caseous,  and  that  the  ordinary  so-called  catarrhal  pneu- 
monia might  terminate  in  phthisis. 

The  contagiousness  of  the  disease,  a  belief  in  which  had  all  along  been 
held  by  individuals,  and  was  widely  spread  in  certain  countries — as  in  Italy — 
was  emphasized  and  confirmed  by  the  brilliant  work  of  Villemin,  who  first 
placed  the  infective  nature  of  the  disease  on  a  solid  experimental  basis.  There 
is  nothing  more  masterly  in  the  literature  of  experimental  medicine  than  his 
work.  Then  came  the  demonstration  by  Kobert  Koch  (in  1882)  of  the  Bacil- 
lus tuberculosis.  The  preliminary  article  in  the  Berliner  klin.  Wochenschrift 
(1882)  and  the  more  complete  work  (Mitteilungen  a.  d.  k.  Gesundheitsamte, 
Bd.  2)  should  be  studied  by  all  who  wish  to  appreciate  the  value  of  scientific 
methods.  The  thoroughness  of  Koch's  work  is  manifested  by  the  fact  that,  in 
the  years  that  have  elapsed,  the  innumerable  workers  have  amplified  and  ex- 
tended, but  in  no  way  essentially  modified  his  original  position. 

During  the  past  thirty  years  we  have  been  gradually  getting  accommodated 
to  the  new  views,  the  most  important  single  effect  of  which  has  been  a  world- 
wide crusade  against  tuberculosis  as  a  preventable  disease. 

Distribution. — The  disease  is  widely  spread  zoologically. 

(a)  IN  ANIMALS. — Of  animals  the  cold-blooded  are  rarely  affected.  In 
birds  the  disease  is  not  uncommon,  particularly  in  fowls,  but  there  are  minor 
differences  betAveen  the  avian  and  mammalian  forms.  In  the  domestic  ani- 
mals tuberculosis  is  a  common  disease,  particularly  in  cattle.  In  sheep,  goats, 
and  horses  it  is  rare.  In  pigs  it  is  not  uncommon  in  certain  parts  of  Europe. 
Cats  and  dogs  are  not  prone  to  the  disease.  In  monkeys  in  confinement  it  is 
very  common.  The  most  important  single  fact  in  the  distribution  of  the 
disease  in  animals  is  its  widespread  prevalence  in  bovines,  from  which  nearly 
all  the  milk  and  a  large  proportion  of  our  meat  are  derived. 

(&)  IN  MAN. — Tuberculosis  is  his  most  universal  scourge,  well  deserving 
the  epithet  bestowed  upon  it  by  Bunyan  of  the  "Captain  of  the  Men  of  Death." 
It  is  estimated  that  at  least  one-seventh  of  all  deaths  are  due  to  it.  In  Eng- 
land and  Wales  there  were  54,435  deaths  from  tuberculosis  in  1909.  In  the 
United  States  it  is  estimated  that  it  is  responsible  for  about  one-ninth  of  the 
deaths  annually.  There  has  been  a  remarkable  reduction  in  England  in  the 
death-rate  within  the  past  forty  years,  as  shown  by  the  following  figures: 

1871-1880  rate  per  100,000  of  population,  219 

1881-1890      "  "          "  "          "  178 

1891-1900      "  "          "  "          "  139 

1901-1910      "  "          "  "          "  117 

It  has  dropped  nearly  50  per  cent,  in  40  years. 

In  London  the  death-rate  from  consumption  has  declined  33  per  cent,  be- 
tween 1901  and  1910,  and  other  forms  of  tuberculosis  show  a  similar  fall. 


156 


In  1909  54  435  deaths  from  tuberculosis  occurred,  38,699  of  which  were 
from  pulmonary  consumption.  Had  the  death-rate  been  as  high  in  1909  as 
during  an  average  year  of  the  1871-1880  period  the  number  of  deaths  from 
phthisis  would  have  been  78,308,  instead  of  38,639  (Newsholme).  The  mor- 
tality has  been  cut  in  half!  To  a  less  striking  degree,  but  practically  every- 
where in  the  civilized  world,  there  has  been  a  reduction  in  the  death-rate- 
the  most  encouraging  feature  of  modern  sanitation.  To  what  is  this  to  be 
attributed?  First.  To  the  improved  social  condition  of  the  people,  better 
housing,  better  food,  better  habits.  The  falling  death-rate  began  before  the 
present  campaign  against  the  disease.  Secondly.  The  education  of  the  people, 
which  has  made  great  strides,  and  a  larger  proportion  are  striving  to  lead 
hygienic  lives.  There  are  less  drunkenness,  less  overcrowding,  better  air,  and 
better  food.  The  habit  of  spitting  in  public  has  been  checked,  and  we  may 
say  confidently  that  the  seeds  of  the  disease  are  not  spread  so  broadcast. 
Thirdly.  As  Newsholme  points  out,  segregation  has  done  much  to  protect  the 
healthy  from  the  sick.  In  the  year  1910,  20.5  per  cent,  of  the  deaths  in  Eng- 
land and  Wales  and  43.4  per  cent,  of  the  deaths  in  London  occurred  in  public 
institutions  for  the  sick.  In  America,  in  Germany,  and  in  France  this  factor 
also  holds  good.  Fourthly.  The  cases  are  seen  earlier  and  the  condition  is 
recognized  before  it  is  hopeless.  Unquestionably  in  a  larger  number  of  per- 
sons with  pulmonary  disease  the  diagnosis  is  made  at  a  stage  when  complete 
healing  is  possible.  The  two  important  elements  then  are,  fewer  seeds,  more 
stony  soil.  The  economic  loss  from  tuberculosis  has  been  estimated  by  vari- 
ous writers.  Baldwin  puts  it  for  the  United  States  at  from  150  to  200  millions 
of  dollars  annually. 

Etiology:  the  Bacillus  tuberculosis. — (a)  THE  SEED. — The  Bacillus  tuber" 
culosis  is  a  minute  rod-shaped  organism  slightly  bent  or  curved,  with  an  aver- 
age length  of  from  3  to  4  A*  .  When  stained  it  may  present  a  beaded  appear- 
ance; whether  due  to  spores  or  vacuoles  is  doubtful.  Aberrant  forms  are  not 
uncommon,  i.  e.,  long  filaments  or  branched  formsv  It  stains  in  a  character- 
istic way  with  aniline  dyes,  and  in  cultures  the  mode  of  growth  is  very  dis- 
tinctive. 

Specific  varieties  are  recognized.  As  already  stated,  the  avian  form  has 
well-marked  peculiarities,  but  the  great  point  of  discussion  has  been  the  rela- 
tion of  the  bacillus  causing  human  to  that  which  causes  bovine  tuberculosis. 
Differences  in  the  character  of  the  tubercles  of  these  two  classes  had  long  been 
recognized,  and  Theobald  Smith  pointed  out  special  differences  between  the 
human  and  the  bovine  bacilli.  But  the  matter  was  brought  to  a  focus  in 
1901  by  Koch's  statement  that  the  bacilli  of  bovine  tuberculosis  did  not  cause 
human  tuberculosis,  and  vice  versa.  The  question  has  now  been  submitted  to 
the  test  by  a  number  of  commissions,  and  it  is  generally  recognized  that  there 
are  differences  between  the  two  forms.  The  recent  report  of  the  English 
commission  confirms  the  view  that  the  bovine  organism  is  capable  of  producing 
the  disease  in  man,  in  whom  it  may  often  be  recognized  as  a  special  form. 

The  virulence  of  the  individual  strains  varies,  a  factor  of  great  importance 
in  all  specific  infections. 

In  the  Body. — The  bacilli  are  found  in  all  tuberculous  lesions,  particularly 
in  those  actively  growing,  but  in  the  chronic  disease  of  the  lymph  glands  and 
of  the  joints  they  are  scanty.  In  all  caseous  foci  they  are  few  in  number. 


TUBERCULOSIS  157 

In  the  sputum  in  pulmonary  tuberculosis  they  may  be  present  in  countless 
myriads.  They  are  found  in  the  blood,  particularly  in  cases  of  miliary  tuber- 
culosis. 

Outside  the  Body. — The  tubercle  bacilli  are  widely  scattered  and  are 
found  in  varying  numbers  wherever  human  beings  are  crowded  together. 
There  are  two  chief  sources — the  expectoration  of  persons  with  advanced 
disease  of  the  lungs  and  the  milk  of  tuberculous  cows. 

From  a  patient  in  my  wards  at  the  Johns  Hopkins  Hospital,  with  mod- 
erately advanced  disease,  ISTuttall  estimated  that  from  1£  to  4  1-3  billions  of 
bacilli  were  thrown  off  each  twenty-four  hours.  Allowed  to  dry,  the  sputum 
becomes  dust  and  is  distributed  far  and  wide.  Scores  of  experiments  have 
shown  the  presence  of  the  bacilli  in  dust  samples  from  hospital  wards,  from 
public  buildings,  streets,  railway  carriages,  and  various  localities.  So  widely 
spread  are  the  bacilli  that  in  cities  at  least  few  individuals  pass  a  week  with- 
out affording  opportunity  for  their  lodgment,  usually -in  the  throat  or  air 
passages,  inhaled  with  dust.  They  may  readily  contaminate  food.  The  hands 
of  tuberculous  subjects  are  almost  always  contaminated.  From  the  street, 
tuberculous  sputum  may  be  brought  into  the  house  on  shoes,  on  the  long 
skirts  of  women,  on  the  hair  of  dogs,  etc.  It  is  interesting  to  note  that  in  some 
of  the  places  most  frequented  by  tuberculous  subjects,  e.  g.,  the  sanatoria, 
the  dust  (as  shown  by  experiments  at  Saranac)  may  be  free  from  bacilli. 

Bovine  bacilli  are  distributed  by  means  of  the  milk,  rarely  by  the  flesh, 
and  still  more  rarely  by  contact  with  the  animals.  A  proportion  of  all  cases 
of  infection  in  childhood  are  with  this  variety.  A  careful  study  by  Park  and 
Krumwiede  showed  that  bovine  tuberculosis  is  practically  negligible  in  adults 
but  in  young  children  it  causes  from  6  to  10  per  cent,  of  the  deaths  from 
tuberculosis. 

So  widely  spread  everywhere  is  the  seed,  that  the  soil,  the  conditions  suit- 
able for  its  growth,  is  practically  of  equal  moment. 

(&)  THE  SOIL. — Many  years  ago  I  drew  the  parallel  between  infection  in 
tuberculosis  and  the  parable  of  the  sower,  which  though  now  somewhat  hack- 
neyed illustrates  in  an  effective  way  the  importance  of  the  nature  of  the 
ground  upon  which  the  seed  falls.  "Some  seeds  fell  by  the  wayside  and  the 
fowls  of  the  air  came  and  devoured  them  up."  These  are  the  bacilli  scattered 
broadcast  outside  the  body,  an  immense  majority  of  which  die.  "Some  fell 
upon  stony  places."  These  are  the  bacilli  that  find  lodgment  in  many  of  us, 
perhaps,  with  the  production  of  a  small  focus,  but  nothing  comes  of  it;  they 
wither  away  "because  they  have  no  root."  "Some  fell  among  thorns,  and  the 
thorns  sprang  up  and  choked  them"  This  represents  the  cases  of  tuberculosis, 
latent  or  active,  in  which  the  seed  finds  the  soil  suitable  and  grows,  but  the 
conditions  are  not  favorable,  as  the  thorns,  representing  the  protecting  force 
of  the  body,  get  the  better  in  the  struggle.  "But  others  fell  on  good  ground 
and  sprang  up  and  bare  fruit  an  hundredfold."  Of  this  fourth  group  were 
the  54,435  who  died  of  the  disease  in  1909  in  England — the  soil  suitable,  the 
protecting  forces  feeble. 

What  makes  a  good  soil  ?  Fortunately  the  human  body  is  not  a  very  good 
culture  medium  for  the  tubercle  bacillus.  The  adult  human  individual  in 
normal  health  seems  to  be  practically  immune  to  natural  infection  (Baldwin). 
And  yet  one-seventh  of  the  human  race  dies  of  tuberculosis,  but  a  large  pro- 


158  SPECIFIC   INFECTIOUS   DISEASES 

portion  of  all  individuals  become  infected  before  reaching  adult  life  and 
never  have  the  disease.  The  studies  of  Naegli,  Burkhardt,  and  others  show 
that  in  fully  90  per  cent,  of  the  bodies  of  city-dwellers  who  have  died  of  dis- 
ease other  than  tuberculosis  small  tuberculous  lesions'  are  present.  This  is 
probably  too  high  an  estimate  for  England  or  the  United  States.  Franz  has 
shown  that  over  60  per  cent,  of  healthy  young  adults  react  to  the  subcutane- 
ous tuberculin  test.  Using  more  delicate  tuberculin  tests  it  is  found  that 
nearly  all  adults  react,  and  according  to  Hamburger,  who  has  employed  the 
subcutaneous-local  reaction,  over  90  per  cent,  of  children  are  infected  before 
reaching  the  twelfth  year  of  life.  This  means,  of  course,  that  in  a  very  small 
proportion  of  those  upon  whom  the  seed  falls  is  the  soil  suitable  for  active 
growth — only  a  natural  immunity  keeps  the  race  alive. 

What  this  suitable  soil  is  has  been  the  subject  of  much  discussion.  From 
the  time  of  Hippocrates  the  profession  has  recognized  a  tuberculous  habitus, 
which  has  been  variously  described  as  disposition,  diathesis,  dyscrasia,  tem- 
perament, constitution,  or  by  the  German  word  "Anlage."  These  terms  are 
not  always  regarded  as  interchangeable,  but  here  for  practical  purposes  Eib- 
bert's  definition  suffices,  that  a  disposition  is  "that  peculiarity  in  the  organism 
which  allows  of  the  effective  working  of  the  exciting  causes  of  a  disease." 
Manifestly,  such  a  disposition  or  constitution  of  the  body  may  be  inherited  or 
acquired.  The  studies  of  Pearson  indicate  the  very  great  importance  of 
heredity  in  the  phthisical  soil.  He  concludes  that  "the  diathesis  of  pulmonary 
tuberculosis  is  certainly  inherited,  and  the  intensity  of  the  inheritance  is  sen- 
sibly the  same  as  that  of  any  normal  physical  character  yet  investigated  in 
man.  Infection  probably  plays  a  necessary  part,  but  in  the  artisan  classes  of 
the  urban  populations  of  this  country  (England)  it  is  doubtful  if  their  mem- 
bers can  escape  the  risks  of  infection,  except  by  the  absence  of  diathesis — i.  e., 
the  inheritance  of  what  amounts  to  a  counter-disposition." 

Hippocrates  defines  the  habitus  phthisicus  in  the  following  words:  "The 
form  of  body  peculiar  to  subjects  of  phthisical  complaints  was  the  smooth, 
the  whitish,  that  resembled  the  lentil;  the  reddish,  the  blue-eyed,  the  leuco- 
phlegmatic,  and  that  with  the  scapulae  having  the  appearance  of  wings."  The 
so-called  scrofulous  type  has  broad  coarse  features,  opaque  skin,  large  thick 
bones,  and  heavy  figure. 

Acquired  disposition  may  arise  through  a  lowering  of  the  resistance  of 
the  body  forces.  Dwellers  in  cities  in  the  dark,  close  alleys,  and  tenement 
houses,  workers  in  cellars  and  ill-ventilated  rooms,  persons  addicted  to  drink, 
are  much  more  prone  to  the  disease.  The  influence  of  environment  was  never 
better  demonstrated  than  in  the  well-known  experiment  of  Trudeau,  who 
found  that  rabbits  inoculated  with  tuberculosis  if  confined  in  a  dark,  damp 
place,  without  sunlight  and  fresh  air,  rapidly  succumbed,  while  others  treated 
in  the  same  way,  but  allowed  to  run  wild,  either  recovered  or  showed  very 
slight  lesions.  The  occupants  of  prisons,  asylums,  and  poorhouse's,  too  often, 

ed,  m  barracks  and  large  workshops,  are  in  the  position  of  Trudeau's 

nts  m  the  cellar,  and  under  the  conditions  most  favorable  to  foster  the 
development  of  the  bacilli  which  may  have  lodged  in  their  tissues. 

No  age  is  exempt.  The  disease  is  met  with  in  the  suckling  and  in  the 
octogenarian,  but  fatal  tuberculosis  is,  as  Hippocrates  pointed  out,  more  com- 
mon between  the  eighteenth  and  thirty-fifth  year.  The  influence  of  sex  is 


TUBERCULOSIS  159 

very  slight.  On  the  other  hand  the  influence  of  race  is  important.  It  is  a 
very  fatal  disease  in  the  negroes,  particularly  in  the  southern  United  States, 
and  in  the  North  American  Indians.  The  Irish,  both  at  home  and  in  the 
United  States,  are  more  prone  to  the  disease  than  other  European  races. 
The  Jews  everywhere  have  a  low  mortality  from  tuberculosis. 

Occupation  has  an  influence,  in  so  far  as  insanitary  surroundings,  exposure 
to  dust,  close  confinement,  long,  irregular  hours,  and  low  rates  of  wages,  favor 
the  prevalence  of  the  disease.  Certain  local  conditions  influence  the  soil  very 
greatly.  Catarrh  of  the  respiratory  passages  appears  to  lower  the  resistance 
and  favor  the  conditions  which  enable  the  bacilli  to  enter  the  system,  or  to 
grow  in  the  tissues.  The  specific  fevers,  particularly  measles  and  whooping- 
cough,  predispose  to  tuberculosis;  and  any  lowering  disease  may  do  so,  but 
in  sucli  cases  it  is  very  often  not  a  fresh  infection,  but  the  blazing  of  a  smould- 
ering fire.  As  is  well  known,  the  soil  of  diabetes  is  very  favorable  to  the 
growth  of  the  tubercle  bacilli.  Many  chronic  affections  lower  the  resistance 
and  make  the  soil  more  favorable.  It  is  notorious  in  hospital  practice  how 
often  the  fatal  event  in  arterio-sclerosis,  cirrhosis  of  the  liver,  etc.,  is  a  ter- 
minal acute  tuberculosis. 

Trauma,  as  for  example  a  blow  on  the  chest,  injury  to  the  knee,  a  blow 
upon  the  head,  may  be  followed  by  local  tuberculosis.  The  injured  part  for  a 
time  is  a  locus  minoris  resist  en tice,  and  the  bacilli  already  present  grow  in 
the  favorable  conditions  caused  by  the  injury. 

(c)  SPECIFIC  REACTIONS  OF  THE  BACILLI. — In  its  growth  the  bacillus  so 
far  as  we  know  does  not  form  soluble  toxins,  at  least  not  in  the  cultures.  It 
causes  (1)  a  local  tissue  reaction  which  results  in  the  formation  of  a  new 
growth,  the  tubercle;  (2)  changes  in  the  metabolism  of  the  body  fluids.  The 
local  tissue  reactions  will  be  considered  later;  here  we  may  speak  of  the  phe- 
nomena grouped  under  the  term  immunity. 

(1)  Tuberculin  Reaction. — An  animal  inoculated  subcutaneously  with  tu- 
bercle bacilli,  or  with  dead  cultures,  has  a  local  reaction  associated  with  the 
formation  of  a  tubercle;  the  neighboring  lymph  glands  become  involved,  and 
in  susceptible  animals  the  disease  generalizes  and  causes  death.  Koch  found 
that  if  to  a  guinea-pig  with  a  subcutaneous  focus  of  tuberculosis  so  caused 
a  second  injection  of  the  bacillus  was  given,  healing  occurred  in  the  primary 
nodule,  and  the  animal  did  not  die.  Upon  these  facts  his  famous  tuberculin 
treatment  was  based.  Tuberculin  consists  of  the  dead  and  macerated  bacilli 
together  with  any  substances  formed  in  the  cultures.  If  into  a  healthy  per- 
son .25  c.  c.  of  tuberculin  is  injected,  there  is  a  very  slight  fever  with  a  little 
feeling  of  uneasiness  which  passes  off  in  from  twelve  to  twenty-four  hours. 
If  into  an  individual  with  a  focus  of  tuberculosis  doses  of  .015  c.  c.  of  tuber- 
culin are  injected  subcutaneously,  there  is  an  active  local  reaction  about  the 
tuberculous  focus,  with  intense  inflammation  leading  often  to  necrosis  and,  in 
the  case  of  a  skin  tubercle,  as  lupus,  in  which  the  process  can  be  followed, 
healing  is  seen  to  take  place.  This  process,  now  known  as  the  "tuberculin 
reaction,"  is  used  extensively  for  purposes  of  diagnosis.  The  chief  methods 
in  use  are  the  ophthalmo-reaction  of  Calmette  and  the  cutaneous  of  von 
Pirquet.  For  the  Calmette  reaction  Koch's  old  tuberculin  is  used,  prepared 
in  a  special  way.  A  drop  of  the  solution,  placed  on  the  conjunctiva  of  a 
person  with  a  focus  of  tuberculosis  anywhere  in  the  system,  is  followed  in  a 


160  SPECIFIC   INFECTIOUS   DISEASES 

fi-w  hours  by  a  deep  injection  of  the  blood-vessels,  increased  lachrymation,  and 
a  slk'ht  swelling  of  the  membrane.  This,  known  as  a  positive  reaction,  lasts 
for  f°rom  twenty-four  to  thirty-six  hours. 

For  the  skin  reaction  of  von  Pirquet  a  couple  of  drops  of  tuberculin  are 
placed  on  a  disinfected  region  of  the  skin,  and  the  epidermis  is  scarified 
through  the  drops  without  drawing  blood.  If  positive,  at  the  end  of  twenty- 
four  hours  there  is  an  inflammatory  reaction  which  reaches  its  maximum  m 
from  thirty-six  to  forty-eight  hours.  For  clinical  purposes  the  tuberculin 
reaction  is  to  be  relied  on,  but  that  it  may  be  given  by  a  small  focus  of  latent 
disease  in  a  healthy  person  and  that  it  has  been  found  to  be  positive  in  as 
large  a  proportion  as  60  per  cent,  of  apparently  normal  individuals  are  facts 
which  diminish  its  practical  value. 

(2)  Immunity  Changes.— In  an  infected  person  certain  changes  occur  in 
the  blood  serum,  depending  upon  the  development  of  so-called  antibodies,  the 
presence  of  which  may  be  demonstrated  by  the  method  of  complement  fixa- 
tion ;  and  the  serum  also  contains  agglutinins  which  possess  an  agglutinating 
action  on  the  tubercle  bacilli.  Either  directly  themselves  or  through  the  toxic 
products  there  are  brought  into  play  certain  cellular  and  humoral  reactions 
which  are  capable  of  destroying  the  infecting  agents  or  of  neutralizing  their 
effects  or  of  limiting  their  activities.  There  exist  in  the  blood-serum  anti- 
bodies, called  by  Wright  opsonins,  which  have  the  power  of  stimulating  phag- 
ocytosis. When  these  opsonins  are  abnormally  low,  the  bacilli  that  gain  en- 
trance to  the  body  can  multiply  at  the  point  of  infection.  This  increase  is 
associated  with  a  still  further  local  reduction  in  the  opsonins.  Wright  be- 
lieves that  the  amount  of  opsonin  in  the  serum  is  an  indication  of  the  defen- 
sive capacity  of  the  individual,  and  he  has  established  what  he  calls  an  "op- 
sonic  index,"  which  is  the  ratio  between  the  number  of  bacteria  found  within 
twenty  to  forty  polymorpho-leucocytes  in  an  emulsion  made  with  the  patient's 
serum  and  the  number  of  bacteria  found  in  the  same  number  of  similar  leu- 
cocytes in  an  emulsion  made  with  a  normal  serum,,  the  latter  being  taken  as 
1.0.  This  index  in  tuberculous  patients  is  usually  low,  varying  from  .1  to  .8. 
When  tuberculin  is  injected,  the  production  of  opsonins  is  stimulated,  and 
the  opsonic  index  rises.  With  the  body  fluids  richer  in  opsonins  than  before, 
the  phagocytes  are  more  active  and  more  bacilli  are  destroyed.  Experimentally 
in  animals,  according  to  the  virulence  of  the  organism  and  the  dose,  all  grada- 
tions of  symptoms  may  be  produced,  from  the  slightest  local  reaction  to  the 
profoundest  septicaemia  with  high  fever  and  death.  In  a  local  tuberculous 
infection,  such  as  happens  to  the  great  majority  of  us  in  some  part  of  our 
bodies  at  some  time  in  our  lives,  happily  the  protective  mechanism  suffices 
to  localize  and  limit  the  invaders.  It  may  amount  only  to  a  skirmish,  such 
as  is  constantly  going  on  at  the  frontiers  of  a  great  empire,  but  if  the  local 
infection  is  more  virulent,  or  becomes  wider  spread,  the  products  of  the  growth 
of  the  bacilli  or  the  bacilli  themselves  enter  the  circulation,  occasioning  what 
is  called  an  auto-inoculation,  in  which  case  the  general  metabolism  is  dis- 
turbed, fever  is  produced,  and  antibodies  are  formed  to  counteract  the  infective 
products.  The  rationale  of  the  use  of  tuberculin  is  to  stimulate  the  fighting 
forces  of  the  body — to  mobilize  them,  so  to  speak — in  the  fight  that  is  going 
on  in  an  infected  area.  The  whole  question  of  active  immunization  in  tuber- 
culosis is  being  thoroughly  studied,  and,  while  many  have  thrown  doubt  on 


TUBERCULOSIS  1G1 

the  trustworthiness  and  the  usefulness  of  the  opsonic  index  as  a  gauge  of  the 
progress  of  a  case,  there  can  be  no  question  that  Wright's  researches  have  put 
us  in  the  right  path  for  a  scientific  treatment  of  the  disease. 

Recent  studies  on  'anaphylaxis  or  hypersensitiveness  to  foreign  proteins 
have  an  important  bearing  on  the  question  of  immunity  in  tuberculosis. 
Baldwin  of  Saranac  Lake,  in  a  series  of  experiments,  has  demonstrated  that 
sensitization  to  and  subsequent  intoxication  by  tubercle  bacillus  protein  follow 
the  general  laws  of  anaphylaxis  established  for  the  parenteral  introduction 
of  horse  serum.  From  his  experiments  we  may  now  reasonably  interpret  the 
tuberculin  reaction  as  an  anaphylactic  phenomenon.  Undoubtedly  hypersensi- 
tiveness to  the  tubercle  bacillus  protein  is  directly  responsible  for  the  so-called 
toxic  symptoms  of  tuberculous  disease.  Koch  in  his  original  experiments  that 
led  up  to  the  introduction  of  tuberculin  observed  a  marked  difference  in  the 
reaction  of  healthy  and  tuberculous  animals  to  cutaneous  inoculation  with 
tubercle  bacilli.  In  healthy  animals  the  wound  closes  and  for  a  few  days 
seems  to  heal,  but  in  from  ten  to  'fourteen  days  a  hard  nodule  appears,  which 
soon  breaks  down.  General  infection  occurs  and  the  ulcer  remains  open  to 
the  time  of  the  death  of  the  animal.  In  tuberculous  animals  extensive  ulcer- 
ation  occurs  on  the  second  or  third  day  after  vaccination,  but  the  ulcer  heals 
quickly  and  permanently,  without  even  the  neighboring  lymph  glands  becom- 
ing infected.  Roemer  has  extended  Koch's  observations  and  has  demonstrated 
that  tuberculous  animals  may  react  in  one  of  three  ways  to  injections  of 
tubercle  bacilli:  (1)  If  a  small  dose  be  given,  a  dose,  however,  surely  fatal 
for  healthy  animals,  infection  does  not  occur.  The  animals  are  therefore 
highly  resistant  to  re-infection.  (2)  If  a  large  dose  be  given,  the  animals 
die  promptly,  with  the  symptoms  of  an  intense  intoxication.  The  condition 
is  analogous  to  the  anaphylactic  shock.  (3)  If  a  moderate  dose  be  given, 
the  animals  display  the  symptoms  of  a  profound  intoxication,  but  gradually 
recover,  and,  although  infection  follows,  a  mild  and  chronic  form  of  the  dis- 
ease is  produced.  Upon  the  same  principle  depends  the  protective  inoculation 
of  calves,  so  successfully  practiced  by  v.  Behring  and  Koch.  The  animals 
receive  injections  of  human  tubercle  bacilli  and,  although  anatomically  disease 
does  not  follow  their  introduction,  the  calves  become  highly  sensitive  to  tuber- 
culin and  at  the  same  time  immune  to  doses  of  bovine  tubercle  bacilli  fatal 
to  unprotected  calves.  At  the  end  of  a  year  the  tuberculin  hypersensitiveness 
disappears,  and  the  calves  again  become  susceptible  to  infection.  While  we  are 
not  in  a  position  to  state  that  protection  depends  upon  the  same  mechanism 
that  produces  hypersensitiveness  to  the  tubercle  bacillus  protein,  the  two  phe- 
nomena are  undoubtedly  closely  related. 

Antituberculous  serums  have  been  obtained  from  animals  immunized  by 
the  tubercle  bacillus  or  its  products.  The  two  most  important  are  those  of 
Marmorek  and  of  Maragliano. 

(d)  MODES  OF  INFECTION. —  (1)  Hereditary  Transmission. — In  order  that 
the  disease  could  be  transmitted  by  the  sperm  it  would  be  necessary  that  the 
tubercle  bacilli  should  lodge  in  the  individual  spermatozoon  which  fecundates 
an  ovum.  The  chances  that  such  a  thing  could  occur  are  extremely  small, 
looking  at  the  subject  from  a  numerical  point  of  view,  although  we  know 
that  bacilli  do  occasionally  exist  in  the  semen ;  they  become  still  smaller  when 
we  consider  that  the  spermatozoon  is  made  up  of  nuclear  material,  which  the 


162  SPECIFIC   INFECTIOUS   DISEASES 

tubercle  bacillus  is  never  known  to  attack.  The  possibility  of  transmission 
by  the  ovum  must  be  accepted.  Baumgarten  has  in  one  instance  been  able 
to  detect  the  tubercle  bacillus  in  the  ovum  of  a  female  rabbit  which  he  had 
artificially  fecundated  with  tuberculous  semen. 

The  almost  constant  method  of  transmission  in  congenital  tuberculosis 
is  through  the  blood  current,  the  tubercle  bacilli  penetrating  by  way  of  the 
placenta.  In  these  cases  the  placenta  itself  is  usually  the  seat  of  tuberculosis ; 
but  there  are  undoubted  instances  in  which,  with  an  apparently  sound  pla- 
centa, both  the  placental  blood  and  the  fetal  organs  contained  tubercle  bacilli, 
notwithstanding  the  fact  that  the  organs  also  appeared  normal.  The  number 
of  cases  of  congenital  tuberculosis  in  man  is  very  small;  it  is  more  common 
in  cattle. 

Possible  Latency  of  the  Tubercle  Germs. — Baumgarten  and  his  followers 
assume  that  the  tubercle  bacilli  lie  latent  in  the  tissues  and  subsequently 
develop  when,  for  some  reason  or  other,  the  individual  resistance  is  lowered. 
He  likens  such  cases  of  latent  tuberculosis  to  the  late  hereditary  forms  of 
syphilis,  and  explains  the  lack  of  development  of  the  germs  by  the  greater 
resisting  power  of  the  tissues  of  children.  Baumgarten  bases  his  belief  in 
germ  transmission  upon  two  main  factors — the  great  frequency  of  the  disease 
in  early  life  and  the  localization  of  tuberculous  lesions  in  children. 

Against  this  theory  are  the  facts  that  the  percentage  of  cases  of  congenital 
tuberculosis  is  extremely  small,  and  that  in  the  great  majority  of  instances 
the  organs  of  fetuses  born  of  tuberculous  mothers  give  negative  results  when 
inoculated  into  guinea-pigs. 

(2)  Inoculation. — Cutaneous. — The  infective  nature  of  tuberculosis  was 
first  demonstrated  by  Villemin,  who  showed  in  1865  that  it  could  be  trans- 
mitted to  animals  by  inoculation.  The  experiments  of  Cohnheim  and  Salo- 
monsen,  who  produced  tuberculosis  in  the  eyes  of  guinea-pigs  and  rabbits 
by  inoculating  fresh  tubercle  into  the  anterior  chamber,  confirmed  and  ex- 
tended Villemin's  original  observations  and  paved  the  way  for  the  reception 
of  Koch's  announcement.  This  mode  of  infection  is  seen  in  persons  whose 
occupation  brings  them  in  contact  with  the  dead  bodies  or  animal  products. 
Demonstrators  of  morbid  anatomy,  butchers,  and  handlers  of  hides  are  subject 
to  a  local  tubercle  of  the  skin,  which  forms  a  reddened  mass  of  granulation 
tissue,  usually  capping  the  dorsal  surface  of  the  hand  or  a  finger.  This  is 
the  so-called  post  mortem  wart,  the  verruca  necrogenica  of  Wilks.  The  demon- 
stration of  its  nature  is  shown  by  the  presence  of  tubercle  bacilli,  and  by 
inoculation  experiments  in  animals. 

In  the  performance  of  the  rite  of  circumcision  children  have  been  acci- 
dentally inoculated.  Infection  in  these  cases  is  probably  always  associated 
with  disease  in  the  operator,  and  occurs  in  connection  with  the  habit  of 
cleansing  the  wound  by  suction. 

Other  means  of  inoculation  have  been  described:  as  the  wearing  of  ear- 
rings, washing  the  clothes  of  phthisical  patients,  the  bite  of  a  tuberculous 
subject,  or  inoculation  from  a  cut  by  a  broken  spit-glass  of  a  consumptive; 
and  Czerny  has  reported  two  cases  of  infection  by  transplantation  of  skin. 

It  has  been  urged  by  the  opponents  of  vaccination  that  tuberculosis,  as 
well  as  syphilis,  may  be  thus  conveyed,  but  of  this  there  is  no  evidence. 
Lymph  of  revaccinated  consumptives  is  non-infective.  Lupus  has  originated 


TUBERCULOSIS  163 

at  the  site  of  vaccination  in  a  few  cases  (C.  Fox,  Graham  Little).  It  may 
be  said,  on  the  whole,  that  inoculation  in  man  plays  a  trifling  role  in  the 
transmission  of  tuberculosis. 

Mucous  membrane  inoculation  is  probably  important  in  childhood  through 
abrasions  of  the  lips,  tongue  or  gums,  though  a  primary  focus  is  not  often 
seen.  The  open  door  in  the  mouth  and  throat  is  more  often  by  loss  of  the 
protective  epithelium  due  to  catarrhal  and  ulcerative  processes. 

(3)  Infection  by  Inhalation. — A  belief  in  the  contagiousness  of  pulmo- 
nary tuberculosis  originated  with  the  early  Greek  physicians,  and  has  per- 
sisted among  the  Latin  races.  The  investigations  of  Cornet  afford  conclusive 
proof  that  the  dust  of  a  room  or  other  locality  frequented  by  patients  with 
pulmonary  tuberculosis  is  infective.  The  bacilli  attached  to  fine  particles 
of  dust  are  inhaled  and  gain  entrance  to  the  system  through  the  lungs. 

Fliigge  denies  that  the  bacillus-containing  dust  is  the  dangerous  element 
in  infection.  Experimentally  he  has  only  succeeded  in  -producing  the  disease 
when  there  is  some  lesion  in  the  respiratory  tract.  He  thinks  that  the  danger 
of  infection  by  the  dry  sputum  is  very  improbable.  On  the  other  hand,  he 
thinks  that  the  infection  is  chiefly  conveyed  by  the  free,  finely  divided  par- 
ticles of  sputum  produced  in  the  act  of  coughing,  and  that  these  tiny  frag- 
ments are  suspended  in  the  atmosphere.  Those  who  cough  very  much  and 
with  the  mouth  open  are  most  liable  to  infect  the  surrounding  air. 

It  is  well  remarked  by  Cornet,  "The  consumptive  in  himself  is  almost 
harmless,  and  only  becomes  harmful  through  bad  habits."  It  has  been  fully 
shown  that  the  expired  air  of  consumptives  is  not  infective.  The  virus  is 
only  contained  in  the  sputum,  which  when  dry  is  widely  disseminated  in  the 
form  of  dust,  and  constitutes  the  great  medium  for  the  transmission  of  the 
disease. 

Among  the  points  urged  in  favor  of  the  inhalation  view  are : 

(i)  Primary  tuberculous  lesions  are  in  a  majority  of  all  cases  connected 
with  the  respiratory  system.  The  frequency  with  which  foci  are  met  with 
in  the  lungs  and  in  the  bronchial  glands  is  extraordinary,  and  the  statistics 
of  the  Paris  morgue  show  that  a  considerable  proportion  of  all  persons  dying 
of  accident  or  by  suicide  present  evidences  of  the  disease  in  these  parts.  The 
post  mortem  statistics  of  hospitals  show  the  same  widespread  prevalence  of 
infection  through  the  air  passages.  Biggs  reports  that  more  than  60  per  cent, 
of  his  post  mortems  showed  lesions  of  pulmonary  tuberculosis.  In  125  autop- 
sies at  the  Foundling  Hospital,  New  York,  the  bronchial  glands  were  tuber- 
culous in  every  case.  In  adults  the  bronchial  glands  may  be  infected  and  the 
individual  remain  in  good  health. 

(n)  The  greater  prevalence  of  tuberculosis  in  institutions  in  which  the 
residents  are  confined  and  restricted  in  the  matter  of  fresh  air  and  a  free 
open  life — conditions  which  would  favor,  on  the  one  hand,  the  presence  of 
the  bacilli  in  the  atmosphere,  and,  on  the  other,  lower  the  vital  resistance  of 
the  individual.  The  investigations  of  Cornet  upon  the  death-rate  from  con- 
sumption among  certain  religious  orders  devoted  to  nursing  give  some  striking 
facts  in  illustration  of  this.  In  a  review  of  38  cloisters,  embracing  the  aver- 
age number  of  4,028  residents,  among  2,099  deaths  in  the  course  of  twenty- 
five  years,  1,320  (62.88  per  cent.)  were  from  tuberculosis.  In  some  cloisters 
more  than  three-fourths  of  the  deaths  are  from  this  disease,  and  the  mortality 


164  SPECIFIC    INFECTIOUS    DISEASES 

in  all  the  residents,  up  to  the  fortieth  year,  is  greatly  above  the  average,  the 
increase  being  due  entirely  to  the  prevalence  of  tuberculosis.  It  has  been 
stated  that  nurses  are  not  more  prone  to  the  disease  than  other  individuals, 
but  Cornet  says  that,  of  100  nurses  deceased,  63  died  of  tuberculosis.  The 
more  perfect  the  prophylaxis  and  hygienic  arrangements  of  an  asylum  or 
institution,  the  lower  the  death-rate  from  tuberculosis.  The  mortality  in 
prisons  has  been  shown  by  Baer  to  be  four  times  as  great  as  outside.  The 
death-rate  from  phthisis  is  estimated  at  15  per  cent,  of  the  total  mortality, 
while  in  prisons  it  constitutes  from  40  to  50  per  cent.,  and  in  some  countries, 
as  Austria,  over  60  per  cent.  Flick  has  studied  the  distribution  of  the  deaths 
from  tuberculosis  in  a  single  city  ward  in  Philadelphia  for  twenty-five  years. 
His  researches  go  far  to  show  that  it  is  a  house  disease.  About  33  per  cent. 
of  infected  houses  have  had  more  than  one  case.  There  are,  however,  oppos- 
ing facts.  The  statistics  of  the  Brompton  Consumption  Hospital  show  that 
doctors,  nurses,  and  attendants  are  rarely  attacked.  Dettweiler  claims  that 
no  case  of  tuberculosis  has  been  contracted  among  his  nurses  or  attendants 
at  Falkenstein.  Among  174  previously  healthy  sanitarium  physicians  whose 
average  term  of  service  was  three  years  only  two  became  tuberculous  (Sang- 
mann).  On  the  other  hand,  in  the  Paris  hospitals  tuberculosis  decimates  the 
attendants. 

(tit)  Special  danger  is  believed  to  exist  when  the  contact  is  very  intimate, 
as  between  man  and  wife.  Until  recently  nearly  all  writers  have  held  that 
under  these  circumstances  the  husband  or  wife  is  much  more  likely  subse- 
quently to  die  of  tuberculosis.  Upon  the  figures  of  the  late  Ernest  Pope,  of 
Saranac,  Karl  Pearson  bases  the  following  conclusions:  (a)  There  is  some 
sensible  but  slight  infection  between  married  couples;  (&)  this  is  largely  ob- 
scured or  forestalled  by  the  fact  of  infection  from  outside  sources;  (c)  the 
liability  to  the  infection  depends  on  the  presence  of  the  necessary  diathesis; 
(d)  assortative  mating  probably  accounts  for  at  least  two-thirds,  and  infective 
action  not  more  than  one-third  of  the  whole  correlation  observed  in  these 
cases.  There  are  cases  in  which  this  source  of  infection  seems  to  play  an 
important  role. 

(4)  Infection  by  Ingestion. — The  work  of  the  past  few  years  has  shown 
that  there  are  two  other  channels,  the  tonsils  and  the  intestines,  both  of  great 
importance. 

(t)  Tonsillar  Infection. — The  frequency  of  involvement  of  these  glands 
has  been  shown  by  Schlenker,  Arthur  Latham,  and  Walsham.  The  bacilli 
pass  to  t,he  glands  of  the  neck  and  of  the  mediastinum,  and  reach  the  circu- 
lation through  the  lymph-channels.  Or  an  infected  bronchial  gland  becomes 
adherent  to  a  branch  of  the  pulmonary  artery;  if  a  large  number  of  bacilli 
escape,  miliary  tuberculosis  follows;  if  only  a  small  number,  they  reach  the 
lungs,  at  the  apices  of  which  they  find  conditions  suitable  for  their  growth. 
Through  this  tonsillar-cervical  route  bacilli  may  gain  entrance  without  causing 
local  disease  at  the  portal  of  entry.  It  is  a  common  method  of  infection  in 
children,  causing  the  "scrofulous"  glands  of  the  neck. 

(u)  Intestinal  Infection. — Behring  announced  in  1903  that  pulmonary 
tuberculosis  could  be  induced  through  intestinal  infection,  and  he  further 
maintained  that  milk  fed  to  infants  was  the  chief  cause  of  consumption  in 
adults,  the  infection  remaining  latent.  Behring's  first  contention  was  sup- 


TUBERCULOSIS  165 

ported  by  Bavenel  and  others,  who  produced  pulmonary  tuberculosis  in  ani- 
mals by  feeding  experiments,  and  it  was  demonstrated  that  the  intestinal 
surface  itself  might  remain  intact.  This  does  away  with  the  objection  raised 
by  Koch  that,  if  infection  through  the  milk  of  tuberculous  cattle  were  common, 
primary  intestinal  tuberculosis  should  be  more  frequent,  whereas  in  ten  years 
among  3.104  cases  of  tuberculosis  in  children  there  were  only  16  of  primary 
bowel  infection.  Becent  experiments  have  shown  in  a  striking  manner  how 
the  lungs  act  as  filters  for  particles  absorbed  from  the  intestines.  Vansteen- 
berghe  and  Grysez  have  produced  anthracosis  of  the  lungs  by  introducing 
china-ink  emulsion  directly  into  the  stomach  (see  Anthracosis).  They  found 
a  remarkable  difference  in  young  and  adult  guinea-pigs;  in  the  former  the 
carbon  particles  were  filtered  out  by  the  mesenteric  glands,  while  the  lungs 
remained  free;  in  the  latter  the  glands  were  unaffected,  but  the  lungs  were 
carbonized.  Calmette  and  Guerin,  repeating  the  experiments  of  Eavenel  with 
improved  technique,  have  shown  how  easily  the  lungs  may  be  infected  through 
the  intestinal  route  without  leaving  the  slightest  trace  of  disease  of  the  bowel 
itself.  Behring's  view  of  the  importance  of  infection  through  the  intestinal 
route  has  thus  received  the  strongest  support,  and  many  go  so  far  as  to  main- 
tain that  a  majority  of  all  cases  of  phthisis  originate  in  this  manner.  The 
truth  is  that  this  ubiquitous  bacillus  is  not  particular,  and  gains  entrance 
through  either  portal,  preferring  the  throat  and  intestines  in  childhood,  the 
bronchi  and  lungs  in  adults.  The  important  matter  for  the  individual  is  the 
nature  of  the  soil  on  which  it  falls. 

Milk  alone  is  a  common  source  of  intestinal  infection,  particularly  in  the 
large  cities.  In  New  York,  Hess  found  tubercle  bacilli  in  16  per  cent,  of 
107  specimens!  The  ordinary  commercial  pasteurization  does  not  kill  them. 

The  flesh  of  tuberculous  animals  is  rarely  dangerous. 

General  Morbid  Anatomy  and  Histology  of  Tuberculous  Lesions. — (a) 
DISTRIBUTION  or  THE  TUBERCLES  IN  THE  BODY. — The  organs  of  the  body  are 
variously  affected  by  tuberculosis.  In  adults,  the  lungs  may  be  regarded  as 
the  seat  of  election;  in  children,  the  lymph-glands,  bones,  and  joints.  In 
1,000  autopsies  there  were  275  cases  with  tuberculous  lesions.  With  but  two 
or  three  exceptions  the  lungs  were  affected.  The  distribution  in  the  other 
organs  was  as  follows:  Pericardium,  7;  peritoneum,  36;  brain,  31;  spleen,  23; 
liver,  12 ;  kidneys,  32 ;  intestines,  65 ;  heart,  4 ;  and  generative  organs,  8. 

Among  8,873  surgical  patients  at  the  Wiirzburg  clinic,  1,287  were  tubercu- 
lous, with  the  following  distribution  of  lesions:  Bones  and  joints,  1,037; 
lymph-glands,  196 ;  skin  and  connective  tissues,  77 ;  mucous  membranes,  10 ; 
genito-urinary  organs,  20. 

(&)  THE  CHANGES  PRODUCED  BY  THE  TUBERCLE  BACILLI. — The  Nodular 
Tubercle. — A  "tubercle"  presents  in  its  early  formation  nothing  distinctive  or 
peculiar,,  either  in  its  components  or  in  their  arrangement.  Identical  struc- 
tures are  produced  by  other  parasites,  such  as  the  actinomyces,  and  b>  the 
strongylus  in  the  lungs  of  sheep. 

The  following  changes  occur  in  the  evolution  of  a  tubercle: 

(1)  The  tubercle  bacilli  multiply  and  disseminate  in  the  surrounding  tis- 
sues, partly  by  growth,  partly  in  the  lymph  currents. 

(2)  The  fixed  cells,  especially  those  of  connective  tissue  and  the  endothe- 
lium  of  the  capillaries,  multiply  and  form  rounded,  cuboidal,  or  polygonal 


166  SPECIFIC   INFECTIOUS   DISEASES 

bodies  with  vesicular  nuclei — the  epithelioid  cells — inside  some  of  which  the 
bacilli  are  soon  seen. 

(3)  Leucocytes,  chiefly  polynuclear,  migrate  in  numbers  and  accumulate 
about  the  focus  of  infection.     They  do  not  survive.     Many  undergo  rapid 
destruction.    Later,  as  the  little  tubercle  grows,  the  leucocytes  are  chiefly  of 
the  mononuclear  variety   (lymphocytes),  which  do  not  undergo   the  rapid 
degeneration  of  the  polynuclear  forms. 

(4)  A  retriculum  of  fibres  is  formed  by  the  fibrillation  and  rarefaction 
of  the  connective-tissue  matrix.     This  is  most  apparent,  as  a  rule,  at  the 
margin  of  the  growth. 

(5)  In  some,  but  not  all,  tubercles  giant  cells  are  formed  by  an  increase 
in  the  protoplasm  and  in  the  nuclei  of  an  individual  cell,  or  possibly  by  the 
fusion  of  several  cells.     The  giant  cells  seem  to  be  in  inverse  ratio  to  the 
number  and  virulence  of  the  bacilli. 

(c)  THE  DEGENERATION  OF  TUBERCLE. — (1)  Cassation. — At  the  central 
part  of  the  growth,  owing  to  the  direct  action  of  the  bacilli  or  their  products, 
p.  process  of  coagulation  necrosis  goes  on  in  the  cells,  which  lose  their  outline, 
become  irregular,  no  longer  take  stains,  and  are  finally  converted  into  a 
homogeneous,  structureless  substance.  Proceeding  from  the  centre  outward, 
the  tubercle  may  be  gradually  converted  into  a  yellowish-gray  body,  in  which, 
however,  the  bacilli  are  still  abundant.  No  blood  vessels  are  found  in  them. 
Aggregated  together  these  form  the  cheesy  masses  so  common  in  tuberculosis, 
which  may  undergo  softening,  fibroid  limitation  (encapsulation),  or  calci- 
fication. 

(2)  Sclerosis. — With  the  necrosis  of  the  cell  elements  at  the  centre  of  the 
tubercle,  hyaline  transformation  proceeds,  together  with  great  increase  in  the 
fibroid  elements ;  so  that  the  tubercle  is  converted  into  a  firm,  hard  structure. 
Often  the  change  is  rather  of  a  fibro-caseous  nature;  but  the  sclerosis  pre- 
dominates. In  some  situations,  as  in  the  peritoneum,  this  seems  to  be 
the  natural  transformation  of  tubercle,  and  it  is  by  no  means  rare  in 
the  lungs.  ' 

In  all  tubercles  two  processes  go  on :  the  one — caseation — destructive  and 
dangerous;  and  the  other — sclerosis — conservative  and  healing.  The  ulti- 
mate result  in  a  given  case  depends  upon  the  capabilities  of  the  body  to  fight 
tbe  invaders.  There  are  tissue-soils  in  which  the  bacilli  are,  in  all  probability, 
killed  at  once.  There  are  others  in  which  a  lodgment  is  gained  and  more  or 
less  damage  done,  but  finally  the  day  is  with  the  conservative,  protecting  forces. 
Thirdly,  there  are  tissue-soils  in  which  the  bacilli  grow  luxuriantly,  caseation 
and  softening,  not  limitation  and  sclerosis,  prevail,  and  the  day  is  with  the 
invaders. 

The  action  of  the  bacilli  injected  directly  into  the  blood-vessels  illustrates 
many  points  in  the  histology  and  pathology  of  tuberculosis.  If  into  the  vein 
of  a  rabbit  a  pure  culture  of  the  bacilli  is  injected,  the  microbes  accumulate 
chiefly  in  the  liver  and  spleen.  The  animal  dies  usually  within  two  weeks, 
and  the  organs  apparently  show  no  trace  of  tubercles.  Microscopically,  in 
both  spleen  and  liver  the  young  tubercles  in  process  of  formation  are  very 
numerous,  and  karyokinesis  is  going  on  in  the  liver-cells.  After  an  injection 
of  a  more  dilute  culture,  or  one  whose  virulence  has  been  mitigated  by  age, 
instead  of  dying  within  a  fortnight  the  animal  survives  for  five  or  six  weeks', 


TUBEKCULOSIS  1G7 

by  which  time  the  tubercles  are  apparent  in  the  spleen  and  liver,  and  often 
in  the  other  organs. 

(d)  THE  DIFFUSED  INFLAMMATORY  TUBERCLE. — This  is  most  frequently 
seen  in  the  lungs  and  results  from  the  fusion  of  many  small  foci  of  infection 
— so  small  indeed  that  they  may  not  be  visible  to  the  naked  eye,  but  which 
histologically  are  seen  to  be  composed  of  scattered  centres,  surrounded  by  areas 
in  which  the  air-cells  are  filled  with  the  products  of  exudation  and  of  the 
proliferation  of  the  alveolar  epithelium.    Under  the  influence  of  the  bacilli, 
caseation  takes  place,  usually  in  small  groups  of  lobules,  occasionally  in  an 
entire  lobe,  or  even  the  greater  part  of  a  lung.     In  the  early  stage  of  the 
process,  the  tissue  has  a  gray  gelatinous  appearance,  the  gray  infiltration  of 
Laennec.     The  alveoli  contain  a  sero-fibrinous  fluid  with  cells,  and  the  septa 
are  also  infiltrated.    These  cells  accumulate  and  undergo  coagulation  necrosis, 
forming  areas  of  caseation,  the  infiltration  tuberculeuse  jaune  of  Laennec, 
the  scrofulous  or  cheesy  pneumonia  of  later  writers.     There  may  also  be  a 
diffuse  infiltration  and  caseation  without  any  special  foci,  a  widespread  tuber- 
culous pneumonia  induced  by  the  bacilli. 

After  all,  the  two  processes  are  identical.  As  Baumgarten  states :  "There 
is  no  well-marked  difference  between  miliary  tubercle  and  chronic  caseous 
pneumonia.  Speaking  histologically,  miliary  tuberculosis  is  nothing  else  than 
a  chronic  caseous  miliary  pneumonia,  and  chronic  caseous  pneumonia  is  noth- 
ing but  a  tuberculosis  of  the  lungs." 

(e)  SECONDARY  INFLAMMATORY  PROCESSES. — (1)  The  irritation  caused 
by  the  bacilli  produces  an  inflammation  which  may,  as  has  been  described, 
be  limited  to  exudation  of  leucocytes  and  serum,  but  may  also  be  much  more 
extensive,  and  vary  with  changing  conditions.    We  find,  for  example,  about 
the  smaller  tubercles  in  the  lungs,  pneumonia — either  catarrhal  or  fibrinous — 
proliferation  of  the  connective-tissue  elements  in  the  septa  (which  also  become 
infiltrated  with  round  cells),  and  changes  in  the  blood  and  lymph-vessels. 

(2)  In  processes  of  minor  intensity  the  inflammation  is  of  the  slow  reac- 
tive nature,  which  results  in  the  production  of  a  cicatricial  connective  tissue 
which  limits  and  restricts  the  development  of  the  tubercles  and  is  the  essential 
conservative  element  in  the  disease.    It  is  to  be  remembered  that  in  chronic 
pulmonary  tuberculosis  much  of  the  fibroid  tissue  which  is  present  is  not  in 
any  way  associated  with  the  action  of  the  bacilli. 

(3)  Suppuration.     Do  the  bacilli  themselves  induce  suppuration?     In 
so-called  cold  tuberculous  abscess  the  material  is  not  histologically  pus,  but 
a  debris  consisting  of  broken-down  cells  and  cheesy  material.    It  is  moreover 
sterile — that  is,  does  not  contain  the  usual  pus  organisms.     The  products  of 
the  tubercle  bacilli  are  probably  able  to  induce  suppuration,  as  in  joint  and 
bone  tuberculosis  pus  is  frequently  produced,  although  this  may  be  due  to  a 
mixed  infection.     Tuberculin  is  one  of  the  best  agents  for  the  production 
of  experimental  suppuration.     In  tuberculosis  of  the  lungs  the  suppuration  is 
largely  the  result  of  an  infection  with  pus  organisms. 

II.     ACUTE    MILIAKY   TUBEECULOSIS 

The  modern  knowledge  of  this  remarkable  form  dates  from  the  statement 
«f  Buhl  (1856),  that  miliary  tuberculosis  is  a  specific  infection  dependent  on 


168  SPECIFIC    INFECTIOUS    DISEASES 

the  presence  in  the  body  of  an  unencapsulated  yellow  tubercle,  or  a  tubercu- 
lous cavity  in  the  lung;  and  that  it  bears  the  same  relation  to  the  primary 
lesion  as  pyaemia  does  to  a  focus  of  suppuration. 

Carl  Weigert  established  the  truth  of  this  brilliant  conception  by  demon- 
strating the  association  of  miliary  tuberculosis  with  tuberculosis  of  the  blood- 
vessels. There  are  two  groups  of  vessel  tubercle — the  tuberculous  periangitis 
in  which  there  is  invasion  of  the  adventitia,  and  the  endangitis  in  which  the 
tubercles  start  in  the  intima.  The  parts  most  frequently  affected  are  the 
pulmonary  veins  and  the  thoracic  duct,  less  often  the  jugular  vein,  the  supra- 
renal and  the  vena  cava  superior,  and  the  sinuses  of  the  dura  mater,  the  aorta, 
and  the  endocardium.  To  the  branches  of  the  pulmonary  veins  it  is  not 
uncommon  to  find  caseous  glands  adherent,  penetrating  the  walls  and  show- 
ing a  growth  of  miliary  tubercles  in  the  intima.  A  special  interest  belongs 
to  tuberculosis  of  the  thoracic  duct,  first  accurately  described  by  Sir  Astley 
Cooper.  Benda  in  a  series  of  19  cases  of  vessel  tuberculosis  found  in  many 
instances  an  enormous  number  of  bacilli,  particularly  in  the  caseous  tubercles 
of  the  thoracic  duct. 

The  bacilli  do  not  increase  in  the  blood,  but  settle  in  the  different  organs, 
producing  a  generalized  tuberculosis,  of  which  Weigert  recognizes  three  types 
or  grades:  I.  The  acute  general  miliary  tuberculosis,  in  which  the  various 
organs  of  the  body  are  stuffed  with  miliary  and  submiliary  nodules.  II.  A 
second  form  characterized  by  a  small  number  of  tubercles  in  one  or  many 
organs.  III.  The  occurrence  of  numerous  tuberculous  foci  widely  spread 
throughout  the  body,  but  in  a  more  chronic  form ;  the  tubercles  are  larger  and 
many  are  caseous.  It  is  the  chronic  generalized  tuberculosis  of  children. 
Transitional  forms  between  these  groups  occur.  In  the  first  variety,  which  we 
are  here  considering,  there  is  an  eruption  into  the  circulation  of  an  enormous 
number  of  bacilli.  Benda  suggests  in  explanation  of  the  profound  toxaemia 
seen  in  certain  cases  (the  typhoid  form)  that  in  addition  the  blood  is  sur- 
charged with  toxins  from  a  large  caseous  focus  which,  has  eroded  the  vessel. 

Clinical  Forms 

The  cases  may  be  grouped  into  those  with  the  symptoms  of  an  acute  gen<- 
eral  infection — the  typhoid  form;  cases  in  which  pulmonary  symptoms  pre- 
dominate; and  cases  in  which  the  cerebral  or  cerebro-spinal  symptoms  are 
marked — tuberculous  meningitis. 

Other  forms  have  been  recognized,  but  this  division  covers  a  large  majority 
of  the  cases. 

Taking  any  series  of  cases  it  will  be  found  that  the  meningeal  form  of  acute 
tuberculosis  exceeds  in  numbers  the  cases  with  general  or  marked  pulmonary 
symptoms. 

General  or  Typhoid  Form.— SYMPTOMS.— The  patient  presents  the  symp- 
toms of  a  profound  infection  which  simulates  and  is  frequently  mistaken  for 
typhoid  fever.  After  a  period  of  failing  health,  with  loss  of  appetite,  he 
becomes  feverish  and  weak.  Occasionally  the  disease  sets  in  more  abruptly, 
but  in  many  instances  the  anamnesis  closely  resembles  that  of  typhoid  fever. 
Nose-bleeding,  however,  is  rare.  The  temperature  increases,  the  pulse  be- 
comes rapid  and  feeble,  the  tongue  dry;  delirium  becomes  marked  and  the 
cheeks  are  flushed.  The  pulmonary  symptoms  may  be  very  slight;  usually 


TUBERCULOSIS  169 

bronchitis  exists,  but  is  not  more  severe  than  is  common  with  typhoid  fever. 
The  pulse  is  seldom  dicrotic,  but  is  rapid  in  proportion  to  the  pyrexia.  Per- 
haps the  most  striking  feature  of  the  temperature  is  the  irregularity;  and  if 
seen  from  the  outset  there  is  not  the  steady  ascent  noted  in  typhoid  fever. 
There  is  usually  an  evening  rise  to  103°  R,  sometimes  104°  R,  and  a  morn- 
ing remission  of  from  two  to  three  degrees.  Sometimes  the  pyrexia  is  inter- 
mittent, and  the  thermometer  may  register  below  normal  during  the  early 
morning  hours.  The  inverse  type  of  temperature,  in  which  the  rise  takes 
place  in  the  morning,  is  held  by  some  writers  to  be  more  frequent  in  general 
tuberculosis  than  in  other  diseases.  In  rare  instances  there  may  be  little  or 
no  fever.  On  two  occasions  I  have  had  a  patient  admitted  to  my  wards 
in  a  condition  of  profound  debility,  with  a  history  of  illness  of  from  three 
to  four  weeks'  duration,  with  rapid  pulse,  flushed  cheeks,  dry  tongue,  and 
very  slight  elevation  in  temperature,  in  whom  (post  mortem)  the  condition 
proved  to  be  general  tuberculosis.  In  one  instance  there  was  tolerably  ex- 
tensive disease  at  the  right  apex.  Eeinhold,  from  Baumler's  clinic,  has  called 
attention  to  these  afebrile  forms  of  acute  tuberculosis.  In  9  of  52  cases  there 
was  no  fever,  or  only  a  transient  rise. 

In  a  considerable  number  of  the  cases  the  respirations  are  increased 
in  frequency,  particularly  in  the  early  stage,  and  there  may  be  signs  of  diffuse 
bronchitis  and  slight  cyanosis.  Cheyne-Stokes  breathing  occurs  toward  the 
close. 

Active  delirium  is  rare.  More  commonly  there  are  torpor  and  dullness, 
gradually  deepening  into  coma,  in  which  the  patient  dies.  In  some  cases 
the  pulmonary  symptoms  become  more  marked;  in  others  meningeal  or  cere- 
bral features  occur. 

DIAGNOSIS. — The .  differential  diagnosis  between  general  miliary  tubercu- 
losis without  local  manifestations  and  typhoid  fever  is  extremely  difficult.  A 
point  of  importance,  to  which  reference  has  already  been  made,  is  the  irregu- 
larity of  the  temperature  curve.  The  greater  frequency  of  the  respirations 
and  the  tendency  to  slight  cyanosis  are  much  more  common  in  tuberculosis. 
There  are  cases,  however,  of  typhoid  fever  in  which  the  initial  bronchitis  is 
severe  and  may  lead  to  dyspnoaa  and  disturbed  oxygenation.  The  cough  may 
be  slight  or  absent.  Diarrhoea  is  rare  in  tuberculosis;  the  bowels  are  usually 
constipated;  but  diarrhoaa  may  occur  and  persist  for  days.  In  certain  cases 
the  diagnosis  has  been  complicated  still  further  by  the  occurrence  of  blood 
in  the  stools.  Enlargement  of  the  spleen  occurs  in  general  tuberculosis,  but 
is  neither  so  early  nor  so  marked  as  in  typhoid  fever.  In  children,  however, 
the  enlargement  may  be  considerable.  The  urine  may  show  traces  of  albu- 
min, and  unfortunately  Ehrlich's  diazo-reaction,  which  is  so  constant  in 
typhoid  fever,  is  also  met  with  in  general  tuberculosis.  The  absence  of  the 
characteristic  roseola  is  an  important  feature.  Occasionally  in  acute  tubercu- 
losis reddish  spots  may  occur  and  for  a  time  cause  difficulty,  but  they  do  not 
come  out  in  crops,  and  rarely  have  the  characters  of  the  true  typhoid  eruption. 
Herpes  is  perhaps  more  common  in  tuberculosis.  Toward  the  close,  petechiae 
may  appear  on  the  skin,  particularly  about  the  wrists.  A  rare  event  is  jaun- 
dice, due  possibly  to  the  eruption  of  tubercles  in  the  liver.  It  is  to  be  remem- 
bered that  the  lesions  of  acute  tuberculosis  and  of  typhoid  fever  have  been 
demonstrated  in  the  same  body. 


170  SPECIFIC    INFECTIOUS    DISEASES 

A  negative  Widal  test  or  ophthalmo-reaction,  and  the  absence  of  typhoid 
bacilli  in  blood-cultures  may  be  of  decisive  importance  in  these  doubtful 
cases.  In  very  rare  instances  tubercle  bacilli  have  been  found  in  the  blood. 
Leucocytosis  is  more  common  in  miliary  tuberculosis  than  in  typhoid  fever, 
in  which  leucopenia  is  the  rule.  Careful  examination  of  the  eyes  may  show 
choroidal  tubercles,  though  I  have  never  known  a  diagnosis  made  on  their 
presence  alone.  In  the  fluid  obtained  by  lumbar  puncture  the  tubercle  bacilli 
may  be  abundant,  even  when  there  is  no  active  meningitis.  In  a  few  cases  the 
bacilli  have  been  found  in  the  urine. 

Pulmonary  Form^—  SYMPTOMS. — From  the  outset  the  pulmonary  symp- 
toms are  marked.  The  patient  may  have  had  a  cough  for  months  or  for 
years  without  much  impairment  of  health,  or  he  may  be  known  to  be  the 
subject  of  chronic  pulmonary  tuberculosis.  In  other  instances,  particularly 
in  children,  the  affection  follows  measles  or  whooping  cough,  and  is  of  a  dis- 
tinctly broncho-pneumonic  type.  The  disease  begins  with  the  symptoms  of 
diffuse  bronchitis.  The  cough  is  marked,  the  expectoration  muco-purulent, 
occasionally  rusty.  Haemoptysis  has  been  noted  in  a  few  instances.  From 
the  outset  dyspncea  is  a  striking  feature  and  may  be  out  of  proportion  to  the 
intensity  of  the  physical  signs.  There  is  more  or  less  cyanosis  of  the  lips  and 
finger-tips,  and  the  cheeks  are  suffused.  Apart  from  emphysema  and  the  later 
stages  of  severe  pneumonia,  I  know  of  no  other  pulmonary  condition  in  which 
the  cyanosis  is  so  marked.  The  physical  signs  are  those  of  bronchitis.  In 
children  there  may  be  defective  resonance  at  the  bases,  from  scattered  areas  of 
broncho-pneumonia;  or,  what  is  equally  suggestive,  areas  of  hyper-resonance. 
Indeed,  the  percussion  note,  particularly  in  the  front  of  the  chest,  in  some 
cases  of  miliary  tuberculosis,  is  full  and  clear,  and  it  will  be  noted  (post  mor- 
tem) that  the  lungs  are  unusually  voluminous.  This  is  probably  the  result 
of  more  or  less  widespread  acute  emphysema.  On  auscultation,  the  rales 
are  either  sibilant  and  sonorous  or  small,  fine,  and  crepitant.  There  may  be 
fine  crepitation  from  the  occurrence  of  tubercles  on  the  pleura  (Jiirgensen). 
In  children  there  may  be  high-pitched  tubular  breathing  at  the  bases  or 
toward  the  root  of  the  lung.  Toward  the  close  the  rales  may  be  larger  and 
more  mucous.  The  temperature  rises  to  102°  or  103°  F.,  and  may  present 
the  inverse  type.  The  pulse  is  rapid  and  feeble.  In  the  very  acute  cases  the 
spleen  is  always  enlarged.  The  disease  may  prove  fatal  in  ten  or  twelve  days, 
or  may  be  protracted  for  weeks  or  even  months. 

DIAGNOSIS. — The  diagnosis  of  this  form  offers  less  difficulty  and  is  more 
frequently  made.  There  is  often  a  history  of  previous  cough,  or  the  patient 
is  known  to  be  the  subject  of  local  disease  of  the  lung,  or  of  the  lymph  glands, 
or  of  the  bones.  In  children  these  symptoms  following  measles  or  whooping 
cough  indicate  in  the  majority  of  cases  acute  miliary  tuberculosis,  with 
or  without  broncho-pneumonia.  Occasionally  the  sputum  contains  tubercle 
bacilli. 

The  choroidal  tubercle  occurs  in  a  limited  number  of  cases  and  may  help 
the  diagnosis.  More  important  in  an  adult  is  the  combination  of  dyspncea 
with  cyanosis  and  the  signs  of  a  diffuse  bronchitis.  In  some  instances  the 
occurrence  of  cerebral  symptoms  at  once  gives  a  clew  to  the  nature  of  the 
trouble. 

Meningeal  Form  (Tuberculous  Meningitis,  Basilar  Meningitis). — This  af- 


TUBERCULOSIS  171 

fection,  which  is  also  known  as  acute  hydrocephalus  or  "water  on  the  brain," 
is  essentially  an  acute  tuberculosis  in  which  the  membranes  of  the  brain, 
sometimes  of  the  cord,  bear  the  brant  of  the  attack.  Our  first  accurate 
knowledge  of  this  affection  dates  from  the  publication  of  Robert  Whytt's 
Observations  on  the  Dropsy  of  the  Brain,  Edinburgh,  1768.  He  studied  20 
cases  and  divided  the  disease  into  three  stages,  according  to  the  condition  of 
the  pulse. 

Though  Guersant  had  as  early  as  1827  used  the  name  granular  menin- 
gitis for  this  form  of  inflammation  of  the  meninges,  it. was  not  until  1830 
that  Papavoine  demonstrated  the  nature  of  the  granules  and  noted  their 
occurrence  with  tubercles  in  other  parts. 

In  1832  and  1833,  W.  W.  Gerhard,  of  Philadelphia,  made  a  very  careful 
study  of  the  disease  in  the  Children's  Hospital  at  Paris,  and  his  publications, 
more  than  those  of  any  other  author,  served  to  place  the  disease  on  a  firm, 
anatomical  and  clinical  basis.  •*.•-: 

There  are  several  special  etiological  factors  in  connection  with  this  form. 
It  is  much  more  common  in  children  than  in  adults.  It  occurs  during  the 
first  year  of  life,  but  is  more  frequent  between  the  second  and  the  fifth  years. 
In  a  majority  of  the  cases  a  focus  of  old  tuberculous  disease  will  be  found, 
commonly  in  the  bronchial  or  mesenteric  glands.  In  a  few  instances  the 
affection  seems  to  be  primary  in  the  meninges.  It  is  very  difficult,  however, 
in  an  ordinary  post  mortem  to  make  an  exhaustive  search,  and  the  lesion  may 
be  in  the  bones,  sometimes  in  the  middle  ear,  or  in  the  genito-urinary  organs. 
In  those  instances  in  which  no  primary  focus  has  been  discovered  it  has  been 
suggested  that  the  bacilli  reach  the  meninges  through  the  cribriform  plate 
of  the  ethmoid  from  the  upper  part  of  the  nostrils,  but  this  is  not 
probable. 

MOKBID  ANATOMY. — The  meninges  at  the  base  are  most  involved,  hence 
the  term  basilar  meningitis.  The  parts  about  the  optic  chiasm,  the  Sylvian 
fissures,  and  the  interpeduncular  space  are  affected.  There  may  be  only  slight 
turbidity  and  matting  of  the  membranes,  and  a  certain  stickiness  with  serous 
infiltration;  but  more  commonly  there  is  a  turbid  exudate,  fibrino-purulent 
in  character,  which  covers  the  structures  at  the  base,  surrounds  the  nerves, 
extends  into  the  Sylvian  fissures,  and  appears  on  the  lateral,  rarely  on  the 
upper,  surfaces  of  the  hemispheres.  The  tubercles  may  be  very  apparent, 
particularly  in  the  Sylvian  fissures,  appearing  as  small,  whitish  nodules  on 
the  membranes.  They  vary  much  in  number  and  size,  and  may  be  difficult 
to  find.  The  amount  of  exudate  bears  no  definite  relation  to  the  abundance 
of  tubercles.  The  arteries  of  the  anterior  and  posterior  perforated  spaces 
should  be  carefully  withdrawn  and  searched,  as  upon  them  nodular  tubercles 
may  be  found  when  not  present  elsewhere.  In  doubtful  cases  the  middle  cere- 
bral arteries  should  be  very  carefully  removed,  spread  on  a  glass  plate  with 
a  black  background,  and  examined  with  a  lens.  The  tubercles  are  then  seen 
as  nodular  enlargements  on  the  smaller  arteries.  The  lateral  ventricles  are 
dilated  (acute  hydrocephalus)  and  contain  a  turbid  fluid;  the  ependyma  may 
be  softened,  and  the  septum  lucidum  and  fornix  are  usually  broken  down. 
The  convolutions  are  often  flattened  and  the  sulci  obliterated  owing  to  the 
increased  intra-ventricular  pressure.  The  meninges  are  not  alone  involved, 
but  the  contiguous  cerebral  substance  is  more  or  less  cedematous  and  infil- 


172  SPECIFIC   INFECTIOUS   DISEASES 

trated  with  leucocytes,  so  that  anatomically  the  condition  is  in  reality  a 
menin go-encephalitis. 

There  are  instances  in  which  the  acute  process  is  associated  with  chronic 
meningeal  tuberculosis;  cases  which  may  for  months  present  the  clinical  pic- 
ture of  brain  tumor.  Although  in  a  majority  of  instances  the  process  is  cere- 
bral, the  spinal  meninges  may  also  be  involved,  particularly  those  of  the  cer- 
vical cord.  There  are  cases,  indeed,  in  which  the  symptoms  are  chiefly  spinal. 

SYMPTOMS.— Tuberculous  meningitis  presents  an  extremely  complex 
clinical  picture.  It  will  be  best  to  describe  the  form  found  in  children. 

Prodromal  symptoms  are  common.  The  child  may  have  been  in  failing 
health  for  some  weeks,  or  may  be  convalescent  from  measles  or  whooping 
cough.  In  many  instances  there  is  a  history  of  a  fall.  The  child  gets  thin, 
is  restless,  peevish,  irritable,  loses  its  appetite,  and  the  disposition  may  com- 
pletely change.  Symptoms  pointing  to  the  disease  may  then  set  in,  either 
quite  suddenly  with  a  convulsion,  or  more  commonly  with  headache,  vomit- 
ing, and  fever,  three  essential  symptoms  of  the  onset  which  are  rarely  absent. 
The  pain  may  be  intense  and  agonizing.  The  child  puts  its  hand  to  its  head 
and  occasionally,  when  the  pain  becomes  worse,  gives  a  short,  sudden  cry,  the 
so-called  hydrocephalic  cry.  Sometimes  the  child  screams  continuously  until 
utterly  exhausted.  The  vomiting  is  without  apparent  cause,  and  is  indepen- 
dent of  taking  of  food.  Constipation  is  usually  present.  The  fever  is  slight, 
but  gradually  rises  to  102°  to  103°  F.  The  pulse  is  at  first  rapid,  subse- 
quently irregular  and  slow.  The  respirations  are  rarely  altered.  During 
sleep  the  child  is  restless  and  disturbed.  There  may  be  twitchings  of  the 
muscles,  or  sudden  startings;  or  the  child  may  wake  up  from  sleep  in  great 
terror.  In  this  early  stage  the  pupils  are  usually  contracted.  These  are  the 
chief  symptoms  of  the  initial  stage,  or,  as  it  is  termed,  the  stage  of  irritation. 

In  the  second  period  of  the  disease  these  irritative  symptoms  subside; 
vomiting  is  no  longer  marked,  the  abdomen  becomes  retracted,  boat-shaped, 
or  carinated.  The  bowels  are  obstinately  constipated,  the  child  no  longer 
complains  of  headache,  but  is  dull  and  apathetic,  and  when  roused  is  more  or 
less  delirious.  The  head  is  often  retracted  and  the  child  utters  an  occasional 
cry.  The  pupils  are  dilated  or  irregular,  and  a  squint  may  develop.  Sighing 
respiration  is  common.  Convulsions  may  occur,  or  rigidity  of  the  muscles  of 
one  side  or  of  one  limb.  The  temperature  is  variable,  ranging  from  100°  to 
102.5°  F.  A  blotchy  erythema  is  not  uncommon  on  the  skin.  If  the  finger- 
nail is  drawn  across  the  skin  of  any  region  a  red  line  comes  out  quickly,  the 
so-called  tache  cerebrale,  which,  however,  has  no  diagnostic  significance. 

In  the  final  period,  or  stage  of  paralysis,  the  coma  increases  and  the  child 
can  not  be  roused.  Convulsions  are  not  infrequent,  and  there  are  spasmodic 
contractions  of  the  muscles  of  the  back  and  neck.  Spasms  may  occur  in  the 
limbs  of  one  side.  Optic  neuritis  and  paralysis  of  the  ocular  muscles  may  be 
present.  The  pupils  become  dilated,  the  eyelids  are  only  partially  closed,  and 
the  eyeballs  are  rolled  up  so  that  the  corneas  are  only  uncovered  in  part  by 
the  upper  eyelids.  Diarrhoea  may  occur,  the  pulse  becomes  rapid,  and  the 
child  may  sink  into  a  typhoid  state  with  dry  tongue,  low  delirium,  and  invol- 
untary passages  of  urine  and  faeces.  The  temperature  often  becomes  sub- 
normal, sinking  in  rare  instances  to  93°  or  94°  F.  In  some  cases  there  is  an 
ante-mortem  elevation  of  temperature,  the  fever  rising  to  106°  F.  The  entire 


TUBERCULOSIS  173 

duration  of  the  disease  is  from  a  fortnight  to  three  or  four  weeks.  A  leuco- 
cytosis  is  not  infrequently  present  throughout  the  disease. 

There  are  cases  of  tuberculous  meningitis  which  pursue  a  more  rapid 
course.  They  set  in  with  great  violence,  often  in  persons  apparently  in  good 
health,  and  may  prove  fatal  within  a  few  days.  In  these  instances,  more 
commonly  seen  in  adults,  the  convex  surface  of  the  brain  is  usually  involved. 
There  are  again  instances  which  are  essentially  chronic  and  display  symptoms 
of  a  limited  meningitis,  sometimes  with  pronounced  psychical  symptoms,  and 
sometimes  with  those  of  cerebral  tumor. 

There  are  certain  features  which  call  for  special  comment. 

The  irregularity  and  slowness  of  the  pulse  in  the  early  and  middle  stages 
of  the  disease  are  points  upon  which  all  authors  agree.  Toward  the  close,  as 
the  heart's  action  becomes  weaker,  the  pulsations  are  more  frequent.  The 
temperature  is  usually  elevated,  but  there  are  instances  in  which  it  does  not 
rise  in  the  whole  course  of  the  disease  -much  above  100°  F.  It  may  be  ex- 
tremely irregular,  and  the  oscillations  are  often  as  much  as  three  or  four 
degrees  in  the  day.  Toward  the  close  the  temperature  may  sink  to  95°  F., 
occasionally  to  94°  F.,  or  there  may  be  hyperpyrexia.  In  a  case  of  Baum- 
ler's  the  temperature  rose  before  death  to  43.7°  C.  (110.7°  F.). 

The  ocular  symptoms  of  the  disease  are  of  special  importance.  In  the 
early  stages  narrowing  of  the  pupils  is  the  rule.  Toward  the  close,  with  in- 
crease in  the  intra-cranial  pressure,  the  pupils  dilate  and  are  irregular.  There 
may  be  conjugate  deviation  of  the  eyes.  Of  ocular  nerves  the  third  is  most 
frequently  involved,  sometimes  with  paralysis  of  the  face,  limbs,  and  hypo- 
glossal  nerve  on  the  opposite  side  (syndrome  of  Weber),  due  to  a  lesion  lim- 
ited to  the  inferior  and  internal  part  of  the  cms.  The  changes  in  the  retina? 
are  very  important.  Neuritis  is  the  most  common.  According  to  Gowers, 
the  disk  at  first  becomes  full  colored  and  has  hazy  outlines,  and  the  veins  are 
dilated.  Swelling  and  striat-ion  become  pronounced,  but  the  neuritis  is  rarely 
intense.  Of  26  cases  studied  by  Garlick,  in  6  the  condition  was  of  diagnostic 
value.  The  tuoercles  in  the  choroid  are  rare  and  much  less  frequently  seen 
during  life  than  post  mortem  figures  would  indicate.  Thus,  Litten  found 
them  (post  mortem)  in  39  out  of  52  cases.  They  were  present  in  only  1  of 
the  26  cases  of  tuberculous  meningitis  examined  by  Garlick.  Heinzel  exam- 
ined with  negative  results  41  cases. 

Among  the  motor  symptoms  convulsions  are  most  common,  but  there  are 
other  changes  which  deserve  special  mention.  A  tetanic  contraction  of  one 
limb  may  persist  for  several  days,  or  a  cataleptic  condition.  Tremor  and 
athetoid  movements  are  sometimes  seen.  The  paralyses  are  either  hemiplegias 
or  monoplegias.  Hemiplegia  may  result  from  disturbance  in  the  cortical 
branches  of  the  middle  cerebral  artery,  occasionally  from  softening  in  the 
internal  capsule,  due  to  involvement  of  the  central  branches.  Of  monoplegias, 
that  of  the  face  is  perhaps  most  common,  and  if  on  the  right  side  it  may  occur 
with  aphasia.  In  two  of  my  cases  in  adults  aphasia  occurred.  Brachial  mono- 
plegia  may  be  associated  with  it.  In  the  more  chronic  cases  the  symptoms 
persist  for  months,  and  there  may  be  a  characteristic  Jacksonian  epilepsy. 
Kernig's  sign  may  be  present,  but  is  not  constant.  The  Babinski  reflex  is 
sometimes  found. 

The  pjAGfrosig  °f  tuberculous  meningitis  is  rarely  difficult,  and  points 


174  SPECIFIC   INFECTIOUS   DISEASES 

upon  which  special  stress  is  to  be  laid  are  the  existence  of  a  tuberculous  focus 
in  the  body  the  mode  of  onset  and  the  symptoms,  and  the  evidence  obtained 
on  lumbar  puncture.  The  fluid  withdrawn  is  turbid,  under  increased  pres- 
sure and  the  protein  content  is  increased.  By  centrifugalization,  careful 
staining  and  long  search,  tubercle  bacilli  can  be  found  in  a  large  proportion 
of  cases— in  135  of  137  in  one  series  (Hemenway).  The  cells  are  usually  much 
increased  in  number  and  a  large  percentage  (over  90  per  cent.)  are  small 
mononuclear  lymphocytes,  though  occasionally  an  excess  of  polymorphonu- 
clear  leucocytes  is  found. 

The  PROGNOSIS  in  this  form  of  meningitis  is  always  most  serious. 
neither  seen  a  case  which  I  regarded  as  tuberculous  recover,  nor  have  I  seen 
post  mortem  evidence  of  past  disease  of  this  nature.  Cases  of  recovery  have 
been  reported  by  reliable  authorities,  but  they  are  extremely  rare,  and  there 
is  always  a  reasonable  doubt  as  to  the  correctness  of  the  diagnosis.  The  differ- 
ential features  and  treatment  are  considered  in  connection  with  acute  men- 
ingitis. 

III.    TUBEECULOSIS  OF  THE  LYMPHATIC  SYSTEM 

1.    Tuberculosis  of  the  Lymph-glands   (Scrofula) 

Scrofula  is  tubercle,  as  it  has  been  shown  that  the  bacillus  of  Koch  is  the 
essential  element.  Formerly  special  attention  was  given  to  different  types 
of  scrofula,  of  which  two  important  forms  were  recognized— the  sanguine,  in 
which  the  child  was  slightly  built,  tall,  with  small  limbs,  a  fine  clear  skin, 
soft  silky  hair,  and  was  mentally  very  bright  and  intelligent;  and  the  phleg- 
matic type,  in  which  the  child  was  short  and  thick-set,  with  coarse  features, 
muddy  complexion,  and  a  dull,  heavy  aspect.  It  is  not  yet  definitely  settled 
whether  the  virus  which  produces  the  chronic  tuberculous  adenitis  or  scrofula 
differs  from  that  which  produces  tuberculosis  in  other  parts,  or  whether  it  is 
the  local  conditions  in  the  glands  which  account  for  the  slow  development  and 
milder  course.  The  observations  of  Lingard  are  important  as  showing  a 
variation  in  the  virulence  of  the  tubercle  bacillus.  '  Guinea-pigs  inoculated 
with  ordinary  tubercle  showed  lymphatic  infection  within  the  first  week,  and 
the  animals  died  within  three  months;  infected  with  material  from  scrofulous 
glands,  the  lymphatic  enlargement  did  not  appear  until  the  second  or  third 
week,  and  the  animals  survived  for  six  or  seven  months.  He  showed,  more- 
over, that  the  virulence  of  the  infection  obtained  from  the  scrofulous  glands 
increased  in  intensity  by  passing  through  a  series  of  guinea-pigs.  In  a  cer- 
tain number  of  cases  the  infection  is  with  the  bovine  germ,  but  exactly  in 
what  proportion,  and  with  what  special  clinical  features  has  not  yet  been 
determined. 

Tuberculous  adenitis,  met  with  at  all  ages,  is  more  common  in  children 
than  in  adults,  and  may  occur  in  old  age. 

Tubercle  bacilli  are  ubiquitous ;  all  are  exposed  to  infection,  and  upon  the 
local  conditions,  whether  favorable  or  unfavorable,  depends  the  fate  of  those 
organisms  which  find  lodgment  in  our  bodies.  A  special  predisposing  factor 
in  lymphatic  tuberculosis  is  catarrh  of  the  mucous  membranes,  which  in  itself 
excites  slight  adenitis  of  the  neighboring  glands.  In  a  child  with  constantly 
recurring  naso-pharyngeal  catarrh,  the  bacilli  which  lodge  on  the  mucous 
membranes  find  in  all  probability  the  gateways  less  strictly  guarded  and  are 


TUBERCULOSIS  175 

taken  up  by  the  lymphatics  and  passed  to  the  nearest  glands.  The  impor- 
tance of  the  tonsils  as  an  infection-atrium  has  of  late  been  urged.  In  condi- 
tions of  health  the  local  resistance,  or,  as  some  would  put  it,  the  phagocytes, 
would  be  active  enough  to  deal  with  the  invaders,  but  the  irritation  of  a 
chronic  catarrh  weakens  the  resistance  of  the  lymph-tissue,  and  the  bacilli  are 
enabled  to  grow  and  gradually  to  change  a  simple  into  a  tuberculous  adenitis. 
The  frequent  association  of  tuberculous  adenitis  of  the  bronchial  glands  with 
whooping  cough  and  with  measles,  and  the  association  of  tubercle  in  the 
mesenteric  glands  in  children  with  intestinal  catarrh,  find  in  this  way  a 
rational  explanation. 

The  following  are  some  of  the  features  of  interest  in  tuberculous  adenitis : 
(a)    The  local  character  of  the  disease.     Thus,  the  glands  of  the  neck,  or 
at  the  bifurcation  of  the  bronchi,  or  those  of  the  mesentery,  may  be  alone 
involved. 

(&)  The  tendency  to  spontaneous  healing.  In  a  large  proportion  of  the 
cases  the  battle  which  ensues  between  the  bacilli  and  the  protective  forces  is 
long;  but  the  latter  are  finally  successful,  and  we  find  in  the  calcified  rem- 
nants in  the  bronchial  and  mesenteric  lymph-glands  evidences  of  victory. 
Too  often  in  the  bronchial  glands  a  truce  only  is  declared  and  hostilities  may 
break  out  afresh  in  the  form  of  an  acute  tuberculosis. 

(c)  The  tendency  of  tuberculous  adenitis  to  pass  on  to  suppuration.    The 
frequency  with  which,  particularly  in  the  glands  of  the  neck,  we  find  the 
tuberculous  processes  associated  with  suppuration  is  a  special  feature  of  this 
form  of  adenitis.     In  nearly  all  instances  the  pus  is  sterile.     Whether  the 
suppuration  is  excited  by  the  bacilli  or  by  their  products,  or  whether  it  is  the 
result  of  a  mixed  infection  with  pus  organisms,  which  are  subsequently  de- 
stroyed, has  not  been  settled. 

(d)  The   existence  of   an  unhealed  tuberculous   adenitis  is  a  constant 
menace  to  the  organism.     It  is  safe  to  say  that  in  three-fourths  of  the  in- 
stances of  acute  tuberculosis  the  infection  is  derived  from  this  source.     On 
the  other  hand,  it  has  been  urged  that  "scrofula"  in  childhood  gives  im- 
munity in  adult  life.    We  certainly  do  meet  with  many  persons  of  exceptional 
bodily  vigor  who  in  childhood  had  enlarged  glands,  but  the  evidence  which 
Marfan  brings  forward  in  support  of  this  view  is  not  conclusive. 

Generalized  Tuberculous  Lymphadenitis.. — In  exceptional  instances  we 
find  diffuse  tuberculosis  of  nearly  all  the  lymph-glands  of  the  body  with  lit- 
tle or  no  involvement  of  other  parts.  The  most  extreme  cases  of  it,  which  I 
have  seen,  have  been  in  negro  patients.  Two  well-marked  cases  occurred  at 
the  Philadelphia  Hospital.  In  a  woman,  the  chart  from  April,  1888,  until 
March,  1889,  showed  persistent  fever,  ranging  from  101°  to  103°  F.,  oc- 
casionally rising  to  104°  F.  On  December  16th  the  glands  on  the  right  side 
of  the  neck  were  removed.  After  an  attack  of  erysipelas,  on  February  17th, 
she  gradually  sank  and  died  March  5th.  The  lungs  presented  only  one  or 
two  puckered  spots  at  the  apices.  The  bronchial,  retro-peritoneal,  and  mesen- 
teric glands  were  greatly  enlarged  and  caseous.  There  was  no  intestinal, 
uterine,  or  bone  disease.  The  continuous  high  fever  in  this  case  depended 
apparently  upon  the  tuberculous  adenitis,  which  was  much  more  extensive 
than  was  supposed  during  life.  In  these  instances  the  enlargement  is  most 
marked  in  the  retro-peritoneal,  bronchial,  and  mesenteric  glands,  but  may  be 


176  SPECIFIC   INFECTIOUS   DISEASES 

also  present  in  the  groups  of  external  glands.  Occurring  acutely,  it  presents  a 
picture  resembling  Hodgkin's  disease.  In  a  case  which  died  in  the  Montreal 
General  Hospital  this  diagnosis  was  made.  The  cervical  and  axillary  glands 
were  enormously  enlarged,  and  death  was  caused  by  infiltration  of  the  larynx. 
In  infants  and  children  there  is  a  form  of  general  tuberculous  adenitis  in 
which  the  various  groups  of  glands  are  successively,  more  rarely  simultane- 
ously, involved,  and  in  which  death  is  caused  either  by  cachexia  or  by  an 
acute  infection  of  the  meninges. 

Local  Tuberculous  Adenitis.— (a)  CERVICAL. — This  is  the  most  common 
form  met  with  in  children.  It  is  seen  particularly  among  the  poor  and 
those  who  live  continuously  in  the  impure  atmosphere  of  badly  ventilated 
lodgings.  Children  in  foundling  hospitals  and  asylums  are  specially  prone  to 
the  disease.  In  the  United  States  it  is  most  common  in  the  negro  race.  As 
already  stated,  it  is  often  met  with  in  catarrh  of  the  nose  and  throat,  or 
chronic  enlargement  of  the  tonsils;  or  the  child  may  have  had  eczema  of  the 
scalp  or  a  purulent  otitis. 

The  submaxillary  glands  are  first  involved,  and  are  popularly  spoken  of 
as  enlarged  kernels.  They  are  usually  larger  on  one  side  than  on  the  other. 
As  they  increase  in  size,  the  individual  tumors  can  be  felt;  the  surface  is 
smooth  and  the  consistence  firm.  They  may  remain  isolated,  but  more  com- 
monly they  form  large,  knotted  masses,  over  which  the  skin  is,  as  a  rule, 
freely  movable.  In  many  cases  the  skin  ultimately  becomes  adherent,  and 
inflammation  and  suppuration  occur.  An  abscess  points  and,  unless  opened, 
bursts,  leaving  a  sinus  which  heals  slowly.  The  disease  is  frequently  asso- 
ciated with  coryza,  with  eczema  of  the  scalp,  ear,  or  lips,  and  with  conjuncti- 
vitis or  keratitis.  When  the  glands  are  large  and  growing  actively  there  is 
fever.  The  subjects  are  usually  anaemic,  particularly  if  suppuration  has  oc- 
curred. The  progress  of  this  form  of  adenitis  is  slow  and  tedious.  Death, 
however,  rarely  follows,  and  many  aggravated  cases  in  children  get  well.  Not 
only  the  submaxillary  group,  but  the  glands  above  the  clavicle  and  in  the 
posterior  cervical  triangle,  may  be  involved.  In  other  instances  the  cervical 
and  axillary  glands  are  involved  together,  forming  a  continuous  chain  which 
extends  beneath  the  clavicle  and  the  pectoral  muscle.  With  them  the  bron- 
chial glands  may  also  be  enlarged  and  caseous.  Not  infrequently  the  en- 
largement of  the  supra-clavicular  and  axillary  group  of  glands  on  one  side 
precedes  a  tuberculous  pleurisy  or  pulmonary  tuberculosis. 

(&)  TRACHEO-BRONCHIAL. — The  mediastinal  lymph-glands  constitute  fil- 
ters in  which  lodge  the  various  foreign  particles  which  escape  the  normal 
phagocytes  of  bronchi  and  lungs.  Among  these  foreign  particles,  and  proba- 
bly attached  to  them,  tubercle  bacilli  are  not  uncommon,  and  we  find  tuber- 
cles and  caseous  matter  with  great  frequency  in  this  group.  Northrup  found 
them  involved  in  every  one  of  127  cases  of  tuberculosis  at  the  New  York 
Foundling  Hospital.  This  tuberculous  adenitis  may,  in  the  bronchial  glands, 
attain  the  dimensions  of  a  tumor  of  large  size.  In  children  the  bronchial 
adenitis  is  apt  to  be  associated  with  suppuration.  The  glands  at  the  bifurca- 
tion of  the  trachea  are  first  involved  and  chiefly  on  the  right  side — in  74  per 
cent  of  Wollstein's  cases.  Irregular  fever,  failure  of  nutrition,  loss  of  appe- 
tite, and  lassitude  may  be  caused  by  the  absorption  of  toxins;  pain  is  rare, 
though  it  is  complained  of  sometimes  in  the  mammary  region.  The  cough 


TUBERCULOSIS  177 

is  paroxysmal,  often  brassy,  so  that  it  has  been  mistaken  for  whooping  cough. 
Stridor,  when  present,  is  more  often  expiratory.  The  physical  signs  are  not 
very  definite.  Dilated  veins  over  the  anterior  aspect  of  the  thorax,  absence 
of  descent  of  the  larynx  during  inspiration,  and  pain  on  pressure  over  the 
upper  dorsal  vertebra  are  mentioned.  Extension  of  the  normal  dulness  over 
the  upper  four  thoracic  vertebrae  to  the  fifth  and  sixth  is  of  importance,  and 
there  may  be  para-vertebral  dulness  on  delicate  percussion.  Some  writers 
lay  stress  upon  the  bronchophony  over  the  upper  thoracic  vertebra?,  and  a 
venous  hum  may  be  heard  sometimes  over  the  manubrium.  The  X-ray  pic- 
tures are  regarded  by  experts  as  distinctive,  showing  the  shadow  extending 
from  either  side  of  the  spine. 

Some  of  the  more  uncommon  effects  are  the  following:  Compression  of 
the  superior  cava,  of  the  pulmonary  artery,  and  of  the  azygos  vein.  The 
trachea  and  bronchi,  though  often  flattened,  are  rarely  seriously  compressed. 
The  pncumogastric  nerve  may  be  involved,  particularly  the  recurrent  laryn- 
geal  branch.  More  important  really  are  the  perforations  of  the  enlarged  and 
softened  glands  into  the  bronchi  or  trachea,  or  a  sort  of  secondary  cyst  may 
be  formed  between  the  lung  and  the  trachea.  Asphyxia  has  been  caused  by 
blocking  of  the  larynx  by  a  caseous  gland  which  has  ulcerated  through  the 
bronchus  (Voelcker),  and  Cyril  Ogle  has  reported  a  case  in  which  the  ulcer- 
ated gland  practically  occluded  both  bronchi.  Perforations  of  the  vessels 
are  much  less  common,  but  the  pulmonary  artery  and  the  aorta  have  been 
opened.  Perforation  of  the  oesophagus  has  been  described  in  several  cases. 
One  of  the  most  serious  effects  is  infection  of  the  lung  or  pleura  by  the  case- 
ous glands  situated  deep  along  the  bronchi.  This  may,  as  is  often  clearly 
seen,  be  by  direct  contact,  and  it  may  be  difficult  to  determine  in  some  sec- 
tions where  the  caseous  bronchial  gland  terminates  and  the  pulmonary  tissue 
begins.  In  other  instances  it  takes  place  along  the  root  of  the  lung  and  is 
subpleural.  Among  other  sequences  may  be  mentioned  diverticulum  of  the 
oesophagus  following  adhesion  of  an  enlarged  gland  and  its  subsequent  retrac- 
tion; and,  in  the  case  of  the  anterior  mediastinal  and  aortic  groups,  the  fre- 
quent production  of  pericarditis,  either  by  contact  or  by  rupture  of  a  soft- 
ened gland  into  the  sac. 

A  serious  danger  is  systemic  infection,  which  takes  place  through  the 
vessels. 

(c)  MESENTERIC;  TABES  MESENTERICA. — In  this  affection,  the  abdomi- 
nal scrofula  of  old  writers,  the  glands  of  the  mesentery  and  retro-peritoneum 
become  enlarged  and  caseate ;  more  rarely  they  suppurate  or  calcify.  A  slight 
tuberculous  adenitis  is  extremely  common  in  children,  and  is  often  acci- 
dentally found  (post  mortem)  when  they  have  died  of  other  diseases.  It  may 
be  a  primary  lesion  associated  with  intestinal  catarrh,  or  it  may  be  secondary 
to  tuberculous  disease  of  the  intestines. 

The  statistics  of  abdominal  tuberculosis  show  a  great  variation  in  different 
localities.  The  small  percentage  in  New  York,  less  than  one  per  cent,  of  all 
cases  (Bovaird  and  Mt.  Sinai  Hospital  figures),  contrasts  with  the  high  fig- 
ures given  for  Scotland  by  John  Thomson,  3.57  for  Edinburgh  and  4.51  for 
Glasgow.  The  general  involvement  of  the  glands  interferes  seriously  with 
nutrition,  and  the  patients  are  puny,  wasted,  and  anaemic.  The  abdomen  is 
enlarged  and  tympanitic;  diarrhoea  is  a  constant  feature;  the  stools  are  thin 


178 

and  offensive.  There  is  moderate  fever,  but  the  general  wasting  and  debility 
are  the  most  characteristic  features.  The  enlarged  glands  can  not  often  be 
felt,  owing  to  the  distended  condition  of  the  bowels.  These  cases  are  often 
spoken  of  as  consumption  of  the  bowels,  but  in  a  majority  of  them  the  intes- 
tines do  not  present  tuberculous  lesions.  In  a  considerable  number  of  the 
cases  of  tabes  mesenterica  the  peritoneum  is  also  involved,  and  in  such  the 
abdomen  is  large  and  hard,  and  nodules  may  be  felt. 

In  adults  tuberculous  disease  of  the  mesenteric  glands  may  occur  as  a 
primary  affection,  or  in  association  with  pulmonary  disease.  Large  tumors 
may  exist  without  tuberculous  disease  in  the  intestines  or  in  any  other  part. 

2.    Tuberculosis  of  the  Serous  Membranes 

General  Serous  Membrane  Tuberculosis  (Polyorrhomenitis) . — The  serous 
membranes  may  be  chiefly  involved,  simultaneously  or  consecutively,  pre- 
senting a  distinctive  and  readily  recognizable  clinical  type  of  tuberculosis. 
There  are  three  groups  of  cases.  First,  those  in  which  an  acute  tuberculosis 
of  the  peritoneum  and  pleurae  occurs  rapidly,  caused  by  local  disease  of  the 
tubes  in  women,  or  of  the  mediastinal  or  bronchial  lymph-glands.  Secondly, 
cases  in  which  the  disease  is  more  chronic,  with  exudation  into  both  peritoneum 
and  pleura, 'the  formation  of  cheesy  masses,  and  the  occurrence  of  ulcerative 
and  suppurative  processes.  Thirdly,  there  are  cases  in  which  the  pleuro- 
peritoneal  affection  is  still  more  chronic,  the  tubercles  hard  and  fibroid,  the 
membranes  much  thickened,  and  with  little  or  no  exudate.  In  any  one  of 
these  three  forms  the  pericardium  may  be  involved  with  the  pleurae  and  peri- 
toneum. It  is  important  to  bear  in  mind  that  there  may  be  no  visceral  tuber- 
culosis in  these  cases. 

Tuberculosis  of  the  Pleura. — (a)  ACUTE  TUBERCULOUS  PLEURISY. — It  is 
difficult  in  the  present  state  of  our  knowledge  to  estimate  the  proportion  of 
instances  of  acute  pleurisy  due  to  tuberculosis  (see  Acute  Pleurisy).  The 
cases  are  rarely  fatal.  Here,  too,  there  are  three  groups  of  cases :  ( 1 )  Acute 
tuberculous  pleurisy  with  subsequent  chronic  course.  '(2)  Secondary  and  ter- 
minal forms  of  acute  pleurisy  (these  are  not  uncommon  in  hospital  practice). 
And  (3)  a  form  of  acute  tuberculous  suppurative  pleurisy.  A  considerable 
number  of  the  purulent  pleurisies,  designated  as  latent  and  chronic,  are 
caused  by  tubercle  bacilli,  but  the  fact  is  not  so  widely  recognized  that  there 
is  an  acute,  ulcerative,  and  suppurative  disease  which  may  run  a  very  rapid 
course.  The  pleurisy  sets  in  abruptly,  with  pain  in  the  side,  fever,  cough, 
and  sometimes  with  a  chill.  There  may  be  nothing  to  suggest  a  tuberculous 
process,  and  the  subject  may  have  a  fine  physique  and  come  of  healthy  stock. 
(6)  THE  SUBACUTE  AND  CHRONIC  TUBERCULOUS  PLEURISIES  are  more 
common.  The  largest  group  of  cases  comprises  those  with  sero-fibrinous  ef- 
fusion. The  onset  is  insidious,  the  true  character  of  the  disease  is  frequently 
overlooked,  and  in  almost  every  instance  there  are  tuberculous  foci  in  the 
lungs  and  in  the  bronchial  glands.  These  are  cases  in  which  the  termination 
is  often  in  pulmonary  tuberculosis  or  general  miliary  tuberculosis.  In  a  few 
cases  the  exudate  becomes  purulent. 

And,  lastly,  there  is  a  chronic  adhesive  pleurisy,  a  primary  proliferative 
form  which  is  of  long  standing,  may  lead  to  very  great  thickening  of  the  mem- 
brane, and  sometimes  to  invasion  of  the  lung. 


TUBERCULOSIS  179 

Secondary  tuberculous  pleurisy  is  very  common.  The  visceral  layer  is 
always  involved  in  pulmonary  tuberculosis.  Adhesions  usually  form  and  a 
chronic  pleurisy  results,  which  may  be  simple,  but  usually  tubercles  are  scat- 
tered through  the  adhesions.  An  acute  tuberculous  pleurisy  may  result  from 
direct  extension.  The  fluid  may  be  sero-fibrinous  or  "haemorrhagic,  or  may 
become  purulent.  And,  lastly,  a  very  common  event  in  pulmonary  tubercu- 
losis is  the  perforation  of  a  superficial  spot  of  softening,  and  the  production 
of  pyo-pneumothorax. 

The  general  symptomatology  of  these  forms  will  be  considered  under  dis- 
ease of  the  pleura. 

Tuberculosis  of  the  Pericardium, — Miliary  tubercles  may  occur  as  a  part 
of  a  general  infection,  but  the  term  is  properly  limited  to  those  cases  in  which, 
either  as  a  primary  or  secondary  process,  there  is  extensive  disease  of  the  mem- 
brane. Tuberculosis  is  not  so  common  in  the  pericardium  as  in  the  pleura 
and  peritoneum,  but  it  is  certainly  more  common  than  the  literature  would 
lead  us  to  suppose.  George  Norris  found  82  instances  among  1,780  post 
mortems  in  tuberculous  subjects. 

We  may  recognize  four  groups  of  cases:  First,  those  in  which  the  condi- 
tion is  entirely  latent,  and  the  disease  is  discovered  accidentally  in  individuals 
who  have  died  of  other  affections  or  of  chronic  pulmonary  tuberculosis. 

A  second  group,  in  which  the  symptoms  are  those  of  cardiac  insufficiency 
following  the  dilatation  and  hypertrophy  consequent  upon  a  chronic  adhesive 
pericarditis.  The  symptoms  are  those  of  cardiac  dropsy,  and  suggest  either 
idiopathic  hypertrophy  and  dilatation,  or,  if  there  is  a  loud  blowing  systolic 
murmur  at  the  apex,  mitral  valve  disease,  either  insufficiency  or  stenosis.  The 
condition  of  adherent  pericardium  is  usually  overlooked. 

In  a  third  group  the  clinical  picture  is  that  of  an  acute  tuberculosis,  either 
general  or  with  cerebro-spinal  manifestations,  which  has  had  its  origin  from 
the  tuberculous  pericardium  or  tuberculous  mediastinal  lymph-glands. 

A  fourth  group,  with  symptoms  of  acute  pericarditis,  includes  cases  in 
which  the  affection  is  acute  and  accompanied  with  more  or  less  exudation 
of  a  sero-fibrinous,  haemorrhagic,  or  purulent  character.  There  may  be  no 
suspicion  whatever  of  the  tuberculous  nature  of  the  trouble. 

Tuberculosis  of  the  Peritoneum. — In  connection  with  miliary  and  chronic 
pulmonary  tuberculosis  it  is  not  uncommon  to  find  the  peritoneum  studded 
with  small  gray  granulations.  They  are  constantly  present  on  the  serous  sur- 
face of  tuberculous  ulcers  of  the  intestines.  Apart  from  these  conditions  the 
membrane  is  often  the  seat  of  extensive  tuberculous  disease,  which  occurs  in 
the  following  forms : 

(a)    Acute  miliary  tuberculosis  with  sero-fibrinous  or  bloody  exudation. 

(&)  Chronic  tuberculosis,  characterized  by  larger  growths,  which  tend  to 
caseate  and  ulcerate.  The  exudate  is -purulent  or  sero-purulent,  and  is  often 
sacculated. 

(c)  Chronic  fibroid  tuberculosis,  which  may  be  subacute  from  the  onset, 
or  which  may  represent  the  final  stage  of  an  acute  miliary  eruption.  The 
tubercles  are  hard  and  pigmented.  There  is  little  or  no  exudation,  and  the 
serous  surfaces  are  matted  together  by  adhesions. 

The  process  may  be  primary  and  local,  which  was  the  case  in  5  of  17 
post  mortems.  In  children  the  infection  appears  to  pass  from  the  intestines, 


180  SPECIFIC    INFECTIOUS    DISEASES 

and  in  adults  this  is  the  source  in  the  cases  associated  with  chronic  phthisis. 
In  women  the  disease  extends  commonly  from  the  Fallopian  tubes.  In  at 
least  30  or  40  per  cent,  of  the  instances  of  laparotomy  in  this  affection  reported 
by  gynaecologists  the  infection  was  from  them.  The  prostate  or  the  sem- 
inal vesicles  may  be  the  starting-point.  In  many  cases  the  peritoneum  is 
involved  with  the  pleura  and  pericardium,  particularly  with  the  former  mem- 
brane. 

It  is  interesting  to  note  that  certain  morbid  conditions  of  the  abdominal 
organs  predispose  to  the  development  of  the  disease;  thus  patients  with  cirrho- 
sis of  the  liver  very  often  die  of  an  acute  tuberculous  peritonitis.  The  fre- 
quency with  which  the  condition  is  met  with  in  operations  upon  ovarian 
tumors  has  been  commented  upon  by  gynecologists.  Many  cases  have  fol- 
lowed trauma  of  the  abdomen.  A  very  interesting  feature  is  the  occurrence 
of  tuberculosis  in  hernial  sacs.  The  condition  is  not  very  uncommon.  In  a 
majority  of  the  instances  it  has  been  discovered  accidentally  during  the  oper- 
ation for  radical  cure  or  for  strangulation.  In  7  instances  the  sac  alone  was 
involved. 

It  is  generally  stated  that  males  are  attacked  oftener  than  females,  but 
in  the  collected  statistics  I  find  the  cases  to  be  twice  as  numerous  in  females 
as  in  males;  in  the  ratio,  indeed,  of  131  to  60. 

Tuberculous  peritonitis  occurs  at  all  ages.  It  is  common  in  children  asso- 
ciated with  intestinal  and  mesenteric  disease.  The  incidence  is  most  fre- 
quent between  the  ages  of  twenty  and  forty.  It  may  occur  in  advanced  life. 
In  one  of  my  cases  the  patient  was  eighty-two  years  of  age.  Of  357  cases 
collected  by  me  from  the  literature,  there  were  under  ten  years,  27 ;  between 
ten  and  twenty,  75;  from  twenty  to  thirty,  87;  between  thirty  and  forty,  71; 
from  forty  to  fifty,  61;  from  fifty  to  sixty,  19;  from  sixty  to  seventy,  4; 
above  seventy,  2.  In  America  it  is  more  common  in  the  negro  than  in  the 
white  race.  More  blacks  than  whites,  77  to  70,  were  admitted  to  the  Johns 
Hopkins  Hospital  (Hamman). 

SYMPTOMS. — In  certain  special  features  the  tube'rculous  varies  consider- 
ably from  other  forms  of  peritonitis.  It  presents  a  symptom-complex  of 
extraordinary  diversity. 

In  the  first  place,  the  process  may  be  latent  and  met  with  accidentally 
in  the  operation  for  hernia  or  for  ovarian  tumor.  The  acute  onset  is  not 
uncommon.  Four  cases  in  our  records  were  diagnosed  appendicitis,  two  acute 
cholecystitis,  and  six  had  symptoms  of  intestinal  obstruction,  in  two  of  these 
coming  on  with  great  abruptness  (Hamman).  The  cases  have  been  mistaken 
for  strangulated  hernia.  Other  cases  set  in  acutely  with  fever,  abdominal 
tenderness,  and  the  symptoms  of  ordinary  acute  peritonitis.  Cases  with  a 
slow  onset,  abdominal  tenderness,  tympanites,  and  low  continuous  fever  are 
often  mistaken  for  typhoid  fever. 

Ascites  is  frequent,  but  the  effusion  is  rarely  large.  It  is  sometimes  hffim- 
orrhagic.  In  this  form  the  diagnosis  may  rest  between  an  acute  miliary 
cancer,  cirrhosis  of  the  liver,  and  a  chronic  simple  peritonitis — conditions 
which  usually  offer  no  special  difficulties  in  differentiation.  A  most  impor- 
tant point  is  the  simultaneous  presence  of  a  pleurisy.  The  tuberculin  test 
may  be  used.  Tympunites  may  be  present  in  the  very  acute  cases,  when  it 
is  due  to  loss  of  tone  in  the  intestines  owing  to  inflammatory  infiltration;  or 


TUBERCULOSIS  181 

it  may  occur  in  the  old,  long-standing  cases  when  universal  adhesion  haa 
taken  place  between  the  parietal  and  visceral  layers.  Fever  is  a  marked 
symptom  in  the  acute  cases,  and  the  temperature  may  reach  103°  or  104°.  In 
many  instances  the  fever  is  slight.  In  the  more  chronic  cases  subnormal 
temperatures  are  common,  and  for  days  the  temperature  may  not  rise  above 
97°,  and  the  morning  record  may  be  as  low  as  95.5°.  An  occasional  symp- 
tom is  pigmentation  of  the  skin,  which  in  some  cases  has  led  to  the  diagnosis 
of  Addison's  disease.  A  striking  peculiarity  of  tuberculous  peritonitis  is  the 
frequency  with  which  the  condition  either  simulates  or  is  associated  with 
tumor.  This  may  be: 

(a)  Omental,  due  to  puckering  and  rolling  of  this  membrane  until  it 
forms  an  elongated  firm  mass,  attached  to  the  transverse  colon  and  lying 
athwart  the  upper  part  of  the  abdomen.  This  cord-like  structure  is  found 
also  with  cancerous  peritonitis,  but  is  much  more  common  in  tuberculosis. 
Gairdner  has  called  special  attention  to  this  form  of  .tumor,  and  in  children 
has  seen  it  undergo  gradual  resolution.  A  resonant  percussion  note  may 
sometimes  be  elicited  above  the  mass.  Though  usually  situated  near  the 
umbilicus,  the  omental  mass  may  form  a  prominent  tumor  in  the  right  iliac 
region. 

(6)  Sacculated  exudation,  in  which  the  effusion  is  limited  and  confined 
by  adhesions  between  the  coils,  the  parietal  peritoneum,  the  mesentery,  and 
the  abdominal  or  pelvic  organs.  This  encysted  exudate  is  most  common  in 
the  middle  zone,  and  has  frequently  been  mistaken  for  ovarian  tumor.  It  may 
occupy  the  entire  anterior  portion  of  the  peritoneum,  or  there  may  be  a  more 
limited  saccular  exudate  on  one  side  or  the  other.  Within  the  pelvis  it  is 
associated  with  disease  of  the  Fallopian  tubes.  Eighteen  cases  in  the  gynaeco- 
logical wards  (J.  H.  H.)  were  operated  upon  for  pyosalpinx  (Hamman). 

(c)  In  rare  cases  the  tumor  formations  may  be  due  to  great  retraction 
or  thickening  of  the  intestinal  coils.    The  small  intestine  is  found  shortened, 
the  walls  enormously  thickened,  and  the  entire  coil  may  form  a  firm  knot 
close  against  the  spine,  giving  on  examination  the  idea  of  a  solid  mass. 
Not  the  small  intestine  only,  but  the  entire  bowel  from  the  duodenum  to  the 
rectum,  has  been  found  forming  such  a  hard  nodular  tumor. 

(d)  Mesenteric  glands,  which  occasionally  form  very  large,  tumor-like 
masses,  more  commonly  found  in  children  than  in  adults.     This  condition 
may  be  confined  to  the  abdominal  glands.     Ascites  may  coexist.     The  condi- 
tion must  be  distinguished  from  that  in  children,  in  which,  with  ascites  or 
tympanites — sometimes  both — there  can  be  felt  irregular  nodular  masses,  due 
to  large  caseous  formations  between  the  intestinal  coils.    No  doubt  in  a  con- 
siderable number  of  cases  of  the  so-called  tabes  mesenterica,  particularly  in 
those  with  enlargement  and  hardness  of  the  abdomen — the  condition  which 
the  French  call  carreau — there  is  involvement  also  of  the  peritoneum. 

The  diagnosis  of  these  peritoneal  tumors  is  sometimes  very  difficult.  The 
omental  mass  is  a  less  frequent  source  of  error  than  any  other ;  but,  as  already 
mentioned,  a  similar  condition  may  occur  in  cancer.  The  most  important 
problem  is  the  diagnosis  of  the  saccular  exudation  from  ovarian  tumor.  In 
fully  one-third  of  the  recorded  cases  of  laparotomy  in  tuberculous  peritonitis 
the  diagnosis  of  cystic  ovarian  disease  had  been  made.  The  most  suggestive 
points  for  consideration  are  the  history  of  the  patient  and  the  evidence  of 


182  SPECIFIC    INFECTIOUS    DISEASES 

old  tuberculous  lesions.  The  physical  condition  is  not  of  much  help,  as  in 
many  instances  the  patients  have  been  robust  and  well  nourished.  Irregular 
febrile  attacks,  gastro-intestinal  disturbance,  and  pains  are  more  common  m 
tuberculous  disease.  Unless  inflamed  there  is  usually  not  much  fever  with 
ovarian  cysts.  The  local  signs  are  very  deceptive,  and  in  certain  cases  have 
conformed  in  every  particular  to  those  of  cystic  disease.  The  outlines  in  sac- 
cular  exudation  are  rarely  so  well  defined.  The  position  and  form  may  be 
yariable,  owing  to  alterations  in  the  size  of  the  coils  of  which  in  parts  the 
walls  are  composed.  Nodular  cheesy  masses  may  sometimes  be  felt  at  the 
periphery.  Depression  of  the  vaginal  wall  is  mentioned  as  occurring  in 
encysted  peritonitis;  but  it  is  also  found  in  ovarian  tumor.  Lastly,  the  con- 
dition of  the  Fallopian  tubes,  of  the  lungs  and  the  pleurae,  should  be  thor- 
oughly examined.  The  association  of  salpingitis  with  an  ill-defined  anoma- 
lous mass  in  the  abdomen  should  arouse  suspicion,  as  should  also  involvement 
of  the  pleura,  the  apex  of  one  lung,  or  a  testis  in  the  male. 

IV.    PULMONAKY  TUBEECULOSIS 
(Phthisis,  Consumption) 

Three  clinical  groups  may  be  conveniently  recognized:  (1)  tuberculo- 
pneumonic  phthisis—  acute  phthisis;  (2)  chronic  ulcerative  phthisis;  and  (3) 
fibroid  phthisis. 

According  to  the  mode  of  infection  there  are  two  distinct  types  of  lesions : 
(a)  When  the  bacilli  reach  the  lungs  through  the  blood-vessels  or  lym- 
phatics the  primary  lesion  is  usually  in  the  tissues  of  the  alveolar  walls,  in 
the  capillary  vessels,  the  epithelium  of  the  air-cells,  and  in  the  connective- 
tissue  framework  of  the  septa.  The  irritation  of  the  bacilli  produces,  within 
a  few  days,  the  small,  gray  miliary  nodules,  involving  several  alveoli  and  con- 
sisting largely  of  round,  cuboidal,  uninuclear  epithelioid  cells.  Depending 
upon  the  number  of  bacilli  which  reach  the  lung  in  this  way,  either  a  localized 
or  a  general  tuberculosis  is  excited.  The  tubercles  'may  be  uniformly  scat- 
tered through  both  lungs  and  form  a  part  of  a  general  miliary  tuberculosis, 
or  they  may  be  confined  to  the  lungs,  or  even  in  great  part  to  one  lung.  The 
changes  which  the  tubercles  undergo  have  already  been  referred  to.  The 
further  stages  may  be:  (1)  Arrest  of  the  process  of  cell  division,  gradual 
sclerosis  of  the  tubercle,  and  ultimately  complete  fibroid  transformation. 
(2)  Caseation  of  the  centre  of  the  tubercle,  extension  at  the  periphery  by 
proliferation  of  the  epithelioid  and  lymphoid  cells,  so  that  the  individual 
tubercles  or  small  groups  become  confluent  and  form  diffuse  areas  which 
undergo  caseation  and  softening.  (3)  Occasionally  as  a  result  of  intense 
infection  of  a  localized  region  through  the  blood-vessels  the  tubercles  are 
thickly  set.  The  intervening  tissue  becomes  acutely  inflamed,  the  air-cells 
are  filled  with  the  products  of  a  desquamative  pneumonia,  and  many  lobules 
are  involved. 

(6)  When  the  bacilli  reach  the  lung  through  the  bronchi — inhalation  or 
aspiration  tuberculosis — the  picture  differs.  The  smaller  bronchi  and  bron- 
chioles are  more  extensively  affected;  the  process  is  not  confined  to  single 
groups  of  alveoli,  but  has  a  more  lobular  arrangement,  and  the  tuberculous 
masses  from  the  outset  are  larger,  more  diffuse,  and  may  in  some  cases  involve 


TUBERCULOSIS  183 

an  entire  lobe  or  the  greater  part  of  a  lung.  It  is  in  this  mode  of  infection 
that  we  see  the  characteristic  peri-bronchial  granulations  and  the  areas  of 
the  so-called  nodular  broncho-pneumonia.  These  broncho-pneumonic  areas, 
with  on  the  one  hand  caseation,  ulceration,  and  cavity  formation,  and  on  the 
other  sclerosis  and  limitation,  make  up  the  essential  elements  in  the  anatom- 
ical picture  of  tuberculous  phthisis. 

1.  Acute  Pneumonic   Tuberculosis  of  the  Lungs 

This  form,  known  also  by  the  name  of  galloping  consumption,  is  met  with 
both  in  children  and  adults.  In  the  former  many  of  the  cases  are  mistaken 
for  simple  broncho-pneumonia. 

Two  types  may  be  recognized,  the  pneumonic  and  broncho-pneumonic. 

The  Pneumonic  Form. — In  the  pneumonic  form  one  lobe  may  be  involved, 
or  in  some  instances  an  entire  lung.  The  organ  is  heavy,  the  affected  portion 
airless;  the  pleura  is  usually  covered  with  a  thin  exudate,  and  on  section  the 
picture  resembles  closely  that  of  ordinary  hepatization.  The  following  is  an 
extract  from  the  post  mortem  report  of  a  case  in  which  death  occurred  twenty- 
nine  days  after  the  onset  of  the  illness,  having  all  the  characters  of  an  acute 
pneumonia:  "Left  lung  weighs  1,500  grams  (double  the  weight  of  the 
other  organ)  and  is  heavy  and  airless,  crepitant  only  at  the  anterior  margins. 
Section  shows  a  small  cavity  the  size  of  a  walnut  at  the  apex,  about  which 
are  scattered  tubercles  in  a  consolidated  tissue.  The  greater  part  of  the  lung 
presents  a  grayish-white  appearance  due  to  the  aggregation  of  tubercles  which 
in  some  places  have  a  continuous,  uniform  appearance,  in  others  are  sur- 
rounded by  an  injected  and  consolidated  lung-tissue.  Toward  the  margins  of 
the  lower  lobe  strands  of  this  firm  reddish  tissue  separate  anasmic,  dry  areas. 
There  are  in  the  right  lung  three  or  four  small  groups  of  tubercles  but  no 
caseous  masses.  The  bronchial  glands  are  not  tuberculous/'  Here  the  intense 
local  infection  was  due  to  the  smaii  focu'b  at  the  apex  of  the  lung,  probably  an 
aspiration  process. 

Only  the  most  careful  inspection  may  reveal  the  presence  of  miliary  tuber- 
cles, or  the  attention  may  be  arrested  by  the  detection  of  tubercles  in  the  other 
lung  or  in  the  bronchial  glands.  The  process  may  involve  only  one  lobe. 
There  may  be  older  areas  which  are  of  a  peculiarly  yellowish-white  color  and 
distinctly  caseous.  The  most  remarkable  picture  is  presented  by  cases  of  this 
kind  in  which  the  disease  lasts  for  some  months.  A  lobe  or  an  entire  lung 
may  be  enlarged,  firm,  airless  throughout,  and  converted  into  a  dry,  yellowish- 
white,  cheesy  substance.  Cases  are  met  with  in  which  the  entire  lung  from 
apex  to  base  is  in  this  condition,  with  perhaps  only  a  small,  narrow  area  of 
air-containing  tissue  on  the  margin.  More  commonly,  if  the  disease  has  lasted 
for  two  or  three  months,  rapid  softening  has  taken  place  at  the  apex  with 
extensive  cavity  formation. 

Males  are  much  more  frequently  attacked  than  females.  Of  my  series  of 
15  cases,  11  were  males.  The  onset  was  acute  in  13,  with  a  chill  in  9.  Ba- 
cilli were  found  in  the  sputum  in  one  case  as  early  as  the  fourth  day.  Fraenkel 
and  Troje  believe  that  the  cases  are  of  bronchogenous  origin,  due  to  infection 
from  a  small  focus  somewhere  in  the  lung.  They  found  tubercle  bacilli  alone 
in  11  of  their  12  cases.  Tendeloo,  who  reports  a  fatal  case  on  the  sixth  day, 
regards  the  infection  as  sometimes  haematogenous. 


184  SPECIFIC    INFECTIOUS    DISEASES 

SYMPTOMS.— The  attack  sets  in  abruptly  with  a  chill,  usually  in  an  indi- 
vidual who  has  enjoyed  good  health,  although  in  many  cases  the  onset  has 
been  preceded  by  exposure  to  cold,  or  there  have  been  debilitating  circum- 
stances. The  temperature  rises  rapidly  after  the  chill,  there  are  pain  in  the 
side  and  cough,  with  at  first  mucoid,  subsequently  rusty-colored  expectora- 
tion which  may  contain  tubercle  bacilli.  The  dyspnoea  may  become  extreme 
and  the  patient  may  have  suffocative  attacks.  The  physical  examination  shows 
involvement  of  one  lobe  or  of  one  lung,  with  signs  of  consolidation,  dulness, 
increased  fremitus,  at  first  feeble  or  suppressed  vesicular  murmur,  and  subse- 
quently well-marked  bronchial  breathing.  The  upper  or  lower  lobe  may  be 
involved,  or  in  some  cases  the  entire  lung. 

At  this  time,  as  a  rule,  no  suspicion  enters  the  mind  of  the  practitioner 
that  the  case  is  anything  but  one  of  frank  lobar  pneumonia.  Occasionally 
there  may  be  suspicious  circumstances  in  the  history  of  the  patient  or  in  his 
family ;  but,  as  a  rule,  no  stress  is  laid  upon  them  in  view  of  the  intense  and 
characteristic  mode  of  onset.  Between  the  eighth  and  tenth  day,  instead 
of  the  expected  crisis,  the  condition  becomes  aggravated,  the  temperature  is 
irregular,  and  the  pulse  more  rapid.  There  may  be  sweating,  and  the  expec- 
toration bcomes  muco-purulent  and  greenish  in  color — a  point  of  special 
importance,  to  which  Traube  called  attention.  Even  in  the  second  or  third 
week,  with  the  persistence  of  these  symptoms,  the  physician  tries  to  console 
himself  with  the  idea  that  the  case  is  one  of  unresolved  pneumonia,  and  that 
all  will  yet  be  well.  Gradually,  however,  the  severity  of  the  symptoms,  the 
presence  of  physical  signs  indicating  softening,  the  existence  of  elastic  tissue 
and  tubercle  bacilli  in  the  sputum  present  the  mournful  proofs  that  the  case  is 
one  of  acute  pneumonic  phthisis.  Death  may  occur  on  the  sixth  day,  as  in 
a  case  of  Tendeloo's.  The  earliest  death  in  my  series  was  on  the  thirteenth  day. 
A  majority  of  the  cases  drag  on,  and  death  does  not  occur  until  the  third 
month.  In  a  few  cases,  even  after  a  stormy  onset  and  active  course,  the 
symptoms  subside  and  the  patient  passes  into  the  chronic  stage. 

DIAGNOSIS. — Waters,  of  Liverpool,  who  gave  an' admirable  description  of 
these  cases,  called  attention  to  the  difficulty  in  distinguishing  them  from  or- 
dinary pneumonia.  Certainly  the  mode  of  onset  affords  no  criterion  whatever. 
A  healthy,  robust-looking  young  Irishman,  a  cab-driver,  who  had  been  kept 
waiting  on  a  cold,  blustering  night  until  three  in  the  morning,  was  seized  the 
next  afternoon  with  a  violent  chill,  and  the  following  day  was  admitted  to 
my  wards  at  the  University  Hospital,  Philadelphia.  He  was  made  the  sub- 
ject of  a  clinical  lecture  on  the  fifth  day,  when  there  was  absent  no  single 
feature  in  history,  symptoms,  or  physical  signs  of  acute  lobar  pneumonia  of 
the  right  upper  lobe.  It  was  not  until  ten  days  later,  when  bacilli  were  found 
in  his  expectoration,  that  we  were  made  aware  of  the  true  nature  of  the  case. 
I  know  of  no  criterion  by  which  cases  of  this  kind  can  be  distinguished  in  the 
early  stage.  A  point  to  which  Traube  called  attention,  and  which  is  also 
referred  to  as  important  by  Herard  and  Cornil,  is  the  absence  of  breath-sounds 
in  the  consolidated  region;  but  this,  I  am  sure,  does  not  hold  good  in  all 
cases.  The  tubular  breathing  may  be  intense  and  marked  as  early  as  the 
fourth  day;  and  again,  how  common  it  is  to  have,  as  one  of  the  earliest  and 
most  suggestive  symptoms  of  lobar  pneumonia,  suppression  or  enfeeblement  of 
the  vesicular  murmur !  In  many  cases,,  however,  there  are  suspicious  circum- 


TUBERCULOSIS  185 

stances  in  the  onset:  the  patient  has  been  in  bad  health,  or  may  have  had 
previous  pulmonary  trouble,  or  there  are  recurring  chills.  Careful  examina- 
tion of  the  sputum  and  a  study  of  the  physical  signs  from  day  to  day  can 
alone  determine  the  true  nature  of  the  case.  In  one  of  my  cases  the  bacilli 
were  found  on  the  fourth  day.  A  point  of  some  moment  is  the  character  of 
the  fever,  which  in  true  pneumonia  is  more  continuous,  particularly  in  severe 
cases,  whereas  in  this  form  of  tuberculosis  remissions  of  1.5°  or  2°  are  not 
infrequent. 

Acute  Tuberculous  Broncho-pneumonia. — Acute  tuberculous  broncho-pneu- 
monia is  more  common,  particularly  in  children,  and  forms  a  majority  of  the 
cases  of  phthisis  florida,  or  "galloping  consumption."  It  is  an  acute  caseous 
broncho-pneumonia,  starting  in  the  smaller  tubes,  which  become  blocked  with 
a  cheesy  substance,  while  the  air-cells  of  the  lobule  are  filled  with  the  products 
of  a  catarrhal  pneumonia.  In  the  early  stages  the  areas  have  a  grayish  red, 
later  an  opaque  white,  caseous  appearance.  By  the.  fusion  of  contiguous 
masses  an  entire  lobe  may  be  rendered  nearly  solid,  but  areas  of  crepitant  air 
tissue  can  usually  be  seen  between  the  groups.  This  is  not  an  uncommon 
picture  in  the  acute  phthisis  of  adults,  but  it  is  still  more  frequent  in  children. 
The  following  is  an  extract  from  the  post  mortem  report  of  a  case  on  a  child 
aged  four  months,  who  died  in  the  sixth  week  of  illness:  "On  section,  the 
right  upper  lobe  is  occupied  Avith  caseous  masses  from  5  to  12  mm.  in  diameter, 
separated  from  each  other  by  an  intervening  tissue  of  a  deep  red  color.  The 
bronchi  are  filled  with  cheesy  substance.  The  middle  and  lower  lobes  are 
studded  with  tubercles,  many  of  which  are  becoming  caseous.  Toward  the 
diaphragmatic  surface  of  the  lower  lobe  there  is  a  small  cavity  the  size  of  a 
marble.  The  left  lung  is  more  crepitant  and  uniformly  studded  with  tubercles 
of  all  sizes,  some  as  large  as  peas.  The  bronchial  glands  are  very  large,  and 
one  contains  a  tuberculous  abscess." 

There  is  a  form  of  tuberculous  aspiration  pneumonia,  to  which  Baumler 
has  called  attention,  occurring  as  a  sequence  of  haemoptysis,  and  due  to  the 
aspiration  of  blood  and  the  contents  of  pulmonary  cavities  into  the  finer  tubes. 
There  are  fever,  dyspnoea,  and  signs  of  a  diffuse  broncho-pneumonia.  Some 
of  these  cases  run  a  very  rapid  course,  and  are  examples  of  galloping  con- 
sumption following  haemoptysis.  This  accident  may  occur  not  only  early  in 
the  disease,  but  may  follow  haemorrhage  in  a  well-marked  pulmonary  tuber- 
culosis. 

In  children  the  enlarged  bronchial  glands  usually  surround  the  root  of  the 
lung,  and  even  pass  deeply  into  the  substance,  and  the  lobules  are  often  in- 
volved by  direct  contact. 

In  other  cases  the  caseous  broncho-pneumonia  involves  groups  of  alveoli 
or  lobules  in  different  portions  of  the  lungs,  more  commonly  at  both  apices, 
forming  areas  from  1  to  3  cm.  in  diameter.  The  size  of  the  mass  depends 
largely  upon  that  of  the  bronchus  involved.  There  are  cases  which  probably 
should  come  in  this  category,  in  which,  with  a  history  of  an  acute  illness  of 
from  four  to  eight  weeks,  the  lungs  are  extensively  studded  with  large  gray 
tubercles,  ranging  in  size  from  5  to  10  mm.  In  some  instances  there  are 
cheesy  masses  the  size  of  a  cherry.  All  of  these  are  grayish-white  in  colorv 
distinctly  cheesy,  and  between  the  adjacent  ones,  particularly  in  the  lower 
lobe,  there  may  be  recent  pneumonia,  or  the  condition  of  lung  which  has  been 
14 


186  SPECIFIC    INFECTIOUS    DISEASES 

termed  splenization.  In  a  case  of  this  kind  at  the  Philadelphia  Hospital 
death  took  place  about  the  eighth  week  from  the  abrupt  onset  of  the  illness 
with  haemorrhage.  There  were  no  extensive  areas  of  consolidation,  but  the 
cheesy  nodules  were  uniformly  scattered  throughout  both  lungs.  No  softening 

had  taken  place. 

Secondary  infections  are  not  uncommon;  but  Prudden  was  able  to  s 
that  the  tubercle  bacillus  could  produce  not  only  distinct  tubercle  nodules,  but 
also  the  various  kinds  of  exudative  pneumonia,  the  exudates  varying  in  ap- 
pearance in  different  cases,  which  phenomena  occurred  absolutely  without  the 
intervention  of  other  organisms.  The  fact  that  these  latter  had  not  sub- 
sequently crept  in  was  shown  by  cultures  at  the  autopsy  on  the  affected  animal. 
SYMPTOMS. — The  symptoms  of  acute  broncho-pneumonic  phthisis  are  very 
variable.  In  adults  the  disease  may  attack  persons  in  good  health,  but  over- 
worked or  "run  down"  from  any  cause.  Haemorrhage  initiates  the  attack  in  a 
few  cases.  There  may  be  repeated  chills;  the  temperature  is  high,  the  pulse 
rapid,  and  the  respirations  are  increased.  The  loss  of  flesh  and  strength  is 
very  striking. 

The  physical  signs  may  at  first  be  uncertain  and  indefinite,  but  finally 
there  are  areas  of  impaired  resonance,  usually  at  the  apices;  the  breath 
sounds  are  harsh  and  tubular,  with  numerous  rales.  The  sputum  may  early 
show  elastic  tissue  and  tubercle  bacilli.  In  the  acute  cases,  within  three 
weeks,  the  patient  may  be  in  a  marked  typhoid  state,  with  delirium,,  dry 
tongue,  and v  high  fever.  Death  may  occur  within  three  weeks.  In  other 
cases  the  onset  is  severe,  with  high  fever,  rapid  loss  of  flesh  and  strength, 
and  signs  of  extensive  unilateral  or  bilateral  disease.  Softening  takes  place; 
there  are  sweats,  chills,  and  progressive  emaciation,  and  all  the  features  of 
phthisis  florida.  Six  or  eight  weeks  later  the  patient  may  begin  to  improve, 
the  fever  lessens,  the  general  symptoms  abate,  and  a  case  which  looked  as  if  it 
would  certainly  terminate  fatally  within  a  few  weeks  drags  on  and  becomes 
chronic. 

In  children  the  disease  most  commonly  follows'  the  infectious  diseases, 
particularly  measles  and  whooping  cough.  At  least  three  groups  of  these 
tuberculous  broncho-pneumonias  may  be  recognized.  In  the  first  the  child 
is  taken  ill  suddenly  while  teething  or  during  convalescence  from  fever;  the 
temperature  rises  rapidly,  the  cough  is  severe,  and  there  may  be  signs  of  con- 
solidation at  one  or  both  apices  with  rales.  Death  may  occur  within  a  few 
days,  and  the  lung  shows  areas  of  broncho-pneumonia,  with  perhaps  here  and 
there  scattered  opaque  grayish-yellow  nodules.  Macroscopically  the  affection 
does  not  look  tuberculous,  but  histologically  miliary  granulations  and  bacilli 
may  be  found.  Tubercles  are  usually  present  in  the  bronchial  glands,  but 
the  appearance  of  the  broncho-pneumonia  may  be  exceedingly  deceptive,  and 
it  may  require  careful  microscopic  examination  to  determine  its  tuberculous 
character.  The  second  group  is  represented  by  the  case  of  the  child  previously 
quoted,  who  died  at  the  sixth  week  with  the  ordinary  symptoms  of  severe 
broncho-pneumonia.  And  the  third  group  is  that  in  which,  during  the  con- 
valescence from  an  infectious  disease,  the  child  is  taken  ill  with  fever,  cough, 
and  shortness  of  breath.  The  severity  of  the  symptoms  abates  within  the 
first  fortnight ;  but  there  is  loss  of  flesh,  the  general  condition  is  bad,  and  the 
physical  examination  shows  the  presence  of  scattered  rales  throughout  the 


TUBERCULOSIS  187 

lungs,  and  here  and  there  areas  of  defective  resonance.  The  child  has  sweats, 
the  fever  becomes  hectic  in  character,  and  in  many  cases  the  clinical  picture 
gradually  passes  into  that  of  chronic  phthisis. 

2.  Chronic  Ulcerative  Tuberculosis  of  the  Lungs. 

Under  this  heading  may  be  grouped  the  great  majority  of  cases  of  pul- 
monary tuberculosis,  in  which  the  lesions  proceed  to  ulceration  and  softening, 
and  ultimately  produce  the  well-known  picture  of  chronic  phthisis. 

Morbid  Anatomy. — Inspection  of  the  lungs  shows  a  remarkable  variety  of 
lesions,  comprising  nodular  tubercles,  diffuse  tuberculous  infiltration,  caseous 
masses,  pneumonic  areas,  cavities  of  various  sizes,  with  changes  in  the  pleura, 
bronchi,  and  bronchial  glands. 

THE  DISTRIBUTION  OF  THE  LESIONS. — For  years  it  has  been  recognized 
that  the  most  advanced  lesions  are  at  the  apices,  and  that  the  disease  pro- 
gresses downward,  usually  more  rapidly  in  one  of  the-  lungs.  This  general 
statement,  which  has  passed  current  in  the  text-books  ever  since  the  masterly 
description  of  Laennec,  has  been  carefully  elaborated  by  Kingston  Fowler, 
who  finds  that  the  disease  in  its  onward  progress  through  the  lungs  follows, 
in  a  majority  of  the  cases,  distinct  routes.  In  the  upper  lobe  the  primary 
lesion  is  not,  as  a  rule,  at  the  extreme  apex,  but  from  an  inch  to  an  inch  and 
a  half  below  the  summit  of  the  lung,  and  nearer  to  the  posterior  and  external 
borders.  The  lesion  here  tends  to  spread  downward,  probably  from  inhala- 
tion of  the  virus,  and  this  accounts  for  the  frequent  circumstance  that  exami- 
nation behind,  in  the  supra-spinous  fossa,  will  give  indications  of  disease 
before  any  evidences  exist  at  the  apex  in  front.  Anteriorly  this  initial  focus 
corresponds  to  a  spot  just  below  the  centre  of  the  clavicle,  and  the  direction 
of  extension  in  front  is  along  the  anterior  aspect  of  the  upper  lobe,  along  a  line 
running  about  an  inch  and  a  half  from  the  inner  ends  of  the  first,  second, 
and  third  interspaces.  A  second  less  common  site  of  the  primary  lesion  in 
the  apex  "corresponds  on  the  chest  wall  with  the  first  and  second  interspaces 
below  the  outer  third  of  the  clavicle."  The  extension  is  downward,  so  that 
the  outer  part  of  the  upper  lobe  is  chiefly  involved. 

In  the  middle  lobe  of  the  right  lung  the  affection  usually  follows  disease 
of  the  upper  lobe  on  the  same  side.  In  the  involvement  of  the  lower  lobe 
the  first  secondary  infiltration  is  about  an  inch  to  an  inch  and  a  half  below 
the  posterior  extremity  of  its  apex,  and  corresponds  on  the  chest  wall  to  a 
spot  opposite  the  fifth  dorsal  spine.  This  involvement  is  of  the  greatest  im- 
portance clinically,  as  "in  the  great  majority  of  cases,  when  the  physical  signs 
of  the  disease  at  the  apex  are  sufficiently  definite  to  allow  of  the  diagnosis  of 
phthisis  being  made,  the  lower  lobe  is  already  affected."  Examination,  there- 
fore, should  be  made  carefully  of  this  posterior  apex  in  all  suspicious  cases. 
In  this  situation  the  lesion  spreads  downward  and  laterally  along  the  line 
of  the  interlobular  septa,  a  line  which  is  marked  by  the  vertebral  border 
of  the  scapula,  when  the  hand  is  placed  on  the  opposite  scapula  and  the 
elbow  raised  abov'e  the  level  of  the  shoulder.  Once  present  in  an  apex,  the 
disease  usually  extends  in  time  to  the  opposite  upper  lobe;  but  not,  as  a 
rule,  until  the  apex  of  the  lower  lobe  of  the  lung  first  affected  has  been 
attacked. 


188  SPECIFIC    INFECTIOUS    DISEASES 

Of  427  cases  above  mentioned,  the  right  apex  was  involved  in  172,  the 
left  in  130,  both  in  111. 

Lesions  of  the  base  may  be  primary,  though  this  is  rare.  Percy  Kidd 
makes  the  proportion  of  basic  to  apical  phthisis  1  to  500,  a  smaller  number 
than  existed  in  my  series.  In  very  chronic  cases  there  may  be  arrested  lesions 
at  the  apex  and  more  recent  lesions  at  the  base. 

SUMMARY  OF  THE  LESIONS  IN  CHRONIC  ULCERATIVE  PHTHISIS. — (a) 
Miliary  Tubercles. — They  have  one  of  two  distributions:  (1)  A  dissemination 
due  to  aspiration  of  tuberculous  material,  the  tubercles  being  situated  in  the 
air-cells  or  the  walls  of  the  smaller  bronchi;  (2)  the  distribution  due  to 
dissemination  of  tubercle  bacilli  by  the  lymph  current,  the  tubercles  being 
scattered  about  the  old  foci  in  a'  radial  manner — the  secondary  crop  of  Laen- 
nec.  Much  more  rarely  there  is  a  scattered  dissemination  from  infection  here 
and  there  of  the  smaller  vessels,  the  tubercles  then  being  situated  in  the  vessel 
walls.  Sometimes,  in  cases  with  cavity  formation  at  the  apex,  the  greater 
part  of  the  lower  lobes  presents  many  groups  of  firm,  sclerotic,  miliary  tuber- 
cles, which  may  indeed  form  the  distinguishing  anatomical  feature — a  chronic 
miliary  tuberculosis. 

(6)  Tuberculous  Broncho-pneumonia. — In  a  large  proportion  of  the  cases 
of  chronic  phthisis  the  terminal  bronchiole  is  the  point  of  origin  of  the  process, 
consequently  we  find  the  smaller  bronchi  and  their  alveolar  territories  blocked 
with  the  accumulated  products  of  inflammation  in  all  stages  of  caseation. 
At  an  early  period  a  cross-section  of  an  area  of  tuberculous  broncho-pneumonia 
gives  the  most  characteristic  appearance.  The  central  bronchiole  is  seen  as 
a  small  orifice,  or  it  is  plugged  with  cheesy  contents,  while  surrounding  it  is 
a  caseous  nodule,  the  so-called  peribronchial  tubercle.  The  longitudinal  sec- 
tion has  a  somewhat  dendritic  or  foliaceous  appearance.  The  condition  of  the 
picture  depends  much  upon  the  slowness  or  rapidity  with  which  the  process 
has  advanced.  The  following  changes  may  occur : 

Ulceration. — When  the  caseation  takes  place  rapidly  or  ulceration  occurs 
in  the  bronchial  wall,  the  mass  may  break  down  and  form  a  small  cavity. 

Sclerosis. — In  other  instances  the  process  is  more  chronic,  and  fibroid 
changes  gradually  produce  a  sclerosis  of  the  affected  area.  The  sclerosis  may 
be  confined  to  the  margin  of  the  mass,  forming  a  limiting  capsule,  within 
which  is  a  uniform,  firm,  cheesy  substance,  in  which  lime  salts  are  often 
deposited.  This  represents  the  healing  of  one  of  these  areas  of  caseous 
broncho-pneumonia.  It  is  only,  however,  when  complete  fibroid  transforma- 
tion or  calcification  has  occurred  that  we  can  really  speak  of  healing.  In  many 
instances  the  colonies  of  miliary  tubercles  about  these  masses  show  that  the 
virus  is  still  active  in  them.  Subsequently,  in  ulcerative  processes,  these  cal- 
careous bodies — lung-stones,  as  they  are  sometimes  called — may  be  expec- 
torated. 

(c)  Pneumonia. — An  important  though  secondary  place  is  occupied  by 
inflammation  of  the  alveoli  surrounding  the  tubercles,  which  become  filled  with 
epithelioid  cells.  The  consolidation  may  extend  for  some  distance  about  the 
tuberculous  foci  and  unite  them  into  areas  of  uniform  consolidation.  Al- 
though in  some  instances  this  inflammatory  process  may  be  simple,  in  others 
it  is  undoubtedly  specific.  It  is  excited  by  the  tubercle  bacilli  and  is  a 
manifestation  of  their  action.  It  may  present  a  very  varied  appearance;  in 


TUBERCULOSIS  189 

some  instances  resembling  closely  ordinary  red  hepatization,  in  others  being 
more  homogeneous  and  infiltrated,  the  so-called  infiltration  tulerculeuse  of 
Laennec.  In  other  cases  the  contents  of  the  alveoli  undergo  fatty  degenera- 
tion, and  appear  on  the  cut  surface  as  opaque  white  or  yellowish-white  bodies. 
In  early  phthisis  much  of  the  consolidation  is  due  to  this  pneumonic  infiltra- 
tion, which  may  surround  for  some  distance  the  smaller  tuberculous  foci. 

(d)  Cavities. — A  vomica  is  a  cavity  in  the  lung  tissue,  produced  by  necro- 
sis and  ulceration.  The  process  usually  begins  in  the  wall  of  the  bronchus  in 
a  tuberculous  area.  Dilatation  is  produced  by  retained  secretion,  and  necrosis 
and  ulceration  of  the  wall  occur  with  gradual  destruction  of  the  contiguous 
tissues.  By  extension  of  the  necrosis  and  ulceration  the  cavity  increases,  con- 
tiguous ones  unite,  and  in  an  affected  region  there  may  be  a  series  of  small 
excavations  communicating  with  a  bronchus.  In  nearly  all  instances  the  pro- 
cess extends  from  the  bronchi,  though  it  is  possible  for  necrosis  and 
softening  to  take  place  in  the  centre  of  a  caseous  -area  without  primary 
involvement  of  the  bronchial  wall.  Three  forms  of  cavities  may  be  recog- 
nized. 

The  fresh  ulcerative,  seen  in  acute  phthisis,  in  which  there  is  no  limiting 
membrane,  but  the  walls  are  made  up  of  softened,  necrotic,  and  caseous  masses. 
A  small  vomica  of  this  sort,  situated  just  beneath  the  pleura,  may  rupture  and 
cause  pneumothorax.  In  cases  of  acute  tuberculo-pneumonic  phthisis  they 
may  be  large,  occupying  the  greater  portion  of  the  upper  lobe.  In  the  chronic 
ulcerative  phthisis  cavities  of  this  sort  are  invariably  present  in  those  por- 
tions of  the  lung  in  which  the  disease  is  advancing.  At  the  apex  there  may 
be  a  large  old  cavity  with  well-defined  walls,  while  at  the  anterior  margin 
of  the  upper  lobes,  or  in  the  apices  of  the  lower  lobes,  there  are  recent  ulcerat- 
ing cavities  communicating  with  the  bronchi. 

Cavities  with  well-defined  Walls.-. — A  majority  of  the  cavities  in  the  chronic 
form  of  phthisis  have  a  well-defined  limiting  membrane,  the  inner  surface 
of  which  constantly  produces  pus.  The  walls  are  crossed  by  trabeculae  which 
represent  remnants  of  bronchi  and  blood-vessels.  Even  the  cavities  with  the 
well-defined  walls  extend  gradually  by  a  slow  necrosis  and  destruction  of  the 
contiguous  lung  tissue.  The  contents  are  usually  purulent,  similar  in  charac- 
ter to  the  grayish  nummular  sputa  coughed  up.  Not  infrequently  the  mem- 
brane is  vascular  or  it  may  be  haemorrhagic.  Occasionally,  when  gangrene  has 
occurred  in  the  wall,  the  contents  are  horribly  fetid.  These  cavities  may  oc- 
cupy the  greater  portion  of  the  apex,  forming  an  irregular  series  which  com- 
municate with  each  other  and  with  the  bronchi,  or  the  entire  upper  lobe  ex- 
cept the  anterior  margin  may  be  excavated,  forming  a  thin-walled  cavity.  In 
rare  instances  the  process  has  proceeded  to  total  excavation  of  the  lung,  not  a 
remnant  of  which  remains,  except  perhaps  a  narrow  strip  at  the  anterior  mar- 
gin. In  a  case  of  this  kind,  in  a  young  girl,  the  cavity  held  40  fluid  ounces, 
in  another  42  ounces. 

Quiescent  Cavities. — When  quite  small  and  surrounded  by  dense  cicatricial 
tissue  communicating  with  the  bronchi  they  form  the  cicatrices  fistuleuses  of 
Laennec.  Occasionally  one  apex  may  be  represented  by  a  series  of  these  small 
cavities,  surrounded  by  dense  fibrous  tissue.  The  lining  membrane  of  these 
old  cavities  may  be  quite  smooth,  almost  like  a  mucous  membrane.  Cavities 
of  any  size  do  not  heal  completely. 


190 

Cases  are  often  seen  in  which  it  has  been  supposed  that  a  cavity  has  healed ; 
but  the  signs  of  excavation  are  notoriously  uncertain,  and  there  may  be  pec- 
toriloquy  and  cavernous  sounds  with  gurgling  resonant  rales  in  an  area  of 
consolidation  close  to  a  large  bronchus. 

In  the  formation  of  cavities  the  blood  vessels  gradually  become  closed  by 
an  obliterating  inflammation.  They  are  the  last  structures  to  yield  and  may 
be  completely  exposed  in  a  cavity,  even  when  the  circulation  is  still  going  on 
in  them.  Unfortunately,  the  erosion  of  a  large  vessel  which  has  not  yet  been 
obliterated  is  by  no  means  infrequent,  and  causes  profuse  and  often  fatal  hem- 
orrhage. Another  common  event  is  the  formation  of  aneurisms  on  the  arte- 
ries running  in  the  walls  of  cavities.  These  may  be  small,  bunch-like  dilata- 
tions, or  they  may  form  sacs  the  size  of  a  walnut  or  even  larger.  Easmussen, 
Douglas  Powell,  and  others  have  called  attention  to  their  importance  in  haem- 
optysis, under  which  section  they  are  dealt  with  more  fully. 

And,  finally,  about  cavities  of  all  sorts,  the  connective  tissue  grows,  tend- 
ing to  limit  their  extent.  The  thickening  is  particularly  marked  beneath  the 
pleura,  and  in  chronic  cases  an  entire  apex  may  be  converted  into  a  mass  of 
fibrous  tissue,  inclosing  a  few  small  cavities. 

(e)  Pleura. — Practically,  in  all  cases  of  chronic  phthisis  the  pleura  is  in- 
volved. Adhesions  take  place  which  may  be  thin  and  readily  torn,  or  dense 
and  firm,  uniting  layers  of  from  2  to  5  mm.  in  thickness.  This  pleurisy  may 
be  simple,  but  in  many  cases  it  is  tuberculous,  and  miliary  tubercles  or  case- 
ous masses  are  seen  in  the  thickened  membrane.  Effusion  is  not  at  all  infre- 
quent, either  serous,  purulent,  or  hasmorrhagic.  Pneumothorax  is  a  common 
accident. 

(/)  Changes  in  the  smaller  bronchi  control  the  situation  in  the  early  stages 
of  tuberculous  phthisis,  and  play  an  important  role  throughout  the  disease. 
The  process  very  often  begins  in  the  walls  of  the  smaller  tubes  and  leads  to 
caseation,  distention  with  products  of  inflammation,  and  broncho-pneumonia 
of  the  lobules.  In  many  cases  the  visible  implication  of  the  bronchus  is  an 
extension  upward  of  a  process  which  has  begun  in  the  smallest  bronchiole. 
This  involvement  weakens  the  wall,  leading  to  bronchiectasis,  not  an  uncom- 
mon event.  The  mucous  membrane  of  the  larger  bronchi,  which  is  usually 
involved  in  a  chronic  catarrh,  is  more  or  less  swollen,  and  in  some  instances 
ulcerated.  Besides  these  specific  lesions,  they  may  be  the  seat,  especially  in 
children,  of  inflammation  due  to  secondary  invasion,  most  frequently  by  the 
Micrococcus  lanceolatus,  with  the  production  of  a  broncho-pneumonia. 

(g)  The  bronchial  glands,  in  the  more  acute  cases,  are  swollen  and  oadema- 
tous.  Miliary  tubercles  and  caseous  foci  are  usually  present.  In  cases  of 
chronic  tuberculosis  the  caseous  areas  are  common,  calcification  may  occur, 
and  not  infrequently  purulent  softening. 

(h)  Changes  in  the  Other  Organs. — Of  these,  tuberculosis  is  the  most  com- 
mon. In  my  series  of  autopsies  the  brain  presented  tuberculous  lesions  in  31, 
the  spleen  in  33,  the  liver  in  12,  the  kidneys  in  32,  the  intestines  in  65,  and 
the  pericardium  in  7.  Other  groups  of  lymphatic  glands  besides  the  bron- 
chial may  be  affected. 

Amyloid  change  may  occur  in  the  liver,  spleen,  kidneys,  and  mucous  mem- 
brane of  the  intestines.  The  liver  is  often  the  seat  of  extensive  fatty  infiltra- 
tion, which  may  cause  marked  enlargement.  The  intestinal  tuberculosis 


TUBERCULOSIS  191 

occurs  in  advanced  cases  and  is  responsible  in  great  part  for  the  troublesome 
diarrhoea. 

Endocarditis  is  not  very  common,  and  was  present  in  12  of  my  post 
mortems  and  in  27  of  Percy  Kidd's  500  cases.  Tubercle  bacilli  have  been 
found  in  the  vegetations.  Tubercles  may  be  present  on  the  endocardium, 
particularly  of  the  right  ventricle. 

The  larynx  is  frequently  involved,  and  ulceration  of  the  vocal  cords  and 
destruction  of  the  epiglottis  are  not  at  all  uncommon. 

Modes  of  Onset. — We  have  already  seen  that  tuberculosis  of  the  lungs  may 
occur  as  the  chief  part  of  a  general  infection,  or  may  set  in  with  symptoms 
which  closely  simulate  acute  pneumonia.  In  the  ordinary  type  of  pulmonary 
tuberculosis  the  invasion  is  gradual  and  less  striking,  but  presents  an  ex- 
traordinarily diverse  picture,  so  that  the  practitioner  is  often  led  into  error. 
Among  the  most  characteristic  modes  of  onset  are  the  following: 

(a)  LATENT  TYPES. — It  is  probable  that  many  slight,  ill-defined  ailments 
are  due  to  a  local  unrecognized  tuberculosis  of  the  lung.  In  the  history  of 
patients  with  tuberculosis  such  attacks  are  not  infrequently  mentioned. 

The  disease  makes  considerable  progress  before  there  are  serious  symp- 
toms to  arouse  the  attention  of  the  patient.  In  workingmen  the  disease  may 
even  advance  to  excavation  of  an  apex  before  they  seek  advice.  It  is  not  a 
little  remarkable  how  slight  the  lung  symptoms  may  have  been. 

The  symptoms  may  be  masked  by  the  existence  of  serious  disease  in  other 
organs,  as  in  the  peritoneum,  intestines,  or  bones. 

(6)  WITH  SYMPTOMS  OF  DYSPEPSIA  AND  ANEMIA. — The  gastric  mode  of 
onset  is  very  common,  and  the  early  manifestations  may  be  great  irritability 
of  the  stomach  with  vomiting  or  a  type  of  acid  dyspepsia  with  eructations. 
In  young  girls  (and  in  children)  with  this  dyspepsia  there  is  very  frequently 
a  pronounced  chloro-anasmia,  and  the  patient  complains  of  palpitation  of  the 
heart,  increasing  weakness,  slight  afternoon  fever,  and  amenorrhcea. 

(c)  MALARIAL  SYMPTOMS. — In  a  considerable  number  of  cases  the  onset 
of  pulmonary  tuberculosis  is  with  symptoms  which  suggest  malarial  fever. 
The  patient  has  repeated  paroxysms  of  chills,  fevers,  and  sweats,  which  may 
recur  with  great  regularity.     In  districts  in  which  malaria  prevails  there  is 
no  more  common  mistake  than  to  confound  the  initial  rigors  of  pulmonary 
tuberculosis  with  it. 

(d)  ONSET  WITH  PLEURISY. — The  first  symptoms  may  be  a  dry  pleurisy 
over  an  apex,  with  persistent  friction  murmur.     In  other  instances  the  pul- 
monary symptoms  have  followed  an  attack  of  pleurisy  with  effusion.     The 
exudate  gradually  disappears,  but  the  cough  persists  and  the  patient  becomes 
feverish,  and  gradually  signs  of  disease  at  one  apex  become  manifest.    About 
one-third  of  all  cases  of  pleurisy  with  effusion  subsequently  have  pulmonary 
tuberculosis. 

(e)  WITH  LARYNGEAL  SYMPTOMS. — The  primary  localization  may  be  in 
the  larynx,  though  in  a  majority  of  the  instances  in  which  huskiness  and 
laryngeal  symptoms  are  the  first  noticeable  features  of  the  disease  there  are  • 
doubtless  foci  already  existing  in  the  lung.     The  group  of  cases  in  which 
for  many  months  throat  and  larynx  symptoms  precede  the  manifestations  of 
pulmonary  tuberculosis  is  a  very  important  one. 

(/)   ONSET  WITH  HEMOPTYSIS. — Frequently  the  very  first  symptom  is 


192  SPECIFIC    INFECTIOUS    DISEASES 

a  brisk  haemorrhage  from  the  lungs,  following  which  the  pulmonary  symptoms 
may  come  on  with  great  rapidity.  In  other  cases  the  haemoptysis  recurs,  and 
it  may  be  months  before  the  symptoms  become  well  established.  In  a  majority 
of  these  cases  the  local  tuberculous  lesion  exists  at  the  date  of  the  haemoptysis. 
(17)  WITH  TUBERCULOSIS  OF  THE  CERVICO-AXILLARY  GLANDS. — Preceding 
the  onset  of  pulmonary  disease  for  months,  or  even  for  years,  the  lymph- 
glands  of  the  neck  or  of  the  neck  and  axilla  of  one  side  may  be  enlarged. 
These  cases  are  by  no  means  infrequent,  and  they  are  of  importance  because 
of  the  latency  of  the  pulmonary  lesions.  Nowadays,  when  operative  interfer- 
ence is  so  common,  it  is  well  to  bear  in  mind  that  in  such  patients  the  corre- 
sponding apex  of  the  lung  may  be  extensively  involved. 

(h)  BRONCHIAL  SYMPTOMS. — And,  lastly,  in  by  far  the  largest  number  of 
all  cases  the  onset  is  with  a  bronchitis,  or,  as  the  patient  expresses  it,  a  neg- 
lected cold.  There  has  been,  perhaps,  a  liability  to  catch  cold  easily  or  the 
patient  has  been  subject  to  naso-pharyngeal  catarrh;  then,  following  some 
unusual  exposure,  a  cough  begins,  which  may  be  frequent  and  very  irritating. 
The  examination  of  the  lungs  may  reveal  localized  moist  sounds  at  one  apex 
and  perhaps  wheezing  bronchitic  rales  in  other  parts.  In  a  few  cases  the 
early  symptoms  are  often  suggestive  of  asthma  with  marked  wheezing  and 
diffuse  piping  rales. 

Symptoms. — In  discussing  the  symptoms  it  is  usual  to  divide  the  disease 
into  three  periods:  the  first  embracing  the  time  of  the  growth  and  develop- 
ment of  the  tubercles;  the  second,  when  they  soften;  and  the  third,  when 
there  is  a  formation  of  cavities.  Unfortunately,  these  anatomical  stages  can 
not  be  satisfactorily  correlated  with  corresponding  clinical  periods,  and  we 
often  find  that  a  patient  in  the  third  stage  with  a  well-marked  cavity  is  in 
a  far  better  condition  and  has  greater  prospects  of  recovery  than  a  patient  in 
the  first  stage  with  diffuse  consolidation.  It  is  therefore  better  perhaps  to 
disregard  them  altogether. 

LOCAL  SYMPTOMS.— Pom  in  the  chest  may  be  early  and  troublesome  or 
absent  throughout.  It  is  usually  associated  with  pleurisy,  and  may  be  sharp 
and  stabbing  in  character,  and  either  constant  or  felt  only  during  coughing. 
Perhaps  the  commonest  situation  is  in  the  lower  thoracic  zone,  though  in 
some  instances  it  is  beneath  the  scapula  or  referred  to  the  apex.  The  attacks 
may  recur  at  long  intervals.  Intercostal  neuralgia  occasionally  occurs  in  the 
course  of  ordinary  pulmonary  tuberculosis. 

Cough  is  one  of  the  earliest  symptoms,  and  is  present  in  the  majority  of 
cases  from  beginning  to  end.  There  is  nothing  peculiar  or  distinctive  about 
it.  At  first  dry  and  hacking,  and  perhaps  scarcely  exciting  the  attention  of 
the  patient,  it  subsequently  becomes  looser,  more  constant,  and  associated  with 
a  glairy,  muco-purulent  expectoration.  In  the  early  stages  of  the  disease  the 
cough  is  bronchial  in  its  origin.  When  cavities  have  formed  it  becomes  more 
paroxysmal,  and  is  most  marked  in  the  morning  or  after  a  sleep.  Cough  is 
not  a  constant  symptom,  however,  and  a  patient  may  present  himself  with 
well-marked  excavation  at  one  apex  who  will  declare  that  he  has  had  little  or 
o  cough.  So,  too,  there  may  be  well-marked  physical  signs,  dulness  and 
moist  sounds,  without  either  expectoration  or  cough.  In  well-established 
ases  the  -nocturnal  paroxysms  are  most  distressing  and  prevent  sleep.  The 
cough  may  be  of  such  persistence  and  severity  as  to  cause  vomiting,  and  the 


TUBERCULOSIS  193 

patient  becomes  rapidly  emaciated  from  loss  of  food — Morton's  cough 
(Phthisiologia,  1689,  p.  101).  The  laryngeal  complications  give  a  peculiarly 
husky  quality  to  the  cough,  and  when  erosion  and  ulceration  have  proceeded 
far  in  the  vocal  cords  the  coughing  becomes  much  less  effective. 

Sputum.— This  varies  greatly  in  amount  and  character  with  the  different 
stages.  There  are  patients  with  well-marked  local  signs  at  one  apex,  with 
slight  cough  and  moderately  high  fever,  without  from  day  to  day  a  trace  of 
expectoration.  So,  also,  there  are  instances  with  the  most  extensive  con- 
solidation (caseous  pneumonia)  and  high  fever,  but  without  enough  expec- 
toration to  enable  an  examination  for  bacilli  to  be  made.  In  the  early  stage 
of  pulmonary  tuberculosis  the  sputum  is  chiefly  catarrhal  and  has  a  glairy, 
sago-like  appearance,  due  to  the  presence  of  alveolar  cells  which  have  under- 
gone the  myeline  degeneration.  There  is  nothing  distinctive  or  peculiar  in 
this  form  of  expectoration,  which  may  persist  for  months  without  indicating 
serious  trouble.  The  earliest  trace  of  characteristic  sputum  may  show  the 
presence  of  small  grayish  or  greenish-gray  purulent  masses.  These,  when 
coughed  up,  are  always  suggestive  and  should  be  the  portions  picked  out  for 
microscopic  examination.  As  softening  comes  on,  the  expectoration  becomes 
more  profuse  and  purulent,  but  may  still  contain  a  considerable  quantity  of 
alveolar  epithelium.  Finally,  when  cavities  exist,  the  sputum  assumes  the  so- 
called  nummular  form ;  each  mass  is  isolated,  flattened,  greenish-gray  in  color, 
quite  airless,  and,  when  spat  into  water,  sinks  to  the  bottom. 

By  the  microscopic  examination  of  the  sputum  we  determine  whether 
the  process  is  tuberculous,  and  whether  softening  has  occurred.  The  bacilli 
in  stained  preparations  are  seen  as  elongated,  slightly  curved,  red  rods,  some- 
times presenting  a  beaded  appearance.  They  are  frequently  in  groups  of 
three  or  four,  but  the  number  varies  considerably.  Only  one  or  two  may  be 
found  in  a  preparation,  or,  in  some  instances,  they  are  so  abundant  that  the 
entire  field  is  occupied.  Repeated  examinations  may  be .  necessary. 

The  continued  presence  of  tubercle  bacilli  in  the  sputum  is  an  infallible 
indication  of  the  existence  of  tuberculosis. 

One  or  two  may  possibly  be  due  to  accidental  inhalation.  A  number  may 
come  from  a  spot  of  softening  3  by  3  cm.  In  the  nummular  sputa  of  later 
stages  the  bacilli  are  very  abundant. 

Elastic  tissue  may  be  derived  from  the  bronchi,  the  alveoli,  or  from  the 
arterial  coats;  and  naturally  the  appearance  of  the  tissue  will  vary  with  the 
locality  from  which  it  comes.  In  the  examination  for  this  it  is  not  necessary 
to  boil  the  sputum  with  caustic  potash.  For  years  I  have  used  a  simple  plan 
which  was  shown  to  me  at  the  London  Hospital  by  Sir  Andrew  Clark.  This 
method  depends  upon  the  fact  that  in  almost  all  instances  if  the  sputum  is 
spread  in  a  sufficiently  thin  layer  the  fragments  of  elastic  tissue  can  be  seen 
with  the  naked  eye.  The  thick,  purulent  portions  are  placed  upon  a  glass 
plate  15  X  15  cm.  and  flattened  into  a  thin  layer  by  a  second  glass  plate 
10  X  10  cm.  In  this  compressed  grayish  layer  between  the  glass  slips  any 
fragments  of  elastic  tissue  show  on  a  black  background  as  grayish-yellow 
spots  and  can  either  be  examined  at  once  under  a  low  power  or  the  uppermost 
piece  of  glass  is  slid  along  until  the  fragment  is  exposed,  when  it  is  picked 
out  and  placed  upon  the  ordinary  microscopic  slide.  Fragments  of  bread 
and  collections  of  milk-globules  may  also  present  an  opaque  white  appearance, 


194  SPECIFIC   INFECTIOUS   DISEASES 

but  with  a  little  practice  they  can  readily  be  recognized.  Fragments  of  epi- 
thelium from  the  tongue,  infiltrated  with  micrococci,  are  still  more  deceptive, 
but  the  miscroscope  at  once  shows  the  difference. 

The  bronchial  elastic  tissue  forms  an  elongated  network,  or  two  or  three 
long,  narrow  fibres  are  found  close  together.  From  the  blood-vessels  a  some- 
what similar  form  may  be  seen  and  occasionally  a  distinct  sheeting  is  found 
as  if  it  had  come  from  the  intima  of  a  good-sized  artery.  The  elastic  tissue 
of  the  alveolar  wall  is  quite  distinctive;  the  fibres  are  branched  and  often 
show  the  outline  of  the  arrangement  of  the  air-cells.  The  elastic  tissue  from 
bronchi  or  alveoli  indicates  extensive  erosion  of  a  tube  and  softening  of  the 

lung-tissue. 

Another  occasional  constituent  of  the  sputum  is  blood,  which  may  be  pres- 
ent as  the  chief  characteristic  of  the  expectoration  in  haemoptyaifl  or  may 
simply  tinge  the  sputum.  In  chronic  cases  with  large  cavities,  in  addition  to 
bacteria,  various  forms  of  fungi  may  be  found,  of  which  the  aspergillus  is  the 
most  important.  Sarcinae  may  also  occur. 

Calcareous  Fragments. — Formerly  a  good,  deal  of  stress  was  laid  upon  their 
presence  in  the  sputum,  and  Morton  described  a  phthisis  a  calculis  in  pulmoni- 
bus  generates.  Bayle  also  described  a  separate  form  of  phthisis  calculeuse. 
The  size  of  the  fragments  varies  from  a  small  pea  to  a  large  cherry.  As  a 
rule,  a  single  one  is  ejected;  sometimes  large  numbers  are  coughed  up  in  the 
course  of  the  disease.  They  are  formed  in  the  lung  by  the  calcification  of  case- 
ous masses,  and  it  is  said  also  occasionally  in  obstructed  bronchi.  They  may 
come  from  the  bronchial  glands  by  ulceration  into  the  bronchi,  and  there  is  a 
case  on  record  of  suffocation  in  a  child  from  this  cause. 

The  daily  amount  of  expectoration  varies.  In  rapidly  advancing  cases, 
with  much  cough,  it  may  reach  as  high  as  500  c.  c.  in  the  day.  In  cases  with 
large  cavities  the  chief  amount  is  brought  up  in  the  morning.  The  expectora- 
tion of  tuberculous  patients  usually  has  a  heavy,  sweetish  odor,  and  occasion- 
ally it  is  fetid,  owing  to  decomposition  in  the  cavities. 

Haemoptysis. — One  of  the  most  famous  of  the  Jlippocratic  axioms  says, 
"From  a  spitting  of  blood  there  is  a  spitting  of  pus."  The  older  writers 
thought  that  the  phthisis  was  directly  due  to  the  inflammatory  or  putrefactive 
changes  caused  by  the  haemorrhage  into  the  lung.  Morton,  however,  in  his 
interesting  section,  Phthisis  ab  Hcemoptde,  rather  doubted  this  sequence. 
Laennec  and  Louis,  and  later  in  the  century  Traube,  regarded  the  haemoptysis 
as  an  evidence  of  existing  disease  of  the  lung.  From  the  accurate  views  of 
Laennec  and  Louis  the  profession  was  led  away  by  Graves,  and  particularly 
by  Niemeyer,  who  held  that  the  blood  in  the  air-cells  set  up  an  inflammatory 
process,  a  common  termination  of  which  was  caseation.  Since  Koch's  dis- 
covery we  have  learned  that  many  cases  in  which  the  physical  examination  is 
negative  show,  either  during  the  period  of  haemorrhage  or  immediately  after  it, 
tubercle  bacilli  in  the  sputum,  so  that  opinion  has  veered  to  the  older  view, 
and  we  now  regard  the  appearance  of  haemoptysis  as  an  indication  of  existing 
disease.  In  young,  apparently  healthy,  persons  cases  of  haemoptysis  may  be 
divided  into  three  groups.  In  the  first  the  bleeding  has  come  on  without 
premonition,  without  overexertion  or  injury,  and  there  is  no  family  history 
of  tuberculosis.  The  physical  examination  is  negative,  and  the  examination 
of  the  expectoration  at  the  time  of  the  haemorrhage  and  subsequently  shows  no 


TUBERCULOSIS  195 

tubercle  bacilli.  Such  instances  are  not  uncommon,  and,  though  one  may 
suspect  strongly  the  presence  of  some  focus  of  tuberculosis,  yet  the  individuals 
may  retain  good  health  for  many  years,  and  have  no  further  trouble.  Of  the 
386  cases  of  haemoptysis  noted  by  Ware  in  private  practice  62  recovered,  and 
pulmonary  disease  did  not  subsequently  occur. 

In  a  second  group  individuals  in  apparently  perfect  health  are  suddenly 
attacked,  perhaps  after  a  slight  exertion  or  during  some  athletic  exercises. 
The  physical  examination  is  also  negative,  but  tubercle  bacilli  are  found  some- 
times in  the  bloody  sputum,  more  frequently  a  few  days  later. 

In  a  third  set  of  cases  the  individuals  have  been  in  failing  health  for  a 
month  or  two,  but  the  symptoms  have  not  been  urgent  and  perhaps  not  noticed 
by  the  patients.  The  physical  examination  shows  the  presence  of  well-marked 
tuberculous  disease,  and  there  are  both  tubercle  bacilli  and  elastic  tissue  in 
the  sputum. 

A  very  interesting  systematic  study  of  the  subject  of  hemoptysis,  particu- 
larly in  its  relation  to  the  question  of  tuberculosis,  has  been  completed  in  the 
Prussian  army  by  Franz  Strieker.  During  the  five  years  1890-'95  there  were 
900  cases  admitted  to  the  hospitals,  which  is  a  percentage  of  0.045  of  the 
strength  (1,728,505).  Of  the  cases,  in  480  the  haemorrhage  came  on  with- 
out recognizable  cause.  Of  these,  417  cases,  86  per  cent.,  were  certainly  or 
probably  tuberculous.  In  only  221,  however,  was  the  evidence  conclusive. 

In  a  second  group  of  213  cases  the  haemorrhage  came  on  during  the  mili- 
tary exercise,  and  of  these  75  patients  were  shown  to  be  tuberculous. 

In  118  cases  the  haemorrhage  followed  certain  special  exercises,  as  in  the 
gymnasium  or  in  riding  or  in  consequence  of  swimming.  In  24  cases  it 
occurred  during  the  exercise  of  the  voice  in  singing  or  in  giving  command  or 
in  the  use  of  wind  instruments.  A  very  interesting  group  of  24  cases  is  re- 
ported in  which  the  haemorrhage  followed  trauma,  either  a  fall  or  a  blow 
upon  the  thorax.  In  7  of  these  tuberculosis  was  positively  present,  and  in  6 
other  cases  there  was  a  strong  probability  of  its  existence. 

Among  the  conclusions  which  Strieker  draws  the  following  are  the  most 
important:  namely,  that  soldiers  attacked  with  haemoptysis  without  special 
cause  are  in  at  least  86.8  per  cent,  tuberculous.  In  the  cases  in  which  the 
haemoptysis  follows  the  special  exercises,  etc.,  of  military  service  at  least  74.4 
per  cent,  are  tuberculous.  In  the  cases  which  come  on  during  swimming  or 
as  a  consequence  of  direct  injury  to  the  thorax  about  one-half  are  not  associ- 
ated with  tuberculosis. 

Haemoptysis  occurs  in  from  60  to  80  per  cent,  of  all  cases  of  pulmonary 
tuberculosis.  It  is  more  frequent  in  males  than  in  females. 

In  a  majority  of  all  cases  the  bleeding  recurs.  Sometimes  it  is  a  special 
feature  throughout  the  disease,  so  that  a  haemorrhagic  form  has  been  recog- 
nized. The  amount  of  blood  brought  up  varies  from  a  couple  of  drachms  to 
a  pint  or  more.  In  69  per  cent,  of  4,125  cases  of  haemoptysis  at  the  Brompton 
Hospital  the  amount  brought  up  was  under  half  an  ounce. 

A  distinction  may  be  drawn  between  the  haemoptysis  early  in  the  disease 
and  that  which  occurs  in  the  later  periods.  In  the  former  the  bleeding  is 
usually  slight,  is  apt  to  recur,  and  fatal  haemorrhage  is  very  rare.  In  these 
cases  the  bleeding  is  usually  from  small  areas  of  softening  or  from  early 
erosions  in  the  bronchial  mucosa.  In  the  later  periods,  after  cavities  have 


196  SPECIFIC    INFECTIOUS    DISEASES 

formed  the  bleeding,  is,  as  a  rule,  more  profuse  and  is  more  apt  to  be  fatal. 
Single  large  haemorrhages,  proving  quickly  fatal,  are  very  rare,  except  in  the 
advanced  stages  of  the  disease.  In  these  cases  the  bleeding  comes  either  from 
an  erosion  of  a  good-sized  vessel  in  the  wall  of  a  cavity  or  from  the  rupture 
of  an  aneurism  of  the  pulmonary  artery. 

The  bleeding,  as  a  rule,  sets  in  suddenly.  Without  any  warning  the  pa- 
tient may  notice  a  warm  salt  taste  and  the  mouth  fills  with  blood.  It  may 
come  up  with  a  slight  cough.  The  total  amount  may  not  be  more  than  a  few 
drachms,  and  for  a  day  or  two  the  patient  may  spit  up  small  quantities.  When 
a  large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount  of  blood  brought 
up  is  large,  and  in  the  course  of  a  short  time  a  pint  or  two  may  be  expec- 
torated. Fatal  haemorrhage  may  occur  into  a  very  large  cavity  without  any 
blood  being  coughed  up.  The  character  of  the  blood  is,  as  a  rule,  distinctive. 
It  is  frothy,  mixed  with  mucus,  generally  bright  red  in  color,  except  when 
large  amounts  are  expectorated,  and  then  it  may  be  dark.  The  sputum  may 
remain  blood-tinged  for  some  days,  or  there  are  brownish-black  streaks  in  it, 
or  friable  nodules  consisting  entirely  of  blood-corpuscles  may  be  coughed  up. 
Blood  moulds  of  the  smaller  bronchi  are  sometimes  expectorated. 

The  microscopic  examination  of  the  sputum  in  haemorrhage  cases  is  most 
important.  If  carefully  spread  out,  there  may  be  noted,  even  in  an  apparently 
pure  heemorrhagic  mass,  little  portions  of  mucus  from  which  bacilli  or  elastic 
tissue  may  be  obtained.  Flick  and  others  have  called  attention  to  the  fre- 
quency with  which  hemoptysis  is  associated  with  the  appearance  or  an 
increase  of  pneumococci  and  influenza  bacilli  in  the  sputum. 

Dyspnoea  is  not  a  common  accompaniment  of  ordinary  tuberculosis.  The 
greater  part  of  one  lung  may  be  diseased  and  local  trouble  exist  at  the  other 
apex  without  any  shortness  of  breath.  Even  in  the  paroxysms  of  very  high 
fever  the  respirations  may  not  be  much  increased.  Dyspnoea  occurs  (a)  with 
the  rapid  extension  in  both  lungs  of  a  broncho-pneumonia;  (&)  with  the 
occurrence  of  miliary  tuberculosis;  (<?)  sometimes  with  pneumothorax ;  (d) 
in  old  cases  with  much  emphysema,  and  it  may  be  a'ssociated  with  cyanosis; 
(c)  and,  lastly,  in  long-standing  cases,  with  contracted  apices  or  great  thick- 
ening of  the  pleura,  the  right  heart  is  enlarged,  and  the  dyspnoea  may  be 
cardiac. 

GENERAL  SYMPTOMS.— Fever. — It  is  well  to  bear  in  mind  that  the  tem- 
perature varies  slightly  in  normal  individuals,  and  the  afternoon  range  may 
be  90°,  99.5°  or  even  100°  F.  The  difference  between  the  mouth  and  rectal 
temperature  may  be  a  full  degree,  and  in  young  full-blooded  persons,  in  the 
nervous,  and  after  exercise  the  normal  rectal  temperature  may  be  100.5°  or 
even  101°  F.  To  get  a  correct  idea  of  the  temperature  range  in  pulmonary 
tuberculosis  it  is  necessary  to  make  observations  every  two  hours  at  first.  The 
usual  8  A.  M.  and  8  p.  M.  record  is,  in  a  majority  of  the  cases,  very  deceptive, 
giving  neither  the  minimum  nor  maximum.  The  former  usually  occurs  be- 
tween 2  and  6  A.  M.,  and  the  latter  between  2  and  6  p.  M. 

Fever,  one  of  the  earliest  and  most  important  symptoms,  is  due  to  the 
effect  on  the  heat  centres  of  the  toxins  or  materials  absorbed  from  the  tuber- 
culous focus.  Later  in  the  disease  the  hectic  fever  is  caused  in  part  by  the 
absorption  of  the  bacterial  products  of  other  organisms.  From  a  small  spot 
-of  disease  not  a  sufficient  amount  of  toxin  'may  be  produced  to  disturb  the 


TUBERCULOSIS  197? 

body  metabolism,  but  in  the  lymph  glands,  lungs,  and  bones,  from  progressing 
areas  of  infection  sufficient  absorption  takes  place  to  cause  fever.  It  is  an 
auto-inoculation  comparable  with  the  fever  prodiiced  by  an  injection  of  tuber- 
culin. Anything  that  stimulates  the  local  lymph  and  blood  flow  favors  the 
discharge  of  the  toxins  and  causes  fever.  A  patient  at  rest  may  be  afebrile; 
after  exercise  the  temperature  may  be  102.5°,  due  to  an  auto-inoculation.  In 
acute  cases  the  fever  is  more  or  less  continuous,  resembling  that  of. typhoid 
fever  or  pneumonia,  with  slight  morning  remissions.  It  may  set  in  with  a 
chill  and  be  followed  by  sweats,  and  there  are  cases  with  a  marked  intermit- 
tent pyrexia  from  the  onset.  As  a  rule,  the  degree  of  activity  of  the  local 
process  may  be  gauged  by  the  persistency  and  the  range  of  the  fever;  and 
favorable  cases  are  those  in  which  the  temperature  yields  rapidly  to  rest. 
In  a  few  cases  progress  of  the  local  disease  continues  and  may  even  be  rapid 
without  fever.  The  temperature  of  consumptives  is  easily  influenced  by 
trivial  causes  which  would  not  affect  a  normal  person,  such  as  mental  excite- 
ment, exercise,  constipation,  etc.  The  patient  is  usually  aware  when  fever 
is  present  and  feels  more  comfortable  with  a  temperature  of  101°.  Except 
the  sweating,  there  are  rarely  any  unpleasant  feelings  connected  with  it. 

With  breaking  down  of  the  lung-tissue  and  formation  of  cavities,  asso- 
ciated as  these  processes  always  are  with  suppuration  and  mixed  infection, 
the  fever  assumes  a  characteristically  intermittent  or  hectic  type.  For  a  large 
part  of  the  day  the  patient  is  not  only  afebrile,  but  the  temperature  is  sub- 
normal. In  the  annexed  two-hourly  chart,  from  a  case  of  chronic  tuberculosis 
of  the  lungs,  it  will  be  seen  that,  from  10  p.  M.  to  8  A.  M.  or  noon,  the  tem- 
perature continuously  fell  and  went  as  low  as  95°.  A  slow  rise  then  took 
place  through  the  late  morning  and  early  afternoon  hours  and  reached  its 
maximum  between  6  and  10  p.  M.  As  shown  in  the  chart,  there  were  in  the 
three  days  about  forty-three  hours  of  pyrexia  and  twenty-nine  hours  of  apy- 
rexia.  The  rapid  fall  of  the  temperature  in  the  early  morning  hours  is  usu- 
ally associated  with  sweating.  This  hectic,  as  it  is  called,  which  is  a  typical 
fever  of  septic  infection,  is  met  with  when  the  process  of  cavity  formation 
and  softening  is  advanced  and  extending. 

Sweating — Drenching  perspirations  are  common  in  phthisis  and  consti- 
tute one  of  the  most  distressing  features  of  the  disease.  They  occur  usually 
with  the  drop  in  the  fever  in  the  early  morning  hours,  or  at  any  time  in  the 
day  when  the  patient  sleeps.  They  may  come  on  early  in  the  disease,  but  are 
more  persistent  and  frequent  after  cavities  have  formed.  Some  patients 
escape  altogether. 

The  pulse  is  increased  in  frequency  and  usually  in  proportion  to  the 
height  of  the  fever.  Even  when  at  rest  and  afebrile  the  pulse  may  be  rapid, 
but  the  excitement  of  counting  it  may  increase  the  rate  20  to  30  beats.  The 
pulse  is  often  remarkably  full,  soft  and  compressible;  even  after  recovery  it 
may  remain  rapid.  Pulsation  may  sometimes  be  seen  in  the  capillaries  and 
in  the  veins  on  the  back  of  the  hand. 

Emaciation  is  a  pronounced  feature,  from  which  the  two  common  names 
of  the  disease  have  been  derived.  The  loss  of  weight  is  gradual  and,  if  the 
disease  is  extending,  progressive.  The  scales  give  one  of  the  best  indications 
of  the  progress  of  the  patient.  It  is  most  rapid  early  in  the  disease,  when  the 
patient  may  lose  at  the  rate  of  five  or  six  pounds  a  week;  and  usually  is  in 


198 


SPECIFIC    INFECTIOUS    DISEASES 


direct  relation  to  the  intensity  and  duration  of  the  fever.  With  the  arrest  of 
the  progress  and  the  fall  in  temperature  the  patient  usually  begins  to  regain 
weight.  The  average  gain  in  weight  of  901  patients  at  the  Adirondack  Sana- 
torium was  fourteen  pounds  (L.  Brown).  A  gain  of  two  pounds  a  week  is 
satisfactory.  Loss  of  strength  may  he  out  of  proportion  to  and  quite  inde- 
pendent of  loss  of  weight.  Early  debility  may  be  a  marked  feature. 


•6 

Pulse 


Ecsp. 


CHART  V-— THREE  DAYS.    CHRONIC  TUBERCULOSIS. 

PHYSICAL  SIGNS. —  (a)  Inspection. — The  shape  of  the  chest  is  often  sug- 
gestive, though  it  is  to  be  remembered  that  the  disease  may  be  met  with  in 
chests  of  any  build,.  Practically,  however,  in  a  considerable  proportion  of 
cases  the  thorax  is  long  and  narrow,  with  very  wide  intercostal  spaces,  the 
ribs  more  vertical  in  direction,  and  the  costal  angle  very  narrow.  The  scap- 
ulae are  "winged,"  a  point  noted  by  Hippocrates.  Another  type  of  chest 
which  is  very  common  is  that  which  is  flattened  in  the  antero-posterior  diam- 
eter. The  costal  cartilages  may  be  prominent  and  the  sternum  depressed. 
Occasionally  the  lower  sternum  forms  a  deep  concavity,  the  so-called  funnel 
breast  (Trichter-Brust) .  Special  examination  should  be  made  of  the  clavicu- 
lar regions  to  see  if  one  clavicle  stands  out  more  distinctly  than  the  other, 
or  if  the  spaces  above  or  below  it  are  more  marked.  Defective  expansion  at 
one  apex  is  an  early  and  important  sign.  The  condition  of  expansion  of  the 


TUBERCULOSIS  199 

lower  zone  of  the  thorax  may  be  well  estimated  by  inspection.  The  condi- 
tion of  the  praecordia  should  also  be  noted,  as  a  wide  area  of  impulse,  particu- 
larly in  the  second,  third,  and  fourth  interspaces,  often  results  from  disease 
of  the  left  apex.  From  a  point  behind  the  patient,  looking  over  the  shoulders, 
one  can  often  better  estimate  the  relative  expansion  of  the  apices.  Atrophy 
of  the  muscles  of  the  shoulder-girdle  on  the  affected  side  is  not  uncommon, 
and  a  slight  scoliosis  may  be  present.  Movement  may  be  restricted  on  the 
affected  side,  particularly  at  the  apex.  Pleurisy  with  adhesions  or  with  ef- 
fusion, fibrosis,  and  pneumonic  consolidation  may  limit  the  movement  of  one 
side.  The  Litten  phenomenon  (seen  best  on  the  right  side)  may  be  restricted 
in  extent  or  absent.  The  chest  expansion  may  be  much  reduced.  It  should 
be  recorded  carefully  at  the  first  examination. 

(6)  Palpation. — Deficiency  in  expansion  at  the  apices  or  bases  is  per- 
haps best  gauged,  by  placing  the  hands  in  the  subclavicular  spaces  and  then 
in  the  lateral  regions  of  the  chest  and  asking  the  patient  to  draw  slowly  a 
full  breath.  Standing  behind  the  patient  and  placing  the  thumbs  in  the 
supraclavicular  and  the  fingers  in  the  infraclavicular  spaces  one  can  judge 
accurately  as  to  the  relative  mobility  of  the  two  sides.  Disease  at  an  apex, 
though  early  and  before  dulness  is  at  all  marked,  may  be  indicated  by  de- 
ficient expansion.  On  asking  the  patient  to  count,  the  tactile  fremitus  is 
increased  wherever  there  is  local  growth  of  tubercle  or  extensive  caseation. 
In  comparing  the  apices  it  is  important  to  bear  in  mind  that  normally  the 
fremitus  is  stronger  over  the  right  than  the  left.  So,  too,  at  the  base,  when 
there  is  consolidation  of  the  lung,  the  fremitus  is  increased;  whereas,  if  the*e 
is  pleural  effusion,  it  is  diminished  or  absent.  In  the  later  stages,  when  cavi- 
ties form,  the  tactile  fremitus  is  usually  much  exaggerated  over  them!  When 
the  pleura  is  greatly  thickened  the  fremitus  may  be  diminished. 

(c)  Percussion. — Tubercles,  inflammatory  products,  fibroid  changes,  and 
cavities  produce  important  changes  in  the  pulmonary  resonance.  There  may 
be  localized  disease,  even  of  some  extent,  without  inducing  much  alteration, 
as  when  the  tubercles  are  scattered  there  is  air-containing  tissue  between 
them.  In  incipient  cases  percussion  may  be  negative,  28  out  of  201  in  L. 
Brown's  series.  It  requires  a  fair-sized  area  of  infiltration  to  cause  a  change 
in  the  percussion  note,  4x6  cm.,  according  to  Cornet.  The  personal  equa- 
tion is  very  important  in  estimating  the  early  physical  signs  in  pulmonary 
tuberculosis,  and  I  remember  a  notable  diagnosis  of  a  cavity  at  the  back  of 
the  left  apex  the  size  of  a  hickory  nut,  with  the  shell  on f  One  of  the  earliest 
and  most  valuable  signs  is  defective  resonance  upon  and  above  a  clavicle.  In 
a  considerable  proportion  of  all  cases  of  phthisis  the  dulness  is  first  noted 
in  these  regions.  The  comparison  between  the  two  sides  should  be  made  also 
when  the  breath  is  held  after  a  full  inspiration,  as  the  defective  resonance 
may  then  be  more  clearly  marked.  In  the  early  stages  the  percussion  note 
is  usually  higher  in  pitch,  and  it  may  require  an  experienced  ear  to  detect  the 
difference.  In  recent  consolidation  from  caseous  pneumonia  the  percussion 
note  often  has  a  tympanitic  quality.  A  wooden  dulness  is  rarely  heard  except 
in  old  cases  with  extensive  fibroid  change  at  the  apex  or  base.  Over  large, 
thin-walled  cavities  at  the  apex  the  so-called  cracked-pot  sound  may  be  ob- 
tained. In  thin  subjects  the  percussion  should  be  carefully  practiced  in  the 
supraspinous  fossa?  and  the  interscapular  space,  as  they  correspond  to  very 


200  SPECIFIC    INFECTIOUS    DISEASES 

important  areas  early  involved  in  the  disease.  By  light  percussion  along  the 
border  of  the  trapezius  and  in  the  supraclavicular  and  supraspinous  fossae, 
areas  of  apical  resonance  may  be  mapped  out  (Kronig's  apical  resonance 
zones).  Under  normal  conditions  the  areas  are  equal  on  the  two  sides.  Con- 
solidation or  retraction  of  an  apex  causes  definite  narrowing  of  the  zone  on. 
the  affected  side.  The  procedure  requires  considerable  skill.  It  gives  valua- 
ble information  in  the  early  stage  of  infiltration.  Goldscheider  uses  a  special 
pleximeter  and  percusses  out  the  borders  of  the  apex  of  the  lung  projecting 
above  the  clavicle.  The  method  is  less  satisfactory  than  that  of  Kronig.  In 
cases  with  numerous  isolated  cavities  at  the  apex,  without  much  fibroid 
tissue  or  thickening  of  the  pleura,  the  percussion  note  may  show  little  change, 
and  the  contrast  between  the  signs  obtained  an  auscultation  and  percussion 
is  most  marked.  In  the  direct  percussion  of  the  chest,  particularly  in  thin 
patients  over  the  pectorals,  one  frequently  sees  the  phenomenon  known  as 
myoidema,  a  local  contraction  of  the  muscle  causing  bulging,  which  per- 
sists for  a  variable  period  and  gradually  subsides.  It  has  no  special  sig- 
nificance. 

(d)  Auscultation. — Feeble  breath-sounds  are  among  the  most  character- 
istic early  signs,  since  not  as  much  air  enters  the  tubes  and  vesicles  of  the 
affected  area.  It  is  well  at  first  always  to  compare  carefully  the  correspond- 
ing points  on  the  two  sides  of  the  chest  without  asking  the  patient  either  to 
draw  a  deep  breath  or  to  cough.  With  early  apical  disease  the  inspiration  on 
quiet  breathing  may  be  scarcely  audible.  Expiration  is  usually  prolonged. 
On  the  other  hand,  there  are  cases  in  which  the  earliest  sign  is  a  harsh,  rude, 
respiratory  murmur.  On  deep  breathing  it  is  frequently  to  be  noted  that 
inspiration  is  jerking  or  wavy,  the  so-called  "cog-wheel"  rhythm;  which, 
however,  is  by  no  means  confined  to  tuberculosis.  With  extension  of  the 
disease  the  inspiratory  murmur  is  harsh,  and,  when  consolidation  occurs, 
whiffing  and  bronchial.  With  these  changes  in  the  character  of  the  murmur 
there  are  rales.  The  patient  should  first  breathe  quietly,  then  take  a  full 
breath,  and  then  cough.  When  heard  with  quiet  brea-thing,  if  they  persist  and 
are  present  in  one  area  only,  they  are  of  great  importance.  The  fine  rustling 
crepitus  at  one  or  both  apices  which  is  heard  when  the  patient  first  takes  a 
deep  breath  is  of  no  moment.  It  may  also  be  present  at  the  bases.  Rales  at 
the  end  of  deep  inspiration  which  disappear  on  repeated  breathing  may  also 
be  disregarded.  Rales  which  are  brought  out  by  coughing,  which  persist,  and 
are  repeatedly  heard  at  the  same  spot  are  of  the  greatest  importance.  It  is 
of  equal  import  when  moist,  clicking  rales  are  present  with  change  in  the 
percussion  note.  Attention  to  these  brief  rules  will  save  many  of  the  unneces- 
sary diagnoses  of  pulmonary  tuberculosis  at  present  made  on  auscultatory 
signs  alone. 

When  softening  occurs  the  rales  are  louder  and  have  a  bubbling,  some- 
times a  characteristic  clicking  quality.  These  "moist  sounds,"  as  they  are 
called,  when  associated  with  change  in  the  percussion  resonance  are  extremely 
suggestive.  When  cavities  form  the  rales  are  louder,  more  gurgling,  and 
sonant  in  quality.  When  there  is  consolidation  of  any  extent  the  breath 
sounds  are  tubular,  and  in  the  large  excavations  loud  and  cavernous,  or  have 
an  amphoric  quality.  In  the  unaffected  portions  of  the  lobe  and  in  the  oppo- 
site lung  the  breath  sounds  may  be  harsh  and  even  puerile.  The  vocal  reso- 


TUBERCULOSIS  201 

nance  is  usually  increased  in  all  stages  of  the  process,  and  bronchophony  and 
pectoriloquy  are  met  with  in  the  regions  of  consolidation  and  over  cavities. 
Pleuritic  friction  may  be  present  at  any  stage  and,  as  mentioned  before,  occurs 
very  early.  There  are  cases  in  which  it  is  a  marked  feature  throughout. 
When  the  lappet  of  lung  over  the  heart  is  involved  there  may  be  a  pleuro- 
pericardial  friction,  and  when  this  area  is  consolidated  there  may  be  curious 
clicking  rales  synchronous  with  the  heart-beat,  due  to  the  compression  by  the 
heart  of  this  portion  with  expulsion  of  air  from  it.  An  interesting  ausculta- 
tory  sign  met  with  in  thin-chested  persons,  in  nervous  patients,  and  often  in 
early  pulmonary  tuberculosis  is  the  so-called  cardio-respiratory  murmur,  a 
whiffing  systolic  bruit  due  to  the  propulsion  of  air  out  of  the  tubes  by  the 
impulse  of  the  heart.  It  is  best  heard  during  inspiration  and  in  the  antero- 
lateral  regions  of  the  chest. 

A  systolic  murmur  is  frequently  heard  in  the  subclavian  artery  on  either 
side,  the  pulsation  of  which  may  be  very  visible.  The  murmur  is  in  all  prob- 
ability due  to  pressure  on  the  vessels  by  the  thickened  pleura. 

The  signs  of  cavity  may  be  here  briefly  enumerated. 

(1)  When  there  is  not  much  thickening  of  the  pleura  or  condensation 
of  the  surrounding  lung-tissue,  the  percussion  sound  may  be  full  and  clear, 
resembling  the  normal  note.  More  commonly  there  is  defective  resonance 
or  a  tympanitic  quality  which  may  at  times  be  purely  amphoric.  The  pitch 
of  the  percussion  note  changes  over  a  cavity  when  the  mouth  is  opened  or 
closed  (Wintrich's  sign),  or  it  may  be  brought  out  more  clearly  on  change 
of  position.  The  cracked-pot  sound  is  obtainable  only  over  tolerably  large 
cavities  with  thin  walls.  It  is  best  elicited  by  a  firm,  quick  stroke,  the  pa- 
tient at  the  time  having  the  mouth  open.  In  those  rare  instances  of  almost 
total  excavation  of  one  lung  the  percussion  note  may  be  amphoric  in  quality. 
(2)  On  auscultation  the  so-called  cavernous  sounds  are  heard:  (i)  Various 
grades  of  modified  breathing — blowing  or  tubular,  cavernous  or  amphoric. 
There  may  be  a  curiously  sharp  hissing  sound,  as  if  the  air  was  passing  from  a 
narrow  opening  into  a  wide  space.  In  very  large  cavities  both  inspiration 
and  expiration  may  be  typically  amphoric,  (ii)  There  are  coarse  bubbling 
rales  which  have  a  resonant  quality,  and  on  coughing  may  have  a  metallic 
or  ringing  character.  On  coughing  they  are  often  loud  and  gurgling.  In 
very  large  thin-walled  cavities,  and  more  rarely  in  medium-sized  cavities, 
surrounded  by  recent  consolidation,  the  rales  may  have  a  distinctly  amphoric 
echo,  simulating  those  of  pneumothorax.  There  are  dry  cavities  in  which  no 
rales  are  heard,  (iii)  The  vocal  resonance  is  greatly  intensified,  and 
whispered  broncophony  is  clearly  heard.  In  large  apical  cavities  the 
heart-sounds  are  well  heard,  and  occasionally  there  may  be  an  intense 
systolic  murmur,  probably  always  transmitted  to,  and  not  produced,  as 
has  been  supposed,  in  the  cavity  itself.  In  large  excavations  of  the  left 
apex  the  heart  impulse  may  cause  gurgling  sounds  or  clicks  synchron- 
ous with  the  systole.  They  may  even  be  loud  enough  to  be  heard  at 
a  little  distance  from  the  chest  wall.  A  large  cavity  with  smooth  walls 
and  thin  fluid  contents  may  give  the  succussion  sound  when  the  trunk  is 
abruptly  shaken  (Walshe),  and  even  the  coin  sound  may  be  obtained. 

Pseudo-cavernous  signs  may  be  caused  by  an  area  of  consolidation  near  a 
large  bronchus.  The  condition  may  be  most  deceptive — the  high-pitched  or 
15 


202  SPECIFIC    INFECTIOUS    DISEASES 

tyrapanitic  percussion  note,  the  tubular   or  cavernous  breathing,    and   the 
resonant  rales  simulate  closely  the  signs  of  cavity. 

3.    Fibroid  Phthisis 

In  their  monograph  on  Fibroid  Diseases  of  the  Lung,  Clark,  Hadley,  and 
Chaplin  make  the  following  classification:  1.  Pure  fibroid — a  condition  in 
which  there  is  no  tubercle.  2.  Tuberculo-fibroid  disease — a  condition  pri- 
marily tuberculous,  but  which  has  run  a  fibroid  course.  3.  Fibro-tubercu- 
lous  disease — a  condition  primarily  fibroid,  but  which  has  become  tuberculous. 
The  tuberculo-fibroid  form  may  come  on  gradually  as  a  sequence  of  a  chronic 
mberculous  broncho-pneumonia  or  follow  a  chronic  tuberculous  pleurisy.  In 
rther  instances  the  process  supervenes  upon  an  ordinary  ulcerative  phthisis. 
The  disease  becomes  limited  to  one  apex,  the  cavity  is  surrounded  by  layers 
of  dense  fibrous  tissue,  the  pleura  is  thickened,  and  the  lower  lobe  is  gradually 
invaded  by  the  sclerotic  change.  Ultimately  a  picture  is  produced  little  if  at 
all  different  from  the  condition  known  as  cirrhosis  of  the  lungs.  It  may  even 
be  difficult  to  say  that  the  process  is  tuberculous,  but  in  advanced  cases  the 
bacilli  are  usually  present  in  the  walls  of  the  cavity  at  the  apex,  or  old,  en- 
capsulated caseous  areas  are  present,  or  there  may  be  tubercles  at  the  apex 
of  the  other  lung  and  in  the  bronchial  glands.  Dilatation  of  the  bronchi  is 
present ;  the  right  ventricle,  sometimes  the  entire  heart,  is  hypertrophied. 

The  disease  is  chronic,  lasting  from  ten  to  twenty  or  more  years,  during 
which  time  the  patient  may  have  fair  health.  The  chief  symptoms  are  cough, 
often  paroxysmal  in  character  and  most  marked  in  the^  morning,  and  dyspnoea 
on  exertion.  The  expectoration  is  purulent,  and  in  some  instances,  when  the 
bronchiectasis  is  extensive,  fetid.  There  is  rarely  any  fever. 

The  physical  signs  are  very  characteristic.  The  chest  is  sunken  and  the 
shoulder  lower  on  the  affected  side;  the  heart  is  often  drawn  over  and  dis- 
placed. If  the  left  lung  is  involved  there  may  be  an  unusually  large  area 
of  cardiac  pulsation  in  the  third,  fourth,  and  fifth  interspaces.  Heart  mur- 
murs are  common.  There  are  dulness  and  deficient  'tactile  fremitus  over  the 
affected  side,  except  over  cavities  where  the  fremitus  is  increased.  At  the 
apex  there  may  be  well-marked  cavernous  sounds;  at  the  base,  distant  bron- 
chial breathing.  In  some  cases  the  other  lung  becomes  involved,  or  the  pa- 
tient has  repeated  attacks  of  haemoptysis,  in  one  of  which  he  dies.  As  a  result 
of  the  chronic  suppuration,  amyloid  degeneration  of  the  liver,  spleen,  and  in- 
testines may  take  place;  dropsy  frequently  supervenes  from  failure  of  the 
right  heart. 

A  more  detailed  account  is  found  under  Cirrhosis  of  the  Lung,  with 
which  this  form  is  clinically  identical. 

Complications  of  Pulmonary  Tuberculosis 

In  the  Respiratory  System. — The  larynx  is  rarely  spared  in  chronic  pul- 
monary tuberculosis.  The  first  symptom  may  be  huskiness  of  the  voice. 
There  are  pain,  particularly  in  swallowing,  and  a  cough  which  is  often  wheez- 
ing, and  in  the  later  stages  very  ineffectual.  Aphonia  and  dysphagia  are  the 
two  most  distressing  symptoms  of  the  laryngeal  involvement.  When  the  epi- 
glottis is  seriously  diseased  and  the  ulceration  extends  to  the  lateral  wall  of 
the  pharynx,  the  pain  in  swallowing  may  be  very  intense,  or,  owing  to  the 


TUBEECULOSIS  203 

imperfect  closure  of  the  glottis,  there  may  be  coughing  spells  and  regurgita- 
tion  of  food  through  the  nostrils.  Bronchitis  and  tracheitis  are  almost  in- 
variable accompaniments. 

Pneumonia  is  a  not  infrequent  complication  of  pulmonary  tuberculosis. 
It  may  run  a  perfectly  normal  course,  while  in  other  instances  resolution  may 
be  delayed,  and  one  is  in  doubt,  in  spite  of  the  abruptness  of  the  onset,  as 
to  the  presence  of  a  simple  or  a  tuberculous  pneumonia.  In  some  cases  a 
pneumonia  is  a  terminal  complication. 

Emphysema  of  the  uninvolved  portions  of  the  lung  is  a  common  feature, 
rarely  producing  any  special  symptoms.  There  are,  however,  cases  of  chronic 
tuberculosis  in  which  emphysema  dominates  the  picture,  and  in  which  the 
condition  comes  on  slowly  during  a  period  of  many  years.  (General  subcu- 
taneous emphysema,  which  has  been  met  with  in  a  few  rare  cases,  is  due 
either  to  perforation  of  the  trachea  or  to  the  rupture  of  a  cavity  adherent  to 
the  chest  wall.) 

Gangrene  of  the  lung  is  an  occasional  event  in  chronic  pulmonary  tuber- 
culosis, due  in  almost  all  instances  to  sphacelus  in  the  walls  of  the  cavity, 
rarely  in  the  lung-tissue  itself. 

Complications  in  the  Pleura. — A  dry  pleurisy  is  a  very  common  accom- 
paniment of  the  early  stages  of  tuberculosis.  It  is  always  a  conservative, 
useful  process.  In  some  cases  it  is  very  extensive,  and  friction  murmurs 
may  be  heard  over  the  sides  and  back.  The  cases  with  dry  pleurisy  and  ad- 
hesions are,  of  course,  much  less  liable  to  the  dangers  of  pneumothorax. 
Pleurisy  with  effusion  more  commonly  precedes  than  occurs  in  the  course  of 
pulmonary  tuberculosis.  Still,  it  is  common  enough  to  meet  with  cases  in 
which  a  sero-fibrinous  effusion  arises  in  the  course  of  the  chronic  disease. 
There  are  cases  in  which  it  is  a  special  feature,  and  it  often,  I  think,  favors 
chronicity.  A  patient  may  during  a  period  of  four  or  five  years  have  signs  of 
local  disease  at  one  apex  with  recurring  effusion  in  the  same  side.  Owing  to 
adhesions  in  different  parts  of  the  pleura,  the  effusion  may  be  encapsulated. 
Efemorrhagic  effusions,  which  are  not  uncommon  in  connection  with  tubercu- 
lous pleurisy,  are  comparatively  rare  in  chronic  phthisis.  Chyliform  or  milky 
exudates  are  sometimes  found.  Purulent  effusions  are  not  frequent  apart 
from  pneumothorax.  An  empyema,  however,  may  occur  in  the  course  of  the 
disease  or  as  a  sequence  of  a  sero-fibrinous  exudate.  Pneumothorax  is  an 
extremely  common  complication.  Of  49  cases  at  the  Johns  Hopkins  Hospital, 
23  were  tuberculous  (Emerson).  It  may  prove  fatal  in  twenty-four  hours. 
In  other  instances  a  pyo-pneumothorax  follows  and  the  patient  lingers  for 
weeks  or  months.  In  a  third  group  of  cases  it  seems  to  have  a  beneficial  effect 
on  the  course  of  the  disease,  and  is  sometimes  produced  for  the  therapeutic 
effect. 

Symptoms  Referable  to  the  Other  Organs. —  (a)  Cardio-vascular. — The 
retraction  of  the  left  upper  lobe  exposes  a  large  area  of  the  heart.  In 
thin-chested  subjects  there  may  be  pulsation  in  the  second,  third,  and  fourth 
interspaces  close  to  the  sternum.  Sometimes  with  much  retraction  of  the 
left  upper  lobe  the  heart  is  drawn  up.  A  systolic  murmur  over  the  pulmo- 
nary area  and  in  the  subclavian  arteries  is  common  in  all  stagee  of  phthisis. 
Apical  murmurs  are  also  not  infrequent  and  may  be  extremely  rough  and 
harsh  without  necessarily  indicating  that  endocarditis  is  present.  The  asso- 


204  SPECIFIC   INFECTIOUS   DISEASES 

ciation  of  heart  disease  with  phthisis  is  not,  however,  very  uncommon.  As 
already  mentioned,  there  were  12  instances  of  endocarditis  in  216  autopsies. 
The  arterial  tension  is  usually  low  and  the  capillary  resistance  lessened  so 
that  the  pulse  is  often  full  and  soft  even  in  the  later  stages  of  the  disease. 
The  capillary  pulse  is  not  infrequently  found,  and  pulsation  of  the  veins  in  the 
back  of  the  hand  is  occasionally  seen. 

(6)  Blood  Glandular  System.— The  early  anaemia  has  already  been 
noted.  It  is  often  more  apparent  than  real,  a  chloro-ansemia,  and  the  blood- 
count  rarely  sinks  below  two  millions  per  cubic  millimetre. 

The  blood-plates  are,  as  a  rule,  enormously  increased  and  are  seen  in  the 
withdrawn  blood  as  the  so-called  Schultze's  granule  masses.  Without  any 
significance,  they  are  of  interest  chiefly  from  the  fact  that  every  few  years 
some  tyro  announces  their  discovery  as  a  new  diagnostic  sign  of  tuberculosis. 
The  leucocytes  are  greatly  increased,  particularly  in  the  later  stages. 

(c)  Gastro-intestinal  System. — The  tongue  is  usually  furred,  but  may 
be  clean  and  red.  Small  aphthous  ulcers  are  sometimes  distressing.  A  red 
line  on  the  gums,  a  symptom  to  which  at  one  time  much  attention  was  paid 
as  a  special  feature  of  phthisis,  occurs  in  other  cachectic  states.  Extensive 
tuberculous  disease  of  the  pharynx,  associated  with  a  similar  affection  of  the 
larynx,  may  interfere  seriously  with  deglutition  and  prove  a  very  distressing 
and  intractable  symptom.  The  saliva  has  very  full  digestive  powers. 

Tuberculosis  of  the  stomach  is  rare.  Ulceration  may  occur  as  an  acci- 
dental complication  and  multiple  catarrhal  ulcers  are  not  uncommon.  Inter- 
stitial and  parenchymatous  changes  in  the  mucosa  are  common  (possibly  asso- 
ciated with  the  venous  stasis)  and  lead  to  atrophy,  but  these  cannot  always 
be  connected  with  the  symptoms,  and  they  may  be  found  when  not  expected. 
On  the  other  hand,  when  the  gastric  symptoms  have  been  most  persistent  the 
mucosa  may  show  very  little  change.  It  is  impossible  always  to  refer  the 
anorexia,  nausea,  and  vomiting  of  consumption  to  local  conditions.  The 
hectic  fever  and  the  neurotic  influences,  upon  which'  Immermann  lays  much 
stress,  must  be  taken  into  account,  as  they  play  an  important  role.  The  organ 
is  often  dilated,  and  to  muscular  insufficiency  alone  may  be  due  some  of  the 
cases  of  dyspepsia.  The  condition  of  the  gastric  secretion  is  not  constant, 
and  the  reports  are  discordant.  In  the  early  stages  there  may  be  superacidity ; 
later,  a  deficiency  of  acid. 

Anorexia  is  often  a  marked  symptom  at  the  onset;  there  may  be  positive 
loathing  for  food,  and  even  small  quantities  cause  nausea.  Sometimes,  with- 
out any  nausea  or  distress  after  eating,  the  feeding  of  the  patient  is  a  daily 
battle.  When  practicable,  Debove's  forced  alimentation  is  of  great  benefit 
in  such  cases.  Nausea  and  vomiting,  though  occasionally  troublesome  at  an 
early  period,  are  more  marked  in  the  later  stages.  The  latter  may  be  caused 
by  the  severe  attacks  of  coughing.  S.  H.  Habershon  refers  to  four  different 
causes  of  the  vomiting  in  phthisis:  (1)  central,  as  from  tuberculous  menin- 
gitis; (2)  pressure  on  the  vagi  by  caseous  glands;  (3)  stimulation  from  the 
peripheral  branches  of  the  vagus,  either  pulmonary,  pharyngeal,  or  gastric; 
and  (4)  mechanical  causes. 

Of  the  intestinal  symptoms  diarrhoea  is  the  most  serious.  It  may  come 
on  early,  but  is  more  usually  a  symptom  of  the  later  stages,  and  is  associated 
with  ulceration,  particularly  of  the  large  bowel.  Extensive  ulceration  of  the 


TUBERCULOSIS  205 

ileum  may  exist  without  any  diarrhoea.  The  associated  catarrhal  condition 
may  account  in  part  for  it,  and  in  some  instances  the  amyloid  degeneration 
of  the  mucous  membrane.  Perforation  occurred  in  13  of  475  autopsies  in 
chronic  pulmonary  tuberculosis. 

(d)  Nervous   System. —  (1)    Focal   lesions   due  to  the   development   of 
coarse  tubercles  and  areas  of  tuberculous  meningo-encephalitis.    Aphasia,  for 
instance,  may  result  from  the  growth  of  meningeal  tubercles  in  the  fissure  of 
Sylvius,  or  even  hemiplegia  may  occur.    The  solitary  tubercles  are  more  com- 
mon in  the  chronic  phthisis  of  children.     (2)  Basilar  meningitis  is  an  oc- 
casional complication.     It  may  be  confined  to  the  brain,  though  more  com- 
monly it  is  a  (3)  cerebro-spinal  meningitis,  which  may  come  on.  in  persons 
without  well-marked  local  signs  in  the  chest.     Twice  have  I  known  strong, 
robust  men  brought  into  hospital  with  signs  of  cerebro-spinal  meningitis,  in 
whom  the  existence  of  pulmonary  disease  was  not  discovered  until  the  post 
mortem.     (4)  Peripheral  neuritis,  which  is  not  common,  may  cause  an  ex- 
tensor paralysis  of  the  arm  or  leg,  more  commonly  the  latter,  with  foot-drop. 
It  is  usually  a  late  manifestation.      (5)   Mental  symptoms.     It  was  noted, 
even  by  the  older  writers,  that  consumptives  had  a  peculiarly  hopeful  tempera- 
ment, and  the  spes  phthisica-  forms  a  curious  characteristic  of  the  disease. 
Patients  with  extensive  cavities,  high  fever,  and  too  weak  to  move  will  often 
make  plans  for  the  future  and  confidently  expect  to  recover. 

Apart  from  tuberculosis  of  the  brain,  there  is  sometimes  in  chronic  phthi- 
sis a  form  of  insanity  not  unlike  that  which  occurs  in  the  canvalescence  from 
acute  affections. 

(e)  A  remarkable  hypertrophy  of  the  mammary  gland  may  occur  in  pul- 
monary tuberculosis,  most  commonly  in  males.    It  may  be  only  on  the  affected 
side.    It  is  a  chronic  interstitial,  non-tuberculous  mamrnitis  (Allot).    Mastitis 
adolescentium,  not  very  uncommon,  is  not  necessarily  suggestive  of  pulmonary 
tuberculosis. 

(/)  Genito-urinary  System. — The  urine  presents  no  special  peculiarities 
in  amount  or  constituents.  Fever,  however,  has  a  marked  influence  upon  it. 
Albumin  is  met  with  frequently  and  may  be  associated  with  the  fever,  or  is 
the  result  of  definite  changes  in  the  kidneys.  In  the  latter  case  it  is  more 
abundant  and  more  curd  like.  Amyloid  disease  of  the  kidneys  is  not  uncom- 
mon. Its  presence  is  shown  by  albumin  and  tube  casts,  and  sometimes  by  a 
great  increase  in  the  amount  of  urine.  In  other  instances  there  is  dropsy,  and 
the  patients  have  all  the  characteristic  features  of  chronic  Bright's  disease. 

Pus  in  the  urine  may  be  due  to  disease  of  the  bladder  or  of  the  pelves 
of  the  kidneys.  In  some  instances  the  entire  urinary  tract  is  involved.  In 
pulmonary  phthisis,  however,  extensive  tuberculous  disease  is  rarely  found 
in  the  urinary  organs.  Bacilli  may  occasionally  be  detected  in  the  pus. 
Hasmaturia  is  not  a  very  common  symptom.  It  may  occur  occasionally  as  a 
result  of  congestion  of  the  kidneys,  and  pass  off,  leaving  the  urine  albuminous. 
In  other  instances  it  results  from  disease  of  the  pelvis  or  of  the  bladder,  and 
is  associated  either  with  early  tuberculosis  of  the  mucous  membranes  or  more 
commonly  with  ulceration.  In  a  medical  clinic  the  routine  inspection  of  the 
testes  for  tubercle  will  save  two  or  three  mistakes  a  year. 

(g)  Cutaneous  System. — The  skin  is  often  dry  and  harsh.  Local  tuber- 
•°>s  occasionally  occur  on  the  hands.  There  may  be  pigmentary  staining, 


206  SPECIFIC    INFECTIOUS    DISEASES 

the  chloasma  phthisicorum,  which  is  more  common  when  the  peritoneum  is 
involved.  Upon  the  chest  and  back  the  brown  stains  of  pityriasis  versicolor 
are  very  frequent.  The  hair  of  the  head  and  beard  may  become  dry  and 
lanky.  The  terminal  phalanges,  in  chronic  cases,  become  clubbed  and  the 
nails  incurvated — the  Hippocratic  fingers.  Landouzy  has  called  attention  to 
a  curious  bending,  usually  of  the  ring  and  little  fingers,  which  permits  of 
flexion,  but  not  of  extension — a  condition  which  he  calls  camptodactaly.  A 
remarkable  and  unusual  complication  is  general  emphysema,  which  may  re- 
sult from  ulceration  of  an  adherent  lung  or  perforation  of  the  larynx. 

'  Diagnosis  of  Pulmonary  Tuberculosis. 

With  fever,  well-marked  physical  signs  and  bacilli  in  the  sputum,  no  dis- 
ease is  more  easily  diagnosed  than  pulmonary  tuberculosis.  Successful  treat- 
ment depends  largely  upon  early  diagnosis,  and  special  attention  must  be 
paid  to  the  obscure,  variable,  and  uncertain  symptoms  and  signs  of  the  initial 
stage.  The  active  crusade  against  the  disease  has  made  both  the  public 
and  the  profession  more  alert,  and  we  have,  as  so  often  happens,  gone  to  an 
extreme,  and  are  apt  to  see  early  tuberculosis  in  trivial  complaints.  I  say  this 
from  an  experience  of  cases  seen  in  consultation,  and  it  is  borne  out  by  the 
records  of  institutions.  Hamman,  in  charge  of  the  Phipps  Tuberculosis  Dis- 
pensary of  the  Johns  Hopkins  Hospital,  makes  the  interesting  confession  that 
in  the  early  days,  when  they  depended  on  slight  physical  signs  and  the  tuber- 
culin reaction,  there  were  innumerable  early  cases,  but  with  a  wider  experi- 
ence and  greater  confidence  in  clinical  symptoms  the  outlook  on  these  border- 
land cases  has  changed  completely,  and  now,  instead  of  condemning  them 
peremptorily  to  a  sanatorium,  they  are  found  to  keep  well  under  the  ordinary 
conditions  of  life,  in  spite  of  the  persistence  of  slight  abnormal  signs.  How 
important  this  feature  of  tuberculosis  work  has  become  is  also  indicated  by 
the  figures  for  the  first  year  at  the  Tuberculosis  Dispensary  of  the  Eadcliffe 
Infirmary.  Of  the  580  cases,  all  sent  by  physicians,  243  were  found  not  to 
be  tuberculous !  One  lesson  from  the  work  of  the  past  few  years  is  that  we 
should  pay  more  attention  to  symptoms  than  to  physical  signs.  The  follow- 
ing are  the  points  of  special  importance  in  the  diagnosis  of  early  cases: 

History. — Tuberculosis  in  the  family,  "Phthisical  habitus,"  unusual  ex- 
posure, special  debilitating  circumstances,  as  worry,  grief,  dissipation,  or  a 
chronic  illness. 

Symptoms.— Loss  of  weight,  loss  of  strength,  and  anemia,  if  progressive 
and  not  to  be  accounted  for  by  mental  worries  or  prolonged  indigestion,  are 
of  first  importance.  Fever  is  at  once  a  most  trustworthy  and  the  most  falla- 
cious symptom.  The  thermometer  has  needlessly  condemned  many  patients 
to  the  sanatorium.  Regard  should  be  had  to  the  points  already  mentioned 
in  speaking  of  the  fever.  In  nervous  persons,  particularly  in  stout,  flabby 
young  girls,  a  temperature  from  99.5°  to  100.5°  may  mean  nothing,  and 
the  rectal  temperature  is  often  very  deceptive:  if  taken  after  exercise  or 
excitement  it  may  be  a  degree  and  a  half  above  normal."  In  the  case  of 
a  flabby,  fat  girl  of  ten,  with  an  anxious  mother,  a  foolish  nurse,  and  an 
alarmist  doctor,  for  months  the  rectal  temperature  was  taken  hourly  during 
the  day;  the  child  had  been  in  bed;  there  was  no  cough,  and  the  only  phy- 
sical sign  a  few  rustling  rales  at  one  apex.  .The  cure  followed  rapidly  on  the 


TUBERCULOSIS  207 

breaking  of  the  thermometer  and  getting  rid  of  the  nurse.  In  a  suspicious 
case  a  two-hour  temperature  record  should  be  taken  during  the  day  for  ten 
days  and  the  influence  of  exercise  upon  it  carefully  estimated. 

A  cough  is  always  suspicions  in  the  young,  more  in  the  winter  than  in 
the  summer,  and  more  in  the  morning  than  at  other  times  in  the  day.  Throat 
conditions  should  be  carefully  excluded,  particularly  the  irritation  from  cigar- 
ette smoking.  The  spitting  of  blood  has  already  been  considered  sufficiently, 
and  its  importance  in  the  diagnosis  of  tuberculosis  is  universally  recognised. 
A  brisk,  early  hemoptysis  is  often  helpful,  not  only  for  the  positive  informa- 
tion it  gives  us,  but  for  its  useful  moral  effect  on  the  patient.  The  greater 
the  care  with  which  the  bloody  sputum  is  examined  the  more  likely  will  it  be 
that  bacilli  are  found. 

Sputum. — The  patient  should  be  instructed  to  collect  what  is  expectorated, 
particularly  early  in  the  morning,  and  everything  brought  up  should  be  sent. 
The  difficulty  in  private  practice  is  that  it  requires  a  long  series  of  examina- 
tions to  exclude  positively  the  presence  of  tubercle  bacilli.  Time  and  again 
with  suspicious  cases,  or  in  pleurisy  with  effusion,  I  have  asked  a  clinical  clerk 
day  by  day  "Any  bacilli  yet  ?",  and  in  one  instance  there  were  none  found  un- 
til the  twentieth  examination !  Of  course,  in  private  practice  this  is  impossi- 
ble, but  it  is  well  to  bear  in  mind  that  one  or  two  negative  examinations  are 
not  sufficient.  Various  methods  of  digesting  the  sputum  and  examining  the 
centrifugalized  sediment  are  important  when  few  bacilli  are  present.  The 
antiformin  method  introduced  by  Uhlenhuth  is  simple  and  often  reveals 
tubercle  bacilli  missed  by  an  ordinary  examination. 

Physical  Signs. — These  raise  the  difficulty.  At  present,  so  far  as  the 
lungs  are  concerned,  the  position  resembles  that  of  twenty-five  years  ago  in 
respect  to  the  heart,  when  any  murmur  was  regarded  as  serious.  Now,  if  we 
see  the  apex  beat  within  the  nipple  line  and  there  is  no  shortness  of  breath, 
and  the  pulse  is  regular,  we  discount  physical  signs  and  tell  the  patient  to 
live  a  rational  life.  This  is  what  we  should  do  with  many  cases  of  suspected 
early  tuberculosis.  If  the  symptoms  above  dealt  with  are  not  present,  "dis- 
count" the  physical  signs.  These  have  already  been  considered :  change  in  the 
character  of  the  respiratory  murmur  and  the  presence  of  rales  are  the  two 
most  important,  as  dulness  is  rarely  present  in  early  eases.  Altogether  too 
much  stress  has  been  laid  upon  roughened  or  impure  inspiration  associated 
with  a  few  dry  rales.  Only  upon  repeated  examination  should  a  decision 
be  reached.  Practically,  in  these  early  cases,  we  have  two  groups — the  one 
with  symptoms  and  no  physical  signs,  and  the  other  with  physical  signs  and 
no  symptoms.  Of  the  two,  the  former  is  of  the  greater  importance. 

Specific  Reaction. — Tuberculin  Test. — The  experience  of  hundreds  of  ob- 
servers in  different  parts  of  the  world  testifies  to  the  value  of  the  Calmette 
and  the  von  Pirquet  tests.  Bnit  we  must  remember  the  reaction  simply  means 
that  the  organism  has  developed  a  responsive  activity  to  tuberculous  infec- 
tion, and  it  by  no  means  indicates  that  an  individual  has  tuberculous  dis- 
ease, in  the  ordinary  sense  of  the  term  "disease."  From  the  careful  studies 
made  at  the  Phipps  Dispensary,  the  conjunctival  test  was  found  of  the  greater 
value  in  indicating  the  presence  of  an  active  lesion.  The  following  conclu- 
sions reached  by  Hamman  and  his  colleagues  appear  to  be  sane:  "When  a 
patient  fails  to  react  to  either  test,  and  there  are  no  striking  symptoms  or 


208 

physical  signs  of  pulmonary  disease,  we  feel  that  the  negative  diagnosis  has 
received  a  valuable  confirmation.  If  the  eye  reaction  is  positive,  this  is  a 
strong  indication  that  the  patient  has  an  active  tuberculous  focus ;  if  symp- 
toms and  signs  are  present  it  is  an  important  aid  in  excluding  other  pulmo- 
nary conditions ;  if  they  are  absent  it  marks  the  patient  as  a  suspect. 
None  of  these  tests  can  replace  in  the  slightest  degree  a  carefully  taken  his- 
tory and  a  well-made  examination.  They  can  never  stand  censor  over  these; 
rather  their  value  must  ultimately  be  judged  by  them.  They  are  aids  and 
nothing  more." 

While  the  cutaneous  and  conjunctival  are  the  more  important  as  a  routine 
procedure,  still  in  special  instances  in  which  it  is  desired  to  elicit  a  focal 
reaction  the  subcutaneous  tuberculin  test  is  invaluable. 

X-ray  Diagnosis. — In  skilful  hands  the  study  of  cases  with  the  Rontgen 
rays  is  of  great  value.  In  a  normal  case  the  radiogram  shows  a  shadow  be- 
neath and  extending  beyond  the  sternum  due  to  the  contents  of  the  mediasti- 
num. Extending  from  the  mediastinum  and  radiating  out  into  the  various 
lobes  is  a  series  of  shadows  which  may  be  likened  to  the  branches  of  a  tree, 
the  thickest  shadow  being  at  the  hilus  and  thinning  toward  the  periph- 
ery of  the  lungs.  In  diseased  conditions  changes  are  seen  in  the  hilus, 
shadows  due  to  enlarged  or  calcified  glands  and  to  the  increase  in  the  fibrous 
and  lymphatic  tissues  in  the  mediastinum.  The  pulmonary  vessels  with  their 
contained  blood  play  an  important  part  in  the  production  of  the  shadow. 
A  study  made  at  the  Phipps'  Dispensary  by  Dunham,  Boardman,  and  Wol- 
man  showed  that  in  a  very  large  percentage  of  all  the  early  cases,  clinically 
found  to  be  tuberculosis,  these  shadows  showed  certain  changes  which  corre- 
sponded to  the  clinical  findings.  It  is  not  proved,  however,  that  other  pul- 
monary conditions,  such  as  those  produced  by  the  influenza  bacillus,  may  not 
cause  the  same  changes.  The  X-rays  undoubtedly  show  very  early  changes  in 
the  lungs,  but  they  can  not  determine  the  etiological  factor.  In  the  majority 
of  cases  the  X-rays  tell  no  more  than  a  careful  clinical  examination,  and  they 
do  not  differentiate  an  active  from  a  healed  lesion.'  More  than  any  others, 
radiographers  need  the  salutory  lessons  of  the  dead  house  to  correct  their 
visionary  interpretations  of  shadows,  particularly  of  those  radiating  from  the 
roots  of  the  lungs. 

Concurrent  Infections  and  Diseases  Associated  with  Pulmonary  Tuberculosis 

Concurrent  Infections  in  Pulmonary  Tuberculosis. — It  has  long  been 
known  that  in  pulmonary  tuberculosis  organisms  other  than  the  specific 
bacilli  are  present,  particularly  Micrococcus  lanceolatus,  Streptococcus  pyo- 
genes,  the  influenza  bacillus,  Micrococcus  catarrhalis,  and  Staphylococcus 
aureus;  less  frequently  Bacillus  pyocyaneus. 

Many  cases  of  pulmonary  tuberculosis  are  combined  infections;  strepto- 
cocci and  pneumococci  may  be  found  in  the  sputum,  and  the  former  have  been 
isolated  from  the  blood.  Prudden,  who  has  very  carefully  studied  this  ques- 
tion, arrives  at  the  following  conclusions:  The  pulmonary  lesions  of  tuber- 
culosis are  subject  to  variations  depending  largely  on  the  different  modes  of 
distribution  of  the  bacilli,  whether  by  the  blood  vessels  or  through  the  bronchi, 
and  also  whether  a  concurrent  infection  with  other  organisms  has  taken 


TUBERCULOSIS  209 

place.  The  pneumonia  complicating  tuberculosis  may  be  the  direct  result  of 
the  tubercle  bacillus  or  its  toxins,  or  it  may  follow  secondary  infection  with1 
other  germs.,  particularly  the  Streptococcus  pyogenes,  the  Micrococcus  lanceo- 
latus,  and  the  Staphylococcus  pyogenes.  An  infection  with  the  influenza  bacil- 
lus or  Micrococcus  catarrlialis  may  be  followed  by  increased  fever  and  an  ag- 
gravation of  the  general  symptoms.  The  frequency  of  these  secondary  in- 
fections and  the  relative  significance  of  their  germs  are  not  yet  fully  decided. 
It  is  very  probable  that  in  man  the  effect  of  contamination  with  the  pus 
organisms  is  a  very  important  one  in  hastening  necrosis  and  softening,  and 
also  in  the  chronic  cases  they  doubtless  produce  in  large  amounts  the  toxins 
which  are  responsible  for  many  of  the  symptoms  of  the  disease.  The  work 
of  Hastings  indicates  that  secondary  infections  are  not  so  important  as  we 
had  thought,  and  a  study  by  Eadcliffe  at  the  King  Edward  Sanatorium  points 
in  this  direction. 

Diseases  Associated  with  Pulmonary  Tuberculosis. — Lobar  pneumonia  is 
a  not  uncommon  cause  of  death.  It  is  met  with,  most  frequently,  indeed,  as 
a  terminal  event  in  the  chronic  cases.  It  may,  however,  occur  early,  and  be 
difficult  to  distinguish  from  an  acute  caseous  pneumonia.  The  sputum  in  the 
latter  is  rarely  rusty,  while  the  fever  in  the  former  is  more  continuous  and 
higher,  but  in  many  cases  it  is  impossible  to  differentiate  between  the  two 
conditions. 

The  association  of  tuberculosis  and  typhoid  fever  has  already  been  dis- 
cussed (page  32). 

Erysipelas  not  infrequently  attacks  old  poitrinaires  in  hospital  wards  and 
almshouses.  There  are  instances  in  which  the  attack  seems  to  be  beneficial, 
as  the  cough  lessens  and  the  symptoms  ameliorate.  It  may,  however,  prove 
fatal. 

The  eruptive  fevers,  particularly  measles,  frequently  precede  but  rarely 
occur  in  the  course  of  pulmonary  tuberculosis.  In  the  revaccination  of  a 
tuberculous  subject  the  vesicles  run  a  normal  course. 

Fistula  in  ano,  so  often  associated  with  pulmonary  tuberculosis,  in  a  ma- 
jority of  such  cases  is  a  tuberculous  process.  The  general  affection  may  pro- 
gress rapidly  after  an  operation.  The  question  is  considered  in  tuberculosis 
of  the  alimentary  canal. 

Heart  Disease. — Cardiac  hypoplasia  seems  uncommon  in  tuberculosis, 
though  it  was  much  referred  to  by  the  older  writers.  It  was  present  in  only 
3  cases  in  1,764  autopsies  on  tuberculous  patients  (Norris).  Eokitansky 
taught  that  there  was  an  antagonism  between  valvular  lesions  and  aneurisms 
and  tuberculosis.  All  forms  of  congenital  heart  disease  predispose  to  it,  par- 
ticularly stenosis  of  the  pulmonary  artery.  Mitral  stenosis,  on  the  other 
hand,  has  a  distinctly  inhibitory  influence.  The  two  conditions  are  rarely 
found  associated.  Endocarditis  has  already  been  referred  to.  A  terminal 
acute  tuberculosis,  particularly  of  the  serous  membranes,  is  not  at  all  uncom- 
mon in  cardio-vascular  diseases. 

In  chronic  and  arrested  phthisis  arterio-sclerosis  and  phlebo-sclerosis  are 
not  uncommon.  Ormerod  noted  30  cases  of  chronic  renal  disease  in  100  post 
mortems. 

The  association  of  tuberculosis  with  chronic  arthritis,  upon  which  certain 
writers  lay  stress,  finds  its  explanation  in  the  lowered  resistance  of  these  pa- 


210  SPECIFIC   INFECTIOUS    DISEASES 

tients  and  the  greater  liability  to  infection  in  the  institutions  in  which  so 
many  of  them  live. 

Peculiarities  of  Pulmonary  Tuberculosis  at  the  Extremes  of  Life 

Old  Age. — It  is  remarkable  how  common  tuberculosis  is  in  the  aged,  par- 
ticularly in  institutions.  McLachlan  noted  145  cases  in  which  tuberculosis 
was  the  cause  of  death  in  old  persons  in  Chelsea  Hospital.  All  were  over 
sixty  years  of  age.  The  experience  at  the  Salpetriere  is  the  same.  Laennec 
met  with  a  case  in  a  person  over  ninety-nine  years  of  age. 

At  the  Philadelphia  Hospital,  in  the  bodies  of  aged  persons  sent  over  from 
the  almshouse,  it  was  extremely  common  to  find  either  old  or  recent  tuber- 
culosis. A  patient  died  under  my  care  at  the  age  of  eighty-two  with  extensive 
peritoneal  tuberculosis.  Pulmonary  tuberculosis  in  the  aged  is  usually  latent 
and  runs  a  slow  course:  The  physical  signs  are  often  masked  by  emphysema 
and  by  the  coexisting  chronic  bronchitis.  The  diagnosis  may  depend  entirely 
upon  the  discovery  of  the  bacilli  and  elastic  tissue.  Contrary  to  the  opinion 
which  was  held  some  years  ago,  tuberculosis  is  by  no  means  uncommon  with 
senile  emphysema.  Some  of  the  cases  of  tuberculosis  in  the  aged  are  in- 
stances of  quiescent  disease  which  may  have  dated  from  an  early  period. 

Infancy. — The  occurrence  of  acute  tuberculosis  in  children  has  already 
been  mentioned,  and  also  the  fact  that  the  disease  is  occasionally  congenital. 
The  incidence  is  very  variable,  from  13  to  42  per  cent,  in  collected  statistics. 
In  Wollstein's  study  from  the  New  York  Babies'  Hospital,  among  1,131 
autopsies  in  children  under  four  years  of  age,  in  192  tuberculosis  was  pres- 
ent; the  percentage  was:  first  year  1.8  per  cent.,  second  year  11  per  cent., 
third  year  16  per  cent.,  and  fourth  year  23  per  cent.  Chronic  ulcerative  tu- 
berculosis of  the  lungs  is  much  more  rare  than  in  adults.  In  Parrot's  series  of 
219  cases  in  children  under  three  years  of  age,  in  only  57  were  cavities  found 
in  the  lungs. 

Modes  of  Death  in  Pulmonary  Tuberculosis 

(a)  By  asthenia,  a  gradual  failure  of  the  strength.     The  end  is  usually 
peaceable  and  quiet,  occasionally  disturbed  by  paroxysms  of  cough.     Con- 
sciousness is  often  retained  until  near  the  close. 

(b)  By  asphyxia,  as  in  some  cases  of  acute  miliary  tuberculosis  and  in 
acute  pneumonic  phthisis.    In  chronic  phthisis  it  is  rarely  seen,  even  when 
pneumothorax  develops. 

(c)  By  syncope.     This  is  not  common.    I  have  known  it  to  happen  once 
or  twice  in  patients  who  insisted  upon  going  about  when  in  the  advanced 
stages  of  the  disease.     There  may  be,  but  not  necessarily,  fatty  degeneration 
of  the  heart.    Rapid  syncope  may  follow  haemorrhage  or  may  be  due  to  throm- 
bosis or  embolism  of  the  pulmonary  artery,  or  to  pneumothorax. 

(d)  From  haemorrhage.    The  fatal  bleeding  in  chronic  phthisis  is  due 
to  erosion  of  a  large  vessel  or  rupture  of  an  aneurism  in  a  pulmonary  cavity, 
most  commonly  the  latter.    Of  26  cases  analyzed  by  S.  West,  in  11  the  fatal 
hemoptysis  was  due  to  aneurism,  and,  of  35  cases"  collected  by  Percy  Kidd, 
aneurism  wa^  pitiseni  m  30.    In  a  case  of  Curtin's,  at  the  Philadelphia  Hos- 
pital, the  bleeding  proved  fatal  before  hemoptysis  occurred,  as  the  eroded 
vessel  opened  into  a  capacious  cavity. 


TUBERCULOSIS  211 

(e)  With  cerebral  symptoms.  Coma  may  be  due  to  meningitis,  less  often 
to  urgemia.  Death  in  convulsions  is  rare.  The  haemorrhagic  pachy-meningitis 
which  occurs  in  some  cases  of  phthisis  occasionally  causes  loss  of  consciousr 
ness,  but  is  rarely  a  direct  cause  of  death.  In  one  of  my  cases  death  resulted 
from  thrombosis  of  the  cerebral  sinuses  with  symptoms  of  meningitis. 

V.     TUBERCULOSIS  -OF  THE  ALIMENTARY  CANAL 

(a)  Lips. — Tuberculosis  of  the  lip  is  very  rare.     It  occurs  occasionally  in 
the  form  of  an  ulcer,  either  alone  or  more  commonly  in  association  with 
laryngeal  or  pulmonary  disease.    The  ulcer  is  usually  very  sensitive  and  may 
be  mistaken  for  a  chancre  or  an  epithelioma.     The  diagnosis  may  be  made  in 
cases  of  doubt  by  inoculation  or  the  examination  of  a  portion  for  tubercle 
bacilli. 

(b)  Tongue. — The  disease  begins  by  an  aggregation  of  small  granular 
bodies  on  the  edge  or  dorsum.    Ulceration  proceeds,  leaving  an  irregular  sore 
with  a  distinct  'but  uneven  margin,  and  a  rough,  often  caseous  base.     The 
disease  extends  slowly  and  may  form  an  ulcer  of  considerable  size.     I  have 
known  it  to  be  mistaken  for  epithelioma  and  the  tongue  to  be  excised.     It  is 
rarely  met  with  except  when  other  organs  are  involved.     The  glands  of  the 
angle  of  the  jaw  are  not  enlarged  and  the  sore  does  not  yield  to  iodide  of 
potassium,  which  are  points  of  distinction  between  the  tuberculous  and  the 
syphilitic  ulcer.     In  doubtful  cases  the  inoculation  test  should  be  made,  or  a 
portion  excised  for  microscopic  examination. 

(c)  Salivary  Glands. — The  salivary  glands  belong  to  that  small  group 
of  organs  of  the  body  which  seem  to  possess  an  immunity;  a  very  few  cases 
have  been  reported. 

(d)  Palate. — Tubercles  of  the  hard  or  soft  palate  nearly  always  follow 
extension  of  the  disease  from  neighboring  parts. 

(e)  Tuberculosis  of  the  Tonsils. — In  7  of  45  consecutive  cases  in  children 
from  three  months  to  fifteen  years,  A.  Latham  demonstrated,  by  inoculation, 
the  presence  of  tuberculosis  of  the  tonsils  either  in  organs  removed  by  oper- 
ation or  post  mortem.     The  observation  is  of  interest  in  connection  with  the 
views  of  Schlenker,  who  claims  that  the  majority  of  the  cases  of  tuberculous 
cervical  glands  result  from  infection  with  tubercle  bacilli  which  gain  admis- 
sion by  way  of  the  tonsil.    A  large  number  of  his  cases  of  tuberculous  cervical 
adenitis  were  definitely  of  a  descending  variety  and  associated  with  tubercu- 
losis of  these  glands.     The  majority  also  had  pulmonary  tuberculosis,  and  he 
regards  surface  infection  of  the  tonsil  by  tuberculous  food  and  sputum  far 
more  common  than  infection  by  way  of  the  circulation.     The  disease  may 
occur  as  a  superficial  ulceration.     More  commonly  there  is  an  infiltration  of 
the  tonsil  with  miliary  tubercles,  which  produces  a  greater  or  less  hypertrophy 
which  it  is  practically  impossible  to  distinguish  from  an  ordinary  enlargement 
of  the  tonsil  without  a  microscopic  examination. 

(f)  Pharynx. — In  extensive  laryngeal  tuberculosis  an  eruption  of  miliary 
granules  on  the  posterior  wall  of  the  pharynx  is  not  very  uncommon.     In 
chronic  phthisis  an  ulcerative  pharyngitis,  due  to  extension  of  the  disease 
from  the  epiglottis  and  larynx,  is  one  of  the  most  distressing  of  complica- 
tions, rendering  deglutition  acutely  painful.     Adenoids  of  the  naso-pharynx 


2.12  SPECIFIC   INFECTIOUS    DISEASES 

may  be  tuberculous,  as  shown  by  Lermoyez.  Macroscopically,  they  do  not 
differ  from  the  ordinary  vegetations  found  in  this  situation. 

(g)  (Esophagus.— A  few  instances  occur  in  the  literature  of  tuberculosis 
of  the  oesophagus.  The  condition  is  a  pathological  curiosity,  except  in  the 
slight  extension  from  the  larynx,  which  is  not  infrequent;  but  in  a  case  in 
my  wards,  described  by  Flexner,  the  ulcer  perforated  and  caused  purulent 
pleurisy.  The  condition  has  been  fully  considered  by  Claribel  Cone,  who  has 
described  a  second  case  from  the  Johns  Hopkins  Hospital  (Bulletin,  Novem- 
ber, 1897). 

(h)  Stomach. — Many  cases  are  reported  which  are  doubtful.  Primary 
disease  is  unknown.  Perforation  of  the  stomach  occurred  six  times  in  the  12 
cases  collected  by  Marfan,  thrice  by  a  tuberculous  gland.  In  Oppolzer's  case 
an  ulcer  of  the  colon  perforated  the  organ.  In  Musser's  case  there  was  a 
large  tuberculous  ulcer  3  by  l1/^  inches  in  extent.  Three  cases  have  been 
described  from  my  wards  by  Alice  Hamilton  (J.  H.  H.  Bulletin,  April,  1897). 

(i)  Intestines. — The  tubercles  may  be  (1)  primary  in  the  mucous  mem- 
brane, or  more  commonly  (2)  secondary  to  disease  of  the  lungs,  or  in  rare 
cases  the  affection  may  (3)  pass  from  the  peritoneum. 

(1)  Primary  intestinal  tuberculosis  occurs  most  frequently  in  children, 
in  whom  it  may  be  associated  with  enlargement  and  caseation  of  the  mesen- 
teric  glands,  or  with  peritonitis.    As  stated,  there  is  great  discrepancy  in  the 
statistics  on  this  point,  and  the  question  needs  careful  study.     Biedert  gives 
16  cases  in  3,104  instances  of  tuberculosis  in  children.     In  adults  primary 
intestinal  tuberculosis  is  rare,  occurring  in  but  1  instance  in  1,000  autopsies 
upon  tuberculous  adults  at  the  Munich  Pathological  Institute;  but  now  and 
then  cases  occur  in  which  the  disease  sets  in  with  irregular  diarrhoea,  moder- 
ate fever,  and  colicky  pains.    In  a  few  cases  haemorrhage  has  been  the  initial 
symptom.    Regarded  at  first  as  a  chronic  catarrh,  it  is  not  until  the  emacia- 
tion becomes  marked  or  the  signs  of  disease  appear  in  the  lungs  that  the  true 
nature  is  apparent.    Still  more  deceptive  are  the  cases  in  which  the  tuberculo- 
sis begins  in  the  caecum  and  there  are  symptoms  of  'appendicitis — tenderness 
in  the  right  iliac  fossa,  constipation,  or  an  irregular  diarrhoea   and  fever. 
These  signs  may  gradually  disappear,  to  recur  again  in  a  few  weeks  and  still 
further  complicate  the  diagnosis.     Fatal  haemorrhage  has  occurred  in  several 
of  my  cases.     Perforation  may  occur  with  the  formation  of  a  pericaecal  ab- 
scess, or  perforation  into  the  peritoneum  may  take  place,  or  in  very  rare 
instances  there  is.  partial  healing  with  great  thickening  of  the  walls  and  nar- 
rowing of  the  lumen. 

(2)  Secondary  involvement  of  the  bowels  is  very  common  in  chronic 
pulmonary  tuberculosis,  e.  g.,  in  566  of  the  1,000  Munich  autopsies  in  tuber- 
culosis just  referred  to.    In  only  three  of  these  cases  were  the  lungs  not  in- 
volved.    The  lesions  are  chiefly  in  the  ileum,  caecum,  and  colon.     The  affec- 
tion begins  in  the  solitary  and  agminated  glands,  or  on  the  surface  of  or 
within  the  mucosa.    The  caseation  and  necrosis  lead  to  ulceration,  which  may 
be  very  extensive  and  involve  the  greater  portion  of  the  mucosa  of  the 
large  and  small  bowels.    In  the  ileum  the  Peyer's  patches  are  chiefly  involved 
and  the  ulcers  may  be  ovoid,  but  in  the  jejunum  and  colon  they  are  usually 

•ound  or  transverse  to  the  long  axis.     The  tuberculous  ulcer  has  the  follow- 
ing characters:     («)    It  is  irregular,  rarely  ovoid  or  in  the  long  axis,  more 


TUBERCULOSIS  213 

frequently  girdling  the  bowel;  (6)  the  edges  and  base  are  infiltrated,  often 
caseous;  (c)  the  submucosa  and  muscularis  are  usually  involved;  and  (d) 
on  the  serosa  may  be  seen  colonies  of  young  tubercles  or  a  well-marked  tuber- 
culous lymphangitis.  Perforation  and  peritonitis  are  not  uncommon  events 
in  the  secondary  ulceration.  Stenosis  of  the  bowel  from  cicatrization  may 
occur;  the  strictures  may  be  multiple. 

Localized  chronic  tuberculosis  of  the  ileo-ccecal  region  is  of  great  impor- 
tance. The  cascum  may  present  a  chronic  hyperplastic  tuberculosis,  which  not 
uncommonly  extends  into  the  appendix.  As  a  consequence  of  the  changes 
produced  a  definite  tumor-like  mass  is  formed  in  the  right  iliac  fossa.  This 
varies  in  size,  is  usually  elongated  in  a  vertical  direction,  hard,  slightly  mov- 
able, or  bound  down  by  adhesions  and  very  sensitive  to  pressure.  The  tumor 
simulates  more  or  less  closely  a  true  neoplasm  of  this  region,  particularly  car- 
cinoma. The  condition  is  characterized  by  gradual  constriction  of  the  lumen 
of  the  bowel,  periodic  attacks  of  severe  pain,  and  alternating  diarrhoea  and 
constipation.  The  extremely  localized  character  of  the  disease  warrants  an  ex- 
ploratory operation,  as  the  results  of  enterectomy  are  remarkably  favorable. 
Of  11  cases  reported  by  F.  M.  Caird,  7  recovered.  In  a  second  form  of  this 
disease,  occurring  less  frequently  than  the  former,  there  is  no  definite  tumor 
mass  to  be  felt,  but  a  general  induration  and  thickening  in  the  right  iliac 
fossa  similar  to  the  local  changes  produced  by  a  recurring  appendicitis.  In 
this  variety  a  fistula  discharging  fnscal  matter  occasionally  results.  Both 
forms  may  be  distinguished  from  the  diseases  they  simulate  by  the  finding 
of  tubercle  bacilli  in  the  stools  or  in  the  discharge  from  the  fistula  when  such 
exists. 

Tuberculosis  of  the  rectum  has  a  special  interest  in  connection  with  fistula 
in  ano,  which  occurs  in  about  3.5  per  cent,  of  cases  of  pulmonary  disease.  In 
many  instances  the  lesion  has  been  shown  to  be  tuberculous.  It  is  very  rarely 
primary,  but  if  the  tissue  on  removal  contains  bacilli  and  is  infective  the  lungs 
are  almost  invariably  found  to  be  involved.  It  is  a  common  opinion  that  the 
pulmonary  symptoms  progress  rapidly  after  the  fistula  is  cut.  This  may  have 
some  basis  if  the  operation  consists  in  laying  the  tract  open,  and  not  in  a  free 
excision. 

(3)  Extension  from  the  peritoneum  may  excite  tuberculous  disease  in 
the  bowels.  The  affection  may  be  primary  in  the  peritoneum  or  extend  from 
the  tubes  in  women  or  the  mesenteric  glands  in  children.  The  coils  of  intes- 
tines become  matted  together,  caseous  and  suppurating  foci  develop  between 
the  folds,  and  perforation  may  take  place  between  the  coils. 

VI.    TUBEECULOSIS  OF  THE  LIVER 

This  organ  is  very  constantly  involved  in  (a)  Miliary  tuberculosis.  This 
is  seen  in  acute  generalized  tuberculosis,  though  the  granules  may  be  small 
and  have  to  be  looked  for  very  carefully.  In  chronic  tuberculosis  miliary 
tubercles  are  not  at  all  uncommon  in  the  liver.  (6)  Solitary  tubercle.  Oc- 
casionally large  tuberculous  masses  are  found  in  the  organ,  sometimes  asso- 
ciated with  perihepatitis,  sometimes  with  tuberculous  peritonitis,  and  in 
children  with  tuberculous  adenitis.  In  a  few  cases  the  masses  are  very 
large,  though  it  is  only  in  exceptional  cases  that  the  tumor  can  be  felt  through 


214  SPECIFIC   INFECTIOUS   DISEASES 

the  abdominal  wall.  The  organ  may  be  enlarged  by  numerous  caseous  masses 
and  present  the  clinical  picture  of  an  enlarged  rough  tender  liver  with 
jaundice,  as  in  a  case  reported  by  Thayer.  The  solitary  tubercles  become 
infected  with  pus  organisms,  soften,  and  form  an  abscess,  (c)  Tuberculosis 
of  the  bile  ducts.  This  is  by  far  the  most  characteristic  tuberculous  change 
in  the  organ,  and  is  not  uncommon.  It  was  well  described  by  Bristowe  in 
1858.  The  liver  is  enlarged,  and  section  shows  numerous  small  cavities,  which 
look  at  first  like  multiple  abscesses  in  suppurative  pylephlebitis,  but  the  pus 
is  bile-stained  and  the  whole  process  is  a  local  tuberculous  cholangitis.  (d) 
Tuberculous  cirrhosis.  With  the  eruption  of  miliary  tubercles  there  may  be 
slight  increase  in  the  connective  tissue,  which  is  overshadowed  by  the  fatty 
change.  In  all  the  chronic  forms  of  tubercle  in  this  organ  there  may  be 
fibrous  overgrowth.  Hanot,  who  has  described  several  varieties,  states  that 
the  condition  may  be  primary.  Practically  it  is  very  rare,  except  in  connec- 
tion with  chronic  tuberculous  peritonitis  and  perihepatitis,  when  the  organ 
may  be  much  deformed  by  a  sclerosis  involving  the  portal  canals  and  the 
capsule,  which  may  be  greatly  involved  in  a  polyserositis. 

VII.  TUBERCULOSIS  OF  THE  BRAIN  AND  CORD 

Tuberculosis  of  the  brain  occurs  as  (a)  an  acute  miliary  infection  caus- 
ing meningitis  and  acute  hydrocephalus ;  (&)  as  a  chronic  meningo-encepha- 
litis,  usually  localized,  and  containing  small  nodular  tubercles;  and  (c)  as 
the  so-called  solitary  tubercle.  Between  the  last  two  forms  there  are  all 
gradations,  and  it  is  rare  to  see  the  meninges  uninvolved.  The  acute  variety 
has  already  been  considered.  I  shall  here  consider  the  chronic  form,  which 
comes  on  slowly  and  has  the  clinical  characters  of  a  tumor. 

It  is  most  common  in  the  young.  Of  148  cases  collected  by  Pribram  118 
were  under  fifteen  years  of  age.  Other  organs  are  usually  involved,  particu- 
larly the  lungs,  the  bronchial  glands,  or  the  bones.  In  rare  instances  no 
tubercles  are  found  elsewhere.  They  occur  most  frequently  in  the  cerebellum ; 
next  in  the  cerebrum,  and  then  in  the  pons.  The  growths  are  often  multiple, 
in  100  out  of  183  cases  (Gowers).  They  range  in  size  from  a  pea  to  a  wal- 
nut; large  tumors  occasionally  occur,  and  sometimes  an  entire  lobe  of  the 
cerebellum  is  affected.  On  section  the  tubercle  presents  a  grayish-yellow, 
caseous  appearance,  usually  firm  and  hard,  and  encircled  by  a  translucent, 
softer  tissue.  The  centre  of  the  growth  may  be  semi-diffluent.  As  in  other 
localities  the  tubercle  may  calcify.  The  tumors  are  as  a  rule  attached  to  the 
meninges,  often  to  the  pia  at  the  bottom  of  a  sulcus  so  that  they  look  im- 
bedded in  the  brain-substance.  About  the  longitudinal  fissure  there  may  be 
an  aggregation  of  the  growths,  with  compression  of  the  sinus,  and  the  forma- 
tion of  a  thrombus.  The  tuberculous  tumor  not  infrequently  excites  acute 
meningitis.  In  localized  meningo-encephalitis  the  pia  is  thickened,  tubercles 
are  adherent  to  the  under  surface  and  grow  about  the  arteries.  It  is  often 
combined  with  cerebral  softening  from  interference  with  the  circulation.  Sev- 
eral of  the  most  characteristic  instances  which  I  have  seen  were  on  the  men- 
inges covering  the  insula.  This  form  may  occur  in  pulmonary  tuberculosis, 
causing  hemiplegia  or  aphasia  which  may  persist  for  months. 

The  symptoms  of  tuberculous  growths  in  the  brain  are  those  of  tumor, 
and  will  be  considered  in  the  section  on  the  brain. 


TUBERCULOSIS  215 

In  the  spinal  cord  the  same  forms  are  found.  The  acute  tuberculous  men- 
ingitis has  been  considered  and  is  almost  always  cerebro-spinal.  The  solitary 
tubercle  of  the  cord  is  rare.  Herter  reported  3  cases  and  collected  24  from 
the  literature.  It  was  secondary  in  all  save  one  case.  The  symptoms  are 
those  of  spinal  tumor  or  meningitis. 

VIII.     TUBEECULOSIS   OF  THE  GENITO-UEINAEY  SYSTEM 

The  studies  of  the  past  few  years,  and  particularly  the  work  of  surgeons 
and  gynaecologists,  have  taught  us  the  great  importance  of  tuberculosis  of  this 
tract.  Any  part  of  the  genito-urinary  system  may  be  invaded.  The  suc- 
cessive involvement  of  the  organs  may  be  so  rapid  that  unless  the  case  has 
been  seen  early  it  may  be  impossible  to  state  with  any  degree  of  certainty 
which  has  been  the  primary  seat  of  infection.  There  may  be  simultaneous 
involvement  of  various  portions  of  the  tract.  In  tuberculosis  of  the  genito- 
urinary system  one  always  has  to  bear  in  mind  the  possibility  of  latent  dis- 
ease elsewhere  in  the  body.  As  -Bollinger  says,  tubercle  bacilli  may  gain 
admission  at  some  part  of  the  respiratory  tract  without  producing  any  lesion 
at  the  point  of  entrance,  and  finally  reach  a  bronchial  gland,  where  they 
set  up  a  tuberculous  process  of  extremely  slow  development  without  producing 
any  symptoms.  From  this  point  bacilli  may  enter  the  blood  stream  and  lodge 
in  the  epididymis  or  testicle  proper,  and  produce  nodules  which  are  readily 
discovered  owing  to  the  ease  with  which  these  parts  are  examined.  Such  a 
case  might  be  quite  easily  mistaken  for  one  of  primary  genital  tuberculosis, 
whereas  the  true  primary  tuberculous  focus  is  far  distant. 

Infection  of  the  genito-urinary  tract  occurs  in  various  ways : 

(a)  BY  HEREDITARY  TRANSMISSION. — It  has  been  met  with  in  the  fetus. 
The  comparative  frequency  of  tuberculosis  of  the  testicle  in  very  young  chil- 
dren suggests  very  strongly  that  the  uro-genital  organs  may  be  involved  as  a 
result  of  direct  transmission  of  the  disease. 

(&)  BY  INFECTION  FROM  AREAS  OF  TUBERCULOSIS  ALREADY  EXISTING 
IN  THE  PATIENT. —  (1)  Infection  through  the  Blood. — In  many  cases  uro- 
genital  tuberculosis  is  found  at  autopsy  associated  with  disease  of  some  distant 
organ,  particularly  the  lungs,  and  it  would  appear  most  probable  that  in  them 
infection  has  been  through  the  blood-vessels.  Jani's  observations,  which  were 
published  by  Weigert  after  the  author's  death,  strongly  support  this  theory. 
In  studying  sections  of  the  genital  organs  of  patients  who  died  of  pulmonary 
tuberculosis,  he  found  tubercle  bacilli  in  5  out  of  8  cases  in  the  testicle,  and 
in  4  out  of  6  cases  in  the  prostate,  without  in  any  instance  finding  micro- 
scopic evidences  of  tubercles  in  these  organs.  The  bacilli  lay,  in  the  testis, 
partly  within  and  partly  close  beside  the  cellular  and  granular  contents  of 
the  seminal  tubules,  while  in  the  prostate  they  were  always  situated  in  the 
neighborhood  of  the  glandular  epithelium. 

(2)  Infection  from  the  Peritoneum. — This  source  of  infection,  in  both 
men  and  women,  is  much  more  frequent  than  is  commonly  supposed.  The 
intimate  relationship  between  the  peritoneum  and  bladder  in  both  sexes, 
and  with  the  vesiculae  seminales  and  vasa  deferentia  in  the  male,  allows  a 
ready  way  of  invasion  of  these  organs  by  direct  extension  of  the  disease.  The 
peritoneum  is  a  frequent  source  of  genital  tuberculosis  in  the  female.  No 


oin  SPECIFIC   INFECTIOUS   DISEASES 

doubt  many  cases  of  tuberculosis  of  the  Fallopian  tubes  originate  from  this 
source.  The  fact  that  the  fimbriated  extremity  of  the  tube  is  often  most 
seriously  involved  points  rather  strongly  in  this  direction,  although  the  fact 
might  be  taken  as  a  point  in  favor  of  blood  infection,  favored  by  its  greater 
vascularity.  Various  observations  go  to  show  that  the  action  of  the  cilia 
lining  the  lumina  of  the  Fallopian  tubes  tends  to  attract  particles  introduced 
into  the  peritoneal  cavity.  Jani's  observation  is  very  interesting  in  this  con- 
nection, as  showing  the  possibility  of  tubercle  bacilli  entering  the  tubes  from 
the  peritoneal  cavity  without  there  being  any  tuberculous  peritonitis.  He 
found  typical  tubercle  bacilli  in  the  lumen,  in  sections  of  a  normal  Fallopian 
tube,  in  a  woman  who  died  of  pulmonary  and  intestinal  tuberculosis.  The 
explanation  advanced  was  that  the  bacilli  made  their  way  through  the  thin 
peritoneal  coat  from  one  of  the  intestinal  ulcers,  thus  reaching  the  peritoneal 
cavity,  and  thence  were  attracted  into  the  Fallopian  tube  by  the  current  pro- 
duced by  the  action  of  the  cilia  lining  the  lumen.  The  intimate  relationship 
between  tuberculous  peritonitis  and  tuberculosis  of  the  Fallopian  tubes  is 
shown  in  the  fact  that  the  latter  are  affected  in  from  30  to  40  per  cent,  of  the 
cases. 

(3)  Infection  from  Other  Organs  by  Direct  Extension. — The  occurrence 
of  direct  extension  from  the  peritoneum  has  already  been  mentioned.  In 
tuberculous  ulceration  of  the  intestine  or  rectum  adhesions  to  the  bladder 
in  the  male  or  to  the  uterus  and  vagina  in  the  female  may  occur,  with  result- 
ing fistula?  and  a  direct  extension  of  the  disease.  Perirectal  tuberculous 
abscesses  may  lead  to  secondary  involvement  of  some  portion  of  the  genito- 
urinary tract.  It  must  not  be  forgotten  that  tuberculosis  of  the  vertebrae 
may  be  followed  by  tuberculosis  of  the  kidney  as  a  result  of  direct  extension 
of  the  disease. 

(c)  BY  INFECTION  FROM  WITHOUT. — Whether  uro-genital  tuberculosis 
may  occur  as  a  result  of  the  entrance  of  tubercle  bacilli  into  the  urethra  or 
vagina  is  still  a  disputed  question.  That  bacilli  gain  admission  to  these 
passages  during  coitus  with  a  person  the  subject  of  uro-genital  tuberculosis, 
or  by  the  use  of  foul  instruments  or  syringes,  seems  quite  probable.  The 
possibility  of  genital  tuberculosis  occurring  in  the  female  as  a  result  of  coitus 
with  a  male  the  subject  of  tuberculosis  in  some  portion  of  the  genito-urinary 
system  was  first  suggested  by  Cohnheim,  who  stated,  however,  that  it  rarely, 
if  ever,  occurred. 

In  a  patient  with  intestinal  tuberculosis  the  tubercle  bacilli  might  acci- 
dentally reach  the  urethra  or  vagina  from  the  rectum. 

Uro-genital  tuberculosis  is  commonest  between  the  ages  of  twenty  and 
forty  years — that  is,  during  the  period  of  greatest  sexual  activity.  Males  are 
affected  much  more  frequently  than  females,  the  proportion  being  3  to  1. 
This  great  difference  is  no  doubt  partly  due  to  the  more  intimate  relationship 
between  the  urinary  and  genital  systems  in  the  former  than  in  the  latter.  In 
the  male  the  urethra  forms  the  common  outlet  for  the  two  systems,  while  in 
the  female  there  is  a  separate  outlet  for  each. 

Once  the  uro-genital  tract  has  been  invaded  the  disease  is  likely  to  spread 
rapidly,  and  the  method  of  extension  is  an  important  one.  Frequently  there 
is  direct  extension,  as  when  the  bladder  is  involved  secondarily  to  the  kidney 
by  passage,  irf  the  disease  along  the  ureter,  or  where  the  tuberculous  process 


TUBERCULOSIS  21? 

extends  along  the  vas  deferens  to  the  vesicular  seminales.  No  doubt  surface 
inoculation  occurs  in  some  instances,  and  to  this  cause  may  be  attributed  a 
certain  percentage  of  cases  of  vesical  and  prostatic  disease  following  tuber- 
culosis of  the  kidney.  Although  this  probability  is  acknowledged,  there  is 
an  element  of  doubt  as  to  the  possibility  of  the  kidney  becoming  affected  sec- 
ondarily to  the  bladder  or  prostate  by  the  direct  passage  of  the  bacilli  up  the 
lumen  of  one  ureter;  for  in  such  a  case  we  have  to  suppose  that  a  non- 
motile  bacillus,  contrary  to  the  laws  of  gravity,  ascends  against  an  almost 
constant  current  .of  urine  flowing  in  the  opposite  direction.  The  lymphatics 
may  afford  a  means  for  the  spreading  of  the  disease,  but  in  a  greater  number 
of  cases  than  is  generally  supposed  it  takes  place  by  way  of  the  blood-vessels. 
Cystoscopic  examinations  of  the  bladder  not  infrequently  show  the  presence 
of  tubercles  beneath  the  mucous  membrane  before  there  is  any  evidence  of 
superficial  ulceration — a  fact  suggesting  strongly  a  blood  infection. 

The  discovery  of  tubercle  bacilli  in  the  urine  and  the  obtaining  of  tuber- 
culous lesions  in  animals  as  a  result  of  inoculation  with  the  urinary  sedi- 
ment afford  us  the  only  positive  evidence  of  genito-urinary  tuberculosis.  So 
far  there  are  no  authentic  accounts  of  tubercle  bacilli  having  been  found  in  the 
semen  of  men  with  tuberculosis  of  the  testicle  or  vesiculae  seminales.  Owing 
to  the  fact  that  the  smegma  bacillus  has  the  same  staining  reaction  as  the 
tubercle  bacillus,  and,  morphologically  is  practically  indistinguishable  from 
it,  the  greatest  care  must  be  used  in  obtaining  the  specimen  of  urine  for 
examination,  to  eliminate,  if  possible,  all  chances  of  contamination.  Thus 
the  urine  examined  must  be  a  catheterized  specimen,  and  even  then  one  runs 
the  risk  of  carrying  back  into  the  bladder  on  the  end  of  the  catheter  a  few 
bacilli  which  may  be  washed  out  in  the  stream  of  urine  and  be  mistaken  for 
tubercle  bacilli  in  the  sediment.  One  or  more  guinea-pigs  should  be  inocu- 
lated with  some  of  the  suspected  urine.  If  tubercle  bacilli  be  present  the  ani- 
mals will  manifest  tuberculous  lesions  in  from  three  to  five  weeks. 

Tuberculosis  of  the  Kidneys  (Phthisis  Renum). — In  general  tuberculosis 
the  kidneys  frequently  present  scattered  miliary  tubercles.  In  pulmonary 
tuberculosis  it  is  common  to  find  a  few  nodules  in  the  substance  of  the  organ, 
or  there  may  be  pyelitis.  In  the  first  17,000  admissions  to  the  medical  wards 
of  the  Johns  Hopkins  Hospital  there  were  1,085  cases  of  tuberculous  infec- 
tion. In  17  of  these  a  clinical  diagnosis  of  renal  tuberculosis  was  made. 
Walker  analyzed  the  first  1,369  autopsies  in  the  same  hospital  and  found 
that  784  had  tuberculosis  in  some  part  of  the  body.  In  all  there  were  61 
cases  of  renal  tuberculosis.  Of  482  cases  of  pulmonary  tuberculosis  showing 
symptoms  during  life,  one  or  both  kidneys  were  involved  in  23.  There  were 
36  cases  of  acute  general  miliary  tuberculosis,  and  in  every  instance  the  kidney 
was  affected.  The  2  other  cases  of  renal  tuberculosis  occurred  in  patie'nts 
with  latent  disease.  Pr.imary  tuberculosis  of  the  kidneys  is  not  very  rare, 
but  in  no  instance  in  the  above  series  did  Walker  demonstrate  a  primary 
infection  in  the  kidney.  The  tuberculous  process  was  primary  in  some  other 
par!;  of  the  genito-urinary  tract  in  6  cases.  In  a  majority  of  the  casea  the 
process  involves  the  pelvis  and  the  ureter  as  well,  sometimes  the  bladder  and 
prostate.  It  may  be  difficult  to  say  in  advanced  cases  whether  the  disease 
has  started  in  the  bladder,  prostate,  or  vesicles,  and  crept  up  the  ureters*, 
or  whether  it  started  in  the  kidneys  and  proceeded  downward.  In  a  majority 
16 


218  SPECIFIC   INFECTIOUS   DISEASES 

of  cases,  I  believe,  the  latter  is  true,  and  the  infection  is  through  the  blood, 
Walker  thinks  that  a  haematogenous  infection  takes  place  in  90  per  cent,  of  the 
cases,  and  that  this  is  the  channel  of  infection  in  the  majority  of  instances 
where  renal  follows  vesical  tuberculosis  rather  thar.  along  the  ureter.  One 
kidney  alone  may  be  involved,  and  the  disease  creeps  down  the  ureter  and 
may  only  extend  a  few  millimetres  on  the  vesical  mucosa.  A  man  with  aortic 
insufficiency,  who  had  no  lesions  in  the  lungs,  presented  a  localized  patch  in 
the  pelvis  of  the  kidney,  involving  a  pyramid,  while  the  ureter,  5  cm.  from  the 
bladder  and  at  its  orifice,  was  thickened  and  tuberculous.  The  prostate 
showed  an  area  of  caseation.  The  process  is  most  common  between  twenty 
and  thirty  years  of  age,  but  it  may  occur  at  the  extremes  of  age.  In  a  series 
of  386  cases  collected  by  Walker  in  which  the  sex  was  stated  182  of  the 
patients  were  males  and  204  females.  In  the  earliest  stage,  which  may  be 
met  with  accidentally,  the  disease  is  seen  to  begin  in  the  pyramids  and  calyces. 
Necrosis  and  caseation  proceed  rapidly,  and  the  colonies  of  tubercles  start 
throughout  the  pyramids  and  extend  upon  the  mucous  membrane  of  the  pel- 
vis. As  a  rule,  from  the  outset  it  is  a  tuberculous  pyo-nephrosis.  The  renal 
infection  may  result  from  direct  extension  of  the  disease  from  a  tuberculous 
vertebra.  It  may  be  confined  to  one  kidney,  or  progress  more  extensively 
in  one  than  in  the  other.  At  autopsy  both  organs  are  usually  found  en- 
larged. In  only  3  of  the  61  autopsies  previously  referred  to  was  the  disease 
unilateral.  One  kidney  may  be  completely  destroyed  and  converted  into  a 
series  of  cysts  containing  cheesy  substance — a  form  of  kidney  which  the  older 
writers  called  scrofulous.  In  the  putty-like  contents  of  these  cysts  lime  salts 
may  be  deposited.  In  other  instances  the  walls  of  the  pelvis  are  thickened 
and  cheesy,  the  pyramids  eroded,  and  caseous  nodules  are  scattered  through 
the  organ,  even  to  the  capsule,  which  may  be  thickened  and  adherent.  The 
other  organ  is  usually  less  affected,  and  shows  only  pyelitis  or  a  superficial 
necrosis  of  one  or  two  pyramids.  The  ureters  are  usually  thickened  and  the 
mucous  membrane  ulcerated  and  caseous.  Involvement  of  the  bladder,  vesi- 
culae  seminales,  and  testes  is  not  uncommon  in  males. 

The  SYMPTOMS  are  those  of  pyelitis.  The  urine  may  be  purulent  for 
years,  and  there  may  be  little  or  no  distress.  Even  before  the  bladder  be- 
comes involved  micturition  is  frequent,  and  many  instances  are  mistaken 
for  cystitis.  The  frequent  micturition  is  in  part  due  to  an  initial  polyuria, 
in  part  to  reflex  irritation,  but  chiefly  to  a  non-tuberculous  inflammation 
over  the  trigone  of  the  bladder.  It  is  usually  the  earliest  and  most  constant 
symptom.  Haematuria,  of  a  mild  grade,  occurs  at  some  time  during  the 
course  of  the  disease  in  the  majority  of  the  cases.  Dull,  aching  pain  in  the 
lumbar  region  on  one  side  is  frequently  complained  of  and  may  be  the  first 
symptom.  The  condition  is  for  many  years  compatible  with  fair  health.  The 
curability  is  shown  by  the  accidental  discovery  of.  the  so-called  scrofulous 
kidney,  converted  into  cysts  containing  a  putty-like  substance.  In  cases  in 
which  the  disease  becomes  advanced  and  both  organs  are  affected  constitu- 
tional symptoms  are  more  marked.  There  is  irregular  fever,  with  chills  and 
.oss  of  weight  and  strength.  General  tuberculosis  is  common.  In  only  one 
of  my  cases  were  the  lungs  uninvolved.  In  a  case  at  the  Montreal  General 
Hospital  a  cyst  perforated  and  caused  fatal  peritonitis. 

Physical  examination  may  detect  special  tenderness  on  one  side    or  the 


TUBERCULOSIS  219 

kidney  may  be  palpable  in  front  on  deep  pressure;  but  tuberculous  pyelo- 
nephritis seldom  causes  a  large  tumor.  Occasionally  the  pelvis  becomes 
enormously  distended;  but  this  is  rare  in  comparison  with  its  frequency  in 
calculous  pyelitis.  The  urine  presents  changes  similar  to  those  of  ordinary 
calculous  pyelitis — pus-cells,  epithelium,  and  occasionally  definite  caseous 
masses.  It  is  nearly  always  acid  in  reaction.  Albumin  is,  of  course,  present. 
Tubercle  bacilli  may  be  demonstrated  by  the  ordinary  methods.  Tube-casts 
are  not  often  seen. 

DIAGNOSIS. — To  distinguish  the  condition  from  calculous  pyelitis  is  often 
difficult.  Haemorrhage  may  be  present  in  both,  though  not  nearly  so  fre- 
quently in  the  tuberculous  disease.  Functional  haematuria,  to  which  Senator 
has  given  the  name  essential  renal  haematuria,  and  Klemperer  that  of  angio- 
neurotic  renal  hcematuria,  has  been  a  source  of  error  in  diagnosis  and  has  led 
to  surgical  interference.  In  this  condition  it  is  highly  probable  that  bleeding 
from  the  kidney  can  occur  in  the  absence  of  any  definite  lesion  of  the  organ, 
although  Israel  denies  the  existence  of  such  an  anomaly.  The  subcutaneous 
injection  of  phenolsulphonephthalein,  introduced  by  Rowntree  and  Geraghty, 
is  of  value  in  determining  the  kidney  affected  and  its  functional  capacity. 
The  diagnosis  rests  on  three  points:  (1)  The  detection  of  some  focus  of 
tuberculosis,  as  in  the  testis;  (2)  the  presence  of  tubercle  bacilli  in  the  sedi- 
ment; and  (3)  the  use  of  tuberculin.  The  kidney  involved  is  now  easily  de- 
termined by  catheterizing  the  ureters. 

Tuberculosis  of  the  suprarenal  capsules  will  be  considered  under  Addison's 
Disease. 

Tuberculosis  of  the  Ureter  and  Bladder. — This  rarely  occurs  as  a  pri- 
mary affection,  but  is  nearly  always  secondary  to  involvement  of  other  parts, 
particularly  the  pelvis  of  the  kidney.  In  the  case  of  uro-genital  tuberculosis, 
above  mentioned,  in  a  patient  who  died  of  heart-disease,  the  ureter,  just  where 
it  entered  the  bladder,  showed  a  fresh  patch  of  tuberculosis. 

Protracted  cystitis  which  has  come  on  without  apparent  cause  is  always 
suggestive  of  tuberculosis.  The  renal  regions,  the  testes,  and  the  prostate 
should  be  examined  with  care.  It  may  follow  a  pyelo-nephritis,  or  be  asso- 
ciated with  primary  disease  of  the  prostate  or  vesiculae  seminales.  Primary 
tuberculosis  of  the  posterior  wall  of  the  bladder  may  simulate  stone. 

Tuberculosis  of  the  Prostate  and  Vesiculse  Seminales. — The  prostate  is  fre- 
quently involved  in  tuberculosis  of  the  uro-genital  tract.  In  Krzyincki's 
cases,  of  15  males  the  prostate  was  involved  in  14  and  the  vesiculaB  seminales 
in  11.  In  Orth's  cases  the  prostate  was  involved  in  18  of  the  37  cases  in 
males.  These  parts  are  much  more  frequently  involved  than  ordinary  post- 
mortem statistics  indicate.  Per  rectum  the  prostatic  lobes  are  felt  to  be 
occupied  by  hard  nodules  varying  in  size  from  a  pea  to  a  bean.  There  is  great 
irritability  of  the  bladder,  and  agonizing  pain  in  catheterization.  An  ex- 
tremely rare  lesion  is  primary  urethral  tuberculosis,  which  may  simulate 
stricture. 

Tuberculosis  of  the  Testes. — This  somewhat  common  affection  may  be 
primary,  or,  more  frequently,  is  secondary  to  tuberculous  disease  elsewhere. 
Many  cases  occur  before  the  second  year,  and  it  is  stated  to  have  been  met 
with  in  the  fetus.  In  infants  it  is  serious  and  usually  associated  with  tubercu- 
lous disease  in  other  parts.  In  9  cases  reported  by  Hutinel  and  Deschamps, 


220  SPECIFIC    INFECTIOUS    DISEASES 

in  every  one  there  was  a  general  affection.  In  20  cases  reported  by  Jullien,  6 
were  under  one  year,  and  6  between  one  and  two  years  old.  In  5  of  the  cases 
both  testicles  were  affected.  Koplik  holds  that  most  of  the  instances  of 
this  kind  are  congenital,  in  Baumgarten's  sense.  In  the  adult  the  tubercles 
begin  within  the  substance  of  the  gland,  but  in  children  the  tunica  albuginea 
is  first  affected.  The  tubercle  does  not  always  undergo  caseation,  but  it  may 
present  a  number  of  embryonic  cells,  not  unlike  a  sarcoma. 

Tubercle  of  the  testes  is  most  likely  to  be  confounded  with  syphilis.  In 
the  latter  the  body  of  the  organ  is  most  often  affected,  there  is  less  pain,  and 
the  outlines  of  the  growth  are  more  nodular  and  irregular.  In  obscure  peri- 
toneal disease  the  detection  of  tubercle  in  a  testis  has  not  infrequently  led 
to  a  correct  diagnosis.  The  association  of  the  two  conditions  is  not  uncom- 
mon. The  lesion  in  the  testis  may  heal  completely,  or  the  disease  may  become 
generalized.  General  infection  has  followed  operation.  Too  much  stress  can 
not  be  laid  on  the  importance  of  a  routine  examination  of  the  testes. 

Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus. — The  Fallopi- 
an tubes  are  by  far  the  most  frequent  seat  of  genital  tuberculosis.  The  dis- 
ease may  be  primary  and  produce  a  most  characteristic  form  of  salpingitis, 
in  which  the  tubes  are  enlarged,  the  walls  thickened  and  infiltrated,  and  the 
contents  cheesy.  Adhesion  takes  place  between  the  fimbriae  and  the  ovaries, 
or  the  uterus  may  be  invaded.  The  condition  is  usually  bilateral.  It  may 
occur  in  young  children.  Although,  as  a  rule,  very  evident  to  the  naked 
eye,  there  are  specimens  resembling  ordinary  salpingitis,  which  show  on 
microscopic  examination  numerous  miliary  tubercles  (Welch  and  Williams). 
Tuberculous  salpingitis  may  cause  serious  local  disease  with  abscess  forma- 
tion, and  it  may  be  the  starting-point  of  peritonitis. 

Tuberculosis  of  the  ovary  is  always  secondary.  There  may  be  an  erup- 
tion of  tubercles  over  the  surface  in  an  extensive  involvement  of  the  stroma 
with  abscess  formation. 

Tuberculosis  of  the  uterus  is  very  rare.  Only  three  examples  have  come 
under  my  observation,  all  in  connection  with  pulmonary  phthisis.  It  may 
be  primary.  The  mucosa  of  the  fundus  is  thickened  and  caseous,  and  tuber- 
cles may  be  seen  in  the  muscular  tissue.  Occasionally  the  process  extends  to 
the  vagina. 

Tuberculosis  of  the  placenta  is  more  common  than  has  been  supposed. 
Of  20  placentas  from  tuberculous  women,  9  were  affected;  5  of  these  were 
from  cases  of  advanced  disease  of  the  lung.  The  lesions  are  easily  overlooked. 

IX.     TUBEECULOSIS  OF  THE  MAMMAEY  GLAND 

Mandry  (Bruns's  Beitrage,  viii)  has  collected  40  cases,  1  of  which  was 
in  a  male.  The  disease  is  most  common  between  the  fortieth  and  sixtieth 
years.  The  breast  is  frequently  fistulous,  unevenly  indurated,  and  the  nipple 
is  retracted.  The  fistulas  and  ulcers  present  a  characteristic  tuberculous 
aspect.  There  is  also  a  cold  tuberculous  abscess  of  the  breast.  The  axillary 
glands  are  affected  in  about  two-thirds  of  the  cases.  The  disease  runs  a 
chronic  course  of  months  or  years.  The  diagnosis  can  be  made  by  the  general 
appearance  of  the  fistulas  and  ulcers,  and  by  the  existence  of  tubercle  bacilli. 
The  prognosis  is  not  serious,  if  total  eradication  of  the  disease  be  possible- 


TUBERCULOSIS  221 

In  1836  Bedor  described  an  hypertrophy  of  the  breast  in  the  subjects  of 
pulmonary  tuberculosis.  As  a  rule,  if  one  gland  is  involved,  usually  on  the 
side  of  the  affected  lung,  as  already  mentioned,  the  condition  is  one  of  chronic 
interstitial  mammitis,  and  is  not  tuberculous. 

X.     TUBERCULOSIS  OF  THE  CIRCULATORY  SYSTEM 

Myocardium. — Scattered  miliary  tubercles  are  sometimes  met  with  in  the 
acute  disease.  Larger  caseous  tubercles  are  excessively  rare.  A.  Moser  found 
46  cases  on  record.  There  is  also  a  sclerotic  tuberculous  myocarditis.  The 
infection  often  passes  from  a  mediastinal  gland. 

Endocardium. — In  216  autopsies  in  cases  of  chronic  phthisis  I  found 
endocarditis  in  12.  It  was  present  in  only  151  among  more  than  11,000 
autopsies  on  tuberculous  cases  (G.  W.  Norris).  As  a  rule,  it  is  a  secondary 
form,  the  result  of  a  mixed  infection,  so  common  in  pulmonary  tuberculosis. 
A  true  tuberculous  endocarditis  does,  however,  occur,  directly  dependent  upon 
infection  with  the  bacillus  of  Koch.  As  a  rule,  it  is  a  vegetative  endocardi- 
tis, not  to  be  distinguished  from  that  caused  by  a  streptococcus  or  staphylo- 
coccus.  In  rare  cases,  however,  caseous  tubercles  develop. 

Arteries. — Primary  tuberculosis  of  the  larger  blood-vessels  is  very  rare, 
and  is  usually  the  result  of  invasion  from  without.  The  disease  may,  how- 
ever, occur  in  a  large  artery  and  not  result  from  external  invasion.  In  a  case 
of  chronic  tuberculosis  Flexner  found  a  fresh  tuberculous  growth  in  the  aorta, 
which  had  no  connection  with  cheesy  masses  outside  the  vessel.  Simmitsky 
has  collected  18  cases  of  tuberculosis  of  the  aorta. 

In  the  lungs  and  other  organs  attacked  by  tuberculosis  the  arteries  are 
involved  in  an  acute  infiltration  which  usually  leads  to  thrombosis,  or  tuber- 
cles may  develop  in  the  walls  and  proceed  to  caseation  and  softening,  fre- 
quently with  a  resulting  haemorrhage.  By  extension  into  vessels,  particu- 
larly veins,  the  bacilli  are  widely  distributed  with  the  production  of  miliary 
tuberculosis. 

XI.     THE  PROGNOSIS  IN  TUBERCULOSIS 

The  parable  of  the  sower  already  referred  to  expresses  better  than  in  any 
other  way  the  question  of  individual  predisposition.  There  are  five  groups 
of  cases  of  tuberculous  infection.  1.  Those  who  become  infected  and  recover 
spontaneously  without  knowing  they  have  been  infected.  2.  Mild  infections 
which  produce  slight  symptoms,  recovery  following  after  a  few  months  of 
change  of  air  or  special  treatment.  3.  Cases  with  well-marked  signs  of  lung  dis- 
ease in  which  thorough  treatment  is  followed  by  complete  recovery.  4.  Cases 
with  extensive  local  disease  and  cavity  formation  in  which  arrest  takes  place 
and  the  patients  live  for  many  years.  5.  The  cases  in  which  the  infection  is  of 
such  a  type  that  death  follows  no  matter  what  is  done.  The  late  Austin 
Flint,  facile  princeps  among  American  students  of  the  disease,  called  atten- 
tion to  the  self-limitation  and  intrinsic  tendency  to  recovery  in  pulmonary 
tuberculosis.  This  natural  tendency  to  cure  is  still  more  strikingly  shown 
in  lymphatic  and  bone  tuberculosis. 

The  following  may  be  considered  favorable  circumstances  in  the  prognosis 
of  pulmonary  tuberculosis :  An  early  diagnosis,  a  good  family  history,  previ- 
ous good  health,  a  strong  digestion,  a  suitable  environment,  and  an  insidious 


222  SPECIFIC    INFECTIOUS    DISEASES 

onset,  without  high  fever,  and  without  extensive  pneumonic  consolidation. 
Cases  beginning  with  pleurisy  seem  to  run  a  more  protracted  and  more  favor- 
able course.  Repeated  attacks  of  haemoptysis  are  unfavorable.  When  well 
established  the  course  of  tuberculosis  in  any  organ  is  marked  by  intervals  of 
weeks  or  months  in  which  the  fever  lessens,  the  symptoms  subside,  and  there  is 
improvement  in  the  general  health. 

In  pulmonary  cases  the  duration  is  extremely  variable.  Laennec  placed 
the  average  duration  at  two  years,  and  for  the  majority  of  cases  this  is  per- 
haps a  correct  estimate.  Pollock's  large  statistics  of  over  3,500  cases  show  a 
mean  duration  of  the  disease  of  over  two  years  and  a  half.  Williams's  analy- 
sis of  1,000  cases  in  private  practice  shows  a  much  more  protracted  course, 
as  the  average  duration  was  over  seven  years. 

Tuberculosis  and  Marriage. — Under  the  subject  of  prognosis  comes  the 
question  of  the  marriage  of  persons  who  have  had  tuberculosis,  or  in  whose 
family  the  disease  prevails.  The  following  brief  statements  may  be  made 
with  reference  to  it : 

(a)  Subjects  with  healed  lymphatic  or  bone  tuberculosis  marry  with  per- 
sonal impunity  and  may  beget  healthy  children.  It  is  undeniable,  however, 
that  in  such  families  scrofula,  caries  of  the  bone,  arthritis,  cerebral  and  pul- 
monary tuberculosis  are  more  common.  The  risks,  however,  are  such  as  may 
properly  be  taken. 

(&)  The  question  of  marriage  of  a  person  who  has  arrested  or  cured  lung 
tuberculosis  is  more  difficult  to  decide.  In  a  male  the  personal  risk  is  not 
so  great;  and  when  the  health  and  strength  are  good,  the  external  environ- 
ment favorable,  and  the  family  history  not  extremely  bad,  the  experiment — 
for  it  is  such — is  often  successful,  and  many  healthy  and  happy  families  are 
begotten  under  these  circumstances.  In  women  the  question  is  complicated 
with  that  of  child-bearing,  which  increases  the  risks  enormously.  With  a 
localized  lesion,  absence  of  hereditary  taint,  good  physique,  and  favorable 
environment  marriage  might  be  permitted.  When  tuberculosis  has  existed, 
however,  in  a  girl  whose  family  history  is  bad,  whose'  chest  expansion  is  slight, 
and  whose  physique  is  below  the  standard,  the  physician  should,  if  possible, 
place  his  veto  upon  marriage. 

(c)  With  existing  disease,  fever,  bacilli,  etc.,  marriage  should  be  prohib- 
ited. Pregnancy  usually  hastens  the  process,  though  it  may  be  held  in  abey- 
ance. After  parturition  the  disease  advances  rapidly.  There  is  much  truth, 
indeed,  in  the  remark  of  Dubois:  "If  a  woman  threatened  with  phthisis 
marries,  she  may  bear  the  first  accouchement  well;  a  second,  with  difficulty; 
a  third,  never."  Conception  may  occur  in  an  advanced  stage  of  the  disease. 

XII.    PROPHYLAXIS  IN  TUBERCULOSIS 

General.— Among  the  more  important  measures  may  be  mentioned  the 
following :  First,  education  of  the  public.  Much  has  been  done  in  this  direc- 
tion by  the  antituberculosis  crusade,  which  has  resulted  in  the  formation  of 
many  active  societies,  and  has  stimulated  widespread  interest  in  the  disease. 
Secondly,  the  placing  of  pulmonary  tuberculosis  on  the  list  of  reportable  dis- 
eases. This  gives  the  board  of  health  control  of  the  situation,  and,  as  the 
New  York  experience  has  demonstrated,  is-  perhaps  the  most  helpful  measure 


TUBEKCULOSIS  223 

in  the  prophylaxis.  Thirdly,  the  improved  sanitary  condition  of  the  poor, 
particularly  with  reference  to  the  housing.  Fourthly,  direct  preventive  meas- 
ures, such  as  the  enactment  of  laws  against  spitting  in  public,  the  proper 
disinfection  and  cleaning  of  the  rooms  and  houses  which  have  been  occupied 
by  tuberculous  patients,  and  the  careful  inspection  of  dairies  and  abattoirs. 
Fifthly,  in  the  large  cities,  organization  of  sanatoria  and  hospitals  for  early 
curable  and  late  incurable  cases,  and  the  establishment  of  separate  dispen- 
saries with  a  system  of  visiting  the  patients  at  their  homes  by  specially 
assigned  nurses.  Lastly,  the  care  of  the  sputum  of  the  consumptive.  Thorough 
boiling  or  putting  it  into  the  fire  is  sufficient.  In  hospitals  it  is  well  to  have 
printed  directions  as  to  the  care  of  the  sputum,  and  also  printed  cards  for  out- 
patients, giving  the  most  important  rules.  It  should  be  explained  to  the 
patient  that  the  only  risk,  practically,  is  from  this  source. 

Individual. — Individual  prophylaxis  in  the  case  of  delicate  children  is 
most  important.  An  infant  born  of  tuberculous  parents,  or  of  a  family  in" 
which  consumption  prevails,  should  be  brought  up  with  the  greatest  care  and 
guarded  most  particularly  against  catarrhal  affections  of  all  kinds.  Special 
attention  should  be  given  to  the  throat  and  nose,  and  on  the  first  indication 
of  mouth-breathing,  or  any  obstruction  of  the  naso-pharynx,  a  careful  ex- 
amination should  be  made  for  adenoid  vegetations.  The  child  should  be  clad 
in  flannel  and  live  in  the  open  air  as  much  as  possible,  avoiding  close  rooms. 
It  is  a  good  practice  to  sponge  the  throat  and  chest  night  and  morning  with 
cold  water.  Special  attention  should  be  paid  to  diet  and  to  the  mode  of 
feeding.  The  meals  should  be  at  regular  hours  and  the  food  plain  and  sub- 
stantial. From  the  outset  the  child  should  be  encouraged  to  drink  freely  of 
milk.  Unfortunately,  in  these  cases  there  seems  to  be  an  uncontrollable 
aversion  to  fats  of  all  kinds.  As  the  child  grows  older,  systematically  regu- 
lated exercise  or  a  course  of  pulmonary  gymnastics  may  be  taken.  In  the 
choice  of  an  occupation  preference  should  be  given  to  an  out-of-door  life. 
Families  with  a  marked  predisposition  to  tuberculosis  should,  if  possible, 
reside  in  an  equable  climate.  The  possibility  of  a  protective  inoculation  has 
been  shown  by  the  experiments  of  Webb  and  Williams,  as  monkeys  so  pro- 
tected can  be  exposed  successfully  in  situations  favorable  to  infection.  It  is 
stated  that  the  method  has  been  used  with  success  in  children. 

The  trifling  ailments  of  children  should  be  carefully  watched.  In  the 
convalescence  from  the  fevers  which  so  frequently  prove  dangerous  the  great- 
est caution  should  be  exercised  to  prevent  catching  cold.  Cod-liver  oil,  the 
syrup  of  the  iodide  of  iron,  and  arsenic  may  be  given.  As  mentioned,  care 
of  the  throat  in  these  children  is  very  important.  Enlarged  tonsils  should 
be  removed. 

XIII.     TEEATMENT  OF  TUBERCULOSIS 

The  Natural  or  Spontaneous  Cure. — The  spontaneous  healing  of  local 
tuberculosis  is  an  every-day  affair.  A  majority  of  those  infected  never  have 
the  disease,  i.  e.,  they  recover  without  symptoms,  without  the  slight  lesion 
having  disturbed  the  health.  Many  cases  of  adenitis  and  disease  of  the  bone 
or  of  the  joints  terminate  favorably.  The  healing  of  pulmonary  tuberculosis 
is  shown  clinically  by  the  recovery  of  patients  in  whose  sputum  elastic  tissue 
and  bacilli  have  been  found;  anatomically,  by  the  presence  of  lesions  in  all 


224  SPECIFIC   INFECTIOUS   DISEASES 

stages  of  repair.  In  the  granulation  products  and  associated  pneumonia  a 
scar-tissue  is  formed,  while  the  smaller  caseous  areas  become  impregnated  with 
lime  salts.  To  such  conditions  alone  should  the  term  healing  be  applied. 
When  the  fibroid  change  encapsulates  but  does  not  involve  the  entire  tubercu- 
lous tissue,  the  tubercle  may  be  termed  involuted  or  quiescent,  but  is  not 
destroyed.  When  cavities  of  any  size  have  formed,  healing,  in  the  proper 
sense  of  the  term,  does  not  occur.  I  have  yet  to  see  a  specimen  which  would 
indicate  that  a  vomica  had  cicatrized.  Cavities  may  be  greatly  reduced  in 

Bize indeed,  an  entire  series  of  them  may  be  so  contracted  by  sclerosis  of  the 

tissue  about  them  that  an  upper  lobe,  in  which  this  process  most  frequently 
occurs,  may  be  reduced  to  a  third  of  its  ordinary  dimensions.  Laennec  under- 
stood thoroughly  this  natural  process  of  cure  in  tuberculosis,  and  recognized 
the  frequency  with  which  old  tuberculous  lesions  occurred  in  the  lungs.  He 
described  cicatrices  completes  and  cicatrices  fistuleuses.,  the  latter  being  the 
shrunken  cavities  communicating  with  the  bronchi;  and  remarked  that,  as 
tubercles  growing  in  the  glands,  which  are  called  scrofula,  often  heal,  why 
should  not  the  same  take  place  in  the  lungs  ? 

There  is  an  old  German  axiom,  "Jedermann  hat  am  Ende  ein  bischen 
Tuberculose,"  a  statement  partly  borne  out  by  the  statistics  showing  the  pro- 
portions of  cases  in  persons  dying  of  all  disease  in  whom  quiescent  or  tuber- 
culous lesions  are  found  in  the  lungs.  We  find  at  the  apices  the  following 
conditions,  which  have  been  held  to  signify  healed  tuberculous  processes: 
(a)  Thickening  of  the  pleura,  usually  at  the  posterior  surface  of  the  apex, 
with  subadjacent  induration  for  a  distance  of  a  few  millimetres.  This  has, 
perhaps,  no  greater  significance  than  the  milky  patch  on  the  pericardium. 
(6)  Puckered  cicatrices  at  the  apex,  depressing  the  pleura,  and  on  section 
showing  a  large  pigmented,  fibrous  scar.  The  bronchioles  in  the  neighborhood 
may  be  dilated,  but  there  are  neither  tubercles  nor  cheesy  masses.  This  may 
sometimes,  but  not  always,  indicate  a  healed  tuberculous  lesion,  (c)  Puck- 
ered cicatrices  with  cheesy  or  cretaceous  nodules,  and  with  scattered  tubercles 
in  the  vicinity,  (d)  The  cicatrices  fistuleuses  of  Laennec,  in  which  the  fibroid 
puckering  has  reduced  the  size  of  one  or  more  cavities  which  communicate 
directly  with  the  bronchi. 

General  Measures. — The  cure  of  tuberculosis  is  a  question  of  nutrition; 
digestion  and  assimilation  control  the  situation;  as  a  rule,  make  a  patient 
grow  fat  and  strong,  and  the  local  disease  may  be  left  to  take  care  of  itself. 
There  are  three  indications :  First,  to  place  the  patient  in  surroundings  most 
favorable  for  the  maintenance  of  a  maximum  degree  of  nutrition;  second,  to 
take  such  measures  as,  in  a  local  or  general  way,  influence  the  tuberculous 
processes;  third,  to  alleviate  symptoms. 

OPEN-AIR  TREATMENT.— The  value  of  fresh  air  and  out-of-door  life  is  well 
illustrated  by  an  experiment  of  Trudeau.  Inoculated  rabbits  confined  in  a 
dark,  damp  place  rapidly  succumbed,  while  others,  allowed  to  run  wild,  either 
recovered  or  show  slight  lesions.  It  is  the  same  in  human  tuberculosis.  A 
patient  confined  to  the  house— particularly  in  the  cltfse,  overheated,  stuffy 
dwellings  of  the  poor,  or  treated  in  a  hospital  ward— is  in  a  position  analogous 
to  that  of  the  rabbit  confined  to  a  hutch  in  the  cellar;  whereas  a  patient  living 
in  the  fresh  air  and  sunshine  for  the  greater  part  of  the  day  has  chances 
comparable  to  those  of  the  rabbit  running  .wild. 


TUBERCULOSIS  225 

The  open-air  treatment  of  tuberculosis  may  be  carried  out  at  home,  by 
Change  of  residence  to  a  suitable  climate,  or  in  a  sanatorium. 

(a)  At  Home. — In  a  majority  of  all  cases  the  patient  has  to  be  cared  for 
in  his  own  home.,  and,  if  in  the  city,  under  very  disadvantageous  circumstances. 
Much,  however,  may  be  done  even  in  cities  to  promote  arrest  by  insisting 
upon  systematic  treatment.  How  much  may  be  done  by  care  and  instruction 
is  shown  by  the  success  of  J.  H.  Pratt's  tuberculosis  classes.  As  not  five  per 
cent,  of  the  patients  can  be  dealt  w.ith  in  sanatoria,  it  is  surprising  and  grati- 
fying to  see  how  successful  the  home  treatment  may  be.  Even  in  cities  the 
patients  may  be  trained  to  sleep  out  of  doors,  and  the  results  obtained  by 
Pratt,  Millett,  and  others  are  as  good  as  any  that  have  been  published.  While 
there  is  fever  the  patient  should  be  at  rest  in  bed,  and  night  and  day  the 
windows  should  be  open,  so  that  he  may  be  exposed  freely  to  the  fresh  air. 
Low  temperature  is  not  a  contra-indication.  If  there  is  a  balcony  or  a  suit- 
able yard  or  garden,  on  the  brighter  days  the  patient  may  be  wrapped  up 
and  put  in  a  reclining  chair  or  on  a  sofa.  The  important  thing  is  for  the 
physician  to  emphasize  the  fact  that  neither  the  cough,  fever,  night  sweats, 
and  not  even  haemoptysis  centra-indicate  a  full  exposure  to  the  fresh  air.  In 
country  places  this  can  be  carried  out  much  more  effectively.  In  the  summer 
the  patient  should  be  out  of  doors  for  at  least  eleven  or  twelve  hours,  and  in 
winter  six  or  eight  hours.  At  night  the  room  should  be  cool  and  thoroughly 
well  ventilated.  It  may  require  several  months  of  this  rest  treatment  in  the 
open  air  before  the  temperature  falls  to  normal. 

(&)  Treatment  in  Sanatoria. — Perhaps  the  most  important  advance  in  the 
treatment  of  tuberculosis  has  been  in  the  establishment  in  favorable  localities 
of  institutions  in  which  patients  are  made  to  live  according  to  strict  rules. 
To  Brehmer,  of  Gobersdorf,  we  owe  the  successful  execution  of  this  plan, 
which  has  been  followed  in  Germany  with  most  gratifying  results.  In  the 
United  States  the  zeal,  energy,  and  scientific  devotion  of  Edward  L.  Trudeau 
have  demonstrated  its  feasibility,  and  the  Saranac  institution  has  become  a 
model  of  its  kind.  The  results  at  hundreds  of  institutions  demonstrate  the 
great  importance  of  system  and  rigid  discipline  in  carrying  out  a  successful 
treatment  of  tuberculosis.  Much  has  been  done  in  the  United  States,  Great 
Britain  and  the  Continent  to  promote  the  sanatorium  treatment  of  tubercu- 
losis. The  past  ten  years  have  been  rich  in  experience.  The  good  results 
have  quite  justified  the  heavy  expenditure  of  money.  In  many  places  it  has 
been  demonstrated  that  with  an  inexpensive  plant  excellent  results  may  be 
obtained.  A  reaction  has  naturally  followed  the  "stuffing"  plan  of  feeding, 
and  more  reasonable  methods  are  now  employed.  The  "absolute  rest"  plan 
has  been  modified  to  meet  individual  cases.  The  all-important  matter  is  the 
establishment  near  to  the  large  cities  of  public  sanatoria  for  the  treatment  of 
cases  in  the  early  stages.  There  should  be  opened  in  the  large  general  hos- 
pitals special  out-patient  departments  for  tuberculous  patients,  from  which 
suitable  cases  could  be  sent  to  the  sanatoria.  Much  discussion  has  taken 
place  as  to  the  result  of  sanatorium  treatment.  Personally  I  am  stongly 
convinced  of  its  extraordinary  benefits  in  suitable  cases.  To  pay  a  visit  with 
Dr.  Bardwell  to  the  King  Edward  Sanatorium  at  Midhurst  and  see  nearly 
every  one  of  100  early  cases  looking  in  good  condition  with  fresh  air,  judicious 
rest,  proper  exercise  and  diet,  without  drugs  and  without  tuberculin,  im- 


226  SPECIFIC   INFECTIOUS   DISEASES 

presses  one  immensely  with  the  value  of  the  method.  Statistics  are  notori- 
ously uncertain,  but  there  is  perhaps  no  institution  of  the  English-speaking 
world  in  which  greater  care  has  been  taken  to  trace  the  after-history  of  the 
patients  than  at  the  Adirondack  Sanatorium,  founded  by  Dr.  Trudeau.  The 
total  number  of  patients  from  the  years  1885  to  1909  inclusive  was  2,878. 
It  has  been  impossible  to  trace  206  of  these.  Of  the  remaining  2,672,  1,512 
were  living  (1911)  and  1,160  dead. 

(c)  Climatic  Treatment— This,  after  .all,  is  only  a  modification  of  the 
open-air  method.  The  first  question  to  be  decided  is  whether  the  patient  is 
fit  to  be  sent  from  home.  In  many  instances  it  is  a  positive  hardship.  A 
patient  with  well-marked  cavities,  hectic  fever,  night  sweats,  and  emaciation 
is  much  better  at  home,  and  the  physician  should  not  be  too  much  influenced 
by  the  importunities  of  the  sick  man  or  his  friends.  The  requirements  of  a 
suitable  climate  are  a  pure  atmosphere,  an  equable  temperature  not  subject  to 
rapid  variations,  and  a  maximum  amount  of  sunshine.  Given  these  three 
factors,  it  makes  little  difference  where  a  patient  goes,  so  long  as  he  lives  an 
outdoor  life.  Major  Woodruff  believes  that  sunshine  may  be  hurtful,  and 
he  has  collected  statistics  to  show  that  tuberculosis  is  more  prevalent  and 
more  fatal  among  the  dark  races,  who  live  where  the  sun  shines  the  brightest. 
The  point  is  one  of  interest,  but  I  do  not  think  the  case  against  the  sun  is 
made  out.  The  different  climates  may  be  grouped  into  the  high  altitudes, 
the  dry,  warm  climates,  and  the  moist,  warm  climates.  Among  high  alti- 
tudes in  the  United  States,  the  Colorado  resorts  are  the  most  important.  Of 
others,  those  in  Arizona  and  New  Mexico  have  been  growing  rapidly.  The 
rarefaction  of  the  air  in  high  altitudes  is  of  benefit  in  increasing  the  respira- 
tory movements  in  pulmonary  disease,  but  brings  about  in  time  a  condition  of 
dilatation  of  the  air-vesicles  and  a  permanent  increase  in  the  size  of  the  chest 
Which  is  a  marked  disadvantage  when  such  persons  attempt  subsequently  to 
reside  at  the  sea-level.  The  great  advantage  of  these  western  resorts  is  that 
they  are  in  progressive,  prosperous  countries,  in  which  a  man  may  find  means 
of  livelihood  and  live  in  comfort.  In  Europe  the  chief  resorts  at  high  alti- 
tudes are  Davos,  Les  Avants,  and  St.  Moritz.  Of  resorts  at  a  moderate  alti- 
tude, Asheville  and  the  Adirondacks  are  the  best  known  in  America.  The 
Adirondack  cure  has  become  of  late  years  quite  famous.  One  very  decided 
advantage  is  that  after  arrest  of  the  disease  the  patient  can  return  to  the  sea- 
level  without  any  special  risk.  The  cases  most  suitable  for  high  altitudes  are 
those  in  which  the  disease  is  limited,  without  much  cavity  formation,  and 
without  much  emaciation.  The  thin,  irritable  patients  with  chronic  tubercu- 
losis and  a  good  deal  of  emphysema  are  better  at  the  sea-level.  The  cold 
winter  climate  seems  to  be  of  decided  advantage  in  tuberculosis,  and  in  the 
Adirondacks,  where  the  temperature  falls  sometimes  to  20°  or  even  more  below 
zero,  the  patients  are  able  to  lead  an  out-of-door  life  throughout  the  entire 
winter. 

Of  the  moist,  warm  climates,  in  America  Florida  and  the  Bermudas,  in 
Europe  the  Madeira  Islands,  and  in  Great  Britain  Eastbourne  Bournemouth, 
Torquay,  and  Falmouth  are  the  best  known.  Of  the  dry,  warm  climates, 
Southern  California  in  the  United  States  is  the  most  satisfactory.  Many  of 
the  health  resorts  in  the  Southern  States,  such  as  Aiken,  Thomasville,  and 
Summerville,  are  delightful  winter  climates  for  tuberculous  cases.  Egypt, 


TUBERCULOSIS  227 

Algiers,  and  the  Riviera  are  the  most  satisfactory  resorts  for  patients  from 
Europe. 

Other  considerations  which  should  influence  the  choice  of  a  locality  are 
good  accommodations  and  good  food.  It  is  also  important  to  be  under  the 
care  of  a  competent  physician.  Very  much  is  said  concerning  the  choice  of 
locality  in  the  different  stages  of  pulmonary  tuberculosis,  but  when  the  dis- 
ease is  limited  to  an  apex,  in  a  man  of  fairly  good  personal  and  family  his- 
tory, the  chances  are  that  he  may  fight  a  winning  battle  if  he  lives  out  of 
doors  in  any  climate,  whether  high,  dry,  and  cold,  or  low,  moist,  and  warm. 
With  bilateral  disease  and  cavity  formation  there  is  but  little  hope  of  perma- 
nent cure,  and  the  mild  or  warm  climates  are  preferable. 

Measures  which,  by  their  Local  or  General  Action,  Influence  the  Tubercu- 
lous Process. — Under  this  heading  we  may  consider  the  specific,  the  dietetic, 
and  the  general  medicinal  treatment  of  tuberculosis. 

(a)  SPECIFIC  TREATMENT. — Introduced  by  Koch  in  1890,  the  tuberculin 
treatment  soon  fell  into  disfavor,  but,  in  spite  of  the  bad  results  that  naturally 
followed  its  injudicious  use,  certain  men  (among  them,  particularly,  Trudeau) 
continued  to  use  it.  Of  late  years  there  has  been  a  reaction  in  its  favor,  and 
now  tuberculin  is  again  lauded  by  some  fanatics  as  the  one  and  only  means 
of  cure  in  the  disease.  Unquestionably  in  suitable  cases  it  has  a  very  bene- 
ficial influence;  the  difficulty  is  to  decide  which  they  are.  At  present  so 
indiscriminate  is  its  use  that  an  estimation  of  the  results  is  very  difficult. 
The  preliminary  question  arises  as  to  what  justifies  the  diagnosis  of  tubercu- 
losis, and  it  is  impossible  to  compare  the  results  obtained  by  different  ob- 
servers. Anybody,  by  any  method,  can  secure  100  per  cent,  of  cures  in  the 
so-called  "closed"  pulmonary  tuberculosis.  As  Hamman  states  very  sensibly: 
"If  in  the  case  of  every  patient  who  presents  himself  for  examination  and 
shows  some  trifling  deviation  from  the  normal  physical  signs  a  diagnosis  of 
tuberculosis  is  made,  or  if  tuberculin  is  made  the  ultimate  test  of  a  correct 
diagnosis,  similar  results  may  be  obtained  with  any  or  with  no  method."  A 
variety  of  preparations  come  under  the  name  Tuberculin:  0.  T.  and  T.  R., 
which  are  Koch's  old  and  new  preparations;  Deny's  tuberculin,  bouillon  filtre, 
known  as  B.  F.,  and  a  bacillary  emulsion  of  Koch,  B.  E.  If  given  in  accord- 
ance with  Wright's  instructions,  the  smallest  dose  which  will  bring  out  a 
response  should  be  used,  1/2000  or  1/1000  mgm.  and  re-inoculations  are 
made  at  intervals  of  from  one  to  two  weeks.  If  the  tuberculo-opsonic  index 
rises,  it  is  taken  as  an  indication  that  the  injections  are  helpful,  and  the 
amount  is  gradually  increased  when  it  is  found  that  the  dose  previously  given 
ceases  to  bring  out  a  sufficient  response.  It  is  administered  to  afebrile 
patients.  It  is  no  longer  thought  desirable — quite  the  contrary,  in  fact — to 
get  a  severe  general  reaction,  particularly  as  this  may  be  associated  with 
marked  focal  reactions.  The  aim  striven  for  is  to  get  as  high  a  grade  of 
tuberculin  tolerance  as  possible.  Trudeau,  who  had  probably  the  longest  in- 
dividual experience  of  anyone  using  tuberculin,  began  with  doses  so  small 
that  no  reaction  is  produced;  then  the  dose  is  cautiously  raised,  avoiding  the 
slightest  reaction.  On  the  other  hand,  Wilkinson  begins  with  a  very  high 
dose,  and  uses  the  tuberculin  in  a  much  wider  range  of  cases. 

(&)  DIETETIC  TREATMENT. — The  outlook  in  tuberculosis  depends  much 
upon  the  digestion.  It  is  rare  to  see  recovery  in  a  patient  in  whom  there  is 


228  SPECIFIC   INFECTIOUS   DISEASES 

persistent  gastric  trouble,  and  the  physician  should  ever  bear  in  mind  the 
fact  that  in  this  disease  the  primes  via  control  the  position.  The  early  nausea 
and  loss  of  appetite  in  many  cases  are  serious  obstacles.  Many  patients  loathe 
food  of  all  kinds.  A  change  of  air  or  a  sea  voyage  may  promptly  restore  the 
appetite.  When  either  of  these  is  impossible,  and  if,  as  is  almost  always  the 
case,  fever  is  present,  the  patient  should  be  placed  at  rest,  kept  in  the  open  air 
nearly  all  day,  and  fed  at  stated  intervals  with  small  quantities  either  of 
milk,  buttermilk,  or  koumyss,  alternating  if  necessary  with  meat  juice  and 
egg  albumin.  Some  patients  who  are  disturbed  by  eggs  and  milk  do  well  on 
koumyss.  It  may  be  necessary  to  resort  to  Debove's  method  of  over-alimenta- 
tion or  forced  feeding.  The  stomach  is  first  washed  out  with  cold  water,  and 
then,  through  the  tube,  a  mixture  is  given  containing  a  litre  of  milk,  an  egg, 
and  100  grams  of  very  finely  powdered  meat.  This  is  given  three  times  a 
day.  Sometimes  the  patients  will  take  this  mixture  without  the  unpleasant 
necessity  of  the  stomach-tube,  in  which  case  a  smaller  amount  may  be  given. 
Raw  eggs  are  very  suitable  for  the  purpose  of  over-feeding,  and  may  be  taken 
in  the  intervals  between  the  meals.  Beginning  with  one  three  times  a  day  the 
number  may  be  increased  to  two,  three,  or  even  four  at  a  time.  In  the  Ger- 
man sanatoria  a  very  special  feature  is  this  over-feeding,  even  when  fever  is 
present.  R.  W.  Philip  advises  a  raw  meat  diet — zomotherapy — half  a  pound 
three  times  a  day,  either  minced  or  as  a  soup. 

In  many  cases  the  digestion  is  not  at  all  disturbed  and  the  patient  can 
take  an  ordinary  diet.  It  is  remarkable  how  rapidly  the  appetite  and  diges- 
tion improve  with  the  fresh-air  treatment,  even  in  patients  who  have  to  remain 
in  the  city.  Care  should  be  taken  that  the  medicines  do  not  disturb  the  stom- 
ach. Not  infrequently  the  sweet  syrups  used  in  the  cough  mixtures,  cod-liver 
oil,  creosote,  and  the  hypophosphites  produce  irritation,  and  by  interfering 
with  digestion  do  more  harm  than  good.  On  the  other  hand,  the  bitter  tonics, 
with  acids,  and  the  various  malt  preparations  are  often  most  satisfactory. 
The  indications  for  alcohol  in  tuberculosis  are  enfeebled  digestion  with  fever, 
a  weak  heart,  and  rapid  pulse.  A  routine  administration  is  not  advisable, 
and  there  is  no  evidence  that  its  persistent  use  promotes  fibroid  processes  in 
the  tuberculous  areas.  In  the  advanced  stages,  particularly  when  the  tem- 
perature is  low  between  eight  and  ten  in  the  morning,  whisky  and  milk,  or 
whisky,  egg,  and  milk  may  be  given  with  great  advantage..  The  red  wines 
are  also  beneficial  in  moderate  quantities. 

(c)  EXERCISE. — It  is  found  as  a  rule  that  the  patient  with  fever  does 
best  at  absolute  rest,  and  that  exercise  should  only  be  taken  after  an  afebrile 
period,  and  then  very  gradually.  It  has  long  been  known  that  following 
exercise  the  temperature  is  raised,  and  Paterson,  of  Frimly,  has  adopted  a 
method  of  graded  exercises  which  have  yielded  excellent  results.  The  plan 
is  based  upon  the  view  that  physical  exercise  induces  auto-inoculation,  the 
extent  of  which  may  be  controlled  by  the  amount  of  muscular  effort.  By  a 
study  of  the  fever-chart,  the  body  weight,  the  amount  of  sputum,  and  the 
appetite  the  rate  of  progress  may  be  estimated.  The  febrile  patient  is 
regarded  as  one  in  whom  the  auto-inoculation  is  excessive.  To  overcome 
this  the  patient  is  immobilized  in  bed  so  far  as  possible,  and  not  allowed  to 
make  any  movements  whatever.  The  effect  of  this  is  often  remarkable  in 
reducing  the  fever.  Once  afebrile,  the  principal  element  in  the  treatment 


TUBERCULOSIS  229 

is  the  induction  of  an  auto-inoculation  by  exercises,  which  Paterson  believes 
have  very  much  the  same  effect  as  a  dose  of  tuberculin.  A  scheme  of  graded 
labor  has  been  devised,  which  has  many  advantages  in  sanatorium  life,  and 
the  results  obtained  at  Frimly  are  certainly  very  gratifying. 

(d)  IMMOBILIZING    THE    LUNG    BY    INDUCTION    OF    PNEUMOTHORAX. — • 
Years   ago   Cayley  induced   pneumothorax   in   a  case   of  haemoptysis.      The 
method  never  came  into  general  use;  but,  on  the  principle  of  keeping  an 
inflamed  organ  at  rest,  this  method  has  been  advocated  in  pulmonary  tubercu- 
losis by  Forlanini  and  by  J.  B.  Murphy.     Sterile  nitrogen  is  introduced  into 
the  pleural  cavity  through  a  thin,  hollow  needle.     It  is  best  to  use  a  special 
apparatus   with   a   water-manometer,   so   that   measured   quantities   may   be 
injected.     At  first  from  200  to  300  c.  c. ;  later  as  much  as  500  c.  c.  are  intro- 
duced, at  intervals  of  a  day  or  every  other  day,  until  the  lung  is  completely 
collapsed,  and  until  there  is  a  positive  interpleural  pressure  of  from  5  to 
10  cm.  of  water.     The  method-  has  been  widely  practiced  in  America  and  on 
the   Continent,  with  excellent  results,  it  is   claimed,  in  certain  cases;   but 
there  are  dangers,  as  haemoptysis,  serous  effusion,  and  empyema,  and  a  serious 
objection  is  the  duration  of  the  treatment,  as  the  pleural  cavity  requires  to 
be  refilled  every  month  or  two. 

(e)  GENERAL   MEDICAL    TREATMENT. — No   medicinal   agents   have   any 
special  or  peculiar  action  upon  tuberculous  processes.     The  influence  which 
they  exert  is  upon  the  general  nutrition,  increasing  the  physiological  resist- 
ance, and  rendering  the  tissues  less  susceptible  to  invasion.     The  following 
are  the  most  important  remedies  which  seem  to  act  in  this  manner: 

Creosote,  which  may  be  administered  in  capsules,  in  increasing  doses,  be- 
ginning with  1  minim  three  times  a  day  and,  if  well  borne,  increasing  the 
dose  to  8  or  10  minims.  It  may  also  be  given  in  solution  with  tincture  of 
cardamon  and  alcohol.  It  is  an  old  remedy,  strongly  recommended  by 
Addison,  and  the  reports  of  Jaccoud,  Fraentzel,  and  many  others  show 
that  it  has  a  positive  value  in  the  disease.  It  may  be  used  as  an  inhala- 
tion. Guaiacol  may  be  given  as  a  substitute,  either  internally  or  hypoder- 
mically. 

Cod-liver  Oil. — In  glandular  and  bone  tuberculosis  this  remedy  is  un- 
doubtedly beneficial  in  improving  the  nutrition.  In  pulmonary  tuberculosis 
its  action  is  less  certain,  and  it  is  scarcely  worthy  of  the  unbounded  confidence 
which  it  enjoyed  for  so  many  years.  It  should  be  given  in  small  doses,  not 
more  than  a  teaspoonful  three  times  a  day  after  meals.  It  seems  to  act  better 
in  children  than  in  adults.  Fever  and  gastric  irritation  are  contra-indications 
to  its  use.  When  it  is  not  well  borne,  a  dessertspoonful  of  rich  cream  three 
times  a  day  is  an  excellent  substitute.  The  clotted  or  Devonshire  cream  is 
preferable. 

The  Hypophosphites. — These  in  various  forms  are  useful  tonics,  but  it  is 
doubtful  if  they  have  any  other  action.  They  certainly  exercise  no  specific 
influence  upon  tubercle. 

Arsenic. — There  is  no  general  tonic  more  satisfactory  in  cases  of  tuber- 
culosis of  all  kinds  than  Fowlers  solution.  It  may  be  given  in  5-minim  doses 
three  times  a  day  and  gradually  increased ;  stopping  its  use  whenever  unpleas- 
ant symptoms  arise,  and  in  any  case  intermitting  it  every  third  or  fourth 
week.  Recently  intramuscular  injections  of  the  salts  of  cacodylic  acid  have 


230  SPECIFIC    INFECTIOUS    DISEASES 

been  used  to  combat  the  anaemia  so  commonly  present  in  tuberculous  infec- 
tions with,  it  is  claimed,  unusual  success. 

Treatment  by  compressed  air  is  in  many  cases  beneficial,  and  under  its 
use  the  appetite  improves,  there  is  gain  in  weight  and  reduction  of  the  fever. 
The  air  may  be  saturated  with  creosote. 

Treatment  of  Special  Symptoms  in  Pulmonary  Tuberculosis.— (a)  THE 
FEVER. — There  is  no  more  difficult  problem  in  practical  therapeutics  than  the 
treatment  of  the  pyrexia  of  tuberculosis.  The  patient  should  be  at  absolute 
rest,  and  in  the  open  air  night  and  day  for  some  weeks.  Fever  does  not  con- 
tra-indicate  an  out-of-door  life,  but  it  is  well  for  patients  with  a  temperature 
above  100.5°  F.  to  be  at  rest.  For  the  continuous  pyrexia  or  the  remit- 
tent type  of  the  early  stages,  quinine,  small  doses  of  digitalis,  and  the  salicyl- 
ates  may  be  tried ;  but  they  are  uncertain  and  rarely  reliable.  In  large  doses 
quinine  has  a  moderate  antipyretic  action,  but  it  is  just  in  these  efficient 
doses  that  it  is  so  apt  to  disturb  the  stomach. 

Antipyrin  and  antifebrin  may  be  used  cautiously;  but  it  is  better,  when 
the  fever  rises  above  103°  F.  to  rely  upon  cold  sponging  or  the  tepid  bath, 
gradually  cooled.  When  softening  has  taken  place  and  the  fever  assumes  the 
characteristic  septic  type,  the  problem  becomes  still  more  difficult.  As  shown 
by  Chart  V  (which  is  not  by  any  means  an  exceptional  one),  the  pyrexia, 
at  this  stage,  lasts  only  for  twelve  or  fifteen  hours.  As  a  rule  there  are  not 
more  than  from  eight  to  ten  hours  in  which  the  fever  is  high  enough  to 
demand  antipyretic  treatment.  Sometimes  antifebrin,  given  in  2-grain  doses 
every  hour  for  three  or  four  hours  before  the  rise  in  temperature  takes  place, 
either  prevents  entirely  or  limits  the  paroxysm.  If  the  temperature  begins  to 
rise  between  two  and  three  in  the  afternoon,  the  antifebrin  may  be  given  at 
eleven,  twelve,  one,  and,  if  necessary,  at  two.  It  answers  better  in  this  way 
than  given  in  the  single  doses.  Careful  sponging  of  the  extremities  for  from 
half  an  hour  to  an  hour  during  the  height  of  the  fever  is  useful.  Quinine  is 
of  little  benefit  in  this  type  of  fever ;  the  salicylates  are  of  still  less  use. 

(6)  SWEATING. — Atropine,  in  doses  of  gr.  T^rrsV?  and  the  aromatic  sul- 
phuric acid  in  large  doses  are  the  best  remedies.  When  there  are  cough  and 
nocturnal  restlessness,  an  eighth  of  a  grain  of  morphia  may  be  given  with  the 
atropine.  Muscarin  (TH  v  of  a  1-per-cent  solution),  tincture  of  nux  vomica 
(HI  xxx,  2  c.  c.),  picrotoxin  (gr.  fa)  may  be  tried.  The  patient  should  use 
light  flannel  night-dresses,  as  the  cotton  night-shirts,  when  soaked  with 
perspiration,  have  a  very  unpleasant  cold,  clammy  feeling. 

(c)  COUGH. — The  cough  is  a  troublesome,  though  necessary,  feature  in  pul- 
monary tuberculosis.  Unless  very  worrying  and  disturbing  sleep  at  night,  or  so 
severe  as  to  produce  vomiting,  it  is  not  well  to  attempt  to  restrict  it.  When  ir- 
ritative and  bronchial  in  character,  inhalations  are  useful,  particularly  the 
tincture  of  benzoin  or  preparations  of  tar,  creosote,  or  turpentine.  The  throat 
should  be  carefully  examined,  as  some  of  the  most  irritable  and  distressing 
forms  of  cough  in  phthisis  result  from  laryngeal  erosions.  The  distressing 
nocturnal  cough,  which  begin  just  as  the  patient  gets  into  bed  and  is  prepar- 
ing to  fall  asleep,  requires,  as  a  rule,  preparations  of  opium.  Codeia,  in 
quarter-  or  half-grain  doses  may  be  given.  An  excellent  combination  for  the 
nocturnal  cough  of  phthisis  is  morphia  (gr.  H),  dilute  hydrocyanic  acid 
j),  and  syrup  of  wild  cherry  (  3  j).  '  The  spirits  of  chloroform,  B.  P., 


TUBERCULOSIS  231 

or  a  mixture  of  chloroform  and  sedatives  or  Hoffman's  anodyne,  given  in 
whisky  before  going  to  sleep,  are  efficacious.  Mild  counter-irritation,  or 
the  application  of  a  hot  poultice,  will  sometimes  promptly  relieve  the 
cough.  The  morning  cough  is  often  much  relieved  by  taking  immedi- 
ately after  getting  up  a  glass  of  hot  milk  or  a  cup  of  hot  water, 
to  which  15  grains  of  bicarbonate  of  soda  have  been  added.  In  the 
later  stages  of  the  disease,  when  cavities  have  formed,  the  accumulated 
secretion  must  be  expectorated  and  the  paroxysms  of  coughing  are  now  most 
exhausting.  The  sedatives,  such  as  morphia  and  hydrocyanic  acid,  should  be 
given  cautiously.  The  aromatic  spirit  of  ammonia  in  full  doses  helps  to  allay 
the  paroxysm.  When  the  expectoration  is  profuse,  creosote  internally,  or  in- 
halations of  turpentine  and  iodine,  or  oil  of  eucalyptus,  are  useful.  For  the 
troublesome  dysphagia  a  strong  solution  of  cocaine  (gr.  x,  0.6  gm.)  with  boric 
acid  (gr.  v,  0.3  gm.)  in  glycerine  and  water  (  |  j,  30  c.  c.)  may  be  used 
locally. 

(d)  DIARRHCEA. — For  the  diarrhoea  large  doses  of  bismuth,  combined 
with  Dover's  powder,  and  small  starch  enemata,  with  or  without  opium,  may 
be  given.     The  acetate  of  lead  and  opium  pill  often  acts  promptly,  and  the 
acid  diarrhoea  mixture,  dilute  acetic  acid  (Til  x-xv,  1  c.  c.),  morphia  (gr.  i/8, 
0.008  gm.),  and  acetate  of  lead  (gr.  j-ij,  0.1  gm.),  may  be  tried. 

(e)  The  treatment  of  the  haemoptysis  will  be  considered  in  the  section  on 
haemorrhage  from  the  lungs.     Dyspnoea  is  rarely  a  prominent  symptom  except 
in  the  advanced  stages,  when  it  may  be  very  troublesome  and  distressing. 
Ammonia  and  morphia,  cautiously  administered,  may  be  used. 

If  the  pleuritic  pains  are  severe,  the  side  may  be  strapped,  or  painted  with 
tincture  of  iodine.  The  dyspeptic  symptoms  require  careful  treatment,  as 
the  outlook  in  individual  cases  depends  much  upon  the  condition  of  the  stom- 
ach. Small  doses  of  calomel  and  soda  often  allay  the  distressing  nausea  of  the 
early  stage. 

A  last  word  on  the  subject  of  tuberculosis  to  the  general  practitioner. 
The  leadership  of  the  battle  against  this  scourge  is  in  your  hands.  Much  has 
been  done,  much  remains  to  do.  By  early  diagnosis  and  prompt,  systematic 
treatment  of  individual  cases,  by  striving  in  every  possible  way  to  improve  the 
social  condition  of  the  poor,  by  joining  actively  in  the  work  of  the  local  and 
national  antituberculosis  societies  you  can  help  in  the  most  important  and  the 
most  hopeful  campaign  ever  undertaken  by  the  profession. 

B.    NON-BACTEKIAL  FUNGUS  INFECTIONS— 
THE  MYCOSES 

Much  attention  has  been  paid  lately  to  the  local  and  general  infections 
caused  by  the  group  of  fungoid  organisms  variously  classed  as  Streptothrix, 
Actinomyces,  Cladothrix  and  Leptothrix.  The  French  workers,  who  have 
done  so  much  lately,  group  the  various  diseases  caused  by  these  organisms 
under  the  term  Mycoses,  which  is  a  convenient  and  useful  designation.  Four 
or  five  of  these  diseases  are  of  sufficient  importance  to  be  considered  in  a 
work  of  this  scope. 


232  SPECIFIC   INFECTIOUS    DISEASES 


I.     ACTINOMYCOSIS 

Definition. — A  chronic  infective  disorder  produced  by  the  actmomyces  or 
ray-fungus,  Streptothrix  actinomyces. 

Etiology.  — The  disease  is  widespread  among  cattle,  and  occurs  also  in  the 
pig.  It  was  first  described  by  Bollinger  in  the  ox,  in  which  it  forms  the  affec- 
tion known  in  America  as  "big-jaw."  The  first  accurate  description  of  the 
disease  in  man  was  given  by  James  Israel,  and  subsequently  Ponfick  insisted 
upon  the  identity  of  the  disease  in  man  and  cattle. 

In  the  United  States  and  England  the  disease  is  less  common  than  in 
Germany.  It  is  nearly  three  times  as  common  in  men  as  in  women. 

The  parasite  belongs  probably  to  the  Streptothrix  group.  In  both  man 
and  cattle  it  can  be  seen  in  the  pus  from  the  affected  region  as  yellowish  or 
opaque  granules  from  one-half  to  two  millimetres  in  diameter,  which  are  made 
up  of  cocci  and  radiating  threads,  presenting  bulbous,  club-like  terminations. 
The  youngest  granules  are  gray  in  color  and  semi-translucent;  in  these  the 
bulbous  extremities  are  wanting. 

The  parasite  has  been  successfully  cultivated,  and  in  a  few  instances  the 
disease  has  been  inoculated  both  with  the  natural  and  artificially  grown  or- 
ganism. 

The  Mode  of  Infection. — There  is  no  evidence  of  direct  infection  with  the 
flesh  or  milk  of  diseased  animals.  The  Streptothrix  has  not  been  detected  out- 
side the  body.  It  seems  highly  probable  that  it  is  taken  in  with  the  food.  The 
site  of  infection  in  a  majority  of  cases  in  man  and  animals  is  in  the  mouth 
or  neighboring  passages.  In  the  cow,  possibly  also  in  man,  barley,  oats,  and 
rye  have  been  carriers  of  the  germ. 

Morbid  Anatomy. — As  in  tubercle,  the  first  effect  is  the  destruction  of 
adjacent  cells  and  the  attraction  of  leucocytes — later  the  surrounding  cells 
begin  to  proliferate.  After  the  tumor  reaches  a  certain  size  there  is  great 
proliferation  of  the  surrounding  connective  tissue,  and  the  growth  may,  par- 
ticularly in  the  jaw,  look  like,  and  was  long  mistaken  for,  osteo-sarcoma. 
Finally  suppuration  occurs,  which  in  man,  according  to  Israel,  may  be  pro- 
duced directly  by  the  Streptothrix  itself. 

Clinical  Forms. — (a)  DIGESTIVE  TRACT. — Israel  is  said  to  have  found 
the  fungus  in  the  cavities  of  carious  teeth.  The  jaw  has  been  affected  in  a 
number  of  cases  in  man.  The  patient  comes  under  observation  with  swelling 
of  one  side  of  the  face,  or  with  a  chronic  enlargement  of  the  jaw  which  may 
simulate  sarcoma. 

The  tongue  has  been  involved  in  several  cases,  showing  small  growths, 
either  primary  or  following  disease  of  the  jaw.  In  the  intestines  the  dis- 
ease may  occur  either  as  a  primary  or  secondary  affection.  The  most  common 
seat  is  the  region  of  the  caecum  and  appendix.  An  actinomycotic  appendi- 
citis has  been  described;  primary  actinomycosis  of  the  large  intestine  with 
metastases  has  also  been  found.  Ransom  has  found  the  actinomyces  in  the 
stools.  Actinomycotic  peritonitis  due  to  infection  through  a  gastrostomy 
wound  has  been  described.  Actinomycosis  of  the  liver  is  rare.  Auvray  in 
1903  could  only  collect  31  cases  (Rolleston).  It  forms  a  most  characteristic 
lesion,  an  alveolar  honey-combed  abscess — like  a  sponge  soaked  in  pus.  It 


ACTINOMYCOSIS  233 

is  usually  secondary  to  an  intestinal  lesion,  but  in  a  few  cases  no  other  focus 
has  been  found. 

(b)  PULMONARY  ACTINOMYCOSIS. — In  September,  1878,  James  Israel  de- 
scribed a  remarkable  mycotic  disease  of  the  lungs,  which  subsequent  observa- 
tion showed  to  be  the  affection  described  the  year  before  by  Bellinger  in  cattle. 
Since  that  date  many  instances  have  been  reported  in  which  the  lungs  were 
affected.     It   is  a  chronic   infectious   pulmonary   disorder,  characterized   by 
cough,  fever,  wasting,  and  a  muco-purulent,  sometimes  fetid,  expectoration. 
The  lesions  are  unilateral  in  a  majority  of  the  cases.    Hodenpyl  classifies  them 
in  three  groups:   (1)   Lesions  of  chronic  bronchitis;  the  diagnosis  has  been 
made  by  the  presence  of  the  actinomyces  in  the  sputum.     (2)  Miliary  actino- 
mycosis,  closely  resembling  miliary  tubercle,  but  the  nodules  are  seen  to  be 
made  up  of  groups  of  fungi,  surrounded  by  granulation  tissue.    This  form  of 
pulmonary  actinomycosis  is  not  infrequent  in  oxen  with  advanced  disease  of 
the  jaw  or  adjacent  structures.     (3)  The  cases  in  which  there  is  more  exten- 
sive destructive  disease  of  the  lungs,  broncho-pneumonia,  interstitial  changes, 
and  abscesses,  the  latter  forming  cavities  large  enough  to  be  diagnosed  during 
life.     Actinomycotic  lesions  of  other  organs  are  often  present  in  connection 
with  the  pulmonary  disease;  erosion  of  the  vertebrae,  necrosis  of  the  ribs  and 
sternum,  with  node-like  formations,  subcutaneous  abscesses,  and  occasionally 
metastases  in  all  parts  of  the  body. 

Symptoms. — The  fever  is  of  an  irregular  type  and  depends  largely  on  the 
existence  of  suppuration.  The  cough  is  an  important  symptom,  and  the  diag- 
nosis in  18  of  the  cases  was  made  during  life  by  the  discovery  of  the  actino- 
myces. Death  results  usually  with  septic  symptoms.  Occasionally  there  is  a 
condition  simulating  typhoid  fever.  The  average  duration  of  the  disease  was 
ten  months.  Eecovery  is  not  very  rare.  Clinically  the  disease  closely  re- 
sembles certain  forms  of  pulmonary  tuberculosis  and  of  fetid  bronchitis.  It  is 
not  to  be  forgotten  in  the  examination  of  the  sputum  that,  as  Bizzozero  men- 
tions, certain  degenerated  epithelial  cells  may  be  mistaken  for  the  organism. 
The  radiating  leptothrix  threads  about  the  epithelium  of  the  mouth  some- 
times present  a  striking  resemblance. 

(c)  CUTANEOUS  ACTINOMYCOSIS. — In  more  than  half  of  the  recorded  cases 
the  disease  has  involved  the  skin  of  the  head  and  neck ;  the  buccal,  lingual  and 
pharyngeal  structures  may  be  involved  also.     It  is  a  very  chronic  affection 
resembling  tuberculosis  of  the  skin,  associated  with  the  growth  of  tumors 
which  suppurate  and  leave  open  sores,  which  may  remain  for  years. 

(d)  CEREBRAL  ACTINOMYCOSIS. — Bellinger  has  reported  an  instance  of 
primary  disease  of  the  brain.    The  symptoms  were  those  of  tumor.     A  second 
remarkable  case  has  been  reported  by  Gamgee  and  Delepine.    The  patient  was 
admitted  to  St.  George's  Hospital  with  left-sided  pleural  effusion.     At  the 
post  mortem  three  pints  of  purulent  fluid  were  found  in  the  left  pleura ;  there 
was  an  actinomycotic  abscess  of  the  liver,  and  in  the  brain  there  were  abscesses 
in  the  frontal,  parietal,  and  temporo-sphenoidal  lobes  which  contained  the 
mycelium,  but  no  clubs.    A  third  case,  reported  by  0.  B.  Keller,  had  empyema 
necessitaiis,  which  was  opened  and  actinomycetes  were  found  in  the  pus.     Sub- 
sequently she  had  Jacksonian  epilepsy,  for  which  she  was  trephined  twice  and 
abscesses  opened,  which  contained  actinomyces  grains.     Death  occurred  after 
the  second  operation. 

17 


234  SPECIFIC    INFECTIOUS    DISEASES 

Diagnosis.— The  disease  is  in  reality  a  chronic  pyaemia.  The  only  test  is 
the  presence  of  the  actinomyces  in  the  pus.  Metastases  may  occur  as  in  pyae- 
mia and  in  tumors.  The  tendency,  however,  is  rather  to  the  production  of 
a  local  purulent  affection  which  erodes  the  bones  and  is  very  destructive. 

Treatment.— This  is  largely  surgical  and  is  practically  that  of  pyaemia. 
Incision  of  the  abscess,  removal  of  the  dead  tissue,  and  thorough  irrigation 
are  appropriate  measures.  Thomassen  has  recommended  iodide  of  potassium, 
which,  in  doses  of  from  40  to  60  grains  (2.5  to  4  gm.)  daily,  has  proved  cura- 
tive in  a  number  of  recent  cases.  The  X-rays  have  been  very  beneficial  in  the 
cutaneous  forms. 

H.     THE  SPOROTRICHOSES 

Definition. — A  chronic  infection  characterized  by  cutaneous  and  internal 
lesions  due  to  the  growth  of  various  forms  of  parasitic  fungi  of  the  sporo- 
trichosis  group. 

History. — In  November,  1896,  a  patient  presented  himself  at  Finney's 
outpatient  clinic  at  the  Johns  Hopkins  Hospital  with  an  infection  of  the 
right  arm,  which  had  lasted  for  several  weeks.  There  were  ulcerations  on 
the  hand  and  indurations  on  the  forearm.  The  condition  was  recognized  as 
unusual  and  Schenck,  who  undertook  its  study,  found  on  culture  a  branched 
mycelium  with  numerous  spores  or  conidia.  Its  identification  was  made  by 
the  well-known  expert,  Erwin  F.  Smith,  and  it  has  been  named  Sporotrichum 
schencJcii.  Since  this  publication,  the  disease  has  become  widely  recognized, 
owing  chiefly  to  the  studies  of  Beurmann  and  Gougerot,  and  it  is  now  recog- 
nized that  the  disease  is  widely  distributed  and  one  of  the  most  clearly  defined 
of  the  mycoses. 

The  Parasite. — In  the  tissues  and  in  the  pus  the  parasite  is  a  large  short 
rod  from  3  to  5  /*  long  and  from  2  to  3  //  in  breadth.  In  cultures  it  grows 
in  filaments  of  about  2  /*  in  diameter  and  forms  characteristic  ovoid  spores. 
The  points  of  differentiation  between  the  forms  are  due  largely  to  variation 
in  the  modes  of  sporulation.  The  parasite  is  introduced  chiefly  by  accidental 
inoculation,  and  possibly  through  grains  and  fruit.  The  fungi  have  an  identi- 
cal action  with  the  pathogenic  bacteria,  producing  toxins  towards  which  there 
are  active  humoral  reactions.  Widal  and  Abrami  determined  the  agglutinat- 
ing and  fixation  properties  of  the  serum  in  individuals  affected,  and  specific 
reactions  have  been  determined.  There  are  minor  differences  between  the 
form  described  by  Schenck  and  that  described  by  Beurmann. 

Clinical  Forms. — Beurmann  and  Gougerot  recognize  three  groups :  First, 
the  disseminated  gummatous  form  in  which  in  the  subcutaneous  tissues  in 
various  parts  of  the  body  there  are  small,  firm,  solid  nodules,  which  break 
down  and  form  small  abscesses,  ulcerating  the  skin.  In  the  second,  ulcera- 
tive,  type  the  lesions  are  not  unlike  those  of  cutaneous  tuberculosis,  occurring 
commonly  on  the  hands  and  arms,  though  they  may  appear  on  the  legs  or  on 
the  body.  They  may  be  single  or  in  groups  of  two  or  three,  and  in  several 
of  the  cases  I  had  an  opportunity  of  seeing  in  Paris  they  resembled  very 
much  eroded  syphilitic  gummata.  In  the  third  form  there  is  a  localized 
lesion,  a  hard  chancroid  body,  eroded  on  the  surface.  Dissemination  occurs 
through  the  lymphatics,  the  regional  glands  become  involved  and  there  may 


OIDIOMYCOSIS  235 

be  a  group  of  open  sores  along  the  arm  or  on  the  side  of  the  head.  Fourthly, 
there  are  certain  extra-cutaneous  forms — ulcerous  lesions  of  the  mucous 
membranes,  gummata  of  the  muscles  and  an  ulcerative  osteo-myelitis.  The 
disease  rarely  generalizes  in  the  internal  organs  but  the  parasite  has  been 
found  in  connection  with  a  pyelonephrosis. 

The  disease  is  essentially  chronic,  lasting  often  for  a  year  or  two;  some- 
times disturbing  the  health  very  slightly,  and  other  times  leading  to  anaemia. 
There  may  be  no  fever,  but  instances  of  acute  attacks  have  been  reported. 

Diagnosis. — This  has  to  be  made  from  tuberculosis,  syphilis,  and  actino- 
mycosis,  which  may  be  done  by  cultures  (as  the  parasites  grow  in  a  very 
specific  way)  and  by  the  methods  of  sporo-agglutination  and  the  fixation  re- 
action, the  full  details  of  which  are  given  in  Beurmann's  and  Gougerot's 
manual. 

Treatment. — As  a  rule  this  is  surgical,  but  the  iodide  of  potassium  has 
a  most  beneficial  effect. 

m.     NOCARDIOSIS 

J.  H.  Wright  of  Boston  has  separated  this  group  from  the  actino- 
mycoses  and  the  streptothrix  infections.  On  the  one  hand  the  parasites  re- 
semble bacteria,  on  the  other  hand  the  hypomycetes  or  moulds,  in  forming 
branching,  thread-like  filaments  and  in  the  production  of  fine  conidia.  They 
represent  a  transition  between  the  bacteria  and  the  lower  fungi. 

Wright  states  that  there  are  not  more  than  a  dozen  well  reported  human 
cases,  the  majority  of  which  have  had  the  signs  and  symptoms  of  pulmonary 
tuberculosis  or  of  multiple  abscesses.  In  the  lungs  nodules,  caseous  masses 
and  lesions  not  unlike  tubercle  have  been  found.  In  three  cases  there  was 
abscess  of  the  brain. 

The  parasite  may  be  recognized  by  the  typically  branched  filaments  and 
by  the  growth  in  cultures. 

IV.     OIDIOMYCOSIS 

Under  this  term  is  now  described  a  form  of  infective  dermatitis,  of  which 
some  50  or  60  cases  have  been  reported,  all,  with  few  exceptions,  in  the  United 
States.  It  has  been  called  blastomycosis  and  saccharomycosis,  and,  as  the 
parasites  were  at  first  thought  to  be  protozoon,  coccidioidal  or  protozoic  der- 
matitis. The  parasite  grows  as  a  spherical  or  oval  budding  cell  which  is  ca- 
pable of  producing  a  mycelium  with  aerial  hyphae. 

The  essential  lesion  is  a  granuloma,  resembling  tuberculosis  and  involving 
the  skin  of  the  face  as  a  rule,  but  sometimes  the  lesions  are  multiple  and  there 
is  extensive  ulceration  from  the  breaking  down  of  the  nodules.  In  a  few 
cases  the  lungs  and  other  parts  have  been  affected.  A  secondary  meningitis 
has  been  described,  and  grayish  nodular  infiltrations  have  been  found  in  the 
liver,  spleen,  lymph  glands  and  other  organs.  The  disease  is  chronic,  last- 
ing for  many  years. 

The  diagnosis  is  easily  made  by  the  microscopic  examination  of  material 
from  the  small  abscesses,  or  a  fragment  of  the  tissue. 

When  localized,  recovery  may  take  place,  but  when  the  lungs  or  internal 


236  SPECIFIC    INFECTIOUS    DISEASES 

organs  are  involved,  or  if  the  skin  lesions  are  very  extensive  death  follows. 
For  treatment,  the  actual  cautery,  excision,  the  X-rays  and  the  internal  ad- 
ministration  of  iodide  of  potassium  may  be  tried. 

V.     MYCETOMA 

(Madura  Disease) 

Vandyke  Carter  of  Bombay,  a  pioneer  in  the  study  of  tropical  diseases, 
gave  an  admirable  description  of  this  affection,  which  prevails  largely  in  cer- 
tain districts  of  India,  and  sporadically  in  other  parts  of  the  world. 

The  disease,  usually  involving  the  foot,  is  characterized  by  great  swelling, 
nodular  growths  and  the  formation  of  multiple  abscesses.  There  are  remark- 
able granules  1  mm.  in  diameter,  usually  of  a  black  color,  which  occur  in 
the  discharges;  in  other  cases  the  granules  are  yellow  or  brownish  in  color. 
In  the  pale  variety  a  streptothrix  has  been  found,  which  morphologically 
closely  resembles  actinomyces.  It  is  held  by  most  observers  that  this  strepto- 
thrix madurse  and  actinomyces  are  distinct  species.  From  the  black  variety 
of  granules  a  hypomycete  has  been  grown,  an  organism  closely  allied  to 
aspergillus. 

The  disease  begins  as  a  granuloma,  with  swelling  of  the  foot,  generally 
on  the  sole.  The  tumors  gradually  soften,  others  form,  the  foot  increases 
enormously  in  bulk,  becomes  much  deformed,  numerous  sinuses  pass  between 
the  bones,  the  discharges  are  muco-purulent  and  contain  the  characteristic 
granules.  The  only  satisfactory  treatment  is  early  excision  or,  in  later 
stages,  amputation  of  the  foot. 

VI.     ASPERGILLOSIS 

Bennett  in  1842  described  the  parasite  from  the  lungs,  the  Aspergillus 
fumigatus,  a  fungus  widely  distributed  as  a  harmless '  parasite,  having  been 
found  in  the  auditory  canal,  nose  and  throat.  In  birds,  in  cattle,  more 
rarely  in  dogs,  the  aspergillus  may  cause  lesions  of  the  lungs  resembling 
tuberculosis,  and  there  have  of  late  years  been  a  good  many  cases  reported 
in  man,  particularly  in  pigeon  keepers  and  hair  sorters.  In  the  majority 
of  cases  the  infection  is  secondary  to  some  long-standing  affection  of  the 
lungs,  but  it  has  been  met  with  as  a  primary  disease  with  lesions  resembling 
broncho-pneumonia,  which  undergo  necrosis  and  softening  and  the  clinical 
picture  is  that  of  ordinary  tuberculosis. 

The  symptoms  are  those  of  chronic  pulmonary  disease,  cough,  fever,  and 
expectoration,  in  which  the  aspergillus  is  found.  It  is  readily  recognized  by 
the  character  of  its  spores.  In  the  case  which  I  reported,  at  intervals  of  two 
or  three  months  for  twelve  years  the  patient  coughed  up,  usually  with  a  good 
deal  of  difficulty,  a  grayish-brown  mass  the  size  of  a  small  bean,  which  was 
made  up  entirely  of  the  mycelium  and  spores  of  the  aspergillus.  The  in- 
teresting point  was  that  the  patient  had  no  symptoms,  other  than  the  cough, 
and  was  in  excellent  health. 

In  the  majority  of  cases  the  outlook  is  bad,  and  the  treatment  is  that  of 
chronic  tuberculosis. 


AMCEBIASIS  237 


C.    PEOTOZOAN  INFECTIONS 

I.     PSOROSPERMIASIS 

Though  widely  spread  in  invertebrates,  pathogenic  psorosperms  are  not 
common  in  mammals,  and  in  man  serious  disease  is  very  rarely  caused  by 
them. 

One  of  the  commonest  and  most  readily  studied  forms  of  psorosperm  is 
the  so-called  Eainey's  tube,  an  ovoid  body  found  in  the  muscle  of  the  pig, 
within  the  sarcolemma,  filled  with  small  sickle-shaped  unicellular  organisms, 
Sarcocystis  miescheri.  In  a  few  instances  similar  structures  have  been  found 
in  the  muscles  of  man.  The  only  human  parasite  of  this  group  which  has 
caused  serious  disease  belongs  to  the  coccidia. 

Coccidiosis. — In  a  majority  of  the  cases  of  this  group  the  psorosperms  have 
been  found  in  the  liver,  producing  a  disease  similar  to  that  which  occurs  in 
rabbits.  In  Guebler's  case  there  were  tumors  which  could  be  felt  during  life, 
and  they  were  determined  by  Leuckart  to  be  due  to  coccidia.  A  patient  of  W. 
B.  Haddon's  was  admitted  to  St.  Thomas's  Hospital  with  slight  fever  and 
drowsiness,  and  gradually  became  unconscious — death  occurring  on  the  four- 
teenth day  of  observation.  Whitish  neoplasms  were  found  upon  the  perito- 
neum, omentum,  and  on  the  layers  of  the  pericardium ;  and  a  few  were  found 
in  the  liver,  spleen,  and  kidneys.  A  somewhat  similar  case,  though  more 
remarkable,  as  it  ran  a  very  acute  course,  is  reported  by  Silcott.  A  woman, 
aged  fifty-three,  admitted  to  St.  Mary's  Hospital,  was  thought  to  be  suffering 
from  typhoid  fever.  She  had  had  a  chill  six  weeks  before  admission.  There 
were  fever  of  an  intermittent  type,  slight  diarrhoea,  nausea,  tenderness  over 
the  liver  and  spleen,  and  a  dry  tongue;  death  occurred  from  heart-failure. 
The  liver  was  enlarged,  weighed  83  ounces,  and  in  its  substance  there  were 
caseous  foci,  around  each  of  which  was  a  ring  of  congestion.  The  spleen 
weighed  16  ounces  and  contained  similar  bodies.  The  ileum  presented  six 
papule-like  elevations.  The  masses  resembled  tubercles,  but  on  examination 
coccidia  were  found. 

The  parasites  are  also  found  in  the  kidneys  and  ureters.  Cases  of  this 
kind  have  been  recorded  by  Bland  Sutton  and  Paul  Eve.  In  Eve's  case 
the  symptoms  were  hsematuria  and  frequent  micturition,  and  death  took 
place'on  the  seventeenth  day.  The  nodules  throughout  the  pelvis  and  ureters 
have  been  regarded  as  mucous  cysts. 

II.     AMCEBIASIS 

(Amcebic  Dysentery,  Amoebic  Hepatitis) 

Definition. — A  colitis,  acute  or  chronic,  caused  by  the  Amoeba  dysenteries 
with  a  special  liability  to  the  formation  of  abscesses  of  the  liver. 

Distribution. — The  disease  is  widely  prevalent  in  Egypt,  in  India  and  in 
tropical  countries.  In  Europe  sporadic  cases  occur,  rarely  small  epidemics. 
It  is  an  uncommon  disease  in  Great  Britain.  It  is  a  common  variety  through- 
put the  United  States,  particularly  in  the  Southern  States,  where  it  is 


238  SPECIFIC    INFECTIOUS    DISEASES 

endemic,  increasing  sometimes  to  such  an  extent  as  to  form  an  epidemic. 
Sporadic  cases  occur  in  all  temperate  regions.  The  relative  frequency  of  this 
form  of  dysentery  in  the  tropics  is  illustrated  by  the  Manila  statistics  as 
given  by  Strong;  of  1,328  cases  in  the  United  States  Army,  561  were  of 
the  amoebic  variety.  The  cases  of  acute  and  chronic  dysentery  in  the  Johns 
Hopkins  Hospital  have  been  almost  exclusively  amoebic.  To  1908  of  182 
cases,  123  came  from  the  State  of  Maryland. 

AGE. — It  is  not  uncommon  in  children  but  the  greatest  number  of  cases 
occur  between  the  ages  of  20  and  35. 

SEX. — Males  are  much  more  frequently  affected.  Of  182  cases  at  the 
Johns  Hopkins  Hospital  171  were  males  (Futcher). 

EACE. — The  white  race  is  more  susceptible,  163  whites  to  19  blacks  in 
the  Johns  Hopkins  Hospital  series.  In  the  Philippines  the  whites  are  more 
often  attacked.  In  India  the  disease  is  common  in  the  native  races. 

The  Amoeba. — The  organism  Amceba  dysenterice  was  first  described  by 
Lanbl  in  1859  and  subsequently  by  Losch  in  1875.  Kartulis  in  1886  found 
them  in  the  stools  of  the  endemic  dysentery  in  Egypt  and  in  the  liver  ab- 
scesses. In  1890  I  found  them  in  a  case  of  dysentery  with  abscess  of  the 
liver  originating  in  Panama.  Subsequently  from  my  wards  a  series  of  cases 
was  described  by  Councilman  and  Lafleur.  The  studies  of  Quincke  and  Roos, 
of  Dock,  Harris  and  others  in  the  United  States,  of  Strong  and  Musgrave  in 
the  Philippines,  of  Kruse  and  Pasquale  in  Egypt  and  of  Leonard  Rogers  in 
India  have  put  our  knowledge  of  the  disease  on  a  firm  basis.  To  find  the 
amceba3  the  little  flakes  of  mucus  or  pus  in  the  stools  should  be  selected  for 
examination  or  the  mucus  obtained  by  passing  a  soft  rubber  catheter.  Mus- 
grave holds  that  the  best  way  is  to  give  the  patient  a  saline  cathartic  and  then 
examine  the  fluid  portion  of  the  stool. 

Amoeba  or  Entamceba  dysenteries  is  from  15  to  20  /*  in  diameter,  has 
a  clear  outer  zone  (ectosarc)  and  a  granular  inner  zone  (endosarc),  and 
contains  a  nucleus  and  one  or  two  vacuoles.  The  movements  are  similar 
to  those  of  the  ordinary  pond  amoeba,  consisting  of  slight  protrusions  of  the 
protoplasm.  They  vary  a  good  deal,  and  usually  may  be  intensified  by  having 
the  slide  heated.  Not  infrequently  the  amoebae  contain  red  blood  corpuscles. 
In  the  tissues  they  are  very  readily  recognized  by  suitable  stains.  They  may 
be  in  enormous  numbers,  and  sometimes  the  field  of  the  microscope  is  com- 
pletely occupied.  In  the  pus  of  a  liver  abscess  they  may  be  very  abundant, 
though  in  large,  long  standing  abscesses  they  may  not  be  found  until  after  a 
few  days,  when  the  pus  begins  to  discharge  from  the  wall.  In  the  sputum 
in  the  cases  of  pulmono-hepatic  abscess  they  are  readily  recognized. 

Amoeba3  are  frequently  found  in  the  stools  of  healthy  persons,  as  Cunning- 
ham and  Lewis  pointed  out.  Schaudinn  found  them  in  from  20  to  60  per 
cent,  in  Germany,  but  they  vary  greatly  in  different  localities.  Among  300 
persons  in  Manila,  Musgrave  found  101  infected  with  amoeba?,  61  of  these 
had  dysentery,  the  remaining  40  had  no  diarrhoea.  In  the  next  two  months 
8  of  the  40  cases  died  and  showed  amcebic  infection  of  the  bowel.  Within 
the  next  three  months  the  remaining  32  had  dysentery.  Musgrave  believes 
that  at  any  time  the  amoeba  may  become  pathogenic.  Schaudinn  described 
two  distinct  forms — a  non-pathogenic  Entamceba  coli,  and  a  pathogenic 
larger  form,  the  Entamceba  hisiolytica,  the  same  as  the  Amceba  dysen-terice, 


AMCEBIASIS  239 

with  a  strongly  refractile  hyaline  ectoplasm.  The  amoebae  can  be  cultivated, 
but  with  difficulty,  and  it  is  doubtful  if  they  grow  apart  from  certain  bac- 
teria. Eesistant  forms,  somewhat  analogous  to  the  gamete  forms  of  the 
malarial  parasite,  have  been  described.  These  "encysted  amoebae"  are  believed 
to  be  necessary,  under  certain  conditions,  for  the  transmission  of  the  disease 
from  one  person  to  another,  and  are  regarded  by  Musgrave  and  Clegg  as  the 
most  dangerous  forms  of  the  organism.  Cultures  of  amoeba?  have  been 
shown  to  withstand  drying  for  from  eleven  to  fifteen  months. 

Morbid  Anatomy. — INTESTINES. — The  lesions  consist  of  ulceration,  pro- 
duced by  preceding  infiltration,  general  or  local,  of  the  submucosa,  due  to  an 
cedematous  condition  and  to  multiplication  of  the  fixed  cells  of  the  tissue. 
In  the  earliest  stage  these  local  infiltrations  appear  as  hemispherical  eleva- 
tions above  the  general  level  of  the  mucosa.  The  mucous  membrane  over 
these  becomes  necrotic  and  is  cast  off,  exposing  the  infiltrated  submucous 
tissue  as  a  grayish  yellow  gelatinous  mass,  which  at  first  forms  the  floor  of 
the  ulcer,  but  Is  subsequently  cast  off  as  a  slough.  The  individual  ulcers  are 
round,  oval,  or  irregular,  with  infiltrated,  undermined  edges.  The  visible 
aperture  is  often  small  compared  to  the  loss  of  tissue  beneath  it,  the  ulcers 
undermining  the  mucosa,  coalescing,  and  forming  sinuous  tracts  bridged  over 
by  apparently  normal  mucous  membrane.  According  to  the  stage  at  which 
the  lesions  are  observed,  the  floor  of  the  ulcer  may  be  formed  by  the  sub- 
mucous,  the  muscular,  or  the  serous  coat  of  the  intestine.  The  ulceration 
may  affect  the  whole  or  some  portion  only  of  the  large  intestine,  particularly 
the  caecum,  the  hepatic  and  sigmoid  flexures,  and  the  rectum.  In  severe 
cases  the  whole  of  the  intestine  is  much  thickened  and  riddled  with  ulcers, 
with  only  here  and  there  islands  of  intact  mucous  membrane.  In  100  autop- 
sies on  this  disease  in  Manila  the  appendix  was  involved  in  7 ;  perforation 
of  the  colon  took  place  in  19. 

The  disease  advances  by  progressive  infiltration  of  the  connective  tissue 
layers  of  the  intestine,  which  produces  necrosis  of  the  overlying  structures. 
Thus,  in  severe  cases  there  may  be  in  different  parts  of  the  bowel  sloughing 
en  masse  of  the  mucosa  or  of  the  muscularis,  and  the  same  process  is  observed, 
but  not  so  conspicuously,  in  the  less  severe  forms.  In  some  cases  a  secondary 
diphtheritic  inflammation  complicates  the  original  lesions.  Healing  takes 
place  by  the  gradual  formation  of  fibrous  tissue  in  the  floor  and  at  the  edges 
of  the  ulcers,  which  may  ultimately  result  in  partial  and  irregular  strictures 
of  the  bowel. 

Microscopic  examination  shows  a  notable  absence  of  the  products  of  puru- 
lent inflammation.  In  the  infiltrated  tissues  polynuclear  leucocytes  are  sel- 
dom found,  and  never  constitute  purulent  collections.  On  the  other  hand, 
there  is  proliferation  of  the  fixed  connective  tissue  cells.  Amoebae  are  found 
more  or  less  abundantly  in  the  tissues  at  the  base  of  and  around  the -ulcers,  in 
the  lymphatic  spaces,  and  occasionally  in  the  blood  vessels.  The  portal  capil- 
laries occasionally  •  contain  them,  and  this  fact  seems  to  afford  the  best  ex- 
planation for  the  mode  of  infection  of  the  liver. 

LIVER. — The  lesions  are  of  two  kinds:  first,  local  necroses  of  the  paren- 
chyma, scattered  throughout  the  organ,  and  possibly  due  to  the  action  of 
chemical  products  of  the  amoebae;  and,  secondly,  abscesses.  These  may  be 
single  or  multiple.  There  were  37  cases  of  hepatic  abscess  among  the  182 


240  SPECIFIC    INFECTIOUS    BFSEASES 

cases  of  amoebic  dysentery  in  my  wards.  Of  these,  18  came  to  autopsy.  In 
10  the  abscess  was  single  and  in  8  multiple.  When  single  they  are  generally 
in  the  right  lobe,  either  toward  the  convex  surface  near  its  diaphragmatic 
attachment  or  on  the  concave  surface  in  proximity  to  the  bowel.  Multiple 
abscesses  are  small  and  generally  superficial.  There  may  be  innumerable 
miliary  abscesses  containing  amoeba?  scattered  throughout  the  organ.  Al- 
though the  hepatic  abscess  usually  occurs  within  the  first  two  months  from 
the  onset  of  the  dysentery,  in  one  of  my  cases  the  latter  had  lasted  one  and 
in  another  six  years.  In  5  cases  the  intestinal  symptoms  had  been  so  slight 
that  dysentery  had  never  been  complained  of.  In  2  fatal  cases  there  were  only 
scars  of  old  ulcers  and  in  2  others  the  mucosa  appeared  normal.  In  an  early 
stage  the  abscesses  are  grayish  yellow,  with  sharply  defined  contours,  and  con- 
tain a  spongy  necrotic  material,  with  more  or  less  fluid  in  its  interstices.  The 
larger  abscesses  have  ragged  necrotic  walls,  and  contain  a  more  or  less  viscid, 
greenish  yellow  or  reddish  yellow  purulent  material  mixed  with  blood  and 
shreds  of  liver  tissue.  The  older  abscesses  have  fibrous  walls  of  a  dense, 
almost  cartilaginous  toughness.  A  section  of  the  abscess  wall  shows  an  inner 
necrotic  zone,  a  middle  zone  in  which  there  are  great  proliferation  of  the  con- 
nective-tissue cells  and  compression  and  atrophy  of  the  liver-cells,  and  an  outer 
zone  of  intense  hyperaemia.  There  is  the  same  absence  of  purulent  inflam- 
mation as  in  the  intestine,  except  in  those  cases  in  which  a  secondary  infec- 
tion with  pyogenic  organisms  has  taken  place. 

LESIONS  IN  THE  LUNGS  are  seen  when  an  abscess  of  the  liver — as  so  fre- 
quently happens — points  toward  the  diaphragm  and  extends  by  continuity 
through  it  into  the  lower  lobe  of  the  right  lung.  This  is  the  commonest  situa- 
tion for  rupture  to  occur.  Nine  of  my  cases  ruptured  into  the  lung.  In  3 
cases  rupture  into  the  right  pleura  occurred,  causing  an  empyema.  In  one  of 
these  the  lung  abscess  ruptured  into  the  pleura,  producing  a  pyo-pneumotho- 
rax.  Perforation  may  occur  into  adjacent  structures.  In  3  of  the  cases  perfo- 
ration took  place  into  the  inferior  vena  cava  and  in  another  the  upper  pole  of 
the  right  kidney  had  been  invaded.  The  abscess  may  rupture  into  the  peri- 
cardium, peritoneum,  stomach,  intestine,  portal  and  hepatic  veins,  or  exter- 
nally. 

Symptoms. — Differing  remarkably  in  their  symptoms,  three  groir,r3  of  cases 
may  be  recognized : 

MILD  FORM. — Infection  may  be  present  for  a  month  or  two  Osfore  the 
individual  is  aware  of  it.  There  may  be  vague  symptoms — head?A-h^,  lassi- 
tude, weakness,  slight  abdominal  pains  and  occasional  diarrhoea,  features 
common  enough  in  the  tropics.  Strong  gives  the  case  of  a  laboratory  chem- 
ist who  had  slight  diarrhoea  for  one  day  and  asked  to  have  the  stools  exam- 
ined; an  unusually  rich  infection  with  amoeba  was  found.  The  next  day  he 
felt  well.  From  August  to  December  amoeba  were  present  in  the  stools, 
though  he  had  no  symptoms.  Liver  abscess  may  occur  in  these  cases. 

ACUTE  AMCEBIC  DYSENTERY. — Many  cases  have  an  acute  onset.  Pain  and 
tenesmus  are  common.  The  stools  are  bloody,  or  mucus  and  blood  occur  to- 
gether. In  very  severe  cases  there  may  be  constant  tenesmus,  with  pain  of 
the  greatest  intensity,  and  the  passage  every  few  minutes  of  a  little  blood  and 
mucus.  In  some  cases  large  sloughs  are  passed.  The  temperature  as  a  rule 
is  not  high.  The  patient  may  become  rapidly  emaciated;  the  heart's  action 


AMCEBIASIS  241 

becomes  feeble,  and  death  may  occur  within  a  week  of  tbe  onset.  Among 
other  symptoms  are  haemorrhage  from  the  bowels,  which  occurred  in  three 
cases,  and  perforation  of  an  ulcer  with  general  peritonitis,  which  occurred 
in  three  cases.  A  majority  of  the  patients  recover;  in  others  the  disease 
drags  on  and  becomes  chronic.  In  a  few  cases,  after  the  separation  of  the 
sloughs,  there  is  extensive  ulceration  remaining,  with  thickening  and  indura- 
tion of  the  colon,  and  the  patient  has  constant  diarrhoea,  loses  weight,  and 
ultimately  dies  exhausted,  usually  within  three  months  of  the  onset.  With 
the  exception  of  cancer  of  the  oesophagus  and  anorexia  nervosa,  no  such  ex- 
treme grade  of  emaciation  is  seen.  Extensive  ulceration  of  the  cornea  may 
occur. 

CHRONIC  AMOEBIC  DYSENTERY. — The  disease  may  be  subacute  from  the 
onset,  and  gradually  passes  into  a  chronic  stage,  the  special  characteristic  of 
which  is  alternating  periods  of  constipation  and  of  diarrhoea.  These  may 
occur  over  a  period  of  from  six  months  to  a  year  or  more.  Some  of  our 
patients  have  been  admitted  to  the  hospital  five  or  six  times  within  a  period 
of  two  years.  During  the  exacerbations  there  are  pain,  frequent  passages  of 
mucus  and  blood,  and  a  slight  rise  of  temperature.  Many  patients  do  not  feel 
very  ill,  and  retain  their  nutrition  in  a  remarkable  way;  indeed,  in  the 
United  States  it  is  rare  to  see  the  extreme  emaciation  so  common  in  the 
chronic  cases  from  the  tropics.  Alternating  periods  of  improvement  with 
attacks  of  diarrhoea  are  the  rule.  The  appetite  is  capricious,  the  digestion 
disordered,  and  slight  errors  in  diet  are  apt  to  be  followed  at  once  by  an 
increase  in  the  number  of  stools.  The  tongue  is  often  red,  glazed,  and  beefy. 

Complications  and  Sequelae. — LIVER  ABSCESS. — A  pre-suppurative  stage 
lasting  for  several  weeks  or  months  is  recognized  by  Rogers,  characterized  by 
fever  of  an  intermittent  type,  moderate  leucocytosis,  and  an  enlarged  and 
tender  liver.  Suppuration  in  the  liver  is-  the  most  -serious  and  frequent 
complication.  Abscess  of  the  brain  has  occurred. 

PERFORATION  OF  THE  INTESTINE  and  PERITONITIS  occurred  in  three  of  my 
cases.  INTESTINAL  HEMORRHAGE  occurred  three  times.  The  infrequency  of 
this  complication  is  probably  due  to  the  thrombosis  of  the  vessels  about  the 
areas  of  infiltration.  Occasionally  an  ARTHRITIS,  probably  toxic  in  origin, 
may  occur.  There  was  one  case  in  my  series.  Five  cases  were  complicated 
by  malaria;  1  by  typhoid  fever;  1  by  pulmonary  tuberculosis;  and  1  by  a 
strongyloides  intestinalis  infection. 

Diagnosis.  — From  the  other  forms  of  dysentery  the  disease  is  recognized 
by  the  finding  of  amoeba?  in  the  stools.  Unless  one  sees  undoubted  amoeboid 
movement  a  suspected  body  should  not  be  considered  an  amoeba.  A  non- 
motile  body  containing  one  or  more  .red  cells  is  most  probably  an  amoeba, 
but  should  only  lead  to  further  search  for  motile  organisms.  Swollen  epithe- 
lial cells  are  confusing,  but  the  hyaline  periphery  is  not  amceboid  in  its  ac- 
tion as  is  the  ectosarc  of  the  amoeba.  The  trichomonads  and  cercomonads  so 
frequently  associated  with  amoeba?  are  not  likely  to  give  trouble.  The  extent 
of  liver  dulness  should  be  watched  throughout  the  course  of  a  case,  and  any 
increase  upward  or  downward  should  lead  to  the  suspicion  of  a  liver  ab- 
scess. Hepatic  abscess  is  usually  accompanied  by  fever,  sweats,  or  chills  and 
local  pain,  but  it  may  be  entirely  latent.  Exploratory  puncture  is  safe  as  a 
rule  and,  personally,  I  have  never  seen  any  ill  effects,  but  severe  hemorrhage 


242  SPECIFIC    INFECTIOUS    DISEASES 

into  the  peritoneum,  six  cases  of  which  were  recorded  by  Hatch  in  India,  may 
occur.  A  varying  leucocytosis  occurs  in  the  abscess  cases.  The  highest 
count  in  my  series  was  53,000,  the  average  being  18,350.  The  average  leuco- 
cyte count  in  the  uncomplicated  dysentery  cases  was  10,600.  Hepato-pul- 
monary  abscess  is  attended  by  local  lung  signs  and  the  expectoration  of  "an- 
chovy sauce"  sputum  in  which  amoebae  are  almost  invariably  found. 

Prognosis. — In  many  cases  the  disease  yields  to  rest  and  intestinal  medi- 
cation. Tendency  to  a  relapse  of  the  dysenteric  symptoms  is  one  of  the  strik- 
ing characteristics  of  the  disease.  One  of  my  patients  was  admitted  to  the 
hospital  five  times  in  nine  months. 

Treatment. — Eest  in  bed  is  very  important,  even  in  mild  attacks,  and  ma- 
terially hastens  recovery.  The  diet  should  be  governed  by  the  severity  of 
the  intestinal  manifestations.  In  the  very  acute  cases  the  patient  should  be 
given  a  liquid  diet,  consisting  of  milk,  whey,  and  broths. 

A  return  to  the  use  of  ipecacuanha  is  the  most  important  event  of  late 
years  in  the  treatment  of  this  form  of  dysentery.  It  should  always  be  tried, 
even  in  chronic  cases.  It  must  be  given  in  salol-coated  pills  or  keratin  capsules 
so  that  it  is  not  dissolved  in  the  stomach.  The  patient  should  be  on  milk  diet 
and  without  anything  by  mouth  for  three  hours  before  the  drug  is  given,  the 
best  time  being  at  bedtime.  One  dose  is  given  each  night;  the  first  may  be 
60  to  90  grains  (4  to  6  gm.),  which  is  reduced  by  five  grains  each  night 
until  it  is  down  to  ten  grains  (0.6  gm.).  This  course  should  be  repeated 
in  a  week  if  amoebae  remain  in  the  stools.  Emetine  hydrochloride  hypoder- 
mically  is  generally  preferable  to  ipecac  by  mouth.  An  average  dose  is  y? 
grain  (0.03  gm.)  three  times  a  day  for  three  to  six  days,  and  this  repeated  if 
necessary.  Rogers  advises  ipecac  to  prevent  liver  abscess  when  there  is  a 
suspicion  of  hepatitis.  Doses  of  20  to  30  grains  (1.3  to  2  gm.)  are  given  daily 
and  continued  for  two  weeks  after  the  temperature  is  normal. 

Bismuth  probably  does  more  harm  than  good,  owing  to  the  fact  that  it 
coats  the  surface  of  the  ulcers  so  that  the  solutions  used  in  the  injections 
can  not  reach  the  amoebae  in  the  ulcer  walls.  It  is  well  in  the  chronic  forms 
to  give  an  occasional  dose  of  saline  or  castor  oil.  Large  injections  of  quinine 
solution  in  the  strength  of  1  to  5,000,  gradually  increasing  to  1  to  500,  have 
given  the  most  satisfactory  results  of  all  the  local  remedies.  The  amoebae 
are  rapidly  destroyed  by  the  drug.  The  success  of  the  treatment  depends 
largely  on  the  care  with  which  the  injections  are  given.  The  failures  are 
undoubtedly,  in  many  instances,  due  to  the  fact  that  sufficient  care  is  not 
used  to  insure  the  solution  reaching  the  caecum  and  ascending  colon,  where  the 
ulceration  is  often  most  severe.  From  a  litre  to  two  litres  should  be  allowed 
to  flow  into  the  colon.  The  patient's  hips  should  be  elevated  and  he  should 
change  his  position  so  as  to  allow  the  fluid  to  flow  into  all  parts  of  the  colon. 
The  solution  should  be  retained,  if  possible,  for  fifteen  minutes.  One  or  two 
injections  may  be  given  daily.  Injections  of  silver  nitrate  solution  (1  to 
2,000,  increased  to  1  to  500)  are  useful  in  chronic  cases,  given  in  the  same 
way.  Tuttle  has  recently  reported  good  results  in  the  treatment  of  amoebic 
dysentery  by  the  use  of  simple  ice-water  enemas,  given  frequently.  When 
there  is  much  tenesmus  a  small  injection  of  thin  starch  and  half  a  drachm 
to  a  drachm  of  laudanum  gives  great  relief.  Local  application  to  the  abdo- 
men, in  the  form  of  light  poultices,  or  turpentine  stupes,  are  very  grateful. 


MALARIAL   FEVER  243 

When  medical  treatment  fails,  colostomy  may  be  tried  or  irrigations  given 
through  the  appendix. 

Hepatic  abscess  should  be  drained  at  once  and  the  cavity  irrigated  by 
quinine  solution  (1  to  1,000).  Ipecacuanha  should  be  given  persistently,  a£ 
advised  for  the  dysentery. 

III.     MALARIAL  FEVER 

Definition. — An  infectious  disease  with :  (a)  paroxysms  of  intermittent 
fever  of  quotidian,  tertian,  or  quartan  type;  (&)  a  continued  fever  with 
marked  remissions;  (c)  certain  pernicious,  rapidly  fatal  forms;  and  (d)  a 
chronic  cachexia,  with  anaemia  and  enlarged  spleen. 

The  ha3mocytozoa  described  by  Laveran,  which  are  transmitted  to  man  by 
the  bite  of  the  mosquito,  are  invariably  associated  with  the  disease.  Malaria, 
occurs  as  an  endemic  and  epidemic  disease,  the  latter  prevailing  in  the  tropics 
under  favoring  conditions.  No  infection  except,  perhaps,  tuberculosis  com- 
pares with  it  in  the  extent  of  its  distribution  or  its  importance  as  a  killing 
and  disabling  disease. 

Geographical  Distribution. — In  Europe,  southern  Russia  and  certain  parts 
of  Italy  are  now  the  chief  seats  of  the  disease.  It  is  rare  in  Germany,  France, 
and  England,  and  the  foci  of  epidemics  are  becoming  yearly  more  restricted. 
In  the  United  States  malaria  has  progressively  diminished  in  extent  and  se- 
verity during  the  past  fifty  years.  From  New  England,  where  it  once  pre- 
vailed extensively,  it  has  gradually  disappeared,  but  there  has  of  late  years 
been  a  slight  return  in  some  places.  In  the  city  of  New  York  even  the  milder 
forms  of  the  disease  are  very  rare.  In  Philadelphia  and  along  the  valleys  of 
the  Delaware  and  Schuylkill  Rivers,  formerly  hot-beds  of  malaria,  the  disease 
has  become  much  restricted.  In  Baltimore  a  few  cases  occur  in  the  autumn, 
but  a  majority  of  the  patients  seeking  relief  are  from  the  outlying  districts 
and  one  or  two  of  the  inlets  of  Chesapeake  Bay.  Throughout  the  Southern 
States  there  are  many  regions  in  which  malaria  prevails;  but  here,  too,  the 
disease  has  diminished  in  prevalence  and  intensity.  In  temperate  regions, 
like  the  central  Atlantic  States,  there  are  only  a  few  cases  in  the  spring, 
usually  in  the  month  of  May,  and  a  large  number  of  cases  in  September  and 
October,  and  sometimes  in  November.  In  the  Northwestern  States  malaria 
is  almost  unknown.  It  is  rare  on  the  Pacific  coast.  In  the  region  of  the 
Great  Lakes  malaria  prevails  only  in  the  Lake  Erie  and  Lake  St.  Clair  re- 
gions. The  St.  Lawrence  basin  remains  free  from  the  disease. 

In  India  the  disease  is  very  prevalent,  particularly  in  the  great  river  ba- 
sins. Terrible  epidemics  occur.  In  the  Punjab  in  1908  there  were  more  than 
three  million  deaths  from  fever,  a  large  proportion  of  which  were  from  ma- 
laria. In  the  months  of  October  and  November  there  were  307,317  deaths 
from  the  disease.  In  Burma  and  Assam  severe  types  are  met  with.  In 
Africa  the  malarial  fevers  form  the  great  obstacle  to  European  settlements  on 
the  coast  and  along  the  river  basins.  The  black-waier  or  West  African  fever 
of  the  Gold  Coast  is  a  very  fatal  type  of  malarial  hasmoglobinuria.  The  At- 
lantic coast  line  of  Central  America  is  severely  infected,  and  the  Isthmus  of 
Panama  for  centuries  was  known  as  the  "white  man's  grave." 

'  In  the  tropics  there  are  minimal  and  maximal  periods,  the  former  cor- 


244  SPECIFIC   INFECTIOUS   DISEASES 

responding  to  the  summer  and  winter,  the  latter  to  the  spring  and  autumn 
months. 

Etiology :  The  Parasite. — HISTORY. — Parasites  of  the  red  blood  corpuscles 
— hsemocytozoa — are  very  widespread  throughout  the  animal  series.  They 
are  met  with  in  the  blood  of  frogs,  fish,  birds,  and  among  mammals  in  mon- 
keys, bats,  cattle,  and  man.  In  birds  and  in  frogs  the  parasites  appear  to  do 
no  harm  except  when  present  in  very  large  numbers. 

In  1880  Layeran,  a  French  army  surgeon  stationed  at  Algiers,  noted  in 
the  blood  of  patients  with  malarial  fever  pigmented  bodies,  which  he  regarded 
as  parasites,  and  as  the  cause  of  the  disease.  Eichard,  another  French  army 
surgeon,  confirmed  these  observations.  In  1885  Marchiafava  and  Celli  de- 
scribed the  parasites  with  great  accuracy,  and  in  the  same  year  Golgi  made 
the  all-important  observation  that  the  paroxysm  of  fever  invariably  coincided 
with  the  sporulation  or  segmentation  of  a  group  of  the  parasites.  In  the  fol- 
lowing year  (1886)  Laveran's  observations  were  brought  before  the  profes- 
sion of  the  United  States  by  Sternberg.  Councilman  and  Abbott  had  already, 
in  the  previous  year,  described  the  remarkable  pigmented  bodies  in  the  red 
blood  corpuscles  in  the  blood  vessels  of  the  brain  in  a  fatal  case,  and  in  1886 
Councilman  confirmed  the  observations  of  Laveran  in  clinical  cases.  Stim- 
ulated by  his  work,  I  began  studying  the  malarial  cases  in  the  Philadelphia 
Hospital,  and  soon  became  convinced  of  the  truth  of  Laveran's  discovery,  and 
was  able  to  confirm  Golgi's  statement  as  to  the  coincidence  of  the  sporulation 
with  the  paroxysm.  The  work  was  taken  up  actively  in  the  United  States  by 
Walter  James,  Dock,  Koplik,  Thayer,  Hewetson,  and  others,  and  in  a  number 
of  subsequent  communications  I  tried  to  emphasize  the  extraordinary  clinical 
importance  of  Laveran's  discovery.* 

Among  British  observers,  Vandyke  Carter  alone,  in  India,  seems  to  have 
appreciated  at  an  early  date  the  profound  significance  of  Laveran's  work. 

The  next  important  observation  was  the  discovery  by  Golgi  that  the  para- 
site of  quartan  malarial  fever  differed  from  the  tertiaji.  From  this  time  on 
the  Italian  observers  took  up  the  work  with  great  energy,  and  in  1889  Marchia- 
fava and  Celli  determined  that  the  organism  of  the  severer  forms  of  malarial 
fever  differed  from  the  parasite  of  the  tertian  and  quartan  varieties. 

The  idea  that  fever  was  transmitted  by  the  bite  of  the  mosquito  prevailed 
widely  in  the  West  Indies  and  in  the  Southern  States.  King,  of  Washing- 
ton, warmly  advocated  this  view.  The  important  role  played  by  insects  as  an 
intermediate  host  had  been  shown  in  the  case  of  the  Texas  cattle  fever,  in 
which  Theobald  Smith  demonstrated  that  the  ha?matozoa  developed  in,  and 
the  disease  was  transmitted  by,  ticks ;  but  it  remained  for  Manson  to  for-  t 

*  The  following  references  to  work  on  malaria  which  has  been  done  in  connection 
with  my  clinic,  chiefly  under  the  supervision  of  my  colleague,  Professor  Thayer,  may  be 
of  interest:  Philadelphia  Medical  Times,  1886;  British  Medical  Journal,  March,  1887; 
Medical  News,  1889,  vol.  i;  Johns  Hopkins  Hospital  Bulletin,  1889;  the  first  edition  of 
my  Text-Book  of  Medicine,  1892;  Thayer  and  Hewetson,  Johns  Hopkins  Hospital  Re- 
ports,  1895;  Thayer,  Lectures  on  Malarial  Fever,  1897;  W.  G.  MacCallum,  Hsematozoa 
of  Birds,  Jour,  of  Exp.  Med.,  1898;  Opie,  on  the  Haematozoa  of  Birds,  1898;  Barker,  on 
Fatal  Cases  of  Malaria,  Johns  Hopkins  Hospital  Reports,  1899 ;  MacCallum,  on  the  Sig- 
nificance of  the  Flagella,  Lancet,  1897;  Thayer,  Transactions  American  Medical  Con- 
gress, vol.  iv,  1900 ;  Lazear,  Structure  of  the  Malarial  Parasites,  Johns  Hopkins  Hospital 
Reports,  1902. 


MALARIAL  FEVER  245 

mulate  in  a  clear  and  scientific  way  the  theory  of  infection  in  malaria  by  the 
mosquito.  Impressed  with  the  truth  of  this,  Ross  studied  the  problem  in 
India,  and  showed  that  the  parasites  developed  in  the  bodies  of  the  mosquitoes, 
demonstrating  conclusively  that  the  infection  in  birds  was  transmitted  by  the 
mosquito.  W.  G.  MacCallum  suggested  that  the  flagella  were  sexual  elements, 
and  observed  the  process  of  fertilization  by  them.  Studies  by  Grassi,  Bastian- 
elli  and  Bignami,  and  many  others,  confirmed  the  observations  of  Ross  and 
demonstrated  the  fact  that  the  malarial  parasites  of  human  beings  develop 
only  in  mosquitoes  of  the  genus  anopheles. 

Then  came  the  practical  demonstration  by  Italian  observers,  and  by  the 
interesting  experiments  on  Manson,  Jr.,  of  the  direct  transmission  of  the 
disease  to  man  by  the  bite  of  infected  mosquitoes.  And  lastly,  as  a  practical 
conclusion  of  the  whole  matter,  the  anti-malarial  campaigns  so  energetically 
advocated  and  carried  out  by  Ross  have  shown  that  by  protecting  the  in- 
dividual from  the  bites  of  mosquitoes,  by  exterminating  the  insects,  or  by 
carefully  treating  all  patients  so  that  no  opportunity  may  he  offered  for  the 
parasite  to  enter  the  mosquito,  malaria  may  be  eradicated  from  any  locality. 

GENERAL  MORPHOLOGY  OF  THE  PARASITE. — Belonging  to  the  sporozoa,  it 
has  received  a  large  number  of  names.  The  term  Plasmodium,  inapt  though 
it  may  be,  must,  according  to  the  rules  of  zoological  nomenclature,  be  ap- 
plied to  the  human  parasite.  There  are  three  well-marked  varieties  which 
exist  in  two  separate  phases  or  stages :  (a)  the  parasite  in  man,  who  acts  as 
the  intermediate  host,  and  in  whom,  in  the  cycle  of  its  development,  it  causes 
symptoms  of  malaria;  and  (&)  an  extracorporeal  cycle,  in  which  it  lives  and 
develops  in  the  body  of  the  mosquito,  which  is  its  definitive  host. 

(a)  The  Parasite  in  Man. —  (1)  The  Parasite  of  Tertian  Fever  (Plasmo- 
dium, vivax). — The  earliest  form  seen  in  the  red  blood  corpuscle  is  round  or  ir- 
regular in  shape,  about  2  //  in  diameter  and  unpigmented.  It  corresponds 
very  much  in  appearance  with  the  segments  of  the  rosettes  formed  during 
the  chill.  A  few  hours  later  the  body  nas  increased  in  size,  is  still  ring-shaped, 
and  there  is  pigment  in  the  form  of  fine  grains.  It  has  a  relatively  large 
nuclear  body,  consisting  of  a  well-defined,  clear  area,  in  part  almost  transpar- 
ent, in  part  consisting  of  a  milk-white  substance,  in  which  there  lies  a  small, 
deeply  staining  chromatin  mass.  At  this  period  it  usually  shows  active 
amoeboid  movements,  with  tongue-like  protrusions.  The  pigment  increases  in 
amount  and  the  corpuscle  becomes  larger  and  paler,  owing  to  a  progressive 
diminution  of  its  haemoglobin.  There  is  a  gradual  growth  of  the  parasite, 
which,  toward  the  end  of  forty-eight  hours,  occupies  almost  all  of  the  swollen 
red  corpuscle.  It  is  now  much  pigmented,  and  is  in  the  stage  of  what  is 
often  called  the  full-grown  parasite.  Between  the  fortieth  and  forty-eighth 
hours  many  of  the  parasites  are  seen  to  have  undergone  the  change  known 
as  segmentation,  in  which  the  pigment  becomes  collected  into  a  single  mass 
or  block,  and  the  protoplasm  divides  into  a  series  of  from  fifteen  to  twenty 
spores,  often  showing  a  radial  arrangement.  Certain  full-grown  tertian  para- 
sites, however,  do  not  undergo  segmentation.  These  forms,  which  are  larger 
than  the  sporulating  bodies,  and  contain  very  actively  dancing  pigment  gran- 
ules, represent  the  sexually  differentiated  form  of  the  parasite — gametocytes. 

(2)  The  Parasite  of  Quartan  Fever  (Plasmodium  malarice). — The  earliest 
form  is  very  like  the  tertian  in  appearance,  but  as  it  increases  in  size  the 


246  SPECIFIC    INFECTIOUS    DISEASES 

earlier  granules  are  coarser  and  darker  and  the  movement  is  not  nearly  so 
marked.  By  the  second  day  the  parasite  is  still  larger,  rounded  in  shape, 
scarcely  at  all  amoeboid,  and  the  pigment  is  more  often  arranged  at  the 
periphery  of  the  parasite.  The  rim  of  protoplasm  about  it  is  often  of  a  deep 
yellowish-green  color  or  of  a  dark  brassy  tint.  On  the  third  day  the  seg- 
menting bodies  become  abundant,  the  pigment  flowing  in  toward  the  centre 
of  the  parasite  in  radial  lines  so  as  to  give  a  star-shaped  appearance.  The 
parasites  finally  break  up  into  from  six  to  twelve  segments.  Here  also,  as  in 
the  case  of  the  tertian  parasite,  some  full-grown  bodies  persist  without  spor- 
ulating,  representing  the  gametocytes. 

(3)  The  Parasite  of  the  ^stivo- Autumnal  Fever  (Plasmodium  falci- 
parum). — This  parasite  is  considerably  smaller  than  the  other  varieties;  at 
full  development  it  is  often  less  than  one-half  the  size  of  a  red  blood  cor- 
puscle. The  pigment  is  much  scantier,  often  consisting  of  a  few  minute 
granules.  At  first  only  the  earlier  stages  of  development,  small,  hyaline 
bodies,  sometimes'  with  one  or  two  pigment  granules,  are  to  be  found  in  the 
peripheral  circulation;  the  later  stages  are  ordinarily  to  be  seen  only  in  the 
blood  of  certain  internal  organs,  the  spleen  and  bone  marrow  particularly. 
The  corpuscles  containing  the  parasites  become  not  infrequently  shrunken, 
crenated,  and  brassy-colored.  After  the  process  has  existed  for  about  a  week, 
larger,  refractive,  crescentic,  ovoid,  and  round  bodies,  with  central  clumps  of 
coarse  pigment  granules,  begin  to  appear.  These  bodies  are  characteristic  of 
sestivo-autumnal  fever.  The  crescentic  and  ovoid  forms  are  incapable  of 
sporulation;  they  are  analogous  to  the  large,  full-grown,  non-sporulating 
bodies  of  the  tertian  and  quartan  parasites  which  have  been  mentioned  above, 
and  represent  sexually  differentiated  forms — gametocytes.  Within  the  human 
host  they  are  incapable  of  further  development,  but  upon  the  slide,  or  within 
the  stomach  of  the  normal  intermediate  host,  the  mosquito,  the  male  elements 
(micro-gametocytes)  give  rise  to  a  number  of  long,  actively  motile  flagella 
(micro-gametes)  which  break  loose,  penetrating  and  fecundating  the  female 
forms — macro-gametes  (W.  G.  MacCallum).  The  fecundated  female  form 
enters  into  the  stomach. wall  of  the  intermediate  host,  the  mosquito,  where  it 
undergoes  a  definite  cycle  of  existence. 

(&)  The  Parasite  within  the  Body  of  the  Mosquito. — The  brilliant  re- 
searches of  Ross,  followed  by  the  work  of  Grassi,  Bastianelli,  Bignami, 
Stephens,  Christophers,  and  Daniels,  have  proved  that  a  certain  genus  of 
mosquito — anopheles — is  not  only  the  intermediate  host  of  the  malarial  para- 
site, but  also  the  sole  source  of  infection.  In  the  present  state  of  our  knowl- 
edge it  would  appear  that  all  species  of  the  genus  anopheles  may  act  as  hosts 
of  the  parasite.  The  more  common  genera  of  mosquito  in  temperate  cli- 
mates are  culex  and  anopheles.  The  different  species  of  culex  form  the  great 
majority  of  our  ordinary  house  mosquitoes,  and  are  apparently  incapable  of 
acting  as  hosts  of  the  malarial  parasite.  All  malarial  regions,  however, 
which  have  been  investigated  contain  anopheles.  Although  this  is  appar- 
ently a  positive  rule,  anopheles  may,  however,  be  present  without  the  exis- 
tence of  malaria  under  two  circumstances :  first,  when  the  climate  is  too  cold 
for  the  development  of  the  malarial  parasite;  and  secondly,  in  a  region  which 
has  not  yet  been  infected.  So  far  as  is  known,  the  parasite  exists  only  in 
the  mosquito  and  in  man.  It  is  apparently  fair  to  state  that  regions  in  which 


MALARIAL  FEVER  247 

mosquitoes  of  the  genus  anopheles  are  present  may  become  malarious  during 
the  warm  season. 

A  large  number  of  species  of  anopheles  have  been  described.  In  North 
America,  however,  only  four  have  been  positively  recognized:  A.  punctipennis 
(Say),  A.  maculipennis  (Wied.),  A.  crucians  (Wied.),  A.  argyritarsis  (Desv.). 
The  commonest  variety,  and  that  which  in  all  probability  is  most  concerned  in 
the  spread  of  the  disease,  is  A.  maculipennis,  which  is,  also,  the  most  impor- 
tant agent  in  the  spread  of  the  disease  in  Europe.  In  parts  of  India,  e.  g. 
Bombay,  the  common  anopheles,  Neocellia  rossi,  plays  no  part,  but  the  carrier 
is  N.  stephensi. 

The  culex  lays  its  eggs  in  sinks,  tanks,  cisterns,  and  any  collection  of 
water  about  or  in  houses,  while  the  anopheles  lays  its  eggs  in  small,  shallow 
puddles  or  slowly  running  streams,  especially  those  in  which  certain  forms 
of  algae  exist.  The  culex  is  essentially  a  city  mosquito,  the  anopheles  a 
country  insect. 

Evolution  in  the  Body  of  the  Mosquito. — "When  a  mosquito  of  the  genus 
anopheles  bites  an  individual  whose  blood  contains  sex-ripe  forms  (gameto- 
cytes)  of  the  malarial  parasite,  flagellation  and  fecundation  of  the  female 
element  occur  within  the  stomach  of  the  insect.  The  fecundated  element 
then  penetrates  the  wall  of  the  mosquito's  stomach  and  begins  a  definite  cycle 
of  development  in  the  muscular  coat.  Two  days  after  biting  there  begin  to 
appear  small,  round,  refractive,  granular  bodies  in  the  stomach  wall  of  the 
mosquito,  which  contain  pigment  granules  clearly  identical  with  those  pre- 
viously contained  in  the  malarial  parasite.  These  develop  until  at  the  end 
of  seven  days  they  have  reached  a  diameter  of  from  60  to  70  fji.  At  this 
period  they  may  be  observed  to  show  a  delicate  radial  striation  due  to  the 
presence  of  great  numbers  of  small  sporoblasts.  The  mother  oocyst  (zygote) 
then  bursts,  setting  free  into  the  body  cavity  of  the  mosquito  an  enormous 
number  of  delicate  spindle-shaped  sporozoids.  These  accumulate  in  the  cells 
of  the  veneno-salivary  glands  of  the  mosquito,  and,  escaping  into  the  ducts, 
are  inoculated  with  subsequent  bites  of  the  insect.  These  little  spindle-shaped 
sporozoids  develop,  after  inoculation  into  the  warm-blooded  host,  into  fresh 
young  parasites.  The  sporozoid  which  has  developed  in  the  oocyst  in  the 
stomach  wall  of  the  mosquito  is  then  the  equivalent  of  the  spore  resulting 
from  the  asexual  segmentation  of  the  full-grown  parasite  in  the  circulation. 
Either  one,  on  entering  a  red  blood  corpuscle,  may  give  rise  to  the  asexual 
or  sexual  cycle.  As  a  rule  the  first  several  generations  of  parasites  in  the 
human  body  pursue  the  asexual  cycle,  the  sexual  forms  developing  later. 
These  sexual  forms,  sterile  while  in  the  human  host,  serve  as  the  means  of 
preserving  the  life  of  the  parasite  and  spreading  infection  when  the  in- 
dividual is  subjected  to  bites  of  anopheles. 

Morbid  Anatomy. — The  changes  result  from  the  disintegration  of  the 
red  blood  corpuscles,  accumulation  of  the  pigment  thereby  formed,  and  pos- 
sibly the  influence  of  toxic  materials  produced  by  the  parasite.  Cases  of 
simple  malarial  infection,  ague,  are  rarely  fatal,  and  our  knowledge  of  the 
morbid  anatomy  of  the  disease  is  drawn  from  the  pernicious  malaria  or  the 
chronic  cachexia.  Rupture  of  the  enlarged  spleen  may  occur  spontaneously, 
but  more  commonly  from  trauma.  I  have  known  fatal  hemorrhage  to  follow 
the  exploratory  puncture  of  an  enlarged  malarial  spleen. 


248  SPECIFIC   INFECTIOUS   DISEASES 

PERNICIOUS  MALARIA. — The  blood  is  hydrgemic  and  the  serum  may  even 
be  tinged  with  haemoglobin.  The  red  blood  corpuscles  present  the  endo- 
globular  forms  of  the  parasite  and  are  in  all  stages  of  destruction.  The 
spleen  is  enlarged,  often  only  moderately;  thus,  of  two  fatal  cases  in  my 
wards  the  spleens  measured  13X8  cm.  and  14X8  cm.  respectively.  In  a 
fresh  infection  the  spleen  is  usually  very  soft,  and  the  pulp  lake-colored 
and  turbid.  The  liver  is  swollen  and  turbid. 

In  some  acute  pernicious  cases  with  choleraic  symptoms  the  capillaries 
of  the  gastro-intestinal  mucosa  may  be  packed  with  parasites. 

MALARIAL  CACHEXIA. — In  fatal  cases  of  chronic  paludism  death  occurs 
usually  from  anaemia  or  the  haemorrhage  associated  with  it.  The  anaemia  is 
profound,  particularly  if  the  patient  has  died  of  fever. 

The  spleen  may  weigh  from  five  to  ten  pounds.  The  liver  may  be  greatly 
enlarged,  and  presents  to  the  naked  eye  a  grayish-brown  or  slate  color,  due 
to  the  large  amount  of  pigment.  In  the  portal  canals  and  beneath  the  cap- 
sule the  connective  tissue  is  impregnated  with  melanin.  The  pigment  is 
seen  in  the  Kupffer's  cells  and  the  perivascular  tissue.  The  kidneys  may  be 
enlarged  and  present  a  grayish-red  color,  or  areas  of  pigmentation  may  be 
seen.  The  peritoneum  is  usually  of  a  deep  slate  color.  The  mucous  mem- 
brane of  the  stomach  and  intestines  may  have  the  same  hue,  due  to  the  pig- 
ment in  and  about  the  blood-vessels.  In  some  cases  this  is  confined  to  the 
lymph  nodules  of  Peyer's  patches,  causing  the  shaven-beard  appearance. 

THE  ACCIDENTAL  AND  LATE  LESIONS  OF  MALARIAL  FEVER. —  (a)  The 
Liver. — Paludal  hepatitis  plays  a  very  important  role  in  the  history  of 
malaria,  as  described  by  French  writers.  Only  those  cases  in  which  the  his- 
tory of  chronic  malaria  is  definite,  and  in  which  the  melanosis  of  both  liver 
and  spleen  coexist,  should  be  regarded  as  of  paludal  origin. 

(&)  Pneumonia  is  believed  by  many  authors  to  be  common  in  malaria, 
and  even  to  depend  directly  upon  the  malarial  poison,  occurring  either  in 
the  acute  or  in  the  chronic  forms  of  the  disease.  I  have  no  personal  knowl- 
edge of  such  a  special  pneumonia. 

(c)  Nephritis. — Moderate  albuminuria  is  a  frequent  occurrence,  having 
occurred  in  46.4  per  cent,  of  the  cases  in  my  wards.  Acute  nephritis  is  rela- 
tively frequent  in  aestivo-autumnal  infections,  baring  occurred  in  over  4.5 
per  cent,  of  my  cases.  Chronic  nephritis  occasionally  follows  long-continued 
or  frequently  repeated  infections. 

Clinical  Forms  of  Malarial  Fever.  —The  relative  frequency  of  the  differ- 
ent forms  varies  in  different  regions.  The  tertian  is  the  most  common  in 
temperate  regions,  the  aestivo-autumnal  in  the  tropics,  the  quartan  is  every- 
where rare  except  in  certain  parts  of  India.  In  the  Canal  Zone  tne  relative 
frequency  of  the  different  forms  from  1904  to  January  1st,  1910,  wag  as 
follows:  sestivo-autumnal,  22,089;  tertian,  8,013;  mixed  infections,  677,  and 
quartan,  20  cases.  The  quartan  is  relatively  much  more  frequent  in  Balti- 
more; of  1,618  cases  of  malaria  at  my  clinic,  there  were  15  instances 
(Thayer). 

I.  THE  BEGULARLY  INTERMITTENT  FEVERS. —  (a)  Tertian  fever;  (&) 
quartan  fever.  These  forms  are  characterized  by  recurring  paroxysms  of 
what  is  known  as  ague,  in  which,  as  a  rule,  chill,  fever,  and  sweat  follow 
each  other  in  oiderly  sepuence.  The  stage  of  incubation  is  not  definitely 


MALARIAL  FEVER  249 

known;  it  probably  varies  much  according  to  the  amount  of  the  infectious 
material  absorbed.  Experimentally  the  period  of  incubation  varies  from 
thirty-six  hours  to  fifteen  days,  being  a  trifle- longer  in  quartan  than  in  tertian 
infections.  Attacks  have  been  reported  within  a  very  short  time  after  the 
apparent  exposure.  On  the  other  hand,  the  ague  may  be,  as  is  said,  "in  the 
system,"  and  the  patient  may  have  a  paroxysm  months  after  he  has  removed 
from  a  malarial  region,  though  of  course  this  can  not  be  the  case  unless  he 
has  had  the  disease  when  living  there. 

Description  of  the  Paroxysm. — The  patient  generally  knows  he  is  going 
to  have  a  chill  a  few  hours  before  its  advent  by  unpleasant  feelings  and  un- 
easy sensations,  sometimes  by  headache.  The  paroxysm  is  divided  into  three 
stages — cold,  hot,  and  sweating. 

Cold  Stage. — The  onset  is  indicated  by  a  feeling  of  lassitude  and  a  desire 
to  yawn  and  stretch,  by  headache,  uneasy  sensations  in  the  epigastrium,  some- 
times by  nausea  and  vomiting.  Even  before  the  chill  begins  the  thermometer 
indicates  a  rise  in  temperature.  Gradually  the  patient  begins  to  shiver,  the 
face  looks  cold,  and  in  the  fully  developed  rigor  the  whole  body  shakes,  the 
teeth  chatter,  and  the  movements  may  often  be  violent  enough  to  shake  the 
bed.  Not  only  does  the  patient  look  cold  and  blue,  but  a  surface  ther- 
mometer will  indicate  a  reduction  of  the  skin  temperature.  On  the  other 
hand,  the  axillary  or  rectal  temperature  may,  during  the  chill,  be  greatly 
increased,  and,  as  shown  in  the  chart,  the  fever  may  rise  meanwhile  even  to 
105°  or  106°.  Of  symptoms  associated  with  the  chill,  nausea  and  vomiting 
are  common.  There  may  be  intense  headache.  The  pulse  is  quick,  small, 
and  hard.  The  urine  is  increased  in  quantity.  The  chill  lasts  for  a  variable 
time,  from  ten  or  twelve  minutes  to  an  hour,  or  even  longer. 

The  hot  stage  is  ushered  in  by  transient  flushes  of  heat;  gradually  the 
coldness  of  the  surface  disappears  and  the  skin  becomes  intensely  hot.  The 
contrast  in  the  patient's  appearance  is  striking :  the  face  is  flushed,  the  hands 
are  congested,  the  skin  is  reddened,  the  pulse  is  full  and  bounding,  the  heart's 
action  is  forcible,  and  the  patient  may  complain  of  a  throbbing  headache. 
There  may  be  active  delirium.  One  of  my  patients  in  this  stage  jumped 
through  a  ward  window  and  sustained  fatal  injuries.  The  rectal  temperature 
may  not  increase  much  during  this  stage;  in  fact,  by  the  termination  of  the 
chill  the  fever  may  have  reached  its  maximum.  The  duration  of  the  hot 
stage  varies  from  half  an  hour  to  three  or  four  hours.  The  patient  is  in- 
tensely thirsty  and  drinks  eagerly  of  cold  water. 

Sweating  Stage. — Beads  of  perspiration  appear  upon  the  face  and  grad- 
ually the  entire  body  is  bathed  in  a  copious  sweat.  The  uncomfortable  feel- 
ing associated  with  the  fever  disappears,  the  headache  is  relieved,  and  within 
an  hour  or  two  the  paroxysm  is  over  and  the  patient  usually  sinks  into  a 
refreshing  sleep.  The  sweating  varies  much.  It  may  be  drenching  in  char- 
acter or  it  may  be  slight. 

Chart  Via  is  from  a  case  of  double  tertian  infection  with  resulting  quo- 
tidian paroxysms.  Charts  VI&  and  Vic  give  temperature  curves  in  aestivo- 
autumnal  forms.  Chart  VId  shows  a  quartan  ague. 

The  total  duration  of  the  paroxysm  averages  from  ten  to  twelve  hours, 
but  may  be  shorter.  Variations  in  the  paroxysm  are  common.  Thus  the  pa- 
tient mav,  instead  of  a  chill,  experience  only  a  slight  feeling  of  coldness.  The 
28 


250 


SPECIFIC   INFECTIOUS   DISEASES 


most  common  variation  is  the  occurrence  of  a  hot  stage  alone,  or  with  very 
slight  sweating.  During  the  paroxysm  the  spleen  is  enlarged  and  the  edge 
can  usually  be  felt  below  the  costal  margin.  In  the  interval  or  intermission 
of  the  paroxysm  the  patient  feels  very  well,  and,  unless  the  di'sease  is  unusually 


Day 


106 
105 


3103 

55       c 


JslOl 

99' 


Oct.  S 


V 


CHAET   Via. — DOUBLE   TERTIAN  INFECTION. — QUOTIDIAN  ±EVER. 

severe,  he  is  able  to  be  up.     Bronchitis  is  a  common  symptom.     Herpes, 
usually  labial,  is  almost  as  frequent  in  malaria  as  in  pneumonia. 

Types  of  the  Regularly  Intermittent  Fevers. — As  has  been  stated  in  the 
description  of  the  parasites,  two  distinct  types  of  the  regularly  intermit- 


4 

4J 

a; 

\ 

22 

- 

X 

f 

<  " 

1fY7 

X 

X 

8 

E 

'  ° 

K 

m 

£ 

i 

^ 

*- 

K 

^2 

n 

" 

i 

5 

/ 

= 

\ 

„; 

i- 

/ 

1 

u- 

o:  104 

i 

/ 

i 

r 

s 

*> 

D 

A 

<  10^° 

m 

\ 

tt 

/ 

V 

f 

\ 

- 

S  uo 

0 

\ 

X 

/ 

^ 

= 

J 

\ 

• 

°-  1<r' 

\ 

ft 

1 

\ 

/ 

V 

^ 

A 

SIUB 

^ 

^ 

f 

"^ 

/ 

\ 

H  IQI 

a 

V 

^ 

/ 

V 

A 

/ 

\ 

V- 

3 

V 

v 

/ 

\ 

^ 

s,, 

*y 

s 

^ 

^~ 

-•s 

V 

\ 

.^ 

V 

. 

^ 

(*S 

f. 

^ 

99° 

V 

s  w 

p 

^ 

\/ 

Oft 

<yr° 

CHART  VI6. — ^STIVO-AUTUMNAL   INFECTION. — KEMITTENT   FEVER. 
The  case  was  treated  for  a  week  as  one  of  typhoid  fever. 

tent  fevers  have  been  separated.    These  are  (a)  tertian  fever  and  (6)  quar- 
tan fever. 

(a)   Tertian  Fever. — This  type  of  fever  depends  upon  the  presence  in 
the  blood  of  the  tertian  parasite,  an  organism  which,  as  stated  above,  is 


MALAEIAL  FEVER 


251 


usually  present  in  sharply  defined  groups,  whose  cycle  of  development  lasts 
approximately  forty-eight  hours,  segmentation  occurring  every  third  day.  In 
infections  with  one  group  of  the  tertian  parasite  the  paroxysms  occur  syn- 
chronously with  segmentation  at  remarkably  regular  intervals  of  about  forty- 


Octob 

er 

I 

3 

2 

i 

i 

n 

• 

> 

6 

;   s 

s 

109° 
108° 
107° 
100 
105 

LJ             0 

§  104 
5  103 

1  102 
• 

-101° 

100 
99° 

• 

98 
97 
96 

^ 

« 

£ 

£ 

-  * 

< 

-^ 

X 

~ 

^ 

S 

• 

fv 

* 

. 

j 

o 

£ 

i- 

'^ 

a 

0 

g 

± 

T- 

> 

"; 

2 

D 

A 

a 

• 

< 

* 

,5 

A 

/  1 

"\ 

UJ 

1 

, 

'\ 

£ 

f 

1 

; 

i 

r. 

f 

N 

\ 

=i 

j* 

^ 

3 

V 

\ 

I 

u 

f1 

\ 

••s^ 

3 

I 

\ 

\ 

f 

\ 

\ 

\ 

1 

I 

^i 

\ 

f 

\ 

\ 

/ 

j 

\ 

\ 

j 

\ 

/ 

\ 

V 

l 

V 

/ 

\ 

\ 

f 

1 

/ 

\  , 

\ 

V 

"2 

/ 

V 

x 

/ 

*- 

-^ 

1 

CHAET  Vic. — ^STIVO-AUTUMNAL  FEVEE. — QUOTIDIAN  PAROXYSMS. 

eight  hours,  every  third  day — hence  the  name  tertian.  Very  commonly, 
however,  there  may  be  two  groups  of  parasites  which  reach  maturity  on  alter- 
nate days,  resulting  thus  in  daily  (quotidian)  paroxysms — double  tertian 
infection. 


Jul 

) 

19 

M 

> 

2 

rrrr 

1 

2-: 

23 

24 

C 

( 

2 

J 

1^5 

*  j  i  i  i  s   .     i 

s~si;ii°"S 

3*;l«5;*Sl; 

E 

O 

_, 

o 

h 

— 

H 

— 

0 

o 

g| 

— 

II 

j 

a 

^ 

^ 

j 

H 

•3         o 

^ 

-j 

I;     I 

o 

. 

If' 

i 

\ 

Q 

i_     j  .-i^*' 

^ 

.T 

O 

E 

i 

z 

-* 

I 

I 

k 

J 

.4 

3 

5     ,  -  ? 

L  ~ 

..   4 

O 

s  101 

3  1  j  I 

Z   4 

I  , 

j         ' 

99° 

j^S. 

ll; 

t: 

^r 

--F-  - 

9sr 

1 

•v 

3-- 

:  :5 

A 

2  ' 

~7^*" 

"\: 

^r 

17 

c 

^•^      -  v 

•V    .  /A/\ 

i 

—  X- 

X**>^ 

A 

/ 

/ 

\ 

X^-p*    li 

j' 

M 

"^ 

Lc 

/ 

CHART  VId. — QUARTAN  FEVEB. 

(6)  Quartan  Fever. — The  symptoms  resemble  those  of  the  tertian  in- 
fection, but  as  a  rule  are  milder.  Paroxysms  appear  on  the  fourth  day  and 
correspond  with  the  evolution  of  a  parasitic  cycle  of  seventy-two  hours.  In 
recent  infections  the  recurrence  of  the  paroxysm  may  be  almost  precisely  the 


252  SPECIFIC    INFECTIOUS    DISEASES 

same  hour  every  fourth  day.  The  infection  may  be  double,  in  which  case 
there  are  two  paroxysms  followed  by  a  day  of  intermission,  or  triple,  in 
which  there  is  a  daily  paroxysm.  As  pointed  out  by  the  old  Greek  physicians, 
the  quartan  infection  is  very  difficult  to  cure.  Disappearing  for  a  time 
spontaneously,  or  yielding  promptly  to  quinine,  it  has  a  singular  proneness 
to  relapse,  even  after  the  most  energetic  treatment. 

Thus  a  quotidian  intermittent  fever  may  be  due  to  infection  with  either 
the  tertian  or  quartan  parasites. 

Course  of  the  Disease. — After  a  few  paroxysms,  or  after  the  disease  has 
persisted  for  ten  days  or  two  weeks,  the  patient  may  get  well  without  any 
special  medication.  I  have  repeatedly  known  the  chills  to  stop  spontane- 
ously. Kelapses  are  common.  The  infection  may  persist  for  years,  and  an 
attack  may  follow  an  accident,  an  acute  fever,  or  a  surgical  operation.  A  rest- 
ing stage  of  the  parasite  has  been  suggested  in  explanation  of  these  long  in- 
tervals. Persistence  of  the  fever  leads  to  anaemia  and  haematogenous  jaun- 
dice, owing  to  the  destruction  of  blood  cells.  Ultimately  the  condition  may 
become  chronic — malarial  cachexia. 

II.  THE  MORE  IRREGULAR,  REMITTENT,  OR  CONTINUED  FEVERS. —  (a) 
JEstivo-autumnal  Fever. — This  type  of  fever  occurs  in  temperate  climates, 
chiefly  in  the  later  summer  and  autumn;  hence  the  term  given  to  it  by 
Marchiafava  and  Celli,  cestivo-autumnal  fever.  The  severer  forms  of  it  pre- 
vail in  the  Southern  States  and  in  tropical  countries. 

This  type  of  fever  is  associated  with  the  presence  in  the  blood  of  the 
sestivo-autumnal  parasite,  an  organism  the  length  of  whose  cycle  of  develop- 
ment, ordinarily  about  forty-eight  hours,  is  probably  subject  to  considerable 
variations,  while  the  existence  of  multiple  groups  of  the  parasite,  or  the 
absence  of  arrangement  into  definite  groups,  is  not  infrequent. 

The  symptoms  are  therefore,  as  might  be  expected,  often  irregular.  In 
some  instances  there  may  be  regular  intermittent  fever  occurring  at  uncer- 
tain intervals  of  from  twenty-four  to  forty-eight  hours,  or  even  more.  In 
the  cases  with  longer  remissions  the  paroxysms  are  longer.  Some  of  the 
quotidian  intermittent  cases  may  closely  resemble  the  quotidian  fever  depend- 
ing upon  double  tertian  or  triple  quartan  infection.  Commonly,  however, 
the  paroxysms  show  material  differences;  their  length  averages  over  twenty 
hours,  instead  of  from  ten  to  twelve;  the  onset  occurs  often  without  chills 
and  even  without  chilly  sensations.  The  rise  in  temperature  is  frequently 
gradual  and  slow,  instead  of  sudden,  while  the  fall  may  occur  by  lysis  instead 
of  by  crisis.  There  may  be  a  marked  tendency  toward  anticipation  in  the 
paroxysms,  while  frequently,  from  the  anticipation  of  one  paroxysm  or  the 
retardation  of  another,  more  or  less  continuous  fever  may  result.  Some- 
times there  is  continuous  fever  without  sharp  paroxysms.  In  these  cases  of 
continuous  and  remittent  fever  the  patient,  seen  fairly  early  in  the  disease, 
has  a  flushed  face  and  looks  ill.  The  tongue  is  furred,  the  pulse  is  full  and 
bounding,  but  rarely  dicrotic.  The  temperature  may  range  from  102°  to 
103°,  or  is  in  some  instances  higher.  The  general  appearance  of  the  patient 
is  strongly  suggestive  of  typhoid  fever — a  suggestion  still  further  borne  out 
by  the  existence  of  acute  splenic  enlargement  of  moderate  grade.  As  in 
intermittent  fever,  an  initial  bronchitis  may  be  present.  The  course  of  these 
cases  is  variable.  The  fever  may  be  continuous,  with  remissions  more  or 


MALARIAL  FEVER  253 

less  marked;  definite  paroxysms  with  or  without  chills  may  occur,  in  which 
the  temperature  rises  to  105°  or  106°F.  Intestinal  symptoms  are  usually 
absent.  A  slight  haematogenous  jaundice  may  arise  early.  Delirium  of  a 
mild  type  may  occur.  The  cases  vary  very  greatly  in  severity.  In  some  the 
fever  subsides  at  the  end  of  the  week,  and  the  practitioner  is  in  doubt 
whether  he  has  had  to  do  with  a  mild  typhoid  or  a  simple  febricula.  In 
other  instances  the  fever  persists  for  from  ten  days  to  two  weeks;  there  are 
marked  remissions,  perhaps  chills,  with  a  furred  tongue  and  low  delirium. 
Jaundice  is  not  infrequent.  These  are  the  cases  to  which  the  terms  bilious 
remittent  and  typho-malarial  fevers  are  applied.  In  other  instances  the 
symptoms  become  grave  and  assume  the  character  of  the  pernicious  type.  It 
is  in  this  form  of  malarial  fever  that  so  much  confusion  still  exists.  The 
similarity  of  the  cases  to  typhoid  fever  is  most  striking,  more  particularly 
the  appearance  of  the  faces;  the  patient  looks  very  ill.  The  cases  occur,  too, 
in  the  autumn,  at  the  very  time  when  typhoid  fever  occurs.  The  fever  yields, 
as  a  rule,  promptly  to  quinine,  though  here  and  there  cases  are  met  with — 
rarely  indeed  in  my  experience — which  are  refractory.  Several  of  the  charts 
in  Thayer  and  Hewetson's  monograph  show  how  closely,  in  some  instances, 
the  disease  may  simulate  typhoid  fever. 

The  diagnosis  may  be  definitely  made  by  the  examination  of  the  blood. 
Eepeated  examinations  at  short  intervals  may  be  required  before  the  para- 
sites are  found.  The  small,  actively  motile,  hyaline  forms  of  the  sstivo- 
autumnal  parasite  are  to  be  found,  while,  if  the  course  has  been  over  a  week, 
the  larger  crescentic  and  ovoid  bodies  are  often  seen.  In  many  cases  in  the 
tropics  one  is  unable  to  distinguish  between  typhoid  and  continued  malarial 
fever  without  a  blood  examination. 

(&)  Pernicious  Malarial  Fever. — This  is  fortunately  rare  in  temperate 
climates,  and  the  number  of  cases  which  now  occur,  for  example,  in  Phila- 
delphia and  Baltimore,  is  very  much  less  than  it  was  thirty  or  forty  years 
ago.  Pernicious  fever  is  always  associated  with  the  aBstivo-autumnal  parasite. 
The  following  are  the  most  important  types : 

(1)  Comatose  Form. — The  comatose  form,  in  which  a  patient  is  struck 
down  with  symptoms  of  the  most  intense  cerebral  disturbance,  either  acute 
delirium  or,  more  frequently,  a  rapidly  developing  coma.     A  chill  may  or 
may  not  precede  the  attack.    The  fever  is  usually  high,  and  the  skin  hot  and 
dry.     The  unconsciousness  may  persist  for  from  twelve  to  twenty-four  hours, 
or  the  patient  may  sink  and  die.     After  regaining  consciousness  a  second 
attack  may  come  on  and  prove  fatal.     In  these  instances,  as  has  been  stated, 
the  special  localization  of  the  infection  is  in  the  brain,  where  actual  thrombi 
of  parasites  with  marked  secondary  changes  in  the  surrounding  tissues  have, 
been  found. 

(2)  Algid  Form. — In  this   the  attack  sets  in  usually  with  gastric  symp- 
toms; there  are  vomiting,  intense  prostration,  and  feebleness  out  of  all  pro- 
portion  to  the   local   disturbance.     The   patient   complains   of   feeling   cold, 
although  there  may  be  no  actual  chill.     The  temperature  may  be  normal, 
or  even  subnormal;  consciousness  may  be  retained.     The  pulse  is  feeble  and 
small,  and  the  respirations  are  increased.     There  may  be  most  severe  diar- 
rhoea, the  attack  assuming  a  choleriform  nature.     The  urine  is  often  dimin- 
ished, or  even  suppressed.    This  condition  may  persist  with  slight  exacerba- 


254  SPECIFIC   INFECTIOUS    DISEASES 

tions  of  fever  for  several  days  and  the  patient  may  die  in  a  condition  of 
profound  asthenia.  This  is  essentially  the  same  as  described  as  the  asthenic 
or  adynamic  form  of  the  disease.  In  the  cases  with  vomiting  and  diarrhoea 
the  gastro-intestinal  mucosa  is  often  the  seat  of  a  special  invasion  by  the 
parasites,  actual  thrombosis  of  the  small  vessels  with  superficial  ulceration 
and  necrosis  occurring. 

(3)  Haemorrhagic  Forms — Black-water  Fever — Haemoglobinuric  Fever — 
Malarial  Haemoglobinuria. — There  are  two  types  of  haemoglobinuria  in  ma- 
laria, the  one  associated  with  any  severe  pernicious  malaria,  in  which  an 
enormous  number  of  red  blood  corpuscles  are  directly  destroyed  by  parasites. 
Not  very  uncommon,  we  had  a  number  of  cases  of  this  type  at  the  Johns  Hop- 
kins Hospital.  But  in  the  true  black-water  fever  there  is  a  solution  of  red 
blood  corpuscles  by  an  unknown  haemolysin,  not  directly  by  the  malarial 
parasites  themselves. 

The  figures  at  Panama,  based  on  five  years'  work  at  the  Ancon  Hospital, 
given  by  Decks  and  James,  show  230  cases  in  more  than  40,000  cases  of 
malaria.  Their  studies  strongly  favor  the  association  of  black-water  fever 
with  malaria,  holding  that  there  are  three  causes  superadded  to  the  previous 
malarial  infection :  (i)  A  renewed  malarial  attack  with  production  of  toxins 
sufficient  to  destroy  many  red  blood  corpuscles;  (ii)  a  lowering  of  the 
bodily  resistance;  (iii)  quinine,  which  appears  to  be  the  tertium  quid  nec- 
essary to  produce  the  haemolysin.  The  general  experience  at  Panama  is 
in  favor  of  withholding  quinine  in  the  true  erytholytic  haemoglobinuria.  It 
is  possible  that  we  may  find  some  measure  to  counteract  the  haemoly- 
sis. 

(c)  Malarial  Cachexia. — The  general  symptoms  are  those  of  secondary 
anaemia — breathlessness  on  exertion,  oedema  of  the  ankles,  and  haemorrhages, 
particularly  into  the  retina.  Occasionally  the  bleeding  is  severe,  and  I  have 
twice  known  fatal  haematemesis  to  occur  in  association  with  the  enlarged 
spleen.  The  fever  is  variable.  The  temperature  may  be  low  for  days,  not 
going  above  99.5°.  In  other  instances  there  may  be  irregular  fever,  and 
the  temperature  rises  gradually  to  102.5°  or  103°F. 

With  careful  treatment  the  outlook  is  good,  and  a  majority  of  cases  re- 
cover. The  spleen  is  gradually  reduced  in  size,  but  it  may  take  several 
months,  or,  indeed,  in  some  instances  several  years,  before  the  "ague-cake" 
entirely  disappears. 

Rarer  Complications. — Paraplegia  may  be  due  to  a  peripheral  neuritis  or 
to  changes  in  the  cord,  and  hemiplegia  may  occur  in  the  pernicious  comatose 
form,  or  occasionally  at  the  very  height  of  a  paroxysm.  Acute  ataxia  has 
been  described,  and  there  are  remarkable  cases  with  the  symptoms  of  dissem- 
inated sclerosis  (Spiller).  Multiple  gangrene  may  occur,  as  in  an  instance 
reported  by  me,  in  which  a  patient  with  aestivo-autumnal  infection  presented 
many  areas  on  the  skin.  Orchitis  has  been  described  by  Charvot  in  Algiers 
and  Fedeli  in  Eome. 

Relapse. — It  is  not  easy  to  explain  the  relapse.  Some  think  there  is  a 
resting  stage  of  the  parasite  which  remains  in  the  spleen  or  the  bone  mar- 
row. Schaudinn  believed  that  there  is  a  special  parthenogenetic  form  which 
may  remain  latent  for  an  indefinite  period.  This  seems  most  likely,  as  there 
can  be  no  question  that  months  or  even  years  may  elapse  between  the  pri- 


MALAEIAL  FEVER  255 

mary  infection  and  a  relapse  occurring  under  conditions  that  preclude  the 
possibility  of  re-infection. 

Diagnosis. — The  endemic  index  of  a  country  may  he  determined  by  the 
"parasite  rate"  or  by  the  "spleen  rate."  It  is  best  sought  for  in  children, 
in  whom,  as  is  well  known,  the  infection  may  occur  without  much  disturb- 
ance of  the  health.  To  determine  the  index  by  examining  the  blood  for  the 
parasites  is  a  laborious  and  almost  impossible  task;  on  the  other  hand,  as 
the  work  of  Eoss  in  Greece  and  Mauritius  has  shown,  the  index  may  be  readily 
gauged  by  an  examination  of  the  spleen.  Thus,  in  the  last-named  island,  of 
31,022  children,  34.1  per  cent,  had  enlarged  spleen.  In  Bombay,  among  50,000 
children  examined,  the  spleen  index  varied  from  5.3  per  cent,  in  the  Hindoos 
to  23.2  per  cent,  in  the  Parsees  (Bentley). 

The  individual  forms  of  malarial  infection  are  readily  recognized,  but  it 
requires  a  long  and  careful  training  to  become  an  expert  in  blood  examination. 
Great  progress  has  been  made  in  the  past  twenty  years,  and  a  diagnosis  of 
malaria  is  no  longer  a  refuge  for  our  ignorance.  One  lesson  it  is  hard  for 
the  practitioner  to  learn — namely,  that  an  intermittent  fever  which  resists 
quinine  is  not  malarial. 

The  malarial  poison  is  supposed  to  influence  many  affections  in  a  remark- 
able way,  giving  to  them  a  paroxysmal  character.  A  whole  series  of  minor 
ailments  and  some  more  severe  ones,  such  as  neuralgia,  are  attributed  to 
certain  occult  effects  of  paludism.  The  more  closely  such  cases  are  investi- 
gated the  less  definite  appears  the  connection  with  malaria. 

Prophylaxis. — In  the  discovery  of  Laveran  there  lay  the  promise  of  bene- 
fits more  potent  than  any  gift  science  had  ever  offered  to  mankind — viz.,  the 
possibility  of  the  extermination  of  malaria.  By  the  persistent  missionary 
efforts  of  Eoss  this  promise  has  reached  the  stage  of  practical  fulfilment,  and 
one  of  the  greatest  scourges  of  the  race  is  now  under  our  command.  The 
story  of  the  Canal  Zone,  Panama,  under  Colonel  Gorgas  is  a  triumph  of  the 
application  of  scientific  methods.  Between  1881  and  1904  among  the  em- 
ployees of  the  French  Canal  Company  (a  maximum  in  1887  of  17,995,  of 
whom  15,726  were  negroes)  the  monthly  mortality  ranged  from  60  to  70,  and 
on  seven  occasions  was  above  100,  once  reaching  the  enormous  figure  of  176.97 
per  1,000.  With  the  measures  given  below,  the  mortality  has  fallen  below  that 
of  temperate  regions.  For  the  year  1910  the  death  rate  among  50,802  em- 
ployees was,  total  deaths  558,  from  disease  381,  from  violence  177;  the  death 
rate  from  disease  was  7.5  per  1,000.  In  August,  1911,  among  49,710  em- 
ployees the  death  rate  from  disease  was  6.27 ! 

This  most  successful  campaign  has  been  carried  out  on  the  following  lines : 
(1)  The  eradication  of  mosquito  propagation  areas  by  drainage,  and  the  fill- 
ing of  places  where  the  Iarva9  exist.  This  has  been  done  successfully  in  large 
districts. 

(2)  The  control  of  propagation  areas  that  are  allowed  to  exist,  or  that 
cannot  be  economically  and  permanently  treated.  On  small  areas  the  larvae 
are  prevented  from  arriving  at  the  adult  stage  by  the  use  of  crude  oil  or  kero- 
sene, and  in  large  bodies  of  water  by  treating  the  edges  where  alone  the  mos- 
quito larvae  exist.  A  concentrated  larvacide  of  carbolic  acid,  resin,  and  caustic 
soda,  so  made  as  to  form  an  emulsion  with  the  water  into  which  it  is  placed, 
has  been  found  effective,  when  applied  to  the  edges  of  large  pools,  ditches,  wet 


256 


SPECIFIC   INFECTIOUS    DISEASES 


areas  and  streams.     A  barrel  of  oil  with  an  automatic  drip  at  the  head  of  a 
stream  has  been  found  to  work  satisfactorily. 

(3)  Protection  by  screening  of  houses.    On  the  Zone  all  the  houses  occu- 
pied by  Americans  are  protected  by  copper-bronze  screens  of  18  mesh  to  the 
inch.     Cotton  bar  treated  with  wax  is  also  recommended  as  inexpensive. 
Screened  vestibules  decrease  the  chance  of  access  of  mosquitoes.     Mosquito 
nets  over  the  beds  are  found,  as  a  rule,  to  be  a  failure,  chiefly  because  few 
persons  sleep  through  a  whole  night  without  an  arm  or  leg  coming  in  contact 
with  the  netting  on  which  the  anopheles  settle. 

(4)  The  destruction  of  adult  anopheles.    In  two  sets  of  barracks  not  far 
apart,  with  many  anopheles,  in  one  all  the  adult  mosquitoes  were  killed  daily, 
in  the  other  they  were  not;  in  the  latter  during  a  period  of  several  months 
there  was  forty-two  times  as  much  malaria.    The  mosquitoes  are  easily  caught ; 
they  are  usually  in  the  corners,  and  very  often  within  a  foot  of  the  floor. 

Of  the  enormous  importance  of  these  anti-malarial  measures  there  can 
now  be  no  question.  It  requires  system,  organization,  energy  and  persever- 
ance. But  the  story  of  Havana,  where  malaria  no  longer  exists,  and  the  story 
of  Ismalia,  and,  above  all,  the  story  of  the  Panama  Canal  Zone  show  what 
can  be  done.  The  following  chart,  taken  from  an  article  of  Le  Prince,  the 
chief  sanitary  inspector  of  the  Zone,  gives  a  good  idea  of  the  results.  The 
objection  offered  on  the  score  of  cost  in  the  tropics  has  been  shown  by  Gorgas 
to  be  fallacious. 


1907 


1908 


1909 


1910 


10* 


A 


A 


9t 


CHAET  VII. — MALABIA  CASES  AMONG  THE  EMPLOYEES  OF  THE  ISTHMIAN  CANAL 
COMMISSION,  1906-1910. 

Every  patient  with  malaria  should  be  regarded  as  a  centre  of  infection,  and 
in  a  systematic  warfare  reported  to  the  health  authorities.  In  the  tropics 
segregation  of  Europeans  may  do  much  to  lessen  the  chances  of  infection. 


MALARIAL  FEVEE  257 

Every  patient  should  receive  thorough  and  prolonged  treatment  with  quinine. 
There  is  far  too  much  carelessness  on  this  point  in  the  profession.  Malarial 
infection  is  a  difficult  one  to  eradicate.  Quinine  is  the  only  known  drug  which 
is  an  effective  parasiticide.  Patients  should  be  told  to  resume  the  treatment 
in  the  spring  and  autumn  for  several  years  after  the  primary  infection.  In 
very  malarial  districts,  as  many  persons  harbor  the  parasites  who  do  not  show 
any  (or  at  the  most  very  few)  signs,  a  systematic  treatment  with  quinine 
should  be  instituted,  particularly  of  the  young  children. 

Patients  with  the  disease  should  be  protected  from  mosquitoes  as  far  as 
possible.  As  a  rule,  anopheles  are  more  likely  to  bite  after  sundown,  so  that 
in  regions  in  which  the  disease  prevails  extensively  mosquito  netting  should 
be  used.  Persons  going  to  a  malarial  region  should  take  about  10  grains 
(0.6  gm.)  of  quinine  daily,  though  Sezary  found  that  2  grains  (0.13  gm.) 
three  times  a  day  was  a  sufficient  protection  against  the  disease. 

Treatment. — The  patient  should  be  in  bed  and  given  liquid  or  soft  diet. 
The  bowels  should  be  moved  freely,  for  which  a  calomel  and  saline  purge  is 
best.  In  quinine  we  possess  a  specific  remedy  against  malarial  infection. 
Experiment  has  shown  that  the  parasites  are  most  easily  destroyed  by  quinine 
at  the  stage  when  they  are  free  in  the  circulation — that  is,  during  and  just 
after  segmentation.  While  in  most  instances  the  parasites  of  the  regularly 
intermittent  fevers  may  be  destroyed,  even  in  the  intra-corpuscular  stage, 
in  sestivo-autumnal  fever  this  is  much  more  difficult.  It  should,  then,  be  our 
object,  if  we  wish  to  most  effectively  eradicate  the  infection,  to  have  as  much 
quinine  in  circulation  at  the  time  of  the  paroxysm  and  shortly  before  as  is 
possible,  for  this  is  the  period  at  which  segmentation  occurs.  In  the  regu- 
larly intermittent  fevers  from  10  to  30  grains  (0.6  to  2  gm.)  in  divided  doses 
throughout  the  day  will  in  many  instances  prevent  any  fresh  paroxysms.  If 
the  patient  comes  under  observation  shortly  before  an  expected  paroxysm, 
the  administration  of  a  good  dose  of  quinine  just  before  its  onset  may  be  ad- 
visable to  obtain  a  maximum  effect  upon  the  group  of  parasites.  The  quinine 
will  not  prevent  the  paroxysm,  but  will  destroy  the  greater  part  of  the  group 
of  organisms  and  prevent  its  recurrence.  It  is  safer  to  give  at  least  20  to  30 
grains  (1.3  to  2  gm.)  daily  for  the  first  three  days,  and  then  to  continue  the 
remedy  in  smaller  doses  for  the  next  two  or  three  weeks.  In  a3stivo-autumnal 
fever  larger  doses  may  be  necessary,  though  in  relatively  few  instances  is  it 
necessary  to  give  more  than  30  grains  (2  gm.)  in  the  twenty-four  hours. 
During  the  paroxysm  the  patient  should,  in  the  cold  stage,  be  wrapped  in 
blankets  and  given  hot  drinks.  The  reactionary  fever  is  rarely  dangerous  eve# 
if  it  reaches  a  high  grade.  The  body  may,  however,  be  sponged. 

The  quinine  should  be  ordered  in  solution  or  in  capsules.  The  pills  aai 
compressed  tablets  are  more  uncertain,  as  they  may  not  be  dissolved^  Euqui- 
nin,  in  the  same  dosage,  may  be  given  to  patients  with  whom  quinine  dis- 
agrees. 

A  question  of  interest  is  the  efficient  dose  of  quinine  necessary  to  cure  the 
disease.  I  have  a  number  of  charts  showing  that  grain  doses  three  times  a 
day  will  in  many  cases  prevent  the  paroxysm,  but  not  always  with  the  cer- 
tainty of  larger  doses.  In  cases  of  sestivo-autumnal  fever  with  pernicious 
symptoms  it  is  necessary  to  get  the  system  under  the  influence  of  quinine  aa 
rapidly  as  possible.  In  these  instances  the  drug  should  be  administered  by 


258  SPECIFIC    INFECTIOUS    DISEASES 

injection  into  the  muscles,  as  the  dihydrochlorate  in  ten-grain  (0.6  gm.) 
doses,  in  a  freshly  prepared  solution  (1  to  2)  in  sterile  water  and  repeated  in 
two  hours.  Further  administration  must  be  decided  by  the  condition.  The 
muriate  of  quinine  and  urea  is  also  a  good  form  in  which  to  administer  the 
drug  hypodermically ;  10-grain  (0.6  gm.)  doses  may  be  given.  In  the  most 
severe  instances  some  observers  advise  the  intravenous  administration  of 
quinine,  for  which  the  very  soluble  bimuriate  is  well  adapted.  Fifteen  grains 
with  40  grains  of  sodium  chloride  may  be  injected  in  ten  ounces  of  freshly  dis- 
tilled water.  The  intravenous  administration  is  not  without  danger.  For 
extreme  restlessness  in  these  cases  opium  is  indicated,  and  cardiac  stimulants, 
such  as  alcohol  and  strychnine,  may  be  necessary.  If  in  the  comatose  form 
the  internal  temperature  is  raised,  the  patient  should  be  sponged  or  given 
a  tub  bath.  For  malarial  anaemia  iron  and  arsenic  are  indicated. 

An  interesting  question  is  much  discussed,  whether  quinine  does  not  cause, 
or  at  any  rate  aggravate,  haemoglobinuria.  We  have  not  yet  seen  a  case  in 
which  this  condition  has  occurred  as  a  result  of  the  use  of  the  drug,  and  Bas- 
tianelli  states  that  it  is  not  seen  in  the  Roman  malarial  fevers.  In  any  case 
of  haemoglobinuria  if  the  blood  shows  parasites  quinine  should  be  administered 
cautiously.  In  the  post-malarial  forms  quinine  aggravates  the  attack.  In  an 
active  malarial  infection  the  patient  runs  less  risk  with  the  quinine. 

In  malarial  cachexia  the  patient  should  have  a  change  of  climate,  be  given 
a  liberal  diet,  and  take  quinine  in  small  doses  and  iron  and  arsenic  for  some 
time. 

IV.     TRYPANOSOMIASIS 

Definition. — A  chronic  disorder  characterized  by  fever,  lassitude,  weak- 
ness, wasting,  and  often  a  protracted  lethargy — sleeping  sickness.  Trypano- 
soma  gambiense  is  the  active  agent  in  the  disease. 

Trypanosomes  are  flagellate  infusoria,  parasitic  in  a  great  many  inverte- 
brate and  vertebrates.  The  life  history  is  in  two  stages,  a  flagellate  monadine 
phase,  in  which  they  live  in  the  blood  stream  of  vertebrates  and  in  some  of 
which  they  cause  serious  disease ;  the  other  is  a  gregarine  non-fl agellate  phase 
which  may  also  be  parasitic  and  which  is  met  with  in  forms  of  Kala-Azar. 

History. — In  1843  Gruby  found  a  blood  parasite  in  the  frog  which  he 
called  Trypanosoma  sanguinis.  Subsequently  it  was  found  to  be  a  very  com- 
mon blood  parasite  in  fishes  and  birds.  In  1878  Lewis  found  it  in  the  rat — 
T.  lewisi — in  which  it  apparently  does  no  harm.  The  pathological  signifi- 
cance of  the  protozoa  was  first  suggested  in  1880  by  Griffith  Evans,  who  dis- 
covered trypanosomes — T.  evansi — in  the  disease  of  horses  and  cattle  in  India 
known  as  surra.  In  1895  Bruce  made  the  important  announcement  that  the 
tsetze  fly  disease  or  nagana  of  South  Africa,  which  made  whole  districts  im- 
passable for  cattle  and  horses,  was  really  due  to  a  trypanosome — T.  Irucei. 
Normally  present  in  the  blood  of  the  big-game  animals  of  the  districts,  and 
doing  them  no  harm,  it  was  conveyed  by  the  tsetze  fly  to  the  non-immune 
horses  and  cattle  imported  into  what  were  called  the  fly-belts.  Other  trypano- 
somes are  the  Philippine  surra,  studied  by  Musgrave,  the  mal  de  caderas — T. 
equinum — of  South  America  and  a  harmless  infection  in  cattle  in  the  Trans- 
vaal caused  by  Trypanosoma  theileri. 


TRYPANOSOMIASIS  259 

Human  Trypanosomiasis.—  In  1901  Button  found  a  trypanosome  in  the 
blood  of  a  West  Indian.  In  1903  Castellani  found  trypanosomes  in  the  cere- 
bro-spinal  fluid  and  in  the  blood  of  five  cases  of  the  African  sleeping  sick- 
ness. The  Royal  Society  Commission  (Bruce  and  Nabarro)  demonstrated  the 
great  frequency  of  the  parasites  in  the  cerebro-spinal  fluid  and  in  the  blood 
in  sleeping  sickness,  and  suggested  that  it  was  a  sort  of  human  tsetze  fly  in- 
fection. 

DISTRIBUTION. — For  many  years  it  had  been  known  that  the  West  African 
natives  were  subject  to  a  remarkable  malady  known  as  the  lethargy  or  sleep- 
ing sickness.  It  was  also  met  with  among  the  slaves  imported  into  America. 
The  demonstration  of  the  association  of  the  trypanosomes  with  the  terrible 
sleeping  sickness  has  been  the  most  important  recent  "find"  in  tropical  medi- 
cine. The  disease  prevails  in  Gambia,  Sierra  Leone,  and  Liberia,  and  is 
spreading  rapidly  in  the  Congo  basin,  Uganda,  and  Rhodesia.  The  recent 
opening  up  of  equatorial  Africa  has  led  to  intercommunication  between  the 
different  districts  which  were  formerly  isolated,  and  the  seriousness  of  the 
disease  may  be  appreciated  from  the  fact  that  within  three  years  after  its 
introduction  100,000  negroes  died  of  it  in  Uganda.  In  the  infected  regions 
a  large  number  of  natives,  not  apparently  suffering  from  the  disease,  har- 
bor the  parasites  in  the  blood  and  suffer  only  with  occasional  attacks  of 
fever,  during  which  the  trypanosomes  are  also  found  in  the  cerebro-spinal 
fluid. 

The  disease  is  not  confined  to  negroes,  and  Europeans  may  be  attacked. 
Persons  particularly  prone  are  those  who  live  on  the  wooded  shores  of  the 
lakes  and  rivers,  such  as  fishermen  and  canoe  men. 

The  parasite  is  introduced  by  the  bite  of  a  fly,  the  Glossina  palpalis,  and 
where  this  insect  exists  the  disease  is  liable  to  prevail.  The  fly  lives  on  the 
bushes  on  the  lake  shores  or  river  banks,  and  feeds  on  the  blood  of  crocodiles, 
antelopes,  etc.  The  trypanosomes  undergo  changes  in  the  body  of  the  fly  and 
the  infectivity  does  not  appear  until  the  thirty-second  day,  but  continues  for 
at  least  75  days  (Bruce). 

Symptoms. — There  is  stated  to  be  a  long  latent  period.  The  Uganda  Com- 
missioners divide  the  course  of  the  disease  into  three  stages:  first,  of  fever 
with  rapid  pulse,  dulling  of  the  mind,  and  loss  of  weight;  secondly,  the  stage 
of  tremors  in  which  the  gait  becomes  shuffling,  the  speech  slow,  and  there  are 
tremors  of  the  tongue  and  of  the  hands  and  feet;  lastly,  a  stage  in  which  the 
patient  becomes  lethargic  with  low  temperature  and  presents  the  typical  pic- 
ture of  the  dreaded  sleeping  sickness.  The  parasites  are  found  in  the  cerebro- 
spinal  fluid,  less  constantly  in  the  blood.  In  the  early  stages  the  glands  of  the 
neck  are  involved,  and  Todd  and  Button  recommend  puncture  of  these  glands 
for  the  purpose  of  diagnosis.  Death  is  usually  caused  by  some  intercurrent 
infection,  as  purulent  meningitis  or  suppuration  of  the  lymph  glands.  The 
duration  is  seldom  longer  than  eighteen  months.  To  stay  the  ravages  and 
prevent  the  spread  of  the  disease  will  tax  the  energies  of  the  nations  interested 
in  the  settlement  of  tropical  Africa.  The  hope  appears  to  be  in  the  extermina- 
tion of  the  animals  upon  which  the  Glossina  palpalis  feeds  (among  which 
Koch  holds  the  crocodile  to  be  the  most  important),  just  as  the  killing  off  of 
the  big  game  in  other  parts  of  Africa  has  saved  the  cattle  from  the  ravages 
of  the  tsetze  fly.  Though  a  colossal  task,  the  examination  of  natives  of  in- 


260  SPECIFIC    INFECTIOUS    DISEASES 

fected  districts  should  be  undertaken,  isolation  villages  established,  and  the 
cases  kept  under  observation  and  treatment. 

Prognosis. — Nine  cases  in  Europeans  have  been  cured,  and  six  of  these 
have  been  without  symptoms  from  three  and  one-half  to  seven  years.  The 
criteria  of  cure  are  the  absence  of  symptoms,  failure  to  find  the  trypanosomes, 
the  absence  of  auto-agglutination,  and  ncgati/e  inoculation  of  the  blood  into 
susceptible  animals. 

Treatment. — Atoxyl  introduced  by  Wolferstan  Thomas  and  Breinl  appears 
to  have  given  the  most  satisfactory  results.  The  parasites  seem  to  vary 
in  their  resistance  to  arsenic.  In  some  places  the  arsenophenylglycin 
seems  to  have  acted  almost  as  a  specific.  Antimony  has  been  used  a  good  deal 
of  late,  and  Kerandel,  a  member  of  the  French  Commission,  has  cured  him- 
self with  it,  injecting  intravenously  on  successive  days  a  solution  of  tartar 
emetic  in  seventeen  10-centigram  doses.  Salvarsan  has  been  used  with  bene- 
fit, but  we  have  not  yet  a  full  knowledge  of  its  effects. 


V.     LEISHMANIASIS 
(Kala-Azar) 

Definition. — Leishmaniasis  is  an  affection  caused  by  parasites  of  the 
Leishmania  group,  of  which  there  are  three  chief  forms :  the  Indian  kala-azar, 
the  infantile  kala-azar,  and  tropical  sore. 

Indian  Kala-Azar. — An  affection  characterized  by  enlarged  spleen,  anae- 
mia and  irregularly  remittent  fever.  Leishman  in  1900  discovered  the  para- 
site, which  was  subsequently  studied  by  Donovan.  It  i  j  a  protozoon  of  very 
constant  form,  living  in  the  cells  of  the  spleen  and  bone-marrow.  It  has  been 
successfully  cultivated  by  Rogers  and  others,  and  develops  into  a  flagellate 
form. 

Distribution. — The  disease  is  widely  spread  in  Asia,  particularly  in  Assam, 
many  parts  of  India,  Burma,  Indo-China,  Ceylon  and  'Syria.  Europeans 
contract  it  rarely. 

ETIOLOGY. — Rogers  believes  the  bedbug  of  India  is  the  chief  agent  in 
transmitting  it,  a  view  which  Patton  shares,  as  he  found  the  ingested  parasite 
in  the  bedbug  underwent  development  into  flagellate  forms.  Donovan  suggests 
that  the  disease  is  transmitted  by  the  plant-feeding  bug,  the  conorrhinus, 
which  is  an  occasional  blood-sucker. 

SYMPTOMS. — Enlargement  of  the  spleen  is  almost  constant ;  there  is  irreg- 
ular fever,  which  lasts  for  months  and  is  sometimes  characterized  by  a  double 
rise  in  the  twenty-four  hours.  The  other  features  are  those  of  a  progressive 
anaemia  of  a  secondary  type.  Recovery  is  possible,  but  the  mortality  is  above 
80  per  cent. 

Infantile  Kala-Azar. — This  form,  separated  by  Nicole  and  his  associates 
at  Tunis,  is  the  infantile  splenic  anaemia  long  recognized  in  the  countries  of 
the  Mediterranean  basin.  It  differs  from  the  Indian  form  in  attacking  chil- 
dren almost  exclusively,  and  in  the  presence  of  a  parasite  which  differs  from 
the  L.  donovani,  and  which  is  known  as  the  L.  infantum.  Another  special 
feature  is  that  the  disease  may  be  reproduced  in  dogs  and  monkeys  and  a 
spontaneous  infection  of  'dogs  exists  in  the  endemic  areas  of  infantile  Kala- 


RELAPSING   FEVER  261 

Azar.  Observations  strongly  suggest  that  the  disease  is  transmitted  to  chil- 
dren through  the  dog  flea,  or  through  the  human  flea  having  bitten  an  in- 
fected dog. 

Tropical  Sore. — Under  the  various  names  Aleppo  boil,  Delhi  boil,  Bagdad 
sore,  Nile  sore  and  many  others,  has  been  described  a  form  of  disease  charac- 
terized by  ulcerating  and  non-ulcerating  lesions,  almost  always  on  the  exposed 
parts  of  the  body.  The  parasite  discovered  by  Homer  Wright  and  known  as 
Leishmania  tropica  has  very  much  the  same  characters  as  the  other  forms,  but 
there  are  slight  differences,  morphological  and  cultural.  The  mode  of  trans- 
mission has  not  been  definitely  determined. 

Treatment. — For  Indian  kala-azar  not  much  can  be  done.  Quinine  given 
in  the  ordinary  way  seems  useless,  but  from  hypodermic  injections  into 
the  muscles  good  results  are  reported.  Atoxyl  has  been  freely  used.  In  some 
regions  the  natives  insert  a  dirty  seton  in  the  region  of  the  spleen.  Both  for 
this  and  the  infantile  form  salvarsan  has  been  used,  but  with  doubtful  benefit. 
For  the  tropical  sore  dusting  with  potassium  permanganate,  and  a  few  days 
later  applying  a  10  per  cent,  solution  of  Prussian  blue,  has  been  found  useful. 


VI.     RELAPSING   FEVER 

(Febris  recurrens) 

Definition. — A  group  of  specific  infections  caused  by  spirochastes,  charac- 
terized by  febrile  paroxysms  which  usually  last  five  or  six  days  with  remissions 
of  about  the  same  length  of  time.  The  paroxysms  may  be  repeated  three  or 
even  four  times,  whence  the  name  relapsing,  or  recurring,  fever. 

European,  Indian,  American  and  African  forms  are  described  presenting 
clinically  much  the  same  features,  but  the  parasites  differ  in  certain  peculiari- 
ties. 

Etiology. — The  European  form,  which  has  also  the  name  "famine  fever" 
and  "seven-day  fever,"  has  been  known  since  the  early  part  of  the  eighteenth 
century,  and  has  from  time  to  time  extensively  prevailed,  especially  in  Ire- 
land. It  is  a  very  rare  disease  in  England.  In  the  United  States  the  disease 
appeared  in  1844,  when  cases  were  admitted  to  the  Philadelphia  Hospital, 
which  are  described  by  Meredith  Clymer  in  his  work  on  Fevers.  Flint  saw 
cases  in  1850-'51.  In  1869  it  prevailed  extensively  in  epidemic  form  in  New 
York  and  Philadelphia;  since  when  it  has  not  reappeared.  While  clinically 
the  same  as  the  European  form,  the  organism  is  different  and  has  been  called 
S.  novyi. 

In  India,  where  the  disease  is  very  prevalent,  the  parasite  called  after  Van- 
dyke Carter,  differs  from  the  spirochate  of  Obermeier.  Possibly  it  may  be 
transmitted  by  mosquitoes  as  well  as  bugs. 

The  African  relapsing  fever,  known  as  tick  fever,  is  a  very  serious  and 
widespread  affection,  the  parasite  of  which,  S.  duttoni,  is  distinct  from  the 
other  forms.  It  is  transmitted  by  the  tick  Ornithodoros  monbata,  but  as 
Leishman  has  shown,  not  by  direct  inoculation  with  the  salivary  secretion,  but 
from  other  secretions  voided  in  the  act  of  gorging.  The  symptoms  are  very 
similar  to  those  of  European  relapsing  fever,  and  as  many  as  from  five  to 
seven  relapses  may  take  place.  The  mortality  is  not  very  high. 


262 


SPECIFIC    INFECTIOUS    DISEASES 


The  Spirillum  or  spirochaete,  described  by  Obermeier  in  1873,  was  one  of 
the  first  micro-organisms  shown  to  be  definitely  associated  with  a  specific 
fever.  It  is  from  15  to  40  fit.  in  length,  spirally  arranged  like  a  corkscrew, 
sometimes  curved  and  twisted.  The  ends  are  tapering;  whether  furnished 
with  flagella  or  not  is  doubtful.  It  is  actively  motile,  and  it  is  present  in  the 
blood  during  the  febrile  paroxysm,  disappearing  at  intervals. 

The  mode  of  transmission  of  the  disease  is  probably  through  lice  and  bed 
bugs.  The  disease. has  been  reproduced  by  injecting  into  a  healthy  monkey 
blood  sucked  by  a  bug  from  an  infected  animal.  The  special  conditions  under 
which  it  occurs  are  similar  to  those  of  typhus  fever.  Neither  age,  sex,  nor 
season  seems  to  have  any  special  influence.  One  attack  does  not  confer 
immunity  from  subsequent  attacks. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  appearances  in 
relapsing  fever.  If  death  takes  place  during  the  paroxysm  the  spleen  is  large 
and  soft,  and  the  liver,  kidneys  and  heart  show  cloudy  swelling.  There  may 
be  infarcts  in  the  kidneys  and  spleen.  The  bone-marrow  has  been  found  in  a 
condition  of  hyperplasia.  Ecchymoses  are  not  uncommon. 

Symptoms. — The  incubation  appears  to  be  short;  in  some  instances  the 
attack  occurs  within  twelve  hours  after  exposure;  more  frequently,  however, 
from  five  to  seven  days  elapse. 

The  invasion  is  abrupt,  with  chill,  fever,  and  intense  pain  in  the  back 
and  limbs.  In  young  persons  there  may  be  nausea,  vomiting,  and  convulsions. 
The  temperature  rises  rapidly  and  may  reach  104°  on  the  evening  of  the  first 
day.  Sweats  are  common.  The  pulse  is  rapid,  ranging  from  110  to  130. 
There  may  be  delirium  if  the  fever  is  high.  Swelling  of  the  spleen  can  be 
detected  early.  Jaundice  is  common  in  some  epidemics.  The  gastric  symp- 
toms may  be  severe,  but  there  are  seldom  intestinal  symptoms.  Cough  may 


Hi 


CHAET  VIII. — EELAPSINO  FEVER  (Murchison). 

be  present.  Occasionally  herpes  is  noted,  and  there  may  be  miliary  vesicles 
and  petechiffi.  During  the  paroxysm  the  blood  invariably  shows  the  spiro- 
chaste,  and  there  is  usually  a  leucocytosis.  After  the  fever  has  persisted  with 
severity  or  even  with  an  increasing  intensity  for  five  or  six  days  the  crisis 
occurs.  In  the  course  of  a  few  hours,  accompanied  by  profuse  sweating,  some- 


SYPHILIS  2G3 

times  by  diarrhoea,  the  temperature  falls  to  normal  or  even  subnormal,  and 
the  period  of  apyrexia  begins. 

The  crisis  may  occur  as  early  as  the  third  day,  or  it  may  be  delayed  to 
the  tenth;  it  usually  comes,  however,  about  the  end  of  the  first  week.  In 
delicate  and  elderly  persons  there  may  be  collapse.  The  convalescence  is  rapid, 
and  in  a  few  days  the  patient  is  up  and  about.  Then  in  a  week,  usually  on 
the  fourteenth  day,  he  again  has  a  rigor,  or  a  series  of  chills ;  the  fever  returns 
and  the  attack  is  repeated.  A  second  crisis  occurs  from  the  twentieth  to  the 
twenty-third  day,  and  again  the  patient  recovers  rapidly.  As  a  rule,  the 
relapse  is  shorter  than  the  original  attack.  A  second  and  a  third  may  occur, 
and  there  are  instances  on  record  of  even  a  fourth  and  a  fifth.  In  epidemics 
there  are  cases  which  terminate  by  crisis  on  the  seventh  or  eighth  day  without 
the  occurrence  of  relapse.  In  protracted  cases  the  convalescence  is  very  tedi- 
ous, as  the  patient  is  much  exhausted. 

Eelapsing  fever  is  not  a  very  fatal  disease.  Murchison  states  that  the  mor- 
tality is  about  4  per  cent.,  but  it  has  been  as  high  as  30  per  cent,  in  India.  In 
the  enfeebled  and  old,  death  may  occur  at  the  height  of  the  first  paroxysm. 

Complications  are  not  frequent.  In  some  epidemics  haematemesis  and 
hasmaturia  have  occurred.  Pneumonia  is  not  infrequent.  The  acute  enlarge- 
ment of  the  spleen  may  end  in  rupture.  Post-febrile  paralyses  may  occur. 
Ophthalmia  has  followed  in  certain  epidemics,  and  may  prove  a  very  tedious 
and  serious  complication.  In  pregnant  women  abortion  usually  takes  place. 
Convulsions  occasionally  follow.  Dutton,  the  well-known  worker  on  tropical 
diseases,  died  in  status  epilepticus  some  weeks  after  the  attack. 

Diagnosis.  — The  onset  and  general  symptoms  may  not  at  first  be  dis- 
tinctive. At  the  beginning  of  an  epidemic  the  cases  are  usually  regarded  as 
anomalous  typhoid;  but  once  the  typical . course  is  followed  in  a  case  the 
diagnosis  is  clear.  The  blood  examination  is  distinctive. 

Prophylaxis. — As  overcrowding  is  an  important  element  in  the  transmis- 
sion, the  patient  should  be  isolated.  The  bedding,  clothing,  and  dwellings 
of  infected  persons  should  be  thoroughly  disinfected  and  care  taken  that  all 
cracks  and  crevices  in  woodwork  which  may  harbor  bedbugs  are  treated  with 
disinfectants. 

Treatment. — The  paroxysm  can  neither  be  cut  short  nor  can  its  recur- 
rence be  prevented.  The  disease  must  be  treated  like  any  other  continued 
fever,  by  careful  nursing,  a  regular  diet,  and  ordinary  hygienic  measures. 
Of  special  symptoms,  pain  in  the  back  and  in  the  limbs  and  joints  demands 
opium.  In  enfeebled  persons  the  collapse  at  the  crisis  may  be  serious,  and 
stimulants  with  ammonia  and  digitalis  should  be  given  freely.  The  arsenical 
preparations  may  be  tried,  but  they  have  not  been  very  successful. 


VII.     SYPHILIS 

I.     HISTOEY,  ETIOLOGY  AND  MORBID  ANATOMY 

Definition. — A  specific  disease  of  slow  evolution  caused  by  Treponema 
pallidum,  propagated  by  inoculation  (acquired  syphilis)  or  transmission 
through  the  mother  (congenital  syphilis). 


264  SPECIFIC    INFECTIOUS    DISEASES 

History. — Whether  the  disease  was  known  in  Europe  before  1493  is  still 
discussed.  Block,  in  the  System  of  Syphilis,  Vol.  I,  1908,  insists  that  there 
is  no  evidence  of  pre-Columbian  syphilis  in  the  Eastern  hemisphere  before 
the  return  of  the  Spanish  sailors  from  Hayti,  from  whom  it  spread  among 
the  inhabitants  of  Barcelona.  In  1493  it  reached  Italy  with  the  army  of 
Charles  VIII.  His  soldiers  syphilized  Naples;  the  disease  spread  throughout 
Italy,  and  in  a  few  years  Europe  was  aflame.  On  the  other  hand,  writers  who 
contend  for  the  antiquity  of  the  disease  in  Asia  and  Europe  rely  on  certain 
old  Chinese  records,  on  references  in  the  Bible  and  in  old  medical  writers  to 
diseases  resembling  syphilis  and  on  suggestive  bone  lesions  in  very  old  skele- 
tons. The  balance  of  evidence,  according  to  the  best  syphilographers,  is  in 
favor  of  the  American  origin.  At  first  it  was  called  the  Neapolitan  disease, 
the  French  pox,  or  Morbus  Gallicus;  and  in  1530  Fracastorius,  in  a  poem 
entitled  "Syphilis  sive  Morbus  Gallicus,"  gave  it  the  name  by  which  it  is  now 
commonly  known.  The  etymology  of  the  name  is  uncertain. 

At  first  the  disease  was  thought  to  be  transmitted  like  any  other  epidemic, 
but  gradually  the  venereal  nature  was  recognized,  and  Fernel,  a  famous  Paris 
physician  of  the  16th  century,  insisted  on  the  necessity  of  a  primary  inocula- 
tion. Paracelsus  observed  its  hereditary  character.  Throughout  the  16th 
'century  the  symptoms  were  well  described.  The  disease  appears  to  have  been 
of  much  .greater  severity  then  than  at  present.  Mercury  and  guaiacum  were 
introduced  as  the  important  remedies.  In  the  18th  century  Lancisi  recognized 
the  relations  existing  between  syphilis  and  aneurism,  and  Morgagni  described 
many  of  the  visceral  lesions.  Hunter,  misled  by  inoculations  made  on  his 
own  person,  decided  in  favor  of  the  unity  of  the  venereal  poisons,  gonor- 
rhoea, soft  chancre  and  syphilis.  Eicord  clearly  differentiated  the  soft  and 
hard  chancre,  and  throughout  the  19th  century  the  clinical  and  pathological 
lesions  were  so  thoroughly  studied  that  scarcely  a  feature  of  the  disease 
remained  unknown.  But  all  efforts  at  discovering  the  cause  had  failed,  until 
in  1905  Schaudinn  demonstrated  the  presence  of  a  spirochaete  in  the  lesions. 
Since  then  his  work  has  been  amply  verified,  and  in  1910'  Ehrlich  announced 
the  discovery  of  a  compound  which  would  destroy  the  parasite  and  not  damage 
the  individual. 

Etiology:  The  Parasite. — The  treponema  is  a  spiral,  curved  organism 
from  5  to  15  A*  in  length,  showing  active  movements  in  fresh  specimens.  It 
is  present  in  the  primary  sore,  in  the  regional  lymph  glands,  in  the  secondary 
lesions,  in  many  gummata,  and  in  special  abundance  in  the  congenital  lesions, 
particularly  in  the  liver.  Its  presence  in  the  body  has  been  demonstrated  as 
long  as  15  to  20  years  after  the  primary  infection.  It  is  inoculable  into  mon- 
keys, with  the  production  of  a  disease  resembling  in  most  particulars  that  of 
man.  The  parasite  has  been  successfully  cultivated  by  Noguchi. 

One  of  the  most  important  results  of  the  discovery  of  the  parasite  has 
been  the  application  of  the  newer  methods  of  serum  diagnosis.  What  is 
called  the  Wassermann  reaction  is  a  special  way  of  determining  the  presence 
of  immune  bodies  in  the  blood  of  a  patient  suffering  from  any  syphilitic  in- 
fection. An  enormous  amount  of  work  has  been  done  upon  it  within  the  past 
few  years  with  the  general  result  of  confirming  its  value  in  diagnosis.  A 
positive  result  has  been  obtained  in  from  90  to  95  per  cent,  of  all  cases.  It 
appears  from  the  end  of  the  second  to  the  end  of  the  fourth  week,  becomes 


SYPHILIS  265 

more  marked  and  may  continue  for  an  indefinite  period.  During  active  treat- 
ment it  may  be  absent,  to  reappear  again.  Its  intensity  bears  some  relation  to 
the  activity  of  the  lesions.  A  positive  result  has  been  found  in  a  large  pro- 
portion of  cases  of  locomotor  ataxia,  and  in  paralysis  of  the  insane. 

Modes  of  Infection.  —  (a)  In  a  large  majority  of  all  cases  the  disease  is 
transmitted  by  sexual  congress,  but  the  designation  venereal  disease  (lues 
venerea)  is  not  always  correct,  as  there  are  many  other  modes  of  inoculation. 
In  the  St.  Louis  Hospital  collection  there  are  illustrations  of  26  varieties  of 
extragenital  chancres. 

(&)  Accidental  Infection. — In  surgical  and  in  midwifery  practice  phy- 
sicians are  not  infrequently  inoculated.  General  infection  may  occur  without 
a  characteristic  local  sore.  Midwifery  chancres  are  usually  on  the  fingers,  but 
they  may  be  on  the  back  of  the  hand.  The  lip  chancre  is  the  most  common 
of  these  erratic  or  extra-genital  forms,  and  may  be  acquired  in  many  ways 
apart  from  direct  infection.  Mouth  and  tonsillar  sores  result  as  a  rule  from 
improper  practices.  Wet-nurses  are  sometimes  infected  on  the  nipple,  and  it 
occasionally  happens  that  relatives  of  a  syphilitic  child  are  accidentally  con- 
taminated. 

(c)  Congenital  Transmission. — The  disease  is  not  directly  inherited,  but 
the  fetus  is  infected  through  the  placenta.  It  is  a  question  entirely  of  intra- 
uterine  infection.  The  mother  herself  may  be,  and  often  is,  apparently  quite 
healthy,  but,  as  recent  observations  have  shown,  the  Wassermann  reaction  is 
present  and  it  is  through  her  and  not  directly  through  the  father  that  the 
disease  is  transmitted.  We  can  now  understand  what  is  known  as  Beaumes' 
or  Colles'  law,  which  was  thus  stated  by  the  distinguished  Dublin  surgeon: 
"That  a  child  born  of  a  mother  who  is  without  obvious  venereal  symptoms, 
and  which,  without  being  exposed  to  any  infection  subsequent  to  its  birth, 
shows  this  disease  when  a  few  weeks  old,  this  child  will  infect  the  most 
healthy  nurse,  whether  she  suckle  it,  or  merely  handle  and  dress  it;  and  yet 
this  child  is  never  known  to  infect  its  own  mother,  even  though  she  suckle  it 
while  it  has  venereal  ulcers  of  the  lips  and  tongue."  So,  too,  a  child  showing 
no  taint,  but  born  of  a  woman  suffering  with  syphilis,  may  with  impunity  be 
suckled  by  its  mother  (Profeta's  law). 

Morbid  Anatomy. — The  primary  lesion,  or  chancre,  shows:  (a)  A  diffuse 
infiltration  of  the  connective  tissue  with  small,  round  cells.  (&)  Larger  epi- 
thelioid  cells,  (c)  Giant  cells,  (d)  Changes  in  the  small  arteries  and  veins, 
chiefly  thickening  of  the  intima,  and  alterations  in  the  nerve  fibres  going  to 
the  part.  The  sclerosis  is  due  in  part  to  this  acute  obliterative  endarteritis. 
Associated  with  the  initial  lesions  are  changes  in  the  adjacent  lymph  glands, 
which  undergo  hyperplasia,  and  finally  become  indurated. 

The  secondary  lesions  of  syphilis  are  too  varied  for  description  here.  They 
consist  of  condylomata,  skin  eruptions,  affections  of  the  eye,  etc. 

The  tertiary  lesions  consist  of  circumscribed  tumors  known  as  gummata, 
various  skin  lesions,  and  a  special  type  of  arteritis. 

Gummata. — Syphilomata  occur  in  the  bones  or  periosteum — here  they  are 
called  nodes — in  the  muscles,  skin,  brain,  lungs,  liver,  kidneys,  heart,  testes, 
and  adrenals.  They  vary  in  size  from  small,  almost  microscopic  bodies  to 
large  solid  tumors  from  3  to  5  cm.  in  diameter.  They  are  usually  firm  and 
hard,  but  in  the  skin  and  on  the  mucous  membranes  they  tend  to  break  down 
19 


266  SPECIFIC    INFECTIOUS    DISEASES 

rapidly  and  ulcerate.    On  cross-section  a  medium-sized  gumma  has  a  grayish- 
white,  homogeneous  appearance,  presenting  in  the  centre  a  firm,  caseous  sub- 
stance, and  at  the  periphery  a  translucent,  fibrous  tissue.     Often  there  are 
groups  of  three  or  more  surrounded  by  dense  sclerotic  tissue. 
The  arteritis  will  be  considered  in  a  separate  section. 

II.    ACQUIRED   SYPHILIS 

Primary  Stage. — This  extends  from  the  appearance  of  the  initial  sore  un- 
til the  onset  of  the  constitutional  symptoms,  and  has  a  variable  duration  of 
from  six  to  twelve  weeks.  The  initial  sore  appears  within  a  month  after 
inoculation,  and  it  first  shows  itself  as  a  small  red  papule,  which  gradually 
enlarges  and  breaks  in  the  centre,  leaving  a  small  ulcer.  The  tissue  about 
this  becomes  indurated  so  that  it  ultimately  has  a  gristly,  cartilaginous  con- 
sistence— hence  the  name,  hard  or  indurated  chancre.  The  size  attained  is 
variable,  and  when  small  the  sore  may  be  overlooked,  particularly  if  it  is  just 
within  the  urethra.  The  initial  lesion  has  no  invariable  characteristic  and 
may  not  be  indurated.  Syphilitic  infection  may  occur  with  a  chancroid.  The 
glands  in  the  lymph-district  of  the  chancre  enlarge  and  become  hard.  Sup- 
puration both  in  the  initial  lesion  and  in  the  glands  may  occur  as  a  secondary 
change.  The  general  condition  of  the  patient  in  this  stage  is  good.  There 
may  be  no  fever  and  no  impairment  of  health. 

Secondary  Stage. — The  first  constitutional  symptoms  are  usually  mani- 
fested within  three  months  of  the  appearance  of  the  primary  sore.  They 
rarely  occur  earlier  than  the  sixth  or  later  than  the  twelfth  week : 

(a)  Fever,  slight  or  intense,  and  very  variable  in  character,  may  occur 
early  before  the  skin  rash ;  more  frequently  it  is  the  "fever  of  invasion"  with 
the  secondary  symptoms,  or  the  fever  may  occur  at  any  period.  It  may  be  a 
mild  continuous  pyrexia,  or  in  other  instances  with  marked  remissions,  but  the 
most  remarkable  form  is  the  intermittent,  often  mistaken  for  malaria.  Such 
cases  have  been  reported  by  Yeo  and  by  Sidney  Phillips.  The  fever  may 
reach  105°  and  the  paroxysms  persist  for  months.  I  have  had  several  cases  in 
which  typhoid  fever  was  suspected,  and  in  others  tuberculosis. 

(6)  Ancemia. — In  many  cases  the  syphilitic  poison  causes  a  pronounced 
anaemia  which  gives  to  the  face  a  muddy  pallor,  and  there  may  even  be  a 
light-yellow  tinging  of  the  conjunctiva?  or  of  the  skin,  a  hasmatogenous  icterus. 
This  syphilitic  cachexia  may  in  some  instances  be  extreme.  The  red  blood 
corpuscles  do  not  show  any  special  alterations.  The  blood  count  may  fall  to 
three  millions  per  cubic  millimetre,  or  even  lower.  The  anaemia  may  come 
on  suddenly.  In  a  case  of  syphilitic  arthritis  in  a  young  girl,  following  three 
or  four  inunctions  of  mercury,  the  blood-count  fell  below  two  millions  per 
cubic  millimetre  in  a  few  days. 

(c)  Cutaneous  Lesions. — The  earliest  and  most  common  is  a  macular 
syphilide  or  syphilitic  roseola,  which  occurs  on  the  trunk,  and  on  the  front  of 
the  arms.  The  face  is  often  exempt.  The  spots,  which  are  reddish-brown 
and  symmetrically  arranged,  persist  for  a  week  or  two.  There  may  be  mul- 
tiple relapses  of  roseola,  sometimes  at  long  intervals,  even  eleven  years  ( Four- 
nier).  The  papular  syphilide,  which  forms  acne-like  indurations  about  the 
face  and  trunk,  is  often  arranged  in  groups.  Other  forms  are  the  pustular 


SYPHILIS  267 

rash,  which  may  closely  simulate  variola.  A  squamous  syphilide  occurs,  not 
unlike  ordinary  psoriasis,  except  that  the  scales  are  less  abundant.  The  rash 
is  more  copper-colored  and  not  specially  confined  to  the  extensor  surfaces. 

In  the  moist  regions  of  the  skin,  such  as  the  perineum  and  groins,  the 
axilla?,  between  the  toes,  and  at  the  angles  of  the  mouth,  the  so-called  mucous 
patches  occur,  which  are  flat,  warty  outgrowths,  with  well-defined  margins  and 
surfaces  covered  with  a  grayish  secretion.  They  are  among  the  most  dis- 
tinctive lesions  of  syphilis. 

Frequently  the  hair  falls  out  (alopecia),  either  in  patches  or  by  a  general 
thinning.  Occasionally  the  nails  become  affected  (syphilitic  onychia). 

(d)  Mucous  Lesions. — With  the  fever  and  the  roseolous  rash  the  throat 
and  mouth  become  sore.     The  pharyngeal  mucosa  is  hyperaemic,  the  tonsils  are 
swollen  and  often  present  small,  kidney-shaped  ulcers  with  grayish-white 
borders.     Mucous  patches  are  seen  on  the  inner  surfaces  of  the  cheeks  and  on 
the  tongue  and  lips.     Hypertrophy  of  the  papilla  in  various  portions  of  the 
mucous  membrane  produces  the  syphilitic  warts  or  condylomata  which  are 
most  frequent  about  the  vulva  and  anus. 

(e)  Adenitis. — The  glands  are  hard,  painless  and  not  much  enlarged.    In- 
volvement of  the  epitrochlear  and  posterior  cervical  glands  is  specially  signifi- 
cant. 

(f)  Arthritis  and  pains  in  the  limbs  are  common  secondary  symptoms. 
Occasionally  the  joint  affection  is  severe  and  rheumatic  fever  is  suspected. 

(</)  Other  Lesions. — Iritis  is  common,  and  usually  affects  one  eye  before 
the  other.  It  comes  on  from  three  to  six  months  after  the  chancre.  There 
may  be  only  slight  ciliary  congestion  in  mild  cases,  but  in  severer  forms  there 
is  great  pain,  and  the  condition  is  serious  and  demands  careful  management. 
Choroiditis  and  retinitis  are  rare  secondary  symptoms.  Ear  affections  are  not 
common  in  the  secondary  stage,  but  instances  are  found  in  which  sudden  deaf- 
ness occurs,  which  may  be  due  to  labyrinthine  disease;  more  commonly  the 
impaired  hearing  is  due  to  the  extension  of  inflammation  from  the  throat  to 
the  middle  ear.  Epididymitis  and  parotitis  are  rare.  Jaundice  may  occur,  the 
icterus  syphiliticus  prcecox.  The  acute  nephritis  will  be  referred  to  later. 

Tertiary  Stage. — Xo  hard  and  fast  line  can  be  drawn  between  the  lesions 
of  the  secondary  and  those  of  the  tertiary  period ;  and,  indeed,  in  exceptional 
cases,  manifestations  which  usually  appear  late  may  set  in  even  before  the 
primary  sore  has  properly  healed.  The  special  affections  of  this  stage  are  cer- 
tain skin  eruptions,  visceral  gummata,  and  amyloid  degenerations. 

(a)  The  late  syphilides  show  a  greater  tendency  to  ulceration  and  destruc- 
tion of  the  deeper  layers  of  the  skin,  so  that  in  healing  scars  are  left.     They 
are  also  more  scattered  and  seldom  symmetrical.     One  of  the  most  character- 
istic of  the  syphilides  is  rupia,  the  dry  stratified  crusts  of  which  cover  an  ulcer 
which  involves  the  deeper  layers  of  the  skin  and  in  healing  leaves  a  scar. 

(b)  Gummata. — These  may  occur  in  the  skin,  subcutaneous  tissue,  mus- 
cles, or  internal  organs.     The  general  character  has  been  already  described. 
In  the  skin  they  tend  to  break  down  and  ulcerate,  leaving  ugly  sores  which 
heal  with  difficulty.     In  the  solid  organs  they  undergo  fibroid  transformation 
and  produce  puckering  and  deformity.     On  the  mucous  membranes  these  ter- 
tiary  lesions   lead  to   ulceration,   in   the   healing   of   which   cicatrices    are 
formed ;  thus,  in  the  larynx  great  narrowing  may  result,  and  in  the  rectum 


268 

ulceration  with  fibroid  thickening  and  retraction  may  lead  to  stricture.    Gum- 
matous  ulcers  may  be  infective. 

(c)  Amyloid  Degeneration. — Syphilis  plays  a  most  important  role  in  the 
production  of  this  affection.  Of  244  instances  analyzed  by  FaggQ,  76  had 
syphilis,  and  of  these  42  had  no  bone  lesions.  It  follows  the  acquired  form  and 
is  very  common  in  association  with  rectal  syphilis  in  women.  In  congenital 
lues  amyloid  degeneration  is  rare. 

Quaternary  Stage.  — Long  years  it  may  be  from  the  primary  sore  and  from 
any  active  manifestations,  certain  diseases  may  follow,  termed  meta-  or  para- 
syphilitic  affections,  the  chief  of  which  are  locomotor  ataxia  and  dementia 
paralytica.  Since  the  introduction  of  the  Wassermann  reaction  these  are 
regarded  as  definitely  syphilitic,  dependent  upon  the  parasite  itself  or  in  some 
unknown  way  upon  its  poison. 

III.     CONGENITAL  SYPHILIS 

With  the  exception  of  the  primary  sore,  every  feature  of  the  acquired  dis- 
ease may  be  seen  in  the  congenital  form. 

The  intra-uterine  conditions  leading  to  the  death  of  the  fetus  do  not  here 
concern  us.  The  child  may  be  born  healthy-looking,  or  with  well-marked  evi- 
dences of  the  disease.  In  the  majority  of  instances  the  former  is  the  case 
and  within  the  first  month  or  two  the  signs  of  the  disease  appear. 

Symptoms.— (a)  At  Birth. — When  the  disease  exists  at  birth  the  child 
is  feebly  developed  and  wasted,  and  a  skin  eruption  is  usually  present,  com- 
monly in  the  form  of  bullas  about  the  hands  and  feet  (pemphigus  neonatorum 
syphiliticus).  The  child  snuffles,  the  lips  are  ulcerated,  the  angles  of  the 
mouth  fissured,  and  there  is  enlargement  of  the  liver  and  spleen.  The  bone 
symptoms  may  be  marked,  and  the  epiphyses  may  even  be  separated.  In  such 
cases  the  children  rarely  survive  long. 

(&)  Early  Manifestations. — When  born  healthy  the  child  thrives,  is  fat 
and  plump,  and  shows  no  abnormity  whatever ;  then  from  the  fourth  to  the 
eighth  week,  rarely  later,  a  nasal  catarrh  occurs,  syphilitic  rhinitis,  which  im- 
pedes respiration,  and  produces  the  characteristic  symptom  which  has  given 
the  name  snuffles  to  the  disease.  The  discharge  may  be  sero-purulent  or 
bloody.  The  child  nurses  with  great  difficulty.  In  severe  cases  ulceration 
takes  place  with  necrosis  of  the  bone,  leading  to  a  depression  at  the  root  of  the 
nose  and  a  deformity  characteristic  of  congenital  syphilis.  This  coryza  may 
be  mistaken  at  first  for  an  ordinary  catarrh,  but  the  coexistence  of  other  mani- 
festations usually  makes  the  diagnosis  clear.  The  disease  may  extend  into 
the  Eustachian  tube  and  middle  ears  and  lead  to  deafness. 

The  cutaneous  lesions  arise  with  or  shortly  after  the  onset  of  the  snuf- 
fles. The  skin  often  has  a  sallow,  earthy  hue.  The  eruptions  are  first  no- 
ticed about  the  nates.  There  may  be  an  erythema  or  an  eczematous  condition, 
but  more  commonly  there  are  irregular  reddish-brown  patches  with  well- 
defined  edges.  A  papular  syphilide  in  this  region  is  by  no  means  uncommon. 
Fissures  occur  about  the  lips,  either  at  the  angles  of  the  mouth  or  in  the 
median  line.  These  rhagades,  as  they  are  called,  are  very  characteristic. 
There  may  be  marked  ulceration  of  the  muco-cutaneous  surfaces.  The  secre- 
tions from  these  mouth  lesions  are  very  virulent,  and  it  is  from  this  source  that 


SYPHILIS  269 

the  wet-nurse  is  usually  infected.  Not  only  the  nurse,  but  members  of  the 
family,  may  be  contaminated.  There  are  instances  in  which  other  children 
have  been  accidentally  inoculated  from  a  syphilitic  infant.  The  hair  of  the 
head  or  of  the  eyebrows  may  fall  out.  The  syphilitic  onychia  is  not  uncom- 
mon. Enlargement  of  the  glands  is  not  so  frequent  in  the  congenital  as  in 
the  acquired  disease.  When  the  cutaneous  lesions  are  marked  the  contiguous 
glands  can  usually  be  felt.  As  pointed  out  by  Gee,  the  spleen  is  enlarged  in 
many  cases.  The  condition  may  persist  for  a  long  time.  Enlargement  of  the 
liver,  though  often  present,  is  less  significant,  since  in  infants  it  may  be  due 
to  various  causes.  These  are  among  the  most  constant  symptoms  of  congenital 
syphilis,  and  usually  arise  between  the  third  and  twelfth  weeks.  Frequently 
they  are  preceded  by  a  period  of  restlessness  and  wakefulness,  particularly  at 
night.  Some  authors  have  described  a  peculiar  syphilitic  cry,  high-pitched 
and  harsh.  Among  rarer  manifestations  are  hemorrhages — the  syphilis  hce- 
morrhagica  neonatorum.  The  bleeding  may  be  subcutaneous,  from  the  mu- 
cous surfaces,  or,  when  early,  from  the  umbilicus.  All  of  such  cases,  however, 
are  not  syphilitic,  and  the  disease  must  not  be  confounded  with  the  acute 
haemoglobinuria  of  new-born  infants.  E.  Fournier  has  described  a  remarkable 
enlargement  of  the  subcutaneous  veins. 

(c)  Late  Manifestations. — Children  with  congenital  syphilis  rarely  thrive. 
Usually  they  present  a  wizened,  wasted  appearance,  and  a  prematurely  aged 
face.  In  the  patients  who  recover  the  general  nutrition  may  remain  good 
and  the  child  may  show  no  further  manifestations  of  the  disease;  commonly, 
however,  at  the  period  of  second  dentition  or  at  puberty  the  disease  reappears. 
Although  the  child  may  have  recovered  from  the  early  lesions,  it  does  not 
develop  like  other  children.  Growth  is  slow,  development  tardy,  and  there  are 
facial  and  cranial  characteristics  which  often  render  the  disease  recognizable 
at  a  glance.  A  young  man  of  nineteen  or  twenty  may  neither  look  older  nor 
be  more  developed  than  a  boy  of  ten  or  twelve.  Fournier  describes  this  condi- 
tion as  infantilism.  The  forehead  is  prominent,  the  frontal  eminences  are 
marked,  and  the  skull  may  be  very  asymmetrical.  The  bridge  of  the  nose  is 
depressed,  the  tip  retrousse.  The  lips  are  often  prominent,  and  there  are 
striated  lines  running  from  the  corners  of  the  mouth.  The  teeth  are  deformed 
and  may  present  appearances  which  Jonathan  Hutchinson  claims  are  specific 
and  peculiar.  The  upper  central  incisors  of  the  permanent  set  are  peg-shaped, 
stunted  in  length  and  breadth,  and  narrower  at  the  cutting  edge  than  at  the 
root.  On  the  anterior  surface  the  enamel  is  well  formed,  and  not  eroded  or 
honeycombed.  At  the  cutting  edge  there  is  a  single  notch,  usually  shallow, 
sometimes  deep,  in  which  the  dentine  is  exposed. 

Among  late  manifestations,  particularly  apt  to  appear  about  puberty,  is 
the  interstitial  keratitis,  which  usually  begins  as  a  slight  steaminess  of  the 
cornea?,  which  present  a  ground-glass  appearance.  It  affects  both  eyes,  though 
one  is  attacked  before  the  other.  It  may  persist  for  months,  and  usually  clears 
completely,  though  it  may  leave  opacities,  which  prevent  clear  vision.  Iritis 
may  also  occur.  Of  ear  affections,  apart  from  those  which  follow  the  pharyn- 
geal  disease,  a  form  occurs,  about  the  time  of  puberty  or  earlier,  in  which 
deafness  comes  on  rapidly  and  persists  in  spite  of  all  treatment.  It  is  unasso- 
ciated  with  obvious  lesions,  and  is  probably  labyrinthine  in  character.  Bone 
lesions,  occurring  oftenest  after  the  sixth  year,  are  not  rare  among  the  late 


270  SPECIFIC    INFECTIOUS    DISEASES 

manifestations  of  hereditary  syphilis.  The  tibiae  are  most  frequently  attacked. 
It  is  really  a  chronic  gummatous  periostitis,  which  gradually  leads  to  great 
thickening  of  the  bone.  The  nodes  of  congenital  syphilis,  which  are  often 
mistaken  for  rickets,  are  more  commonly  diffuse  and  affect  the  bones  of  the 
upper  and  lower  extremities.  They  are  generally  symmetrical  and  rarely  pain- 
ful. They  may  occur  late,  even  after  the  twenty-first  year. 

Joint  lesions  are  rare.  Glutton  has  described  a  symmetrical  synovitis  of 
the  knee  in  hereditary  syphilis.  Enlargement  of  the  spleen,  sometimes  with 
the  lymph-glands,  may  be  one  of  the  late  manifestations,  and  may  occur  either 
alone  or  in  connection  with  disease  of  the  liver. 

Gummata  of  the  liver,  brain,  and  kidneys  have  been  found  in  late  hered- 
itary syphilis.  General  paresis  may  follow. 

/*  syphilis  transmitted  to  the  third  generation?  Opinion  on  this  subject 
is  divided.  Occasionally  cases  of  pronounced  congenital  syphilis  are  met  with 
in  the  children  of  parents  who  are  perfectly  healthy,  and  who  have  not,  so  far 
as  is  known,  had  syphilis;  and  yet,  as  remarked  by  Coutts  in  reporting  such  a 
group  of  cases,  they  do  not  always  bear  careful  scrutiny.  E.  Fournier,  in  his 
L'Heredo-Syphilis  Tardive  (1907),  cites  interesting  examples  which  appear 
to  prove  the  transmission  to  the  third  generation,  and  this  appears  to  be  the 
view  of  the  French  syphilographers.  Sir  Jonathan  Hutchinson  was  opposed 
to  this  view. 

IV.     VISCERAL  SYPHILIS 
1.  Syphilis  of  the  Brain  and  Cord 

Pathology. — There  are  three  anatomical  changes  in  the  central  nervous 
system — new  growths,  arteritis,  and  chronic  degenerative  (sclerotic)  pro- 
cesses. 

(a)  The  new  formations  or  gummata  form  definite  tumors,  ranging  in 
size  from  a  pea  to  a  walnut,  usually  multiple  and  attached  to  the  pi  a  mater, 
sometimes  to  the  dura.  Very  rarely  they  are  found  unassociated  with  the 
meninges.  When  small  they  present  a  uniform,  translucent  appearance,  but 
when  large  the  centre  undergoes  a  fibro-caseous  change,  while  at  the  periphery 
there  is  a  firm,  translucent,  grayish  tissue.  They  may  resemble  large  tubercu- 
lous tumors.  The  growths  are  most  common  in  the  cerebrum.  They  may  be 
multiple  and  may  even  attain  a  considerable  size  without  becoming  caseous. 
Occasionally  gummata  undergo  cystic  degeneration.  In  the  cord  large  growths 
are  not  so  common. 

In  the  neighborhood  of  the  growths  gummous  meningitis  occurs,  in  which 
all  the  membranes  are  involved.  This  is  more  common  at  the  base,  about  the 
chiasma  and  the  interpeduncular  space,  and  along  the  Sylvian  fissures. 

(&)  Arteritis  occurs  in  the  form  of  nodular  tumors  on  the  vessels,  which 
may  break  down  or  lead  to  rupture,  or  there  is  a  progressive  obliterative  en- 
darteritis. 

(c)  Degenerative  fibroid  changes,  not  distinctive  anatomically,  but  clin- 
ically directly  connected  with  the  disease,  are  known  as  post-  or  meta-syphi- 
litic. 

Secondary  Changes. — In  the  brain  gummatous  arteritis  is  one  of  the  com- 
mon causes  of  softening,  which  may  be  extensive,  as  when  the  middle  cerebral 


SYPHILIS  271 

artery  is  involved,  or  when  there  is  a  large  patch  of  meningitis.  In  such 
instances  the  process  is  really  a  meningo-encephalitis,  and  the  symptoms  are 
due  to  the  secondary  changes,  not  directly  to  the  gumma.  In  the  neighborhood 
of  the  gumma  intense  encephalitis  or  myelitis  may  occur,  and  within  a  few 
days  change  the  clinical  picture. 

Syphilitic  disease  of  the  nerve-centres  occurs  usually  in  the  acquired  form. 
In  the  congenital  cases  the  tumors  usually  occur  early,  but  may  be  as  late  as 
the  twenty-first  year.  Of  late  years  it  has  been  recognized  that  the  nervous 
lesions  may  occur  very  early  in  the  disease,  even  before  the  induration  of  the 
primary  sore  has  gone.  In  a  majority  of  the  cases  brain  symptoms  come  on 
within  three  or  four  years  after  infection. 

Symptoms. — The  chief  features  of  cerebral  syphilis  are  those  of  tumor 
cerebri,  which  will  be  considered  later.  They  may  be  classified  here  as  follows : 

(a)  Psychical  features.  A  sudden  and  violent  onset  of  delirium  may  be 
the  first  symptom.  In  other  instances  prior  to  the  occurrence  of  delirium 
there  have  been  headache,  alteration  of  character,  and  loss  of  memory.  The 
condition  may  be  accompanied  by  convulsions.  There  may  be  no  neuritis,  no 
palsy,  and  no  localizing  symptoms. 

(&)  More  commonly  following  headache,  giddiness,  or  an  excited  state 
which  may  amount  to  delirium,  the  patient  has  an  epileptic  seizure  or  a  hemi- 
plegic  attack,  or  there  is  involvement  of  the  nerves  of  the  base.  Some  of  these 
cases  display  a  prolonged  torpor,  a  special  feature  of  brain  syphilis  to  which 
both  Buzzard  and  Huebner  have  referred,  which  may  persist  for  a  month. 

(c)  In  some  cases  the  clinical  picture  is  that  of  dementia  paralytica. 

(d)  Many  cases  of  cerebral  syphilis  display  the  symptoms  of  brain  tumor 
— headache,  optic  neuritis,  vomiting,  and  convulsions.     Of  these  symptoms 
convulsions  are  the  most  important,  and  both  Fournier  and  Wood  have  laid 
great  stress  on  the  value  of  this  symptom  in  persons  over  thirty.     The  first 
symptoms  may,  however,  rather  resemble  those  of  embolism  or  thrombosis; 
thus  there  may  be  sudden  hemiplegia,  with  or  without  loss  of  consciousness. 

The  symptoms  of  spinal  syphilis  are  extremely  varied  and  may  be  caused 
by  large  gummatous  growths  attached  to  the  meninges,  in  which  case  the 
features  are  those  of  tumor,  by  gummatous  arteritis  with  secondary  softening, 
by  meningitis  with  secondary  cord  changes,  or  by  late  scleroses.  Syphilitic 
myelitis  will  be  considered  under  affections  of  the  spinal  cord. 

Diagnosis. — The  history  is  of  the  first  importance,  but  it  may  be  extremely 
difficult  to  get  a  trustworthy  account.  Careful  examination  should  be  made 
for  traces  of  the  primary  sore,  for  the  cicatrices  of  bubo,  for  scars  of  the  skin 
eruption  or  throat  ulcers,  and  for  bone  lesions.  The  character  of  the  symp- 
toms is  often  of  great  assistance.  They  are  multiform,  variable,  and  often 
such  as  could  not  be  explained  by  a  single  lesion;  thus  there  may  be  anoma- 
lous spinal  symptoms  or  involvement  of  the  nerves  of  the  brain  on  both  sides. 
The  Wassermann  reaction  in  the  blood  and  spinal  fluid  is  of  the  greatest  aid; 
the  spinal  fluid  shows  lymphocytosis  (in  85-90  per  cent.),  a  positive  globulin 
reaction  (in  90-95  per  cent.)  and  the  colloidal  gold  reaction  (in  75-80  per 
cent.) ;  and  lastly  the  result  of  treatment  has  a  definite  bearing  on  the  diag- 
nosis, as  the  symptoms  may  clear  up  and  disappear  with  the  use  of  anti- 
syphilitic  remedies. 


272 


2.  Syphilis  of  the  Respiratory  Organs 


Syphilis  of  the  Trachea  and  Bronchi. — L.  A.  Conner  has  analyzed  128 
recorded  cases  of  syphilis  of  the  trachea  and  bronchi.  In  52  per  cent,  of  the 
cases  the  trachea  was  alone  involved.  In  only  10  per  cent,  were  characteristic 
lesions  of  syphilis  found  in  the  lungs.  Bronchial  dilatation  below  the  lesion 
was  found  in  15  per  cent,  of  the  cases.  In  ten  of  the  cases  the  lesion  occurred 
in  congenital  syphilis. 

Syphilis  of  the  Lung. — This  is  a  very  rare  disease.  In  2,800  post  mor- 
tems  at  the  Johns  Hopkins  Hospital  there  were  12  cases  with  syphilitic  dis- 
ease in  the  lungs;  in  8  of  these  the  lesions  were  in  congenital  syphilis.  In  11 
cases  there  were  definite  gummata.  Clinically  the  presence  of  syphilis  of  the 
lung  was  suspected  in  three  cases.  Some  years  ago  Fowler  visited  the  museums 
of  the  London  hospitals  and  the  Royal  College  of  Surgeons,  and  could  find 
only  twelve  specimens  illustrating  syphilitic  lesions  of  the  lungs,  two  of  which 
are  doubtful.  For  the  most  full  and  satisfactory  consideration  of  pulmonary 
syphilis,  the  reader  is  referred  to  chapter  xxxvii  of  Fowler  and  Godlee's  work 
on  Diseases  of  the  Lungs. 

It  occurs  under  the  following  forms: 

(a)  The  white  pneumonia  of  the  fetus.  This  may  affect  large  areas  or 
an  entire  lung,  which  then  is  firm,  heavy,  and  airless,  even  though  the  child 
may  have  been  alive.  On  section  it  has  a  grayish-white  appearance — the  so- 
called  white  hepatization  of  Virchow.  »  The  chief  change  is  in  the  alveolar 
walls,  which  are  greatly  thickened  and  infiltrated,  and  the  section  is  like  one 
of  the  pancreas — "pancreatization"  of  the  lung.  In  the  early  stages,  for  exam- 
ple, in  a  seven  or  eight  months'  fetus,  there  may  be  scattered  miliary  foci  of 
this  induration  chiefly  about  the  arteries.  The  air-cells  are  filled  with  des- 
quamated and  swollen  epithelium. 

(6)  In  the  form  of  definite  gummata,  which  vary  in  size  from  a  pea  to 
a  goose-egg.  They  occur  irregularly  scattered  through  the  lung,  but,  as  a 
rule,  are  more  numerous  toward  the  root.  They  present  a  grayish-yellow 
caseous  appearance,  are  dry  and  usually  imbedded  in  a  translucent,  more  or 
less  firm,  connective  tissue.  In  a  case  from  my  wards  described  by  Council- 
man there  was  extensive  involvement  of  the  root  of  the  lungs.  Bands  of  con- 
nective tissue  passed  inward  from  the  thickened  pleura,  and  between  these 
strands  and  surrounding  the  gummata  there  was  in  places  a  mottled  red 
pneumonic  consolidation.  In  the  caseous  nodules  there  is  typical  hyaline 
degeneration.  In  a  few  rare  instances  there  are  most  extensive  caseous  gum- 
mata with  softening  and  formation  of  bronchiectatic  cavities,  and  clinically 
a  picture  of  pulmonary  tuberculosis  without  the  presence  of  tubercle  bacilli. 
In  one  case,  a  man  aged  twenty-seven,  admitted  in  April,  1902,  had  had  for 
a  year  cough  and  bloody  expectoration  and  died  of  severe  hemoptysis.  Bacilli 
were  never  found  in  the  sputum.  There  were  extensive  caseous  gummata 
throughout  both  lungs,  with  much  fibrous  thickening,  and  in  the  lower  lobe 
of  the  right  lung  a  cavity  3  by  5  cm.  in  diameter,  on  the  wall  of  which  a 
branch  of  the  pulmonary  artery  was  eroded.  This  is  the  only  instance  among 
my  cases  in  which  there  was  an  extensive  destruction  of  the  lung  tissue  with 
the  clinical  picture  simulating  pulmonary  phthisis. 

(c)  A.  majority  of  authors  follow  Virchow  in  recognizing  the  fibrous  in- 


SYPHILIS  273 

terstitial  pneumonia  at  the  root  of  the  lung  and  passing  along  the  bronchi  and 
vessels  as  probably  syphilitic.  This  much  may  be  said,  that  in  certain  cases 
gummata  are  associated  with  these  fibroid  changes.  Again,  this  condition 
alone  is  found  in  persons  with  well-marked  syphilitic  history  or  with  other 
visceral  lesions.  It  seems  in  many  instances  to  be  a  purely  sclerotic  process, 
advancing  sometimes  from  the  pleura,  more  commonly  from  the  root  of  the 
lung,  and  invading  the  interlobular  tissue,  gradually  producing  a  more  or  less 
extensive  fibroid  change.  It  rarely  involves  more  than  a  portion  of  a  lobe  or 
portions  of  the  lobes  at  the  root  of  the  lung.  The  bronchi  are  often  dilated. 
Diagnosis. — It  is  to  be  borne  in  mind,  in  the  first  place,  that  hospital  physi- 
cians and  pathologists  the  world  over  bear  witness  to  the  extreme  rarity  of 
lung  syphilis.  In  the  second  place,  the  therapeutic  test  upon  which  so  much 
reliance  is  placed  is  by  no  means  conclusive.  With  pulmonary  tuberculosis 
there  should  be  no  confusion,  owing  to  the  readiness  with  which  the  presence 
of  bacilli  is  determined.  Bronchiectasis  in  the  lower  lobe  of  a  lung,  dependent 
upon  an  interstitial  pneumonia  of  syphilitic  origin,  could  not  be  distinguished 
from  any  other  form  of  the  disease.  In  persons  with  well-marked  syphilitic 
lesions  elsewhere,  when  obscure  pneumonia  with  dilated  bronchi  and  no 
tubercle  bacilli  are  present,  the  condition  may  possibly  be  due  to  syphilis.  So 
far  as  my  experience  goes,  tuberculous  phthisis  occurring  in  a  syphilitic  s ab- 
ject has  no  special  peculiarities.  The  lesions  of  syphilis  and  tuberculosis  could 
of  course  coexist  in  a  lung.  The  Wassermann  reaction  is  helpful  in  a  doubtful 
case. 

3.  Syphilis  of  the  Liver 

Varieties. — INHEEITED. — (a)  Congenital. — Gubler  in  1852  first  described 
the  diffuse  hepatitis  which  occurs  in  a  large  percentage  of  all  deaths  in  con- 
genital lues.  While  there  may  be  little  or  no  macroscopic  change,  the  liver 
preserves  its  form  and  is  usually  enlarged,  hard  and  resistant,  and  has  a  yel- 
lowish color,  compared  by  Trousseau  to  sole-leather,  or  by  Gubler  to  that  of 
flint.  Small  grayish  nodules  may  be  seen  on  the  section.  In  other  cases  there 
are  definite  gummata  with  extensive  sclerosis.  The  spirochaetes  are  present  in 
extraordinary  numbers. 

The  child  may  be  still-born  or  die  shortly  after  birth,  or  it  may  be  healthy 
when  born  and  the  liver  enlarges  within  a  few  weeks.  The  organ  is  firm ;  the 
edge  may  be  readily  felt,  usually  far  below  the  navel.  The  spleen  is  also 
enlarged.  The  general  features  are  those  of  a  hypert'rophic  cirrhosis,  but 
jaundice  and  ascites  are  not  common.  Hochsinger  states  that  of  45  cases 
recovery  took  place  in  30. 

(6)  Delayed  Congenital  Syphilis. — The  condition  is  by  no  means  rare. 
Of  132  cases  of  syphilis  hereditaria  tarda  collected  by  Forbes,  in  34  the  liver 
was  involved.  The  children  are  nearly  always  ill-developed,  sometimes  with 
marked  clubbing  of  the  fingers  and  showing  signs  of  infantilism.  Jaundice 
is  rare.  The  liver  is  usually  enlarged,  or  it  may  show  nodular  masses. 

ACQUIRED  SYPHILIS. —  (a)  In  the  secondary  stages  of  the  disease  the 
liver  is  not  often  involved.  Jaundice  may  occur  coincident  with  the  rash 
and  with  the  enlargement  of  the  superficial  glands.  Eolleston  thinks  it  is 
probably  due  to  a  catarrhal  condition  of  the  smaller  ducts,  part  of  a  general 
syphilitic  hepatitis.  There  are  cases  in  which  it  has  passed  on  to  a  state  of 


274  SPECIFIC    INFECTIOUS    DISEASES 

acute  yellow  atrophy.  The  liver  is  slightly  enlarged.  The  prognosis  is  gen- 
erally good. 

(b)  Tertiary  Lesions. — The  frequency  with  which  the  liver  is  involved  in 
syphilis  in  adults  is  very  variously  estimated.  J.  L.  Allen,  quoted  by  Rolleston, 
found  37  cases  of  hepatic  gummata  among  11,G29  autopsies  at  St.  George's 
Hospital ;  in  27  cases  cicatrices  alone  were  present.  Flexner  at  the  Philadel- 
phia Hospital  found  88  cases  of  hepatic  syphilis  among  5,088  autopsies. 
Among  2,300  autopsies  at  the  Johns  Hopkins  Hospital  (Professor  Welch) 
there  have  been  47  cases  of  syphilis  of  the  liver,  gummata  in  19,  scars  in  16, 
cirrhosis  in  21  cases;  6  of  the  cases  were  congenital.  My  experience  coincides 
with  that  of  Einhorn  and  of  Stockton,  who  hold  that  in  the  United  States 
the  disease  is  by  no  means  uncommon.  In  21  cases  the  diagnosis  of  syphilis 
of  the  liver  was  made  clinically. 

Anatomically  the  lesions  may  be  either  gummata  or  scars  or  a  syphilitic 
sclerosis.  The  gummata  range  in  size  from  a  pea  to  an  orange.  When  small 
they  are  pale  and  gray;  the  larger  ones  present  yellowish  centres;  but  later 
there  is  a  "pale,  yellowish,  cheese-like  nodule  of  irregular  outline,  surrounded 
by  a  fibrous  zone,  the  outer  edge  of  which  loses  itself  in  the  lobular  tissue,  the 
lobules  dwindling  gradually  in  its  grasp.  This  fibrous  zone  is  never  very 
broad ;  the  cheesy  centre  varies  in  consistence  from  a  gristle-like  toughness  to 
a  pulpy  softness;  it  is  sometimes  mortar-like,  from  cretaceous  change" 
(Wilks).  They  may  form  enormous  tumors,  as  in  the  remarkable  one  figured 
on  page  351  in  Rolleston's  work  on  Diseases  of  the  Liver.  They  may  be  felt 
as  large  as  an  orange  beneath  the  skin  in  the  epigastrium  and  they  may  dis- 
appear with  the  same  extraordinary  rapidity  as  the  subcutaneous  or  periosteal 
gumma.  Macroscopically  they  may,  indeed,  at  first  look  like  massive  cancer. 
Extensive  caseation,  softening  and  calcification  may  occur.  The  syphilitic 
scars  are  usually  linear  or  star-shaped.  They  may  be  very  numerous  and 
divide  the  liver  into  small  sections — the  so-called  botyroid  organ,  of  which  a 
remarkable  example  is  figured  in  my  Lectures  on  Abdominal  Tumors.  The 
syphilitic  cirrhosis  is  usually  combined  with  gummata,  or  with  marked  scar- 
ring in  the  portal  canal,  leading  to  lobulation  of  the  organ,  but  the  ordinary 
multilobular  cirrhosis  is  not  common. 

Symptoms. — In  the  first  place,  the  clinical  picture  may  be  that  of  cirrhosis 
— slight  jaundice,  fever,  portal  obstruction,  ascites.  There  may  not  be  the 
slightest  suspicion  of  the  syphilitic  nature  of  the  case.  One  of  my  patients 
had  been  tapped  thirteen  times  before  admission  to  the  hospital.  The  diag- 
nosis was  made  by  finding  gummata  on  the  shins.  She  recovered  promptly. 

In  a  second  group  of  cases  the  patient  is  anaemic,  passes  large  quantities 
of  pale  urine  containing  albumin  and  tube-casts;  the  liver  is  enlarged,  per- 
haps irregular,  and  the  spleen  also  is  enlarged.  Dropsical  symptoms  may 
supervene,  or  the  patient  may  be  carried  off  by  some  intercurrent  disease. 
Extensive  amyloid  degeneration  of  the  spleen,  the  intestinal  mucosa,  and  of 
the  liver,  with  gummata,  is  found. 

Thirdly,  in  a  very  important  group  the  symptoms  are  those  of  tumor  of 
the  liver,  causing  pain  and  distress,  and  on  examination  an  irregular  mass 
is  discovered.  The  tumor  may  be  large,  causing  a  prominent  bulging  in  the 
epigastrium.  Naturally  carcinoma  is  thought  of,  as  there  may  be  nothing  to 
suggest  syphilis.  In  other  cases  the  history  or  the  presence  of  gummata  else- 


SYPHILIS  275 

where  should  aid  in  the  diagnosis.  In  other  instances  the  rapid  disappearance 
under  treatment  even  of  a  large  visible  tumor  makes  the  syphilitic  nature  quite 
positive.  Lastly,  in  a  few  cases  the  irregular  fever  with  enlargement  and 
irregularity  of  the  liver  may  suggest  suppuration,  or  the  uniform  great  en- 
largement of  the  organ  hypertrophic  biliary  cirrhosis,  while  there  are  some 
cases  in  which  the  spleen  is  so  greatly  enlarged,  the  anaemia  so  pronounced, 
and  the  liver  so  small  and  contracted  that  the  diagnosis  of  splenic  anaemia  is 
made. 

4.  Syphilis  of  the  Digestive  Tract 

The   oesophagus  is   very  rarely  affected.      Stenosis   is  the  usual  result. 
Syphilis  of  the  stomach  is  excessively  rare.     Flexner  reported  a  remarkable 
case  in  association  with  gummata  of  the  liver,  and  collected  14  cases  in  the 
literature.     Syphilitic  ulceration  has  been  found  in  ths  small  intestine  and  in 
the  caecum. 

The  most  common  seat  in  this  tract  is  the  rectum.  The  affection  is  found 
most  commonly  in  women,  and  results  from  the  growth  of  gummata  in  the 
submucosa  above  the  internal  sphincter.  The  process  is  slow  and  tedious, 
and  may  last  for  years  before  it  finally  induces  stricture.  The  symptoms  are 
usually  those  of  narrowing  of  the  lower  bowel.  The  condition  is  readily  rec- 
ognized by  rectal  examination.  The  history  of  gradual  on-coming  stricture, 
the  state  of  the  patient,  and  the  fact  that  there  is  a  hard,  fibrous  narrowing, 
not  an  elevated  crater-like  ulcer,  usually  render  easy  the  diagnosis  from  ma- 
lignant disease.  In  medical  practice  these  cases  come  under  observation  for 
other  symptoms,  particularly  amyloid  degeneration;  and  the  rectal  disease 
may  be  entirely  overlooked,  and  only  discovered  post  mortem. 

5.  Circulatory  System 

Syphilis  of  the  Heart. — A  fresh,  warty  endocarditis  due  to  syphilis  is  not 
recognized,  though  occasionally  in  persons  dead  of  the  disease  this  form  '«* 
present,  as  is  not  uncommon  in  conditions  of  debility.  Myocarditis  is  common , 
there  may  be  fatty  degeneration  and  fibroid  changes.  Pain,  precordial  tender- 
ness, disturbance  of  rhythm  and  tachycardia  are  special  features.  There  may 
be  a  soft  apex  systolic  murmur,  not  transmitted  and  increased  by  exer- 
cise. Changes  in  the  blood-vessels  of  the  walls  of  the  heart  are  common  both 
in  congenital  and  acquired  syphilis,  even  in  cases  without  clinical  symptoms 
or  gross  lesions  (Adler). 

Kupture  may  take  place,  as  in  the  cases  reported  by  Dandridge  and  Nalty, 
or  sudden  death,  as  in  the  cases  of  Cayley  and  Pearce  Gould;  indeed,  sudden 
death  is  frequent,  occurring  in  21  of  63  cases  (Mracek). 

Syphilis  of  the  Arteries. — Syphilis  plays  an  important  role  in  arterio- 
sclerosis and  aneurism.  Its  connection  with  these  processes  will  be  considered 
later ;  here  we  shall  refer  only  to  the  syphilitic  affection  of  the  smaller  vessels, 
which  occurs  in  two  forms : 

(a)  An  obliterating  endarteritis,  characterized  by  a  proliferation  of  the 
subendothelial  tissue.  The  new  growth  lies  within  the  elastic  lamina,  and 
may  gradually  fill  the  entire  lumen;  hence  the  term  obliterating.  The  media 
and  adventitia  are  also  infiltrated  with  small  cells.  This  form  of  endarteritis 


276  SPECIFIC   INFECTIOUS    DISEASES 

described  by  Huebner  is  not,  however,  characteristic  of  syphilis,  and  its  pres- 
ence alone  in  an  artery  could  not  be  considered  pathognomonic.  If,  however, 
there  are  gummata  in  other  parts,  or  if  the  condition  about  to  be  described 
exists  in  adjacent  arteries,  the  process  may  be  regarded  as  syphilitic. 

(6)  Gummatous  Periarteritis. — With  or  without  involvement  of  the  in- 
tima,  nodular  gummata  may  develop  in  the  adventitia  of  the  artery,  produc- 
ing globular  or  ovoid  swellings,  which  may  attain  considerable  size.  They 
are  not  infrequently  seen  in  the  cerebral  arteries,  which  seem  to  be  specially 
prone  to  this  affection.  This  form  is  specific  and  distinctive  of  syphilis. 
Many  observers  have  found  Treponema  pallidum  in  the  syphilitic  aortitis,  and 
also  in  gummatous  arteritis  of  the  cerebral  vessels. 

6.  Renal  Syphilis 

Gummata. — Gummata  occasionally  are  found  in  the  kidneys,  particularly 
in  cases  in  which  there  is  extensive  gummatous  hepatitis.  They  are  rarely 
numerous,  and  occasionally  lead  to  scattered  cicatrices.  Clinically  the  affec- 
tion is  not  recognizable. 

Acute  Syphilitic  Nephritis. — This  condition  has  been  carefully  stud- 
ied by  the  French  writers  and  by  Lafleur  of  Montreal.  It  is  estimated  to 
occur  in  the  secondary  stage  in  about  3.8  per  cent.,  and  may  occur  in  from 
three  to  six  months,  sometimes  later,  from  the  initial  lesion.  The  outlook 
is  good,  though  often  the  albuminuria  may  persist  for  months;  more  rarely 
chronic  nephritis  follows.  In  a  few  instances  syphilitic  nephritis  has  proved 
rapidly  fatal  in  a  fortnight  or  three  weeks.  The  lesions  are  not  specific,  but 
are  similar  to  those  in  other  acute  infections. 

7.  Syphilitic  Orchitis 

This  affection  is  of  special  significance  to  the  physician,  as  its  detection 
frequently  clinches  the  diagnosis  in  obscure  internal  disorders.  Syphilis 
occurs  in  the  testes  in  two  forms: 

(a)  The  gummatous  growth,  forming  an  indurated  mass  or  group  of 
masses  in  the  substance  of  the  organ,  and  sometimes  difficult  to  distinguish 
from  tuberculous  disease.  The  area  of  induration  is  harder  and  it  affects 
the  body  of  the  testes,  while  tubercle  more  commonly  involves  the  epididymis. 
It  rarely  tends  to  invade  the  skin,  or  to  break  down,  soften,  and  suppurate, 
and  is  usually  painless. 

(&)  There  is  an  interstitial  orcJiitis  regarded  as  syphilitic,  which  lead* 
to  fibroid  induration  of  the  gland  and  gradually  to  atrophy.  It  is  a  slow, 
progressive  change,  coming  on  without  pain,  usually  involving  one  organ 
more  than  another. 

V.     DIAGNOSIS,  TKEATMENT,  ETC. 

Diagnosis. — GENERAL  DIAGNOSIS  OF  SYPHILIS. — There  is  seldom  any 
doubt  concerning  the  recognition  of  syphilitic  lesions;  but  the  number  of 
persons,  without  any  evident  sign  of  the  disease,  in  whom  a  positive  Wasser- 
mann  reaction  is  found  proves  that  a  negative  diagnosis  cannot  be  based  on 
the  absence  of  history  and  clinical  manifestations.  Syphilis  is  common  in  the 


SYPHILIS  277 

community,  and  is  no  respecter  of  age,  sex,  or  station  in  life.  It  is  possible 
that  the  primary  sore  may  have  been  of  trifling  extent,  or  urethral  and  masked 
by  a  gonorrhoea,  and  the  patient  may  not  have  had  severe  secondary  symptoms, 
but  such  instances  are  extremely  rare.  Inquiries  should  be  made  into  the  his- 
tory to  ascertain  if  the  patient  has  had  skin  rashes,  sore  throat,  or  if  the  hair 
has  fallen  out.  Careful  inspection  should  be  made  of  the  throat  and  skin  for 
signs  of  old  lesions.  Scars  in  the  groins,  the  result  of  buboes,  are  uncertain 
evidences  of  syphilitic  infection.  The  cicatrices  on  the  legs  are  often  copper- 
colored,  though  this  cannot  be  regarded  as  peculiar  to  syphilis.  The  bones 
should  be  examined  for  nodes.  In  doubtful  cases  the  scar  of  the  primary 
sore  may  be  found,  or  there  may  be  signs  of  atrophy  or  of  hardening  of  the 
testes.  In  women  special  stress  has  been  laid  upon  the  occurrence  of  frequent 
miscarriages,  whick,  in  connection  with  other  circumstances,  are  always  sug- 
gestive. 

In  the  congenital  disease, ;  the  occurrence  within  the  first  three  months  of 
snuffles  and  skin  rash  is  conclusive.  Later,  the  characters  of  the  syphilitic 
facies,  already  referred  to,  often  give  a  clew  to  the  nature  of  some  obscure 
visceral  lesion.  Other  distinctive  features  are  the  symmetrical  development 
of  nodes  on  the  bones  and  the  interstitial  keratitis. 

The  Treponema  pallidum  may  be  studied  from  the  fresh  lesion.  After 
cleaning  carefully,  serum  is  sucked  out  with  a  small  Bier  apparatus,  and  the 
living  spirochsetes  may  be  seen  in  the  special  "dark  field"  apparatus  used  for 
the  purpose. 

SERUM  DIAGNOSIS. — The  Wassermann  reaction  in  good  hands  may  be 
accepted  as  a  most  valuable  aid  in  diagnosis.  It  is  obtained  in  from  80  to  90 
per  cent,  of  all  cases  of  syphilis  with  manifestations.  The  results  in  tabes  and 
dementia  paralytica  are  very  constant. 

CUTANEOUS  EEACTION. — An  emulsion  or  extract  of  pure  cultures  of  Tre- 
ponema pallidum — termed  luetin — has  been  employed  by  Noguchi  to  obtain 
a  skin  reaction.  The  skin  is  sterilized  and  0.05  c.  c.  injected  intradermically. 
The  local  reaction  is  usually  papular,  and  surrounded  by  a  zone  of  redness, 
but  may  become  pustular.  There  is  very  slight  constitutional  effect.  The 
reaction  is  most  constant  and  marked  in  tertiary  and  hereditary  cases;  it  is 
infrequent,  and,  if  present,  mild  in  the  primary  and  secondary  stages,  in 
which  the  Wassermann  reaction  is  more  constant.  Treatment  affects  the  Was- 
sermann more  than  the  cutaneous  reaction. 

THERAPEUTIC  TEST. — In  a  doubtful  case,  as,  for  example,  an  obstinate 
skin  rash  or  an  obscure  tumor  in  the  abdomen,  antisyphilitic  treatment  may 
prove  successful,  but  this  cannot  always  be  relied  upon. 

Prophylaxis. — Irregular  intercourse  has  existed  from  the  beginning  of 
recorded  history,  and  unless  man's  nature  wholly  changes — and  of  this  we, 
can  have  no  hope — will  continue.  Resisting  all  attempts  at  solution,  the 
social  evil  remains  the  great  blot  upon  our  civilization,  and  inextricably 
blended  with  it  is  the  question  of  the  prevention  of  syphilis.  Two  measures 
are  available — the  one  personal,  the  other  administrative. 

Personal  purity  is  the  prophylaxis  which  we,  as  physicians,  are  especially 
bound  to  advocate.  Continence  may  be  a  hard  condition  (to  some  harder  than 
to  others),  but  it  can  be  borne,  and  it  is  our  duty  to  urge  this  lesson  upon 
young  and  old  who  seek  our  advice  in  matters  sexual.  Certainly  it  is  better, 


278  SPECIFIC    INFECTIOUS    DISEASES 

as  St.  Paul  says,  to  marry  than  to  burn,  but  if  the  former  is  not  feasible  there 
are  other  altars  than  those  of  Venus  upon  which  a  young  man  may  light  fires, 
He  may  practice  at  least  two  of  the  five  means  by  which,  as  the  physician 
Rondibilis  counseled  Panurge,  carnal  concupiscence  may  be  cooled  and 
quelled — hard  work  of  body  and  hard  work  of  mind.  Idleness  is  the  mother  of 
lechery;  and  a  young  man  will  find  that  absorption  in  any  pursuit  will  do 
much  to  cool  passions  which,  though  natural  and  proper,  cannot  in  the  exig- 
encies of  our  civilization  always  obtain  natural  and  proper  gratification. 

To  carry  out  successfully  any  administrative  measures  seems  hopeless,  at 
any  rate  in  our  Anglo-Saxon  civilization.  The  state  accepts  the  responsibility 
of  guarding  citizens  against  small-pox  or  cholera,  but  in  dealing  with  syphilis 
the  problem  has  been  too  complex  and  has  hitherto  baffled  solution.  Inspec- 
tion, segregation,  and  regulation  are  difficult,  if  not  impossible,  to  carry  out, 
and  public  sentiment  is  bitterly  opposed  to  this  plan.  The  compulsory  regis- 
tration of  every  case  of  gonorrhoea  and  syphilis,  with  greatly  increased  facili- 
ties for  thorough  treatment,  offers  a  more  acceptable  alternative. 

The  patient  should  be  warned  of  the  various  ways  in  which  he  may  spread 
the  disease  and  given  directions  regarding  this.  Measures  for  the  prevention 
of  infection  after  exposure  can  be  carried  out  in  the  military  and  naval  services 
more  readily  than  in  civil  life.  The  most  successful  is  the  application  of  mer- 
curial ointment  mixed  with  lanolin  soon  after  exposure. 

Treatment. — That  the  later  stages  which  come  under  the  charge  of  the 
physician  are  so  common  results,  in  great  part,  from  the  carelessness  of  the 
patient,  who,  wearied  with  treatment,  can-not  understand  why  he  should  con- 
tinue to  take  medicine  after  all  the  symptoms  have  disappeared ;  but,  in  part, 
the  profession  also  is  to  blame  for  not  insisting  more  urgently  that  acquired 
syphilis  is  not  cured  in  a  few  months,  but  takes  at  least  three  years,  during 
which  time  the  patient  should  be  under  careful  supervision. 

The  patient  should  lead  a  regular  life,  avoiding  excess  of  all  kinds.  If 
there  is  fever  rest  in  bed  is  advisable.  The  usual  diet  can  be  taken  and  the 
patient  should  drink  large  quantities  of  water.  The  use  of  alcohol  and  to- 
bacco should  be  forbidden  during  active  treatment.  When  mercury  is  being 
taken  special  care  must  be  given  to  the  mouth.  A  mouth  wash  and  a  potas- 
sium chlorate  tooth  paste  should  be  used  frequently.  Treatment  consists 
essentially  in  the  use  of  three  remedies,  mercury,  arsenic  and  iodide  of 
potassium. 

MERCURY. — It  is  usually  well  to  push  the  administration  of  mercury  so 
that  the  patient  is  brought  under  its  influence  as  rapidly  as  possible,  but 
salivation  is  to  be  avoided.  Mercury  may  be  given  by  the  mouth  in  the  form 
of  gray  powder,  the  hydrargyrum  cum  creta,  which  Hutchinson  recommends  to 
be  given  in  pills,  one-grain  doses  with  a  grain  of  Dover's  powder.  One  pill 
from  four  to  six  times  a  day  will  usually  suffice.  I  warmly  endorse  the  ex- 
cellent results  which  are  obtained  by  this  method,  under  which  the  patient 
often  gains  rapidly  in  weight,  and  the  general  health  improves  remarkably. 
It  may  be  continued  for  months  without  any  ill  effects.  Other  forms  given 
by  the  mouth  are  biniodide  (gr.  1/16),  the  protoiodide  (gr.  1/4),  or  the 
bichloride  (gr.  1/16  to  1/8),  three  times  a  day. 

Inunction  is  a  still  more  effective  means.  A  drachm  of  the  ordinary  mer- 
curial ointment  or  the  oleate  of  mercury  is  thoroughly  rubbed  into  the  skin, 


SYPHILIS  279 

on  areas  free  from  hair,  every  evening  for  six  days;  on  the  seventh  a  warm 
bath  is  taken,  and  on  the  eighth  the  mercurial  course  is  resumed.  At  least 
half  an  hour  should  be  given  to  each  inunction.  It  is  well  to  apply  it  to 
different  places  on  successive  days.  The  sides  of  the  chest  and  abdomen  and 
the  inner  surfaces  of  the  arms  and  thighs  are  the  best  positions.  A  course 
of  thirty  to  forty  inunctions  should  be  given. 

The  mercury  may  be  given  by  intramuscular  injection.  If  proper  pre- 
cautions are  taken  in  sterilizing  the  syringe,  and  if  the  injections  are  made 
into  the  muscles,  not  into  the  subcutaneous  tissue,  abscesses  rarely  result. 
Mercury  salicylate  as  a  10  per  cent,  solution  in  albolene,  of  which  ten  minims 
are  given  every  five  to  seven  days,  bichloride  of  mercury  (gr.  1/20  to  1/10) 
in  olive  oil,  the  "gray  oil,"  or  calomel  (gr.  i)  in  equal  parts  of  glycerine 
and  water  (1  of  calomel  to  10  of  the  mixture)  are  the  usual  preparations. 
A  course  of  twenty  to  thirty  injections  should  be  given. 

Intravenous  injections  are  sometimes  given  in  malignant  cases.  Fifteen 
minims  of  a  .1  to  .2  per  cent,  solution  of  the  bichloride  in  sterile  salt  solution 
are  administered. 

Still  another  method  in  vogue  in  certain  parts  of  the  Continent  and  in 
institutions  is  fumigation.  The  patient  sits  on  a  chair  wrapped  in  blankets, 
with  the  head  exposed.  Calomel  (gr.  xx,  1.3  gin.)  is  volatilized  and  de- 
posited with  the  vapor  on  the  patient's  skin.  The  process  lasts  about  twenty 
minutes,  and  the  patient  goes  to  bed  wrapped  in  blankets  without  washing 
or  drying  the  skin. 

ARSENIC. — While  atoxyl  and  cacodylate  of  sodium  have  been  employed, 
the  most  useful  preparations  are  salvarsan  (dioxydiamido-arsenobenzol)  and 
neo-salvarsan.  We  are  not  yet  able  to  speak  with  finality  regarding  all  the 
points  with  reference  to  them,  but  they  are  certainly  a  valuable  addition  to  our 
treatment  of  syphilis.  They  should  be  given  intravenously  and  only  by  those 
who  are  properly  instructed  in  the  method.  The  salt  solution  employed  should 
be  prepared  from  water  freshly  distilled  not  more  than  a  few  hours  before 
from  glass  and  not  from  metal.  The  solution  is  prepared  as  follows:  To  30 
c.  c.  of  sterile  freshly  distilled  water  in  a  graduated  sterile  glass  vessel  the 
amount  of  salvarsan  to  be  given  is  added  and  dissolved  by  vigorous  shaking 
which  may  be  aided  by  glass  beads.  When  complete  solution  has  occurred 
a  15  per  cent,  solution  of  sodium  hydroxide  solution  is  added  drop  by  drop. 
This  causes  a  precipitate  to  form  and  sufficient  sodium  hydroxide  is  then 
added  drop  by  drop  until  this  dissolves.  Sterile  salt  solution  (0.5  per  cent.) 
is  then  added  to  bring  the  quantity  up  to  200  c.  c.  Salvarsan  should  be  given 
well  diluted  (40  c.  c.  of  solution  to  0.1  gm.  of  salvarsan),  and  always  in  a 
freshly  prepared  solution.  The  solution  is  best  injected  into  one  of  the  veins 
at  the  elbow  and  may  be  given  by  a  syringe  with  a  three-way  cock  or  by  gravity 
through  a  funnel  or  from  a  glass  cylinder.  Some  salt  solution  should  be  run 
in  first  to  be  sure  that  the  needle  is  in  the  vein  and  the  salvarsan  solution 
then  given.  Salt  solution  should  be  given  at  the  end.  It  is  wise  for  the 
patient  to  remain  in  bed  for  a  day  after  the  injection. 

The  most  suitable  dosage  is  not  yet  determined.  Some  give  two  doses 
(0.5  gm.,  7^2  grains)  at  intervals  of  ten  days,  others  one  dose  (0.5  gm.)" 
followed  by  several  smaller  ones  (0.2  gm.,  3  grains),  others  repeated  small 
doses  (0.2  gm.)  at  intervals;  half  a  gram  may  be  regarded  aa  an  average 


280  SPECIFIC   INFECTIOUS   DISEASES 

maximum  dose,  but  larger  amounts  are  sometimes  given.  For  young  children 
doses  of  0.1  to  0.2  gm.  are  used  and  for  infants  0.02  to  0.1  gm.  In  deter- 
mining the  amount,  the  weight  of  the  patient  is  a  good  indication.  Changes 
in  the  eye  grounds  and  severe  circulatory  and  renal  lesions  may  be  contra- 
indications in  some  cases.  Caution  is  advisable  in  the  syphilitic  lesions  of  the 
aorta  and  aortic  valves;  if  salvarsan  is  used,  small  doses  (0.2  gm.)  should  be 
given.  Neo-salvarsan  is  given  in  about  double  the  dose  of  salvarsan. 

The  conditions  in  which  salvarsan  is  especially  useful  are:  (1)  at  the 
onset  when  the  diagnosis  is  made  early;  one  dose  (0.5  gm.)  may  be  suffi- 
cient. (2)  In  patients  with  severe  skin  or  mucous  membrane  lesions.  (3) 
In  intractable  cases,  in  those  resistant  to  or  unable  to  take  mercury.  (4)  In 
malignant  cases.  (5)  In  congenital  syphilis.  (6)  In  latent  cases,  in  which 
without  any  signs  of  syphilis  a  Wasserman  reaction  is  present.  In  visceral 
syphilis  the  drug  is  less  useful.  Its  value  in  lesions  of  the  nervous  system  is 
not  settled;  some  patients  are  undoubtedly  benefited  and  the  same  may  be 
said  of  the  para-syphilitic  affections.  In  general  the  earlier  in  the  course 
the  drug  is  given  the  better  the  effect. 

Mercury  should  always  be  given  after  salvarsan,  which,  except  perhaps  in 
a  few  cases  given  at  the  onset,  can  not  be  regarded  as  a  complete  remedy  in 
itself.  If  the  patient  is  seen  early  salvarsan  should  be  given  and  followed 
by  mercury,  the  first  course  of  which  should  be  by.  inunction  or  injection  if 
possible,  and  after  this  by  mouth.  The  mixed  treatment  should  only  be 
given  after  a  thorough  course  of  mercury.  For  one  year  mercury  should 
be  given  as  continuously  as  possible;  during  the  second  year  intermissions 
are  advisable,  but  not  for  more  than  one-quarter  of  the  time. 

In  CONGENITAL  SYPHILIS  the  treatment  of  cases  born  with  bullae  and 
other  signs  of  the  disease  is  not  satisfactory,  and  the  infants  usually  die 
within  a  few  days  or  weeks.  The  child  should  be  nursed  by  the  mother  alone, 
or,  if  this  is  not  feasible,  should  be  hand-fed,  but  under  no  circumstances 
should  a  wet-nurse  be  employed.  The  child  is  most  rapidly  and  thoroughly 
brought  under  the  influence  of  the  drug  by  inunction.  The  mercurial  oint- 
ment may  be  smeared  on  the  flannel  roller.  This  is  not  a  very  cleanly 
method,  and  sometimes  rouses  the  suspicion  of  the  mother.  It  is  preferable 
to  give  the  drug  by  the  mouth,  in  the  form  of  gray  powder,  half  a  grain 
three  times  a  day.  In  the  late  manifestations  associated  with  bone  lesions 
the  combination  of  mercury  and  iodide  of  potassium  is  most  suitable  and 
is  well  given  in  the  form  of  Gilbert's  syrup,  which  consists  of  the  biniodide 
of  mercury  (gr.  j),  of  potassium  iodide  (5ss-)>  and  water  (§ij)-  Of  this  the 
dose  for  a  child  under  three  is  from  five  to  ten  drops  three  times  a  day,  grad- 
ually increased.  Under  these  measures  the  cases  of  congenital  syphilis 
usually  improve  with  great  rapidity.  The  medication  should  be  continued 
at  intervals  for  many  months,  and  it  is  well  to  watch  these  patients  carefully 
during  the  period  of  second  dentition  and  at  puberty,  and  if  necessary  to 
place  them  on  specific  treatment. 

In  the  treatment  of  the  VISCERAL  LESIONS  of  syphilis,  which  come  more 
distinctly  within  the  province  of  the  physician,  iodide  of  potassium  is  of 
equal  or  even  greater  value  than  mercury.  Under  its  use  ulcers  rapidly  heal, 
gummatous  tumors  melt  away,  and  we  have  an  illustration  of  a  specific  action 
only  equaled  by  that  of  mercury  in  the  secondary  stages,  by  iron  in  certain 


DISEASES   DUE   TO    PARASITIC    INFUSORIA  281 

form'"  of  anaemia,  and  by  quinine  in  malaria.  It  is  as  a  rule  well  borne  in  an 
initial  dose  of  10  grains  (0.6  gm.) ;  given  in  milk  the  patient  does  not  notice 
the  taste.  It  should  be  gradually  increased  to  30  or  more  grains  three  times  a 
day.  In  syphilis  of  the  nervous  system  it  may  be  used  in  still  larger  doses. 

When  syphilitic  hepatitis  is  suspected  the  combination  of  -mercury  and 
iodide  of  potassium  is  most  satisfactory.  If  there  is  ascites,  Addison's  or 
Guy's  pill  (as  it  is  often  called)  of  calomel,  digitalis,  and  squill  will  be 
found  very  useful.  Occasionally  the  iodide  of  sodium  is  more  satisfactory 
than  the  iodide  of  potassium.  It  is  less  depressing  and  agrees  better  with 
the  stomach. 

Syphilis  and  Marriage.  — Upon  this  question  the  family  physician  is  often 
called  to  decide.  He  should  insist  upon  the  necessity  of  two  full  years 
elapsing  between  the  date  of  infection  and  the  contracting  of  marriage. 
This,  it  should  be  borne  in  mind,  is  the  earliest  possible  limit,  and  marriage 
should  be  allowed  only  if  the  treatment  has  been  thorough  and  if  at  least  a 
year  has  passed  without  any  manifestation  of  the  disease. 

Syphilis  and  Life  Insurance.  — An  individual  with  syphilis  can  not  be  re- 
garded as  a  first-class  risk  unless  he  can  furnish  evidence  of  prolonged  and 
thorough  treatment  and  of  immunity  for  two  or  three  years  from  all  mani- 
festations. Even  then,  when  we  consider  the  extraordinary  frequency  of  the 
cerebral  and  other  complications  in  persons  who  have  had  this  disease  and 
who  may  even  have  undergone  thorough  treatment,  the  risk  to  the  company 
is  certainly  increased  (see  Bramwell,  Clinical  Studies,  vol.  i). 


VIII.     DISEASES  DUE  TO  PARASITIC  INFUSORIA 

Several  flagellates  are  parasitic  in  man.  The  Trichomonas  vaginalis, 
which  measures  15  /*  to  25  //in  length  and  has  four  flagella,  which  are  as 
long  as  or  longer  than  the  body,  is  by  no  means  uncommon  in  the  acid  vaginal 
mucus. 

The  Trichomonas  or  Cercomonas  hominis  lives  in  the  intestines,  and  is 
met  with  in  the  stools  under  all  sorts  of  conditions.  Freund  from  Dock's 
clinic  has  reported  a  series  of  cases  which  show -that  the  parasite  may  cause 
acute  and  chronic  diarrhoea  with  severe  abdominal  pain,  and  anatomically  an 
acute  enteritis.  In  one  of  Dock's  cases  the  parasites  were  associated  with  a 
haemorrhagic  cystitis  without  bacteria. 

The  Lamblia  intestinalis  is  another  intestinal  monad,  larger  than  the 
common  trichomonas.  Flagellates  have  also  been  found  in  the  expectoration 
in  cases  of  gangrene  of  the  lung  and  of  bronchiectasis,  and  in  the  exudate 
of  pleurisy. 

The  Bahntidium  coli,  oval  in  form,  70  p  to  100  //  long  and  50  jn  to  70  n 
broad,  may  be  pathogenic.  It  is  common  in  pigs,  and  has  been  known  to 
produce  an  epidemic  dysentery  in  apes  (Harlow  Brooks).  The  pathological 
significance  of  this  parasite  has  been  demonstrated  by  Strong  and  Musgrave 
in  the  Philippines,  where  it  is .  a  cause  of  dysentery.  It  has  not  only  been 
found  in  the  stools  and  on  the  mucous  membrane  of  the  intestine,  but  the 
parasites  have  occurred  in  the  mucosa  itself  and  in  the  submucosa.  Appar- 
ently they  do  not  extend  beyond  the  wall  of  the  bowel. 
20 


282  SPECIFIC   INFECTIOUS    DISEASES 

D.    DISEASES   DUE   TO    METAZOAN   PAEASITES 

I.     DISEASES  DUE  TO  FLUKES— DISTOMIASIS 

The  Trematoda  or  flukes  are  parasitic  platyhelminths,  usually  with  flattened 
or  leaf-shaped  bodies.  The  term  Distomiasis  is  based  upon  Distoma,  the 
term  being  used  to  designate  the  trematodes. 

The  following  are  the  important  clinical  forms: 

1.  Pulmonary  Distomiasis;  Parasitic  Haemoptysis. — Paragonimus  (Disto- 
ma) westermanii,  the  Asiatic  lung  or  bronchial  fluke,  is  from  8  to  16  mm. 
in  length  by  4  to  8  mm.  broad,  and  of  a  pinkish  or  reddish-brown  color. 

It  is  found  extensively  in  China  and  Japan,  Formosa,  and  the  Philippines, 
and  cases  are  occasionally  imported  into  Europe  and  America,  and  has  been 
met  with  in  the  oriental  population  of  the  Pacific  coast.  It  has  been  found 
in  the  United  States  in  the  cat,  in  the  dog,  and  in  the  hog.  One  instance 
of  pulmonary  distomiasis  has  been  reported  caused  by  the  giant  liver  fluke. 

Clinically  the  disease,  as  described  by  Manson  and  Ringer,  is  characterized 
by  a  chronic  cough,  with  rusty-brown  sputum,  and  occasional  attacks  of 
haemoptysis,  usually  trifling,  but  sometimes  very  severe.  The  disease  is  very 
apt  to  be  mistaken  for  tuberculosis,  but  the  diagnosis  is  easily  made  by 
microscopic  examination  of  the  sputum.  The  ova,  which  are  abundant  in 
the  sputum,  are  oval,  smooth,  and  measure  from  80  ju  to  100  }*•  in  length  by 
40  fj,  to  60  J*  in  breadth.  The  parasites  may  affect  other  organs — the  liver, 
the  brain,  and  eyelid. 

2.  Hepatic  Distomiasis. — Six  species  of  liver  flukes  are  known  to  occur  in 
man.     More  specifically  these  are:     (1)   The  common  liver  fluke — Fasciola 
hepatica — which  is  a  very  common  parasite  in  the  ruminants.     It  is  a  rare 
and  accidental  parasite  in  man,  but  in  Syria  a  strange  disease  called  Halzoun 
is  caused  by  eating  raw  goat-liver  infected  with  the  parasite.      (2)    The 
lancet  fluke — Dicroccelium    (Distoma)    lanceatum.    '  (3)    Opisthorchis    (Dis- 
toma) felineus,  which  is  found  in  Prussia  and  Siberia,  and  by  Ward  in  cats 
in  Nebraska.     (4)  Opisthorchis  noverca — Distomum  conjunctum — the  Indian 
liver  fluke  described  in  man  by  McConnell.      (5)    Opisthorchis   (Distoma) 
sinensis,  which  is  by  far  the  most  important  of  the  liver  flukes  and  occurs 
extensively  in  Japan,  China,  and  India.    It  is  10  to  20  mm.  long  by  2  to  5 
mm.  broad.     The  eggs  are  oval,  27  //  to  30  ju  by  15  ^  to  17  ju,  dark  brown, 
with  sharply  defined  operculum.     A  number  of  imported  cases  have  been 
found  in   Canada  and  the  United  States.     White  found   18  cases  in   San 
Francisco. 

The  symptoms  of  hepatic  distomiasis  are  best  described  in  connection  with 
the  last  form.  The  following  account  is  abstracted  from  Wallace  Taylor. 
Young  children  are  the  chief  sufferers.  Many  members  of  a  family  are  usu- 
ally affected.  In  some  villages  a  large  proportion  of  the  inhabitants  are 
attacked.  Among  important  symptoms  is  an  irregular,  intermittent  diar- 
rhoea ;  at  first  there  may  or  may  not  be  blood.  The  liver  enlarges  and  a  con- 
dition of  cirrhosis  gradually  comes  on.  There  may  be  pain  and  an  intermittent 
jaundice.  There  is  not  much  fever.  After  lasting  for  two  or  three  years 
dropsy  comes  on,  with  anasarca  and  ascites.  Even  then  transient  recovery  may 


DISEASES  DUE  TO  FLUKES— DISTOMIASIS  283 

take  place,  but  as  a  rule  there  is  a  recurrence,  and  the  patient  dies  after  many 
years  of  illness.    The  ova  of  the  parasite  are  readily  found  in  the  stools. 

3.  Intestinal  Distomiasis. — In  India  the  Fasciolopsis   (Distoma)    buskii 
has  been  found  in  a  number  of  cases  in  the  small  intestines.    The  Mesogoni- 
mus  heterophyes  has  been  found  in  Egypt  and  Japan. 

The  Asiatic  Amphistome — Gastrodiscus  (Amphistoma)  hominis — a  not 
uncommon  parasite  in  India — is  easily  recognized  by  its  large  posterior  sucker. 

4.  Heemic  Distomiasis ;  Bilharziasis.  — One  of  the  most  important  of  para- 
sitic diseases,  caused  by  the  blood  fluke,  Schistosomum  hcematobium  or  Bil- 
harzia  Jicematobia.    Endemic  haematuria   has   been   known   for   many   years, 
particularly  in  Egypt,  where  in  1851  Bilharz  discovered  the  parasite  of  the 
disease.     It  prevails  in  South  and  North  Africa,  particularly  the  latter,  in 
Arabia,  Persia,  and  the  west  coast  of  India.     Imported  cases  are  not  very 
uncommon  in  Europe,  and  an  occasional  instance  is  met  with  in  the  United 
States.     In  Egypt,  among  11,698  patients  admitted  to  the  Cairo  Hospital, 
1,270  were  infected,  practically  10  per  cent.  (Madden).     Of  500  autopsies  at 
the  same  hospital,  in  8  per  cent,  death  was  due  to  the  effects  of  Bilharzial 
disease.     The  seriousness  of  the  condition  in  Egypt  is  well  illustrated  by  the 
fact  that  in  7.5  per  cent,  of  army  recruits  the  ova  are  found  in  the  urine. 
An  Asiatic  blood  fluke,  Schistosomum  japonicum,  has  recently  been  discov- 
ered which  differs  in  small  details  from  the  African  variety. 

The  parasite  is  singular  among  flukes  as  having  the  sexes  separate,  and 
the  male  usually  carries  the  female  in  a  gynsecophorous  canal.  The  mode  of 
entrance  into  the  body  is  unknown,  whether  by  the  mouth,  the  urethra,  or 
through  the  skin.  The  eggs  are  very  characteristic,  oval  in  shape,  0.16  mm.  by 
0.06  mm.,  and  one  end  has  a  terminal  spine.  The  eggs  hatch  in  water,  but  the 
further  development  of  the  free-swimming  embryos  has  not  been  followed. 
Taken  into  the  body,  possibly  with  water  or  on  cresses,  it  reaches  the  portal 
veins,  in  which  the  worms  are  most  commonly  found,  usually  young  speci- 
mens and  uncoupled.  The  males  bearing  the  females  creep  to  various  parts, 
particularly  the  bladder  and  rectum.  The  vesciculse  seminales  may  be  first 
attacked.  The  eggs  are  laid  in  the  tissues,  but  wander,  like  other  sharp 
foreign  bodies,  and  escape  with  the  urine  and  faeces.  A  majority  of  them 
remain  in  the  tissues  and  cause  irritation,  fibroid  changes,  and  papillomata 
in  the  bladder  and  rectum.  Collecting  in  the  bladder  as  foreign  bodies  they 
form  the  nuclei  of  calculi. 

Symptoms. — As  is  so  often  the  case  with  animal  parasites,  they  may 
cause  no  inconvenience.  Irritability  of  the  bladder,  dull  pain  in  the  peri- 
neum, and  haematuria  are  the  most  frequent  symptoms.  A  chronic  cystitis 
follows  when  the  walls  of  the  bladder  are  much  thickened  by  the  irritation 
caused  by  the  ova.  The  anasmia  caused  by  the  haemorrhage  is  slight  in  com- 
parison with  that  of  ankylostomiasis.  When  the  rectum  is  involved  there  are 
straining  and  tenesmus,  with  the  passage  of  mucus  and  blood ;  in  severe  cases' 
large  papillomata  form  and  a  chronic  ulcerative  proctitis.  There  may  be  a 
chronic  vaginitis. 

Of  the  complications,  calculi  in  kidney  and  bladder  are  the  most  impor- 
tant. Milton,  Madden,  and  others  of  the  Cairo  School  of  Medicine  have 
studied  carefully  the  surgical  aspects  of  the  disease.  Periurethral  abscess 
and  perineal  fistula?  are  very  common  in  the  chronic  cases. 


284  SPECIFIC    INFECTIOUS    DISEASES 

Few  symptoms  are  caused  by  the  presence  of  the  parasites  in  the  portal 
veins,  but  there  may  be  an  advanced  cirrhosis  of  a  Glissonian  type  due  to  an 
enormous  thickening  of  the  periportal  tissues  (Symmers).  This  author 
has  also  reported  an  instance  of  the  Bilharzia  in  the  pulmonary  blood  in  a 
case  of  Bilharzial  colitis,  and  the  worms  were  found  living  in  the  pulmonary 
circulation. 

The  diagnosis  is  readily  made  by  finding  the  characteristic  ova  in  the 
bloody  urine  or  in  the  blood  and  mucus  from  the  rectum.  The  Bilharzia  may 
be  present  in  the  body  for  years  without  producing  serious  damage,  and  in 
slight  infections  the  symptoms  may  disappear  (Sandwith),  particularly  in 
children. 

5.  Schistosoma  japonicum  vel  cattoi. — In  China  and  Japan  and  in  the 
Philippines  there  is  a  disease  characterized  by  cirrhosis  of  the  liver,  spleno- 
megaly, ascites,  dysentery,  progressive  anaemia,  and  sometimes  by  focalized  epi- 
lepsy. It  occurs  extensively  in  one  district  of  Japan,  and  is  known  as  the 
"Katayama"  disease.  Woolley  has  met  with  it  in  the  Philippines,  and  Catto 
in  China.  It  seems  that  the  so-called  urticarial  fever,  which  is  not  very  un- 
common in  China  and  Japan,  is  associated  with  the  presence  of  this  para- 
site, and  an  eosinophilia  with  fever  and  urticaria  should  lead  to  a  careful 
examination  of  the  stools  for  its  eggs.  The  parasite  lives  in  the  vessels  of  the 
alimentary  canal;  the  ova  are  smaller  than  those  of  S.  hosmatobium,  and  have 
not  the  characteristic  spinous  ends. 

Treatment. — We  know  of  nothing  which  can  kill  the  parasites  in  the 
blood.  Extract  of  male  fern  is  recommended  for  the  haematuria.  The 
chronic  cystitis  and  proctitis  demand  the  usual  measures  for  these  disorders. 


H.    DISEASES    CAUSED    BY    CESTODE&-TJENIASIS 

Man  harbors  the  adult  parasites  in  the  small  intestine,  the  larval  forms 
in  the  muscles  and  solid  organs. 

1.     INTESTINAL   CESTODES;    TAPEWORMS 

Tfenia  solium  (Pork  Tapeworm). — This  is  not  a  common  form  in  the 
United  States.  It  is  not  uncommon  in  Panama.  It  is  more  frequent  in 
parts  of  Europe  and  Asia.  When  mature  it  is  from  6  to  12  feet  in  length. 
The  head  is  small,  round,  not  so  large  as  the  head  of  a  pin,  and  provided 
with  four  sucking  disks  and  a  double  row  of  booklets;  hence  it  is  called, 
in  contradistinction  to  the  other  form  in  man,  the  armed  tapeworm.  To  the 
head  succeeds  a  narrow,  thread-like  neck,  then  the  segments,  or  proglottides, 
as  they  are  called.  The  segments  possess  both  male  and  female  generative 
organs,  and  at  about  the  four-hundred-and-fiftieth  they  become  mature  and 
contain  ripe  ova.  The  worm  attains  its  full  growth  in  from  three  to  three 
and  a  half  months,  after  which  time  the  segments  are  continuously  shed 
and  appear  in  the  stools.  The  segments  are  about  1  cm.  in  length  and  from 
7  to  8  mm.  in  breadth.  Pressed  between  glass  plates  the  uterus  is  seen  as 
a  median  stem  with  about  eight  to  fourteen  lateral  branches.  There  are 
many  thousands  of  ova  in  each  ripe  segment,  and  each  ovum  consists  of  a 


DISEASES  CAUSED  BY  CESTODES— T^INIASIS  285 

firm  shell,  inside  of  which  is  a  little  embryo,  provided  with  six  booklets. 
The  segments  are  continuously  passed,  and  if  the  ova  are  to  attain  further 
development  they  must  be  taken  into  the  stomach,  either  of  a  pig,  or  of  man 
himself.  The  egg-shells  are  digested,  the  six-hooked  embryos  become  free, 
and  passing  from  the  stomach  reach  various  parts  of  the  body  (the  liver, 
muscles,  brain,  or  eye),  where  they  develop  into  the  larvae  or  cysticerci.  A 
hog  under  these  circumstances  is  said  to  be  measled,  and  the  cysticerci  are 
spoken  of  as  measles  or  bladder  worms. 

Tcenia  solium  received  its  name  because  it  was  thought  to  exist  as  a  soli- 
tary parasite  in  the  bowel,  but  two  or  three  or  even  more  worms  may  occur. 

Taenia  saginata  or  Mediocanellata  (Unarmed,  Fat,  or  Beef  Tapeworm.) — 
This  is  a  longer  and  larger  parasite  than  Tcenia  solium.  It  is  certainly  the 
common  tapeworm  of  Xorth  America.  Of  scores  of  specimens  which  I  have 
examined  almost  all  were  of  this  variety.  According  to  Berenger-Feraud  it 
has  spread  rapidly  in  western  Europe,  owing  probably  to  the  importation 
of  beef  and  live-stock  from  the  Mediterranean  basin.  It  may  attain  a  length 
of  15  or  20  feet,  or  more.  The  head  is  large  in  comparison  with  that  of 
Tcenia  solium,  and  measures  over  2  mm.  in  breadth.  It  is  square-shaped 
and  provided  with  four  large  sucking  disks,  but  there  are  no  booklets.  The 
ripe  segments  are  from  17  to  18  mm.  in  length  and  from  8  to  10  mm.  in 
breadth.  The  uterus  consists  of  a  median  stem  with  from  fifteen  to  thirty- 
five  lateral  branches,  which  are  given  off  more  dichotomously  than  in  Tcenia 
solium.  The  ov#  are  somewhat  larger,  and  the  shell  is  thicker,  but  the  two 
forms  can  scarcely  be  distinguished  by  their  ova.  The  ripe  segments  are 
passed  as  in  Tcenia  solium,  and  are  ingested  by  cattle,  in  the  flesh  or  organs 
of  which  the  eggs  develop  into  the  bladder  worms  or  cysticerci. 

Of  other  forms  of  tapeworm  may  be  mentioned: 

Dipylidium  caninum  (Taenia  elliptica,  Tsenia  cucumerina) . — A  small 
parasite  very  common  in  the  dog  and  occasionally  found  in  man;  the  larvas 
develop  in  the  lice  and  fleas  of  the  dog. 

Hymenolepis  diminuta  (Taenia  flavo-punctata) . — This  small  cestode  was 
found  in  the  intestine  of  a  child  in  Boston,  and  has  since  been  met  with  in 
twelve  cases  (Eansom).  It  is  common  in  rats.  The  larvae  develop  in  Lepi- 
doptera  and  in  beetles. 

Hymenolepis  nana  (Taenia  nana)  occurs  not  infrequently  in  Italy.  It 
is  not  very  uncommon  in  the  United  States  (Stiles).  The  Davainea  mada- 
gascariensis  (Tcenia  madagascariensis)  is  a  rare  form. 

Tsenia  confusa,  a  new  species  described  by  Ward. 

Dibothriocephalus  latus. — A  cestode  worm  found  only  in  certain  districts 
bordering  on  the  Baltic  Sea,  in  parts  of  Switzerland,  and  in  Japan,  dicker- 
son  has  shown  that  it  is  common  among  the  Finns  in  the  Northwestern  States, 
and  it  seems  not  improbable  that  the  fish  in  the  Great  Lakes  have  become  in- 
fected, as  cases  have  increased  of  late  years.  The  parasite  is  large  and  long, 
measuring  from  25  to  30  feet  or  more.  Its  head  is  different  from  that  of  the 
taenia,  as  it  possesses  two  lateral  grooves  or  pits  and  has  no  booklets.  The 
larvae  develop  in  the  peritoneum  and  muscles  of  the  pike  and  other  fish,  and 
it  has  been  shown  experimentally  that  they  grow  into  the  adult  worm  when, 
eaten  by  man. 

Symptoms  of  Tapeworm    Infection. — These   parasites   are   found   at  all 


286  SPECIFIC    INFECTIOUS    DISEASES 

ages.  They  are  not  uncommon  in  children  and  are  occasionally  found  in 
sucklings.  W.  T.  Plant  refers  to  a  number  of  cases  in  children  under  two 
years,  and  there  is  one  in  the  literature  in  which  it  is  stated  that  the  tape- 
worm was  found  in  an  infant  five  days  old ! 

The  parasites  may  cause  no  disturbance  and  are  rarely  dangerous.  A 
knowledge  of  the  existence  of  the  worm  is  generally  a  source  of  worry  and 
anxiety;  the  patient  may  have  considerable  distress  and  complain  of  ab- 
dominal pains,  nausea,  diarrhoea,  and  sometimes  anaemia.  Occasionally  the 
appetite  is  ravenous.  In  women  and  in  nervous  patients  the  constitutional 
disturbance  may  be  considerable,  and  we  not  infrequently  see  great  mental 
depression  and  even  hypochondria.  Various  nervous  phenomena,  such  as 
chorea,  convulsions,  or  epilepsy,  are  believed  to  be  caused  by  the  parasites. 
Such  effects,  however,  are  very  rare.  The  Dibothriocephalus  may  cause  a 
severe  and  even  fatal  form  of  anaemia,  which  has  been  described  fully  in 
the  monograph  of  Schaumann,  of  Helsingfors.  It  has  been  suggested  that 
the  metabolic  products  of  the  worm  may  have  in  some  cases  a  hasmolytic 
action.  Eosinophilia  may  occur. 

Diagnosis. — The  diagnosis  is  never  doubtful.  The  presence  of  the  seg- 
ments is  distinctive.  The  ova,  too,  may  .be  recognized  in  the  stools.  It  makes 
but  little  difference  as  to  the  form  of  tapeworm,  but  the  ripe  segments  of 
Tcenia  saginata  are  larger  and  broader,  and  show  differences  in  the  genera- 
tive system  as  already  mentioned. 

Prophylaxis.  — The  prophylaxis  is  most  important.  Careful  attention 
should  be  given  to  three  points.  First,  all  tapeworm  segments  should  be 
burned;  they  should  never  be  thrown  into  the  water-closet  or  outside;  sec- 
ondly, careful  inspection  of  meat  at  the  abattoirs;  and,  thirdly,  cooking  the 
meat  sufficiently  to  kill  the  parasites. 

In  the  case  of  the  beef  measles,  the  distribution  of  the  parasites,  as 
given  by  Ostertag,  shows  that  the  muscles  of  the  jaw  are  much  more  fre- 
quently affected  than  other  parts — 360  times — while  other  organs  were  infect- 
ed but  55  times.  Sometimes  there  are  instances  of  -general  infection.  In  Ber- 
lin the  proportion  of  cattle  infected  in  1892-'93  was  about  1  to  672.  Cold 
storage  kills  the  cysticercus  usually  within  three  weeks.  The  measles  are 
more  readily  overlooked  in  beef  than  in  pork,  as  they  do  not  present  such  an 
opaque  white  color. 

In  the  examination  of  hogs  for  cysticerci  "particular  stress  should  be 
laid  upon  the  tongue,  the  muscles  of  mastication,  and  the  muscles  of  the 
shoulder,  neck,  and  diaphragm"  (Stiles).  They  may  be  seen  very  easily 
on  the  under  surface  of  the  tongue.  American  hogs  are  comparatively 
free.  In  Prussia  one  hog  is  infected  in  about  every  637.  Specimens  have 
been  found  alive  twenty-nine  days  after  slaughtering.  In  the  examination 
of  1,000  hogs  in  Montreal,  Clement  and  I  found  76  instances  of  cysticerci. 
For  full  details  with  reference  to  the  inspection  of  meat  for  animal  parasites, 
the  practitioner  is  referred  to  the  work  of  Dr.  Stiles,  in  Bulletin  No.  19, 
United  States  Department  of  Agriculture,  1898. 

Treatment. — Three  days  should  be  given  to  preparation  for  treatment, 
•whatever  drug  is  employed.  For  two  days  the  patient  should  take  soft  food 
and  the  third  day  liquids  only.  The  bowels  should  be  well  moved  by  castor 
.oil  taken  each  evening  and  a  saline  in  the. morning  if  necessary.  Unless  the 


DISEASES  CAUSED  BY  CESTODES— T^ENIASIS  287 

bowels  have  moved  freely  an  enema  should  be  given.  On  the  third  night  a 
laxative,  such  as  cascara,  should  be  taken.  There  are  many  drugs,  but  male 
fern  is  usually  the  most  reliable,  given  in  the  form  of  the  ethereal  extract. 
This  is  taken  early  in  the  morning  of  the  fourth  day  before  any  food  is 
taken.  The  usual  dose  is  3i  (4  c.  c.),  which  is  repeated  in  an  hour.  It 
may  be  given  in  capsules  or  in  glycerine  (3  ss,  15  c.  c.).  If  there  is  fear  of 
nausea  a  cup  of  coffee  may  be  taken  before  the  drug.  After  taking  the  male 
fern  the  patient  should  remain  quiet  and  resist  any  desire  to  vomit.  One 
hour  after  the  second  dose  of  male  fern  a  full  dose  of  saline  is  taken  (mag- 
nesium or  sodium  sulphate,  or  magnesium  citrate),  and  an  hour  later  a  sec- 
ond dose  if  the  bowels  have  not  moved.  Great  care  should  be  taken  during 
the  expulsion  of  the  worm,  which  should  be  passed  into  a  chamber  containing 
water  at  about  the  body  temperature,  a  practice  recommended  by  Celsus. 

The  pomegranate  root  is  a  very  efficient  remedy,  and  may  be  given  as 
an  infusion  of  the  bark,  3  ounces  of  which  may  be  macerated  in  10  ounces 
of  water  and  then  reduced  to  one-half  by  evaporation.  The  entire  quantity 
is  then  taken  in  divided  doses.  It  occasionally  produces  colic,  but  is  a  very 
effective  remedy.  The  active  principle,  pelletierine,  is  now  much  employed 
as  the  tannate,  given  in  doses  of  6  to  8  or  even  10  grains  (0.4  to  0.6  gm.),  and 
followed  in  an  hour  by  a  purge. 

Pumpkin  seeds  are  sometimes  very  efficient.  Three  or  four  ounces  should 
be  carefully  bruised  and  then  macerated  for  twelve  or  fourteen  hours,  and 
the  entire  quantity  taken  and  followed  in  an  hour  by  a  purge.  .  Of  other 
remedies,  cusso,  naphthalein  (gr.  v,  0.3  gm.),  turpentine  in  ounce  doses  in 
honey,  and  kamala  may  be  mentioned.  Sometimes  a  combination  of  rem- 
edies is  effectual  when  one  fails.  In  children  the  use  of  pumpkin  seeds  or 
pelletierine  is  generally  best.  One  cause  of  failure  is  the  use  of  drugs  which 
are  old  and  inert. 

Unless  the  head  is  brought  away,  the  parasite  continues  to  grow,  and 
within  a  few  months  the  segments  again  appear.  Some  instances  are 
extraordinarily  obstinate.  Doubtless  almost  everything  depends  upon  the 
exposure  of  the  worm.  The  head  and  neck  may  be  thoroughly  protected 
beneath  the  valvula?  conniventes,  in  which  case  the  remedies  may  not  act. 
Owing  to  its  armature  Tcenia  solium  is  more  difficult  to  expel.  It  is  probable 
that  no  degree  of  peristalsis  could  dislodge  the  head,  and  unless  the  worm  is 
killed  it  does  not  let  go  its  extraordinarily  firm  hold  on  the  mucous  mem- 
brane. Owing  to  the  danger  of  cysticercosis,  treatment  should  not  be  de- 
layed in  case  of  infection  with  Tcenia  solium. 

2.    SOMATIC   T^ENIASIS 

Whereas  adult  taenia  may  give  rise  to  little  or  no  disturbance,  and  rarely, 
if  ever,  prove  directly  fatal,  the  affections  caused  by  the  larvae  or  immature 
forms  in  the  solid  organs  are  serious  and  important.  There  are  two  chief 
cestode  Iarva3  known  to  frequent  man :  (a)  the  Cysticercus  celluloses,  the 
larva  of  Tcenia  solium,  and  (&)  the  Echinococcus,  the  larva  of  Tcenia  echino- 
coccus.  The  Cysticercus  tcenia  saginatce  has  been  found  only  two  or  three 
times  in  man. 

Cysticercus  cellulosae. — When  man   accidentally  takes   into  his  stomach 


288  SPECIFIC   INFECTIOUS    DISEASES 

the  ripe  ova  of  Tcenia  solium  he  is  liable  to  become  the  intermediate  host, 
a  part  usually  played  for  this  tapeworm  by  the  pig.  This  accident  may  occur 
in  an  individual  the  subject  of  Tcenia  solium,  in  which  case  the  mature 
proglottides  either  themselves  wander  into  the  stomach  or,  what  is  more  like- 
ly, are  forced  into  the  organ  in  attacks  of  prolonged  vomiting.  Of  course  the 
accidental  ingestion  'from  the  outside  of  a  few  ova  is  quite  possible,  and  the 
liability  of  infection  should  always  be  borne  in  mind  in  handling  the  seg- 
ments of  the  worm. 

The  symptoms  depend  entirely  upon  the  number  of  ova  ingested  and 
the  localities  reached.  In  the  hog  the  cysticerci  produce  very  little  disturb- 
ance. The  muscles,  the  connective  tissue,  and  the  brain  may  be  swarming 
with  the  measles,  as  they  are  called,  and  yet  the  nutrition  is  maintained 
and  the  animal  does  not  appear  to  be  seriously  incommoded.  In  the  in- 
vasion period,  if  large  numbers  of  the  parasites  are  taken,  there  is,  in  all 
probability,  constitutional  disturbance;  certainly  this  is  seen  in  the  calf,  when 
fed  with  the  ripe  segments  of  Tcenia  saginata. 

In  man  a  few  cysticerci  lodged  beneath  the  skin  or  in  the  muscles  give 
no  trouble,  and  in  time  the  larvae  die  and  become  calcified.  They  are  occa- 
sionally found  in  dissection  subjects  or  in  post  mortems  as  ovoid  white  bodies 
in  the  muscles  or  subcutaneous  tissue.  In  America  they  are  very  rare.  I 
saw  but  one  instance  in  my  post  mortem  experience.  Depending  -on  the 
number  and  the  locality  specially  affected,  the  symptoms  may  be  grouped  into 
general,  cerebro-spinal,  and  ocular.  In  155  cases  compiled  by  Stiles,  the 
parasite  in  117  was  found  in  the  brain,  in  32  in  the  muscles,  in  9  in  the 
heart,  in  3  in  the  lungs,  subcvtaneously  in  5,  in  the  liver  in  2. 

1.  GENERAL. — As  a  rule  the  invasion  of  the  Iarva3  in  man,  unless  in  very 
large  numbers,  does  not  cause  very  definite  symptoms.     It  occasionally  hap- 
pens, however,  that  a  striking  picture  is  produced.     A  patient  was  admitted 
to  my  wards  very  stiff  and  helpless,  so  much  so  that  he  had  to  be  assisted 
upstairs  and  into  bed.     He  complained  of  numbness  and  tingling  in  the 
extremities  and  general  weakness,  so  that  at  first  he  was  thought  to  have  a 
peripheral  neuritis.    At  the  examination,  however,  a  number  of  painful  sub- 
cutaneous nodules  were  discovered,  which  proved  on  excision  to  be  the  cys- 
ticerci.   Altogether  75  could  be  felt  subcutaneously,  and  from  the  soreness 
and  stiffness  they  probably  existed  in  large  numbers  in  the  muscles.     There 
were  none  in  his  eyes,  and  he  had  no  brain  symptoms. 

2.  CEREBRO-SPINAL. — Remarkable  symptoms  may  result  from  the  pres- 
ence of  the  cysticerci  in  the  brain  and  cord.     In  the  silent  region  they  may 
be  abundant  without  producing  any  symptoms.    I  have  in  my  possession  the 
brain  of  a  pig  containing  scores  of  "measles,"  yet  the  animal  in  the  few 
moments  in  which  I  saw  it  just  prior  to  death  did  not  present  any  symptoms 
to  attract  attention.    In  the  ventricles  of  the  brain  the  cysticerci  may  attain 
a  considerable  size,  owing  to  the  fact  that  in  regions  in  which  they  are  unre- 
strained in  their  growth,  as  in  the  peritoneum,  the  bladder-like  body  grows 
freely.    When  in  the  fourth  ventricle  remarkable  irritative  symptoms  may  be 
produced.     In  1884  I  saw  with  Friedlander  in  Berlin  a  case  from  Riess's 
wards  in  which  during  life  there  had  been  symptoms  of  diabetes  and  anom- 
alous nervous  symptoms.     Post  mortem,  the  cysticercus  was  found  beneath 
the  valve  of  Vieussens,  pressing  upon  the  floor  of  the  fourth  ventricle. 


DISEASES  CAUSED  BY  CESTODES— T^ENIASIS  289 

3.  OCULAR. — Since  von  Graefe  demonstrated  the  presence  of  the  cysticer- 
cus  in  the  vitreous  humor  many  cases  have  been  placed  on  record,  as  it  is  a 
condition  easily  recognized. 

Except  in  the  eye,  the  diagnosis  can  rarely  be  made;  when  the  cysticerci 
are  subcutaneous  one  may  be  excised.  It  is  possible  that  when  numerous 
throughout  the  muscles  they  may  be  seen  under  the  tongue,  in  which  situa- 
tion they  may  exist  in  the  pig  in  numbers. 

Echinococcus  Disease. — The  hydatid  worms  or  echinococci  are  the  larvae 
of  Tcenia  echinococcus  of  the  dog.  This  is  a  tiny  cestode  not  more  than  4 
or  5  mm.  in  length,  consisting  of  only  three  or  four  segments,  of  which 
the  terminal  one  alone  is  mature,  and  has  a  length  of  about  2  mm.  and  a 
breadth  of  0.6  mm.  The  head  is  small  and  provided  with  four  sucking 
disks  and  a  rostellum  with  a  double  row  of  booklets.  This -is  an  exceedingly 
rare  parasite  in  the  dog.  Cobbold  states  that  he  has  never  met  with  a  natural 
specimen  in  England.  Leidy  had  not  one  in  his  large  collection.  I  did  not 
meet  with  an  instance  in  America;  Curtice,  of  Washington,  found  it  once  in 
an  American  dog.  The  worms  are  so  small  that  they  may  be  readily  over- 
looked, since  they  form  small,  white,  thread-like  bodies  closely  adherent  among 
the  villi  of  the  small  intestines.  The  ripe  segment  contains  about  5,000  eggs, 
which  attain  their  development  in  the  solid  organs  of  various  animals,  particu- 
larly the  hog  and  ox,  more  rarely  the  horse  and  the  sheep.  In  some  countries 
man  is  a  common  intermediate  host,  owing  to  the  accidental  ingestion  of 
the  ova. 

DEVELOPMENT. — The  little  six-hooked  embryo,  freed  from  the  egg-shell  by 
digestion,  burrows  through  the  intestinal  wall  and  reaches  the  peritoneal  cav- 
ity or  the  muscles ;  it  may  enter  the  portal  vessels  and  be  carried  to  the  liver. 
It  may  enter  the  systemic  vessels,  and,  passing  the  pulmonary  capillaries,  as  it 
is  protoplasmic  and  elastic,  may  reach  the  brain  or  other  parts.  Once  having 
reached  its  destination,  it  undergoes  the  following  changes:  The  booklets 
disappear  and  the  little  embryo  is  gradually  converted  into  a  small  cyst  which 
presents  two  distinct  layers — an  external,  laminated,  cuticular  membrane  or 
capsule,  and  an  internal,  granular,  parenchymatous  layer,  the  endocyst.  The 
little  cyst  or  vesicle  contains  a  clear  fluid.  There  is  more  or  less  reaction  in 
the  neighboring  tissues,  and  the  cyst  in  time  has  a  fibrous  investment.  When 
this  primary  cyst  or  vesicle  has  attained  a  certain  size,  buds  develop  from 
the  parenchymatous  layer,  which  are  gradually  converted  into  cysts,  present- 
ing a  structure  identical  with  that  of  the  eriginal  cyst,  namely,  an  elastic 
chitinous  membrane  lined  with  a  granular  parenchymatous  layer.  These  sec- 
ondary or  daughter  cysts  are  at  first  connected  with  the  lining  membrane  of 
the  primary  cyst,  but  are  soon  set  free.  In  this  way  the  parent  cyst  :as  it 
grows  may  contain  a  dozen  or  more  daughter  cysts.  Inside  these  'daughter 
cysts  a  similar  process  may  occur,  and  from  buds  in  the  walls  granddaughter 
cysts  are  developed.  From  the  granular  layer  of  the  parent  and  daughter 
cysts  buds  arise  which  develop  into  brood  capsules.  From  the  lining  mem- 
brane the  little  outgrowths  arise  and  gradually  develop  into  bodies  known  as 
scolices,  which  represent  in  reality  the  head  of  the  Tcenia  echinococcus  and 
present  four  sucking  disks  and  a  circle  of  booklets.  Each  scolex  is  capable 
when  transferred  to  the  intestines  of  a  dog  of  developing  into  an  adult  tape- 
worm. The  difference  between  the  ovum  of  an  ordinary  tapeworm,  such 


290 

as  Tcenia  solium,  and  Tcenia  echinococcus  is  in  this  way  very  striking.  In 
the  former  case  the  ovum  develops  into  a  single  larva — Cysticercus  cellulosce 
— whereas  the  egg  of  Tcenia  echinococcus  develops  into  a  cyst  which  is  capa- 
ble of  multiplying  enormously  and  from  the  lining  membrane  of  which 
millions  of  larval  tapeworms  develop.  Ordinarily  in  man  the  development  of 
the  echinococcus  takes  place  as  above  mentioned  and  by  an  endogenous  form 
in  which  the  secondary  and  tertiary  cysts  are  contained  within  the  primary ; 
but  in  animals  the  formation  may  be  different,  as  the  buds  from  the  primary 
cyst  penetrate  between  the  layers  and  develop  externally,  forming  the  exoge- 
nous variety.  A  third  form  is  the  multilocular  echinococcus,  in  which  form 
the  primary  cyst  buds  develop  which  are  cut  off  completely  and  are  sur- 
rounded by  thick  capsules  of  a  connective  tissue,  which  join  together  and 
ultimately  form  a  hard  mass  represented  by  strands  of  connective  tissue 
inclosing  alveolar  spaces  about  the  size  of  peas  or  a  little  larger.  In  these 
spaces  are  found  the  remnants  of  the  echinococcus  cyst,  occasionally  the 
scolices  or  hooklets,  but  they  are  often  sterile. 

The  fluid  is  limpid,  non-albuminous ;  specific  gravity  1.005  to  1.009,  occa- 
sionally higher.  It  may  contain  sugar  and  succinic  acid,  and,  after  repeated 
tapping  of  the  cyst,  albumin.  When  not  degenerated  the  hydatid  heads  or 
the  characteristic  hooklets  are  found  in  the  contents  of  the  cyst. 

CHANGES  IN  THE  CYST. — It  is  not  known  definitely  how  long  the  echino- 
coccus remains  alive,  probably  many  years,  possibly  as  long  as  twenty  years. 
The  most  common  change  is  death  and  the  gradual  inspissation  of  the  contents 
and  conversion  of  the  cyst  into  a  mass  containing  putty-like  or  granular  ma- 
terial which  may  be  partially  calcified.  Remnants  of  the  chitinous  cyst  wall 
or  hooklets  may  be  found.  These  obsolete  hydatid  cysts  are  not  infrequently 
found  in  the  liver.  A  more  serious  termination  is  rupture,  which  may  take 
place  into  a  serous  sac,  or  perforation  may  take  place  externally  when  the 
cysts  are  discharged,  as  into  the  bronchi  or  alimentary  canal  or  urinary 
passages.  More  unfavorable  are  the  instances  in  which  rupture  occurs  into 
the  bile-passages  or  into  the  inferior  cava.  Recovery  -may  follow  the  rupture 
and  discharge  of  the  hydatids  externally.  Sudden  death  has  been  known  to 
follow  the  rupture.  A  third  and  very  serious  mode  of  termination  is  sup- 
puration, which  may  occur  spontaneously  or  follow  rupture  and  is  found 
most  frequently  in  the  liver. 

GEOGRAPHICAL  DISTRIBUTION  OP  THE  ECHINOCOCCUS. — The  disease  pre- 
vails most  extensively  in  those  countries  in  which  man  is  brought  into  close 
contact  with  the  dog,  particularly  when,  as  in  Australia,  the  dogs  are  used 
for  herding  sheep,  the  animal  in  which  the  larval  form  of  Tcenia  echinococcus 
is  most  often  found.  In  Iceland  the  cases  are  very  numerous.  In  Europe  the 
disease  is  not  uncommon.  In  Great  Britain  and  in  North  America  it  is 
rare,  and  a  majority  of  the  cases  are  in  foreigners.  Statistics  of  the  preva- 
lence of  the  disease  in  America  have  been  published  by  Osier  (1882),  Som- 
mer  (1895-'96),  and  by  Lyon  (1902),  who  has  collected  241  cases.  Of  these, 
136  cases  were  in  foreigners;  in  92  the  nationality  was  not  stated;  10  were 
negroes;  2  Canadians,  and  only  1  a  native  American.  Fifty-six  cases  oc- 
curred in  Manitoba,  in  which  province  there  is  a  large  settlement  of  Ice- 
landers, who  have  brought  the  disease  with  them.  Only  one  instance  is 
known  in  a  Canadian-born  offspring  of  an  Icelandic  emigrant. 


DISEASES  CAUSED  BY  CESTODES— T^ENIASIS  291 

DISTRIBUTION  IN  THE  BODY. — Of  1,634  cases  comprised  in  the  statistics 
of  Davaine,  Bocker,  Finsen,  and  Neisser,  the  parasite  existed  in  the  liver  in 
820;  in  the  lung  or  pleura  in  137;  in  the  abdominal  organs,  including  the 
kidneys,  bladder,  and  genitalia,  in  334 ;  in  the  nervous  system  in  122 ;  in  the 
circulatory  system  in  42;  in  other  organs  179.  Of  the  241  cases  in  Lyon's 
series  in  America  the  liver  was  the  seat  in  177,  and  the  omentum,  peri- 
toneal cavity,  and  mesentery  in  26.  In  11  cases  cysts  were  passed  per  rectum, 
in  7  cases  cysts  or  hooklets  were  expectorated,  and  in  2  cases  passed  per 
urethram. 

SYMPTOMS. — 1.  Hydatids  of  the  Liver. — Small  cysts  may  cause  no  dis- 
turbance; large  and  growing  cysts  produce  signs  of  tumor  of  the  liver  with 
great  increase  in  the  size  of  the  organ.  Naturally  the  physical  signs  depend 
much  upon  the  situation  of  the  growth.  Near  the  anterior  surface  in  the 
epigastric  region  the  tumor  may  form  a  distinct  prominence  and  have  a  tense, 
firm  feeling,  sometimes  with  fluctuation.  A  not  infrequent  situation  is  to 
the  left  of  the  suspensory  ligament,  the  resulting  tumor  pushing  up  the  heart 
and  causing  an  extensive  area  of  dulness  in  the  lower  sternal  and  left  hypo- 
chondriac regions.  In  the  right  lobe,  if  the  tumor  is  on  the  posterior  sur- 
face, the  enlargement  of  the  organ  is  chiefly  upward  into  the  pleura  and  the 
vertical  area  of  dulness  in  the  posterior  axillary  line  is  increased.  Super- 
ficial cysts  may  give  what  is  known  as  the  hydatid  fremitus.  If  the  tumor 
is  palpated  lightly  with  the  fingers  of  the  left  hand  and  percussed  at  the  same 
time  with  those  of  the  right,  there  is  felt  a  vibration  or  trembling  movement 
which  persists  for  a  certain  time.  It  is  not  always  present,  and  it  is  doubtful 
whether  it  is  peculiar  to  the  hydatid  tumors  or  is  due,  as  Briangon  held,  to 
the  collision  of  the  daughter  cysts.  Very  large  cysts  are  accompanied  by 
feelings  of  pressure  or  dragging  in  the  hepatic  region,  sometimes  actual  pain. 
The  general  condition  of  the  patient  is  at  first  good  and  the  nutrition  little, 
if  at  all,  interfered  with.  Unless  some  of  the  accidents  already  referred  to 
occur,  the  symptoms  indeed  may  be  trifling  and  due  only  to  the  pressure  or 
weight  of  the  tumor. 

Historically,  one  of  the  most  interesting  cases  is  that  of  the  first  Lord 
Shaftesbury  (Achitopel),  who  had  a  tumor  below  the  costal  border  for  many 
years.  It  suppurated  and  was  opened  by  the  philosopher  John  Locke,  his 
physician,  who  describes  with  great  detail  the  escape  of  the  bladder-like  bodies. 
Among  the  Shaftesbury  papers  in  the  Record  Office  are  several  other  cases 
collected  by  Locke;  the  disease  may  have  been  more  common  in  England  at 
that  period. 

Suppuration  of  the  cyst  changes  the  clinical  picture  into  one  of  pya?- 
mia.  There  are  rigors,  sweats,  more  or  less  jaundice,  and  rapid  loss  of 
weight.  Perforation  may  occur  into  the  stomach,  colon,  pleura,  bron- 
chi, or  externally,  and  in  some  instances  recovery  has  taken  place.  Per- 
foration has  occurred  into  xthe  pericardium  and  inferior  vena  cava;  in 
the  latter  case  the  daughter  cysts  have  been  found  in  the  heart,  plug- 
ging the  tricuspid  orifice  and  the  pulmonary  artery.  Perforation  of  the 
bile-passages  causes  intense  jaundice,  and  may  lead  to  suppurative  cholan- 
gitis. 

An  interesting  symptom  connected  with  the  rupture  of  hydatid  cysts  is 
the  occurrence  of  urticaria,  which  may  also  follow  aspiration  of  the  cysts. 


292  SPECIFIC    INFECTIOUS    DISEASES 

Brieger  has  separated  a  highly  toxic  material  from  the  fluid,  and  to  it  the 
symptoms  of  poisoning  may  be  due. 

Diagnosis. — Cysts  of  moderate  size  may  exist  without  producing  symp- 
toms. Large  multiple  echinococci  may  cause  great  enlargement  with  irregu- 
larity of  the  outline,  and  such  a  condition  persisting  for  any  time  with  re- 
tention of  the  health  and  strength  suggests  hydatid  disease.  An  irregular, 
painless  enlargement,  particularly  in  the  left  lobe,  or  the  presence  of  a  large, 
smooth,  fluctuating  tumor  of  the  epigastric  region  is  also  very  suggestive, 
and  in  this  situation,  when  accessible  to  palpation,  it  gives  a  sensation  of  a 
smooth  elastic  growth  and  possibly  also  the  hydatid  tremor.  When  suppura- 
tion occurs  the  clinical  picture  is  really  that  of  abscess,  and  only  the  exis- 
tence of  previous  enlargement  of  the  liver  with  good  health  would  point  to 
the  fact  that  the  suppuration  was  associated  with  hydatids.  Syphilis  may 
produce  irregular  enlargement  without  much  disturbance  in  the  health,  some- 
times also  a  very  definite  tumor  in  the  epigastric  region,  but  this  is  usually 
firm  and  not  fluctuating.  The  clinical  features  may  simulate  cancer  very 
closely.  In  a  case  which  I  reported  the  liver  was  greatly  enlarged  and  there 
•were  many  nodular  tumors  in  the  abdomen.  The  post  mortem  showed  enor- 
mous suppurating  hydatid  cysts  in  the  left  lobe  of  the  liver  which  hao1 
perforated  the  stomach  in  two  places  and  also  the  duodenum.  The  omen- 
turn,  mesentery,  and  pelvis  also  contained  numerous  cysts.  As  a  rule,  the 
clinical  course  of  the  disease  would  suffice  to  separate  it  clearly  from  cancer. 
Dilatation  of  the  gall-bladder  and  hydronephrosis  have  both  been  mistaken 
for  hydatid  disease.  In  the  former  the  mobility  of  the  tumor,  its  shape,  and 
the  mucoid  character  of  the  contents  suffice  for  the  diagnosis.  In  some  in- 
stances of  hydronephrosis  only  the  exploratory  puncture  could  distinguish 
between  the  conditions.  More  frequent  is  the  mistake  of  confounding  a 
hydatid  cyst  of  the  right  lobe  pushing  up  the  pleura  with  pleural  effusion  of 
the  right  side.  The  heart  may  be  dislocated,  the  liver  depressed,  and  dul- 
ness,  feeble  breathing,  and  diminished  fremitus  are  present  in  both  condi- 
tions. Frerichs  lays  stress  upon  the  different  character  of  the  line  of  dul- 
ness;  in  the  echinococcus  cyst  the  upper  limit  presents  a  curved  line,  the 
maximum  of  which  is  usually  in  the  scapular  region.  Suppurative  pleurisy 
may  be  caused  by  the  perforation  of  the  cyst.  If  adhesions  result,  the  per- 
foration takes  place  into  the  lung,  and  fragments  of  the  cysts  or  small  daugh- 
ter cysts  may  be  coughed  up.  For  diagnostic  purposes  the  exploratory  punc- 
ture should  be  used.  As  stated,  the  fluid  is  usually  perfectly  clear  or  slightly 
opalescent,  the  reaction  is  neutral,  and  the  specific  gravity  varies  from  1.005 
to  1.009.  It  is  non-albuminous,  but  contains  chlorides  and  sometimes  traces 
of  sugar.  Booklets  may  be  found  either  in  the  clear  fluid  or  in  the  sup- 
purating cysts.  They  are  sometimes  absent,  however,  as  the  cyst  may  be 
sterile. 

2.  Echinococcus  of  the  Respiratory  System. — Of  809  cases  of  single  hy- 
datid cyst  collected  by  Thomas  in  Australia,  the  lung  was  affected  in  134 
cases.  Of  241  American  cases,  in  16  the  pleura  or  lung  was  affected.  The 
larvae  may  develop  primarily  in  the  pleura  and  attain  a  large  size.  The 
symptoms  are  at  first  those  of  compression  of  the  lung  and  dislocation  of  the 
heart.  The  physical  signs  are  those  of  fluid  in  the  pleura.  The  line  of  dul- 
ness  may  be  quite  Irregular.  As  in  the  echinococcus  of  the  liver,  the  general 


DISEASES  CAUSED  BY  CESTODES— T^NIASIS  293 

condition  of  the  patient  may  be  excellent  in  spite  of  the  existence  of  extensive 
disease.  Pleurisy  is  rarely  excited.  The  cysts  may  become  inflamed  and 
perforate  the  chest  wall.  Gary  and  Lyon  have  analyzed  40  cases  of  primary 
cchinococcus  cyst  of  the  pleura ;  death  results  in  a  majority  of  the  cases  from 
the  toxaemia  following  the  rupture  and  the  absorption  of  the"  fluid  or  from 
the  sepsis  following  suppuration. 

Echinococci  occur  more  frequently  in  the  lung  than  in  the  pleura.  If 
small,  they  may  exist  for  some  time  without  causing  serious  symptoms.  In 
their  growth  they  compress  the  lung  and  sooner  or  later  lead  to  inflamma- 
tory processes,  often  to  gangrene,  and  the  formation  of  cavities  which  connect 
with  the  bronchi.  Fragments  of  membrane  or  small  cysts  may  be  expectorated. 
Haemorrhage  is  not  infrequent.  Perforation  into  the  pleura  with  empyema 
is  common.  A  majority  of  the  cases  are  regarded  during  life  as  either  phthi- 
sis or  gangrene,  and  it  is  only  the  detection  of  the  characteristic  membranes 
or  the  booklets  which  leads  to  the  diagnosis.  Of  a  series  of  21  cases,  17  re- 
covered; 5  of  the  cases  suppurated  (C.  H.  Fleming,  Victoria,  personal  com- 
munication). 

3.  Echinococcvs  of  the  Kidneys. — In  the  collected  statistics  referred  to 
above  the  geni to-urinary  system  comes  second  as  the  seat  of  hydatid  disease, 
though  here  the  affection  is  rare  in  comparison  with  that  of  the  liver.     Of 
the  241  American  cases,  there  were  17  in  which  the  kidneys  or  bladder  were 
involved.     The  kidney  may  be  converted  into  an  enormous  cyst  resembling  a 
hydronephrosis. 

The  diagnosis  is  only  possible  by  puncture  and  examination  of  the  fluid. 
The  cyst  may  perforate  into  the  pelvis  of  the  kidney,  and  portions  of  the 
membrane  or  cysts  may  be  discharged  with  the  urine,  sometimes  producing 
renal  colic.  I  have  reported  a  case  in  which  for  many  months  the  patient 
passed  at  intervals  numbers  of  small  cysts  with  the  urine.  The  general  health 
was  little  if  at  all  disturbed,  except  by  the  attacks  of  colic  during  the  pas- 
sage of  the  parasites. 

4.  EcJiinococcus  of  the  Nervous  System. — The  common  cystic  disease  of 
the  choroidal  plexuses  has  been  mistaken  for  hydatids.     Davies  Thomas,  of 
Australia,  has  tabulated  97  cases,  including  some  of  the  Cysiicercus  cellu- 
losce.    According  to  his  statistics,  the  cyst  is  more  common  on  the  right  than 
on  the  left  side,  and  is  most  frequent  in  the  cerebrum. 

The  symptoms,  very  indefinite,  as  a  rule  are  those  of  tumor.  *  Persistent 
headache,  convulsions,  either  limited  or  general,  and  gradually  developing 
blindness  have  been  prominent  features  in  many  cases. 

Multilocular  Echinococcus. — This  form  merits  a  brief  separate  descrip- 
tion, as  it  differs  so  remarkably  from  the  usual  type.  It  has  been  met  with 
only  in  Bavaria,  Wiirttemberg,  the  adjacent  districts  of  Switzerland,  and 
in  the  Tyrol.  Possett  has  reported  13  cases  from  von  Eokitansky's  clinic  at 
Innsbruck.  In  the  United  States  six  cases  have  been  described,  chiefly  in 
Germans.  Delafield  and  Prudden's  patient  had  lived  there  five  years,  and 
for  a  year  before  his  death  had  been  jaundiced.  A  fluctuating  tumor  was 
found  in  the  right  flank,  apparently  connected  with  the  liver.  This  was 
opened,  and  death  followed  from  hemorrhage.  In  Oertel's  case  the  patient 
had  lived  there  ten  years.  He  was  deeply  jaundiced,  and  had  a  tumor  mass 
at  the  right  border  of  the  liver,  which  was  enlarged.  Bacon  resected  a  cyst 


294  SPECIFIC   INFECTIOUS    DISEASES 

from  the  left  lobe  of  the  liver.  The  primary  tumor  presents  irregularly 
formed  cavities  separated  from  each  other  by  strands  of  connective  tissue, 
and  lined  with  the  echinococcus  membrane.  The  cavities  are  filled  with  a 
gelatinous  material,  so  that  the  tumor  has  very  much  the  appearance  of  an 
alveolar  colloid  cancer.  It  is  quite  possible  that  a  special  form  of  taenia 
echinococcus  represents  the  adult  type  of  this  peculiar  parasite.  This  form 
is  almost  exclusively  confined  to  the  liver,  and  the  symptoms  resemble  more 
those  of  tumor  or  cirrhosis.  The  liver  is,  as  a  rule,  enlarged  and  smooth,  not 
irregular  as  in  presence  of  the  ordinary  echinococcus.  Jaundice  is  a  com- 
mon symptom.  The  spleen  is  usually  enlarged,  there  is  progressive  emacia- 
tion, and  toward  the  close  hemorrhages  are  common. 

Treatment  of  Echinococcus  Disease. — Medicines  are  of  no  avail.  Post 
mortem  reports  show  that  in  a  considerable  number  of  cases  the  parasite 
dies  and  the  cyst  becomes  harmless.  Operative  measures  should  be  resorted 
to  when  the  cysUs  large  or  troublesome.  The  simple  aspiration  of  the  con- 
tents has  been  successful  in  a  large  number  of  cases,  and  may  be  tried  before 
the  more  radical  procedure  of  incision  and  evacuation  of  the  cysts.  Sup- 
puration has  occasionally  followed  the  puncture.  Injections  into  the  sac 
should  not  be  practiced.  With  modern  methods  surgeons  now  open  and 
evacuate  the  echinococcus  cysts  with  great  boldness,  and  the  Australian  rec- 
ords, which  are  the  most  numerous  and  important  on  this  subject,  show  that 
recovery  is  the  rule  in  a  large  proportion  of  the  cases.  Suppurative  cysts  in 
the  liver  should  be  treated  as  abscess.  Naturally  the  outlook  is  less  favor- 
able. The  practical  treatment  of  hydatid  disease  has  been  greatly  advanced 
by  Australian  surgeons.  The  works  of  the  Australian  physicians,  James 
Graham  and  Thomas,  may  be  consulted  for  interesting  details  in  diagnosis 
and  treatment. 

Spargannm  mansoni  is  a  larval  bothriocephalus  met  with  in  Japan  and 
China,  usually  in  the  subcutaneous  tissues,  the  adult  form  of  which  is  not 
known. 

HI.    DISEASES  CAUSED  BY  NEMATODES 

1.  ASCAEIASIS 

Ascaris  lumbricoides,  the  most  common  human  parasite,  is  found  chiefly 
in  children.  The  female  is  from  7  to  12  inches  in  length,  the  male  from 
4  to  8  inches.  In  form  it  is  cylindrical,  pointed  at  both  ends,  with  a  yel- 
lowish-brown, sometimes  a  slightly  reddish  color.  Four  longitudinal  bands 
can  be  seen,  and  it  is  striated  transversely.  The  ova,  which  are  sometimes 
found  in  large  numbers  in  the  faeces,  are  small,  brownish-red  in  color,  ellip- 
tical, and  have  a  very  thick  covering.  They  measure  0.075  mm.  in  length  and 
0.058  mm.  in  width.  The  life  history  has  been  demonstrated  to  be  "direct" — 
t.  e.,  without  intermediate  host.  The  parasite  occupies  the  upper  portion  of 
the  small  intestine.  Usually  not  more  than  one  or  two  are  present,  but  oc- 
casionally they  occur  in  enormous  numbers.  The  migrations  are  peculiar. 
They  may  pass  into  the  stomach,  whence  they  may  be  ejected  by  vomiting, 
or  they  may.  crawl  up  the  oesophagus  and  enter  the  pharynx,  from  which  they 
may  be  withdrawn.  A  child  under  my  care  in  the  smallpox  department  of 


DISEASES   CAUSED  BY  NEMATODES  295 

the  Montreal  General  Hospital,  during  convalescence,  withdrew  in  this  way 
more  than  thirty  round  worms  within  a  few  weeks.  In  other  instances  the 
worm  reaches  the  larynx,  and  has  been  known  to  produce  fatal  asphyxia,  or, 
passing  into  the  trachea,  to  cause  gangrene  of  the  lung.  They  may  go  through 
the  Eustachian  tube  and  appear  at  the  external  meatus.  The  worms  have 
been  found  in  extraordinary  numbers  in  the  bile-ducts.  Remarkable  speci- 
mens exist  in  the  Dupuytren,  the  Wistar-Horner  (Philadelphia),  and  the 
Netley  Museums.  Chalmers  (Ceylon)  and  Leys  (U.  S.  N.)  have  called 
attention  to  their  importance  in  causing  abscess  of  the  liver.  Ebstein  reports 
certain  markings,  strangulations,  on  the  round  worms,  as  if  they  had  been 
nipped  in  the  bile-ducts !  The  bowel  may  be  blocked,  or  in  rare  instances  an 
ulcer  may  be  perforated.  Even  the  healthy  bowel  wall  may  be  penetrated. 

A  peculiarly  irritating  substance,  often  evident  to  the  sense  of  smell  in 
handling  specimens,  is  formed  by  the  round  worms.  Peiper  and  others  sug- 
gest that  the  nervous  symptoms,  sometimes  resembling  those  of  meningitis, 
are  due  to  this  poison.  Chauffard,  Marie,  and  Tauchon  have  gone  still  fur- 
ther, and  report  a  remarkable  condition  of  fever,  intestinal  symptoms,  foul 
breath,  and  intermittent  diarrhoea  in  connection  with  the  presence  of  lum- 
bricoides.  They  call  it  typho-lumbricosis.  The  febrile  condition  may  con- 
tinue for  a  month  or  more.  There  may  be  eosinophilia  to  25  to  30  per  cent., 
and  in  some  cases  a  marked  anaemia.  The  question  of  the  toxins  produced 
by  intestinal  parasites  is  still  an  open  one. 

A  few  parasites  may  cause  no  disturbance.  In  children  there  are  irrita- 
tive symptoms  usually  attributed  to  worms,  such  as  restlessness,  irritability, 
picking  at  the  nose,  grinding  of  the  teeth,  twitchings,  or  convulsions. 

Treatment. — Care  should  be  taken  to  avoid  auto-infection  by  thorough 
washing  after  defecation,  and  those  infected  should  not  be  allowed  to  prepare 
food  or  serve  it  to  others.  It  is  well  to  give  soft  diet  on  the  day  previous 
and  give  a  dose  of  castor  oil  the  night  before  treatment.  Santonin  is  usually 
efficient  given  in  the  morning  in  doses  of  one  grain  (0.065  gm.)  for  a  small 
child,  and  three  to  five  grains  (0.2  to  0.3  gm.)  for  an  adult.  One  to  two 
grains  of  calomel  should  be  given  with  it.  Three  hours  later  a  good  dose 
of  saline  should  be  given.  This  should  be  done  two  mornings  in  succes- 
sion and  repeated  in  a  week  if  worms  or  eggs  are  again  passed.  The  occa- 
sional unpleasant  effects  of  santonin  (yellow  vision,  vertigo)  should  be 
explained  beforehand.  If  santonin  is  not  effectual  male  fern  or  thymol  may 
be  given. 

Oxyuris  vermicularis  (Thread-worm;  Pin-worm). — This  common  para- 
site occupies  the  rectum  and  colon.  The  male  measures  about  4  mm.  in 
length,  the  female  about  10  mm.  They  produce  great  irritation  and  itching, 
particularly  at  night,  symptoms  which  become  intensely  aggravated  by  the 
nocturnal  migration  of  the  parasites.  The  oxyuris  may  traverse  the  intes- 
tinal wall,  and  has  been  found  in  the  peritoneal  cavity,  where  they  may  form 
verminous  tubercles  in  Douglas's  fossa  or  peri-rectal  abscesses. 

The  patients  become  extremely  restless  and  irritable,  the  sleep  is  often 
disturbed,  and  there  may  be  loss  of  appetite  and  anaemia.  Though  most 
common  in  children,  the  parasite  occurs  at  all  ages. 

The  worm  is  readily  detected  in  the  faeces.  Infection  probably  takes  place 
through  the  water,  or  possibly  through  salads,  such  as  lettuce  and  cresses.  A 


296  SPECIFIC   INFECTIOUS    DISEASES 

person  the  subject  of  the  worms  passes  ova  in  large  numbers  in  the  faeces,  and 
the  possibility  of  re-infection  must  be  scrupulously  guarded  against. 

Treatment. — Every  care  should  be  taken  to  avoid  auto-infection  or  the 
infection  of  others,  by  care  in  cleansing  the  anus  and  perineum,  and  thor- 
ough washing  of  the  hands  after  defecation.  Auto-infection  is  often  re- 
sponsible for  the  persistence  of  the  disease.  Treatment  must  be  directed  to 
the  removal  of  the  worms  both  from  the  small  intestine  and  rectum.  San- 
tonin and  calomel  are  useful,  given  as  in  ascaris  infection,  and  for  several 
days.  Thymol  and  naphthalein  are  also  used.  To  remove  the  worms  from 
the  rectum  injections  are  required  which  should  be  retained  as  long  as  pos- 
sible; it  is  well  to  wash  out  the  bowel  before  giving  them  and  the  injection 
need  not  be  over  six  ounces.  Cold  solutions  of  salt  and  water,  ice  water, 
vinegar  (1  to  40),  infusion  of  quassia  (one  ounce  of  quassia  chips  to  a 
pint  of  water),  lime  water,  carbolic  acid  (1  to  500),  may  be  employed  and 
should  be  used  daily  for  two  weeks.  For  the  itching,  carbolated  vaseline,  the 
gall  and  opium  ointment,  or  menthol  (5  per  cent.)  in  vaseline  may  be 
employed. 

2.     TEICHINIASIS 

The  Trichina  or  Trichinella  spiralis  in  its  adult  condition  lives  in  the 
small  intestine.  The  disease  is  produced  by  the  embryos,  which  pass  from 
the  intestines  and  reach  the  voluntary  muscles,  where  they  finally  become 
encapsulated  larvae — muscle  trichinae.  It  is  in  the  migration  of  the  embryos 
(possibly  from  poisons  produced  by  them)  that  the  group  of  symptoms 
known  as  trichiniasis  is  produced. 

The  ovoid  cysts  were  described  in  human  muscle  by  Tiedemann  in  1822, 
and  by  Hilton  in  1832 ;  the  parasite  was  figured  and  named  by  Eichard  Owen. 
Leidy  in  1845  described  it  in  the  pig.  For  a  long  time  the  trichina  was 
looked  upon  as  a  pathological  curiosity;  but  in  1860  Zenker  discovered  in  a 
girl  in  the  Dresden  Hospital,  who  had  symptoms  of 'typhoid  fever,  both  the 
intestinal  and  muscle  forms,  and  established  their  connection  with  a  serious 
and  often  fatal  disease. 

Description  of  the  Parasites. —  (a)  Adult  or  intestinal  form.  The  female 
measures  from  3  to  4  mm. ;  the  male,  1.5  mm.,  and  has  two  little  projections 
from  the  hinder  end. 

(&)  The  larva  or  muscle  trichina  is  from  0.6  to  1  mm.  in  length  and  lies 
coiled  in  an  ovoid  capsule,  which  is  at  first  translucent,  but  subsequently 
opaque  and  infiltrated  with  lime  salts.  The  worm  presents  a  pointed  head 
and  a  somewhat  rounded  tail. 

When  flesh  containing  the  trichinae  is  eaten  by  man  or  by  any  animal  in 
which  the  development  can  take  place,  the  capsules  are  digested  and  the 
trichinae  set  free.  They  pass  into  the  small  intestine,  and  about  the  third 
day  attain  their  full  growth  and  become,  sexually  mature.  Virchow's  experi- 
ments have  shown  that  on  the  sixth  or  seventh  day  the  embryos  are  fully 
developed.  The  young  produced  by  each  female  trichina  have  been  esti- 
mated at  several  hundred.  Leuckart  thought  that  various  broods  are  devel- 
oped in  succession,  and  that  as  many  as  a  thousand  embryos  may  be  pro- 
duced by  a  single  worm.  The  time  from  the  ingestion  of  the  flesh  containing 


DISEASES   CAUSED  BY  NEMATODES  297 

the  muscle  trichinae  to  the  development  of  the  brood  of  embryos  in  the  in- 
testines is  from  seven  to  nine  days.  The  female  worm  penetrates  the  intes- 
tinal wall  and  the  embryos  are  probably  discharged  directly  into  the  lymph 
spaces,  thence  into  the  venous  system,  and  by  the  blood  stream  to  the  muscles, 
which  constitute  their  seat  of  election.  J.  Y.  Graham  reviewed  the  question 
of  the  mode  of  transmission  in  an  exhaustive  monograph,  and  he  gives 
strong  arguments  in  favor  of  the  transmission  through  the  blood  stream. 
They  have  been  found  in  the  blood  early  in  the  infection  and  since  the 
demonstration  of  their  presence  by  Herrick  and  Janeway  they  have  been 
seen  by  a  number  of  observers.  After  a  preliminary  migration  in  the  inter- 
muscular  connective  tissue  they  penetrate  the  primitive  muscle-fibres,  and  in 
about  two  weeks  develop  into  the  full-grown  muscle  form.  In  this  process 
an  interstitial  myositis  is  excited  and  gradually  an  ovoid  capsule  develops 
about  the  parasite.  Two,  occasionally  three  or  four,  worms  may  be  seen 
within  a  single  capsule.  This  process  of  encapsulation  has  been  estimated 
to  take  about  six  weeks.  Within  the  muscles  the  parasites  do  not  undergo 
further  change.  Gradually  the  capsule  becomes  thicker,  and  ultimately  lime 
salts  are  deposited  within  it.  This  change  may  take  place  in  man  within 
four  or  five  months.  In  the  hog  it  may  be  deferred  for  many  years.  The 
calcification  renders  the  cyst  visible,  and,  since  first  seen  by  Tiedemann  and 
Hilton,  these  small,  opaque,  oat-shaped  bodies  have  been  familiar  objects  to 
demonstrators  of  normal  and  morbid  anatomy.  The  trichina?  may  live  within 
the  muscles  for  an  indefinite  period.  They  have  been  found  alive  and  ca- 
pable of  developing  as  late  as  twenty  or  even  twenty-five  years  after  their 
entrance  into  the  system.  In  many  instances,  however,  the  worms  are  com- 
pletely calcified.  The  trichina  has  been  found  or  "raised"  in  twenty-six 
different  species  of  animals  (Stiles).  Medical  literature  abounds  in  refer- 
ences to  its  presence  in  fish,  earthworms,  etc.,  but  these  parasites  belong  to 
other  genera.  In  fa?cal  examinations  for  the  parasite  it  is  well  to  remember 
that  the  "cell  body"  of  the  anterior  portion  of  the  intestine  is  a  diagnostic 
criterion  of  the  jP.  spiralis.  Experimentally,  guinea-pigs  and  rabbits  are 
readily  infected  by  feeding  them  with  muscle  containing  the  larval  form. 
Dogs  are  infected  with  difficulty ;  cats  more  readily.  Experimentally,  animals 
sometimes  die  of  the  disease  if  large  numbers  of  the  parasites  have  been  eaten. 
In  the  hog  the  trichina?,  like  the  cysticerci,  cause  few  if  any  symptoms.  An 
animal  the  muscles  of  which  are  swarming  with  living  trichina?  may  be  well 
nourished  and  healthy-looking.  An  important  point  also  is  the  fact  that  in 
the  hog  the  capsule  does  not  readily  become  calcified,  so  that  the  parasites  are 
not  visible  as  in  the  human  muscles. 

The  anatomical  changes  are  chiefly  in  the  voluntary  muscles.  The  tri- 
china? enter  the  primitive  muscle  bundles,  which  undergo  granular  degenera- 
tion with  marked  nuclear  proliferation.  There  is  a  local  myositis,  and 
gradually  about  the  parasite  a  cyst  wall  is  formed.  These  changes,  as  well 
as  the  remarkable  alterations  in  the  blood,  have  been  described  in  full  by 
Brown.  Cohnheim  has  described  a  fatty  degeneration  of  the  liver  and  en- 
largement of  the  mesenteric  glands.  At  the  time  of  death,  in  the  fourth  or 
fifth  week  or  later,  the  adult  trichina?  are  still  found  in  the  intestines. 

Incidence. — Man  is  infected  by  eating  the  flesh  of  trichinous  hogs.  In 
Germany,  where  a  thorough  and  systematic  microscopic  examination  of  all 
21 


£98  SPECIFIC   INFECTIOUS    DISEASES 

swine  flesh  is  made,  the  proportion  of  trichinous  hogs  is  about  1  in  1,852. 
Statistics  are  not  available  in  England.  In  America  inspections  have  been 
made  since  1892.  The  percentage  of  animals  found  infected  has  ranged 
from  1.04  to  1.95.  In  1883,  in  conjunction  with  A.  W.  Clement,  I  examined 
1,000  hogs  at  the  Montreal  abattoir,  and  found  only  4  infected. 

Modes  of  Infection. — The  danger  of  infection  depends  entirely  upon  the 
mode  of  preparation  of  the  flesh.  Thorough  cooking,  so  that  all  parts  of 
the  meat  reach  the  boiling  point,  destroys  the  parasites;  but  in  large  joints 
the  central  portions  are  often  not  raised  to  this  temperature.  The  frequency 
of  the  disease  in  different  countries  depends  largely  upon  the  habits  of  the 
people  in  the  preparation  of  pork.  In  North  Germany,  where  raw  ham  and 
Wurst  are  freely  eaten,  the  greatest  number  of  instances  have  occurred.  In 
South  Germany,  France,  and  England  cases  are  rare.  In  the  United  States 
the  greatest  number  of  persons  attacked  have  been  Germans.  Salting  and 
smoking  the  flesh  are  not  always  sufficient,  and  the  Havre  experiments 
showed  that  animals  are  readily  infected  when  fed  with  portions  of  the 
pickled  or  the  smoked  meat  as  prepared  in  America.  Carl  Fraenkel,  how- 
ever, states  that  the  experiments  on  this  point  have  been  negative,  and  that 
it  is  very  doubtful  if  any  cases  of  trichiniasis  in  Germany  have  been  caused 
by  American  pork.  Germany  has  yet  to  show  a  single  case  of  trichiniasis  due 
to  pork  of  unquestioned  American  origin. 

Frequency  of  Infection. — H.  U.  Williams,  of  Buffalo,  made  a  thorough 
study  of  the  muscle  from  505  unselected  autopsies,  and  found  27  cases  of 
trichiniasis,  5.3  per  cent.  The  subjects  had  all  died  of  causes  other  than 
trichiniasis.  This  important  study  shows  how  widespread  is  the  disease, 
and  that  in  reality  we  frequently  overlook  the  sporadic  form. 

The  disease  occurs  in  groups  or  outbreaks  in  which  from  a  dozen  to 
several  hundred  individuals  are  attacked,  and  in  sporadic  cases  which  have 
been  shown  of  late  years  to  be  not  infrequent.  In  the  epidemics  a  large 
number  of  persons  are  infected  from  one  source;  in  the  two  famous  out- 
breaks of  Hedersleben  and  Emersleben  337  and  250  individuals  were  at- 
tacked. In  the  United  States  Stiles  estimates  that  there  have  been  more 
than  1,000  small  outbreaks.  The  discovery  in  my  wards  at  the  Johns  Hop- 
kins Hospital  by  T.  K.  Brown  of  the  eosinophilia  in  the  disease  has  led  to 
the  much  more  frequent  detection  of  the  sporadic  cases,  and  this  form  of 
the  disease  is  not  at  all  uncommon  in  the  United  States. 

Symptoms. — The  ingestion.of  trichinous  flesh  is  not  necessarily  followed 
by  the  disease.  When  a  limited  number  are  eaten  only  a  few  embryos  pass 
to  the  muscles  and  may  cause  no  symptoms.  Well-characterized  cases  pre- 
sent a  gastro-intestinal  period  and  a  period  of  general  infection. 

In  the  course  of  a  few  days  after  eating  the  infected  meat  there  are  signs 
of  gastro-intestinal  disturbance — pain  in  the  abdomen,  loss  of  appetite,  vom- 
iting, and  sometimes  diarrhoea.  The  preliminary  symptoms,  however,  are  by 
no  means  constant,  and  in  some  of  the  large  epidemics  cases  have  been  ob- 
served in  which  they  have  been  absent.  In  other  instances  the  gastro-intes- 
tinal features  have  been  marked  from  the  outset,  and  the  attack  has  resembled 
cholera  nostras.  Pain  in  different  parts  of  the  body,  general  debility,  and 
weakness  have  been  noted  in  some  of  the  epidemics. 

The  invasion  symptoms  occur  between  the  seventh  and  the  tenth  day, 


DISEASES  CAUSED  BY  NEMATODES  299 

sometimes  not  until  the  end  of  the  second  week.  There  is  fever,  except  in 
very  mild  cases.  Chills  are  not  common.  The  thermometer  may  register 
102°  or  104°  F.,  and  the  fever  is  usually  remittent  or  intermittent.  The  mi- 
gration of  the  parasites  into  the  muscles  excites  a  more  or  less  intense  myositis, 
which  is  characterized  by  pain  on  pressure  and  movement,  and  by  swelling 
and  tension  of  the  muscles,  over  which  the  skin  may  be  cedematous.  The 
limbs  are  placed  in  the  positions  in  which  the  muscles  are  in  least  tension. 
The  involvement  of  the  muscles  of  mastication  and  of  the  larynx  may  cause 
difficulty  in  chewing  and  swallowing.  In  severe  cases  the  involvement  of 
the  diaphragm  and  intercostal  muscles  may  lead  to  intense  dyspnoea,  which 
sometimes  proves  fatal.  (Edema,  a  feature  of  great  importance,  may  be  early 
in  the  face,  particularly  about  the  eyes.  Later  it  occurs  in  the  extremities 
when  the  swelling  and  stiffness  of  the  muscles  are  at  their  height.  Profuse 
sweats,  tingling  and  itching  of  the  skin,  and  in  some  instances  urticaria, 
have  been  described. 

BLOOD. — A  marked  leucocytosis,  which  may  reach  above  30,000,  is  usually 
present.  A  special  feature  is  the  extraordinary  increase  in  the  number  of 
eosinophilic  cells,  which  may  comprise  more  than  50  per  cent,  of  all  the 
leucocytes.  There  were  in  four  years,  in  the  Johns  Hopkins  Hospital,  7 
cases  in  which  the  eosinophilia  was  most  pronounced.  In  4  of  them  the 
diagnosis  was  actually  suggested  by  the  great  increase  in  the  eosinophiles; 
in  1  case  they  reached  68  per  cent,  of  the  total  number  of  leucocytes. 

The  general  nutrition  is  much  disturbed  and  the  patient  becomes  emaci- 
ated and  often  anaemic,  particularly  in  the  protracted  cases.  The  patellar 
tendon  reflex  may  be  absent.  The  patients  are  usually  conscious,  except  in 
cases  of  very  intense  infection,  in  which  the  delirium,  dry  tongue,  and 
tremor  give  a  picture  suggesting  typhoid  fever.  In  addition  to  the  dyspnoea 
present  in  the  severer  infections,  there  may  be  bronchitis,  and  in  the  fatal 
cases  pneumonia  or  pleurisy.  In  some  epidemics  polyuria  has  been  a  com- 
mon symptom.  Albuminuria  is  frequent. 

The  intensity  and  duration  of  the  symptoms  depend  entirely  upon  the 
grade  of  infection.  In  the  mild  cases  recovery  is  complete  in  from  ten  to 
fourteen  days.  In  the  severe  forms  convalescence  is  not  established  for  six 
or  eight  weeks,  and  it  may  be  months  before  the  patient  recovers  the  mus- 
cular strength.  One  patient  in  the  Hedersleben  epidemic  was  weak  eight 
years  after  the  attack. 

Of  72  fatal  cases  in  the  Hedersleben  epidemic,  the  greatest  mortality 
occurred  in  the  fourth  and  fifth  and  sixth  weeks;  namely,  52  cases.  Two 
died  in  the  second  week  with  severe  choleraic  symptoms. 

The  mortality  has  ranged  in  different  outbreaks  from  1  or  2  per  cent,  to 
30  per  cent.  In  the  Hedersleben  epidemic  101  persons  died.  Among  456 
cases  reported  in  the  United  States  there  were  122  deaths. 

The  prognosis  depends  much  upon  the  quantity  of  infected  meat  which 
has  been  eaten  and  the  number  of  trichina?  which  mature  in  the  intestines. 
In  children  the  outlook  is  more  favorable.  Early  diarrhoea  and  moderately 
intense  gastro-intestinal  symptoms  are,  as  a  rule,  more  favorable  than  con- 
stipation. 

Diagnosis. — The  disease  should  always  be  suspected  when  a  large  birth- 
day party  or  Fest  among  Germans  is  followed  by  cases  of  apparent  typhoid 


300 

fever.  The  parasites  may  be  found  in  the  remnants  of  the  ham  or  sausages 
used  on  the  occasion.  The  worms  may  be  discovered  in  the  stools.  The 
stools  should  be  spread  on  a  glass  plate  or  black  background  and  examined 
with  a  low-power  lens,  when  the  trichinae  are  seen  as  small,  glistening,  silvery 
threads.  In  doubtful  cases  the  diagnosis  may  be  made  by  the  removal  of  a 
small  fragment  of  muscle  under  cocaine  anesthesia.  The  disease  may  be 
mistaken  for  rheumatic  fever,  particularly  as  the  pains  are  so  severe  on 
movement,  but  there  is  no  special  swelling  of  the  joints.  The  great  increase 
in  the  eosinophiles  in  the  blood  is  a  most  suggestive  point  in  diagnosis.  The 
tenderness  is  in  the  muscles  both  on  pressure  and  on  movement.  The  in- 
tensity of  the  gastro-intestinal  symptoms  in  some  cases  has  led  to  the  diag- 
nosis of  cholera.  Many  of  the  former  epidemics  were  doubtless  described 
as  typhoid  fever,  which  the  severer  cases,  owing  to  the  prolonged  fever,  the 
sweats,  the  delirium,  dry  tongue,  and  gastro-intestinal  symptoms,  somewhat 
resemble.  The  pains  in  the  muscles,  with  tension  and  swelling,  oedema,  par- 
ticularly about  the  eyes,  and  shortness  of  breath,  are  the  most  important 
diagnostic  points. 

Prophylaxis.— It  is  not  definitely  known  how  swine  become  diseased.  It 
has  been  thought  that  they  are  infected  from  rats  about  slaughter-houses, 
but  it  is  just  as  reasonable  to  believe  that  the  rats  are  infected  by  eating 
portions  of  the  trichinous  flesh  of  swine.  The  swine  should,  so  far  as  pos- 
sible, be  grain-fed,  and  not,  as  is  so  common,  allowed  to  eat  offal.  The  most 
satisfactory  prophylaxis  is  the  complete  cooking  of  pork  and  sausages,  and 
to  this  custom  in  England,  France,  South  Germany,  and  the  United  States 
immunity  is  largely  due. 

Treatment. — If  it  has  been  discovered  within  twenty-four  or  thirty-six 
hours  that  a  large  number  of  persons  have  eaten  infected  meat,  the  indica- 
tions are  to  thoroughly  evacuate  the  gastro-intestinal  canal.  Calomel  (gr. 
ii,  0.13  gm.)  should  be  given  at  once  and  repeated  in  two  hours.  Four 
hours  after  the  second  dose  half  an  ounce  of  castor  oil  or  magnesium 
sulphate  should  be  given  and  repeated  if  necessary.  'An  enema  should  be 
given  unless  the  bowels  move  freely.  Glycerin  has  been  recommended  in 
large  doses,  in  order  that  by  passing  into  the  intestines  it  may  by  its  hygro- 
scopic properties  destroy  the  worm.  Male  fern,  kamala,  santonin,  and  thymol 
have  all  been  recommended  in  this  stage.  Turpentine  may  be  tried  in  full 
doses.  There  is  no  doubt  that  diarrhoea  in  the  first  week  or  ten  days  of  the 
infection  is  distinctly  favorable.  The  indications  in  the  stage  of  invasion 
are  to  relieve  the  pains,  to  secure  sleep,  and  to  support  the  patient's  strength. 
There  are  no  medicines  which  have  any  influence  upon  the  embryos  in  their 
migration  through  the  muscles. 

3.    ANKYLOSTOMIASIS 
(Hookworm  Disease) 

Synonyms. — One  of  the  most  important,  widespread  of  all  metazoan  in- 
fections, variously  known  as  uncinariasis ;  anemia  of  miners,  bricklayers, 
tunnel-workers;  tropical  and  Egyptian  chlorosis. 

History. — For  three  centuries  the  disease,  but  not  its  nature,  was  recog- 


DISEASES   CAUSED  BY  NEMATODES  301 

nized  in  the  tropics  under  various  names.  Dubini,  in  1838,  first  described 
the  worms,  and  gave  the  name  from  the  curved  or  bent  appearance  of  the 
mouth.  In  1853  and  1854  Bilhartz  and  Griesinger  recognized  the  relation 
of  the  parasites  to  the  anaemia  and  dropsy.  In  South  America  in  1866 
Wucherer  called  attention  to  the  frequency  of  the  disease  in  negro  slaves. 
In  the  "seventies"  and  "eighties"  of  the  last  century  the  anaemia  of  brick- 
workers  in  Italy  and  of  miners  and  tunnel  diggers  was  shown  to1  be  due 
to  this  parasite.  Occasional  statements  were  made  as  to  the  occurrence  of 
the  disease  in  the  United  States,  but  it  was  not  until  the  extensive  investiga-  . 
tions  of  Stiles  in  1901,  and  later,  that  it  was  shown  that  the  hookworm  was 
widely  prevalent,  and  that  it  was  responsible  for  an  enormous  amount  of 
ill  health  and  anasmia,  and  that  it  was  directly  connected  with  the  old  and 
long-ago  described  practice  of  dirt-eating.  The  studies  of  Allen  J.  Smith 
and  others  showed  how  widespread  was  the  disease  in  the  Southern  States. 
Ashford  and  King  studied  the  disease  in  Porto  Eico,  and  carried  out  one 
of  the  most  successful  of  modern  sanitary  campaigns.  In  1898  Looss  dis- 
covered the  cardinal  fact  of  the  penetration  of  the  skin  by  the  larva?,  and 
of  the  route  by  which  they  reach  the  intestine.  His  great  work,  one  of  the 
most  important  of  recent  contributions  to  helminthology,  has  just  been  com- 
pleted (Part  ii,  1911).  Special  clinical  monographs  have  been  published  by 
•Dock  and  Bass,  by  Ashford  and  Igaravidez,  and  by  Boycott  (all  in  1911). 

Distribution. — The  parasite  exists  in  most  parts  of  the  world,  and  recent 
studies  show  that  there  is  scarcely  a  tropical  country  in  which  the  disease 
caused  by  it  does  not  prevail.  In  India  the  infection  is  from  60  to  80  per 
cent.,  in  Porto  Rico  90  per  cent.,  in  the  Philippines  about  15  per  cent.  In 
Europe  it  is  chiefly  an  affection  of  miners  in  Germany,  Hungary,  France 
and  Belgium.  In  England  there  was  a  small  outbreak  in  Cornwall,  but 
the  disease  has  not  extended.  The  Southern  United  States  are  badly -infected. 
Stiles  shows  that  more  than  12  per  cent,  of  cotton-mill  employees  are  in- 
fected, and  the  examination  of  recruits,  college  students,  and  school  children 
in  different  parts  of  the  country  gives  a  percentage  of  infection  of  from 
20  to  70  or  even  80. 

Parasites. — There  are  two  chief  forms,  the  Arikylostoma  duodencile,  the 
old  world  species,  and  the  Necator  americanus,  the  new  world  species.  The 
Ankylostoma  is  a  small  cylindrical  nematode,  the  male  about  10  mm.  and 
the  female  from  10  to  18  mm.  in  length.  The  mouth  has  chitinous  plates, 
and  is  provided  with  two  pairs  of  sharp,  hook-shaped  teeth,  with  which  they 
pierce  the  mucosa  of  the  bowel.  The  male  has  a  prominent,  umbrella-like 
caudal  expansion.  The  new  world  worm  has  much  the  same  characters, 
only  it  is  more  slender,  the  mouth  globular,  and  the  arrangement  of  the 
teeth  quite  different.  The  eggs  are  from  52  p  to  60  p  by  about  34  /*  in 
width  in  the  European  form,  and  from  64  /*  to  76  /*  by  about  36  /*  in 
breadth  in  the  American  form.  They  are  very  characteristic  bodies  in  the 
faeces  of  infected  individuals.  When  laid  they  are  already  in  process  of 
segmentation.  Complete  dessication,  and  direct  sunlight,  or  much  water  in 
the  faeces  kills  the  eggs;  but  they  are  sometimes  very  tenacious  of  life,  and 
freezing,  followed  by  a  gentle  thawing,  may  be  resisted.  The  rapidity  of 
development  depends  upon  favoring  conditions  and  temperature,  and  the 
larvae  after  escaping  from  the  eggs  may  live  for  months  in  the  mud  or 


302  SPECIFIC  INFECTIOUS  DISEASES 

water  of  the  mines,  and  they  pass  through  a  series  of  moults  before  they 
reach  what  is  called  the  ripe  stage.  They  then  show  a  remarkable  tenacity 
of  life,  and  may  live  in  water  or  slime  for  many  months;  and  in  this, 
which  is  the  infective  stage,  they  have  a  great  tendency  to  wander. 

Modes  of  Infection. — An  extraordinary  number  of  eggs  are  passed  with 
each  stool  of  a  badly  infected  person,  as  many  it  has  been  estimated  as  four 
millions.  They  develop  most  readily  in  faeces  mixed  with  sand  or  earth 
at  a  temperature  of  from  70°  to  90°.  The  larvae  become  infective  when 
about  4  or  5  days  old.  Infection  takes  place  either  by  the  mouth  directly, 
which  is  rare,  or  by  the  skin.  Looss  showed  experimentally  that  the  larvae 
entering  the  skin  are  carried  by  the  veins  to  the  "heart,  and  thence  to  the 
lungs,  in  which  they  escape  from  the  pulmonary  vessels,  pass  up  the  bronchi 
and  trachea,  and  so  to  the  gullet,  stomach  and  intestines.  These  remark- 
able observations  of  Looss  have  been  abundantly  confirmed.  As  C.  A. 
Smith's  work  has  shown,  it  takes  about  seven  weeks  before  the  ova  appear 
in  the  stools,  and  in  the  process  of  infection  there  may  be  sore  throat  and 
fever.  It  would  appear  that  the  skin  is  the  common  channel  of  entrance, 
and  usually  shows  signs  of  irritation — ground  itch.  Larvae  accidentally 
swallowed  may  pass  through  the  stomach,  and  develop  in  the  intestines. 

The  careless  disposition  of  the  fasces  permits  the  pollution  of  the  soil, 
and  in  the  tropical  and  sub-tropical  districts,  and  in  mines,  it  is  an  easy- 
matter  to  understand  how  children  and  others  are  infected  through  the  skin 
Ashford  and  King  give  a  history  of  more  than  90  per  cent,  of  ground-itck 
in  their  cases. 

Morbid  Anatomy  and  Pathology. — The  worms  are  chiefly  in  the  jeju- 
num ;  Sandwith  found  1,353  out  of  1,524-  worms  in  the  first  six  feet  of  the 
bowel.  They  are  also  occasionally  found  in  the  stomach.  A  variable  num- 
ber of  worms  are  found  attached  to  the  mucosa.  Very  characteristic  lesions 
are  the  ecchymoses  and  small  erosions  of  the  mucosa,  in  the  centre  of  which 
may  be  a  pale  area,  slightly  raised,  to  which  the  worm  is  attached;  it  may 
be  almost  buried  in  the  mucosa.  There  are  usually  more  bites  or  holes  than 
worms.  Blood  cysts  occur  in  the  sub-mucosa,  in  which,  occasionally,  worms 
are  found  (Whipple).  The  contents  of  the  bowel  are  often  blood-stained. 
In  long-standing  cases  the  mucosa  may  show  many  areas  of  pigmentation. 
Other  lesions  are  those  of  chronic  anaemia  with  fatty  degeneration.  Much 
discussion  has  taken  place  as  to  whether  the  worms  live  on  blood  or  not. 
They  are  certainly  built  for  blood-sucking,  and,  as  Whipple  states,  when 
the  mucosa  is  normal  the  worms  feed  chiefly  on  blood,  when  it  is  thickened 
and  infiltrated  they  have  to  be  content  with  the  epithelium  and  mucosa.  The 
loss  of  blood  is  largely  direct,  but  it  has  been  shown  by  Loeb  and  A.  J. 
Smith  that  the  head-glands  of  the  worm  secrete  a  substance  which  retards 
coagulation,  probably  a  haemolytic  poison,  the  presence  of  which  Whipple 
has  demonstrated.  Another  feature  of  importance  is  the  liability  to  infec- 
tion through  the  bites ;  and  the  anaemia,  may  in  part,  at  any  rate,  be  due  to 
poisonous  products  absorbed  through  the  bowel  lesions. 

Symptoms. — The  hookworm  disease  presents  a  very  variable  picture,  nor 
does  the  severity  of  the  symptoms  seem  to  depend  always  upon  the  number 
of  worms.  There  have  been  fatal  cases  in  which  only  ten  or  twelve  worms 
were  found,  while  recovery  has  followed  after  more  than  4,000  worms  have 


DISEASES  CAUSED  BY  NEMATODES  303 

been  expelled  (Dock).  In  infected  districts,  as  in  the  Southern  States,  the 
hookworm  disease  causes  a  widespread  degeneration  in  the  community,  the 
children  and  young  adults  showing  a  pallor,  under-development,  and  failure 
of  nutrition.  With  the  infection,  too,  are  associated  an  apathy  and  lack  of 
energy,  so  that  the  common  opinion  in  the  Scuth  is  that  the  hookworm  is 
the  cause  of  laziness.  There  is  no  question  that,  as  Stiles  and  others  have 
shown,  the  widespread  infection  is  responsible  for  a  great  deal  of  ill  health 
and  physical  incapacity,  often  without  any  actual  illness.  In  more  severe 
cases  the  anasmia  is  pronounced,  the  haemoglobin  being  from  40  to  50  per 
cent. ;  the  child  is  stunted  and  puberty  is  long  delayed,  and  the  patient  may 
belong  to  the  group  of  dirt-eaters.  The  retardation  of  growth  is  remark- 
able, and  the  individual  may  continue  to  grow  until  he  is  25  or  26  years 
of  age.  In  the  severest  type  of  all  the  anaemia  is  still  more  pronounced ;  the 
hemoglobin  below  25  or  20  per  cent.;  oedema  occurs,  the  patient  is  bedridden, 
and  death  occurs  from  exhaustion,  diarrhoea,  or  some  intercurrent  affection. 
The  ancemia  is  of  a  secondary  type,  averaging  from  50  to  60  per  cent,  of 
the  corpuscles,  with,  as  a  rule,  a  low  color  index.  Leucocytosis  is  not  often 
present,  and  the  differential  count  shows  nothing  unusual  except  the  great 
increase  in  the  eosinophiles,  ranging  from  15  to  26  or  even  30  per  cent. 

"Ground-itch"  the  local  lesion  through  which  the  parasites  enter  the 
system,  is  most  commonly  on  the  feet  and  legs  in  children,  or  on  the  arms 
and  hands  in  gardeners  and  miners.  The  most  common  region  is  between 
and  beneath  the  toes.  The  eruption  is  vesicular  at  first,  and  then  pustules 
form  with  a  sticky  exudate,  and  sometimes  with  much  swelling  of  the  skin. 
The  vesicles  and  pustules  gradually  dry,  and  in  about  eight  or  ten  days  heal 
with  exfoliation.  , 

Other  general  features  are  the  well  known  circulatory  and  respiratory 
features  of  anaemia.  The  digestive  symptoms  are  remarkable.  In  the  mild 
cases  there  are  slight  epigastric  pain  and  discomfort ;  in  the  severer  ones  there 
are  anorexia  and  remarkable  perversion  of  appetite;  the  patients  eat  earth, 
paper,  chalk,  starch,  hair  and  clay.  The  dirt-eaters  of  the  Southern  States 
are  all  subject  to  the  hookworm  disease.  Mental  inertia  has  already  been 
referred  to,  and  popularly  the  affection  is  spoken  of  as  the  "lazy  disease." 
With  the  apathetic,  listless  expression  there  is  dilatation  of  the  pupils,  and 
Stiles  has  remarked  upon  the  "dull,  blank,  almost  fish-like  or  cadaveric 
stare,"  which  gives  a  very  characteristic  appearance  to  the  expression. 

Diagnosis. — In  tropical  and  sub-tropical  regions  slight  anaemia  and  ill 
health  should  lead  to  the  examination  of  the  stools,  from  which  a  certain 
diagnosis  may  be  made  by  finding  the  eggs.  "The  combination  of  anaemia 
with  under-development,  weakness,  dilated  heart,  and  the  history  of  ground- 
itch  is  not  likely  to  be  confused  with  anything  else"  (Stiles).  In  badly 
infected  regions  a  fairly  accurate  diagnosis  may  be  made  on  inspection  alone, 
and  the  diagnosis  may  be  confirmed  in  the  examination  of  the  faeces  by 
the  rapid  improvement  after  the  administration  of  thymol.  Two  or  three 
drachms  of  faeces  suffice;  they  should  be  collected  in  a  wide-mouthed  bottle. 
A  little  practice  may  be  required  at  first,  but  the  necessary  technique  is 
easily  acquired.  The  eggs  are  characteristic  structures,  usually  containing 
4  or  8  segments,  sometimes  the  complete  embryo  nearly  ready  to  burst  its 
shell.  Various  estimates  have  been  made  of  the  number  of  worms  based  on 


Ml  SPECIFIC  INFECTIOUS  DISEASES 

the  number  of  eggs  found.  It  is  to  be  remembered  that  the  eggs  vary  greatly 
in  numbers,  and  the  stools  may  be  negative  one  day  and  contain  many  a 
few  days  later.  Grassi  states  that  150  eggs  per  centigram  of  faeces  rep- 
resent about  1,000  worms.  For  other  special  methods  of  examining  the 
stools  the  student  is  referred  to  the  monograph  of  Dock  and  Bass. 

The  presence  of  eosinophilia  is  an  important  diagnostic  aid.  Boycott  and 
Haldane  found  that  94  per  cent,  of  infected  persons  had  over  8  per  cent,  of 
eosinophiles. 

Prophylaxis. — Destruction  of  the  adult  worms,  removing  conditions  suit- 
able to  the  growth  of  the  embryos,  and  a  campaign  of  sanitary  education 
are  the  three  essentials.  The  proper  disposal  of  faeces,  obtaining  a  pure  water 
supply,  and  decreasing  the  chance  of  infection  by  wearing  shoes  and  stock- 
ings are  important  points.  The  work  of  the  Porto  Eico  commission,  inaugu- 
rated by  Ashford  and  King,  and  carried  on  by  Ashford,  Igaravidez  and  their 
colleagues,  shows  what  can  be  done  in  the  tropics,  even  in  the  most  unfavor- 
able surroundings.  The  fighting  unit  in  this  battle  has  been  the  anaemia 
dispensary,  of  which  55  were  established  in  Porto  Eico,  each  one  with  a 
visiting  nurse,  and  with  provisions  for  the  proper  examination  of  the  pa- 
tients. According  to  the  last  report,  nearly  50,000  patients  were  treated  in 
1909-1910.  More  than  300,000  persons  have  received  specific  treatment  for 
the  disease  since  the  commission  began  its  work.  That  the  mortality  in  the 
island  has  fallen  from  42  per  1,000  in  1899-1900  to  20.9  in  1910  is  in 
great  part  due  to  the  devoted  work  of  the  medical  staff  and  the  nurses  in 
dealing  with  the  hookworm  disease. 

In  mines  care  should  be  taken  to  prevent  local  conditions  favoring  the 
growth  of  the  embryos.  Oliver  has  found  that  cinder  and  slag  are  destruc- 
tive of  the  larvae.  New  workers  should  be  examined  and  proved  not  to  have 
the  disease  before  being  admitted. 

Treatment. — The  following  directions  are  given  by  the  Porto  Eican  com- 
mission : 

Take  one  of  the  two  purgatives  to-night  in  water. 

Take  at  6  o'clock  to-morrow  morning  half  of  the  capsules  (thymol). 

Take  the  other  half  at  8  o'clock  the  same  morning. 

Take  the  other  purgative  at  10  o'clock. 

You  should  neither  drink  wine  nor  any  alcoholic  liquor  during  the  time  you  are 
taking  these  medicines. 

Come  for  more  medicine  until  the  physician  says  you  are  cured. 

Have  a  privy  in  your  house.  Do  not  defecate  on  the  surface  of  the  ground,  but 
in  the  privy. 

Do  not  walk  barefooted,  so  that  you  may  avoid  contracting  the  disease  in  your 
feet.  Wear  shoes  and  you  will  never  suffer  from  anaemia. 

The  purgative  preferred  is  an  ordinary  saline,  and  the  dose  of  the  thymol 
is  graduated  according  to  the  age  of  the  patient,  seven  grains  (0.5  gm.)  for 
children  under  five,  and  increasing  the  dose  according  to  age  and  strength 
to  sixty  grains  (4  gm.)  for  adults.  Very  few  ill  effects  follow  its  use,  but 
t  sometimes  is  irritating  to  the  bowels,  and  occasionally  it  has  been  toxic. 
This  treatment  should  be  carried  out  on  one  day  of  each  week  until  the 
patient  is  cured.  No  alcohol  or  oil  should  be  given  at  the  time  of  admin- 
istration of  thymol. 

Eucalyptus  and  chloroform  may  be  given  as  Hermann's  mixture  (chloro- 


DISEASES   CAUSED  BY  NEMATODES  305 

form  3  c.  c.,  oil  of  eucalyptus  2  c.  c.,  castor  oil  40  c.  c.,  taken  in  two  doses 
at  intervals  of  one  hour).  Beta-naphthol  has  been  much  used  in  doses  of 
thirty  grains  (2  gin.)  for  adults.  Male  fern  has  also  been  given.  The 
anaemia  should  receive  the  usual  treatment. 

4.     FILAEIASIS 

For  a  full  discussion  of  the  zoological  relations  of  this  important  group 
see  Stiles'  article  in  my  "System  of  Medicine,"  Vol.  I. 

Under  the  general  term  Filaria  sanguinis  hominis  three  species  of  nema- 
todes  are  included: 

Filaria  bancrofti  Cobold,  1877.  This  is  the  ordinary  blood  filaria.  The 
embryos  are  found  in  the  peripheral  circulation  only  during  sleep  or  at  night. 
The  mosquito  is  the  intermediate  host.  The  embryos  measure  270  to  340  /* 
long  by  7  to  11  /*  broad;  tail  pointed.  The  adult  male  measures  83  mm. 
long  by  0.407  mm.  broad;  the  tail  forms  two  turns  of  a  spiral.  The  adult 
female  measures  155  mm.  long  by  0.715  mm.  broad;  vulva  2.56  mm.  from 
anterior  extremity;  eggs  38  /*  by  14  /tt.  This  is  the  species  to  which  the 
hsematochyluria  and  elephantiasis  are  attributed. 

Filaria  diurna  Manson,  1891.  The  larva?  agree  with  the  preceding, 
except  that  Manson  indicates  the  absence  of  granules  in  the  axis  of  the  body. 
The  worms  occur  in  the  peripheral  circulation  only  during  the  day,  or  when 
the  patient  stays  awake.  Manson  suspects  that  the  Filaria  loa  represents  the 
adult  stage. 

Filaria  perstans  Manson,  1891.  Only  the  embryos  are  known.  These 
are  much  smaller  than  the  preceding — 200  p.  long,  posterior  extremity  obtuse, 
anterior  extremity  with  a  sort  of  retractile  rostellum. 

Manson  is  inclined  to  regard  the  Filaria  perstans  as  the  cause  of  craw- 
craw,  a  papillo-pustular  skin  eruption  of  the  west  coast  of  Africa,  which  is 
probably  the  same  as  Nielly's  dermatose  parasitaire,  the  parasite  of  which  was 
called  by  Blanchard  Rhdbditis  niellyi.  Manson  has  shown  that  in  the  blood 
of  the  aboriginal  Indians  in  British  Guiana  there  are  two  forms  of  filarial 
embryos  which  differ  somewhat  from  the  ordinary  types.  Daniels  and  Ozzard 
have  shown  the  extraordinary  prevalence  of  these  parasites  in  the  aborigines — 
fully  58  per  cent.  Daniels  has  found  the  mature  filaria  in  two  subjects  in  the 
upper  part  of  the  mesentery,  near  the  pancreas  and  in  the  subpericardial  fat. 

The  most  important  of  these  is  the  Filaria  bancrofti,  which  produces  the 
hamatochyluria  and  the  lymph-scrotum. 

The  female  produces  an  extraordinary  number  of  embryos,  which  enter 
the  blood  current  through  the  lymphatics.  Each  embryo  is  within  its  shell, 
which  is  elongated,  scarcely  perceptible,  and  in  no  way  impedes  the  move- 
ments. They  are  about  the  ninetieth  part  of  an  inch  in  length  and  the 
diameter  of  a  red  blood-corpuscle  in  thickness,  so  that  they  readily  pass 
through  the  capillaries.  They  move  with  the  greatest  activity,  and  form 
very  striking  and  readily  recognized  objects  in  a  blood-drop  under  the 
microscope.  A  'remarkable  feature  is  the  periodicity  in  the  occurrence  of  the 
embryos  in  the  blood.  In  the  daytime  they  are  almost  or  entirely  absent, 
whereas  at  night,  in  typical  cases,  they  are  present  in  large  numbers.  If, 
however,  as  Stephen  Mackenzie  has  shown,  the  patient,  reversing  his  habits, 


306  SPECIFIC  INFECTIOUS  DISEASES 

sleeps  during  the  day,  the  periodicity  is  reversed.  In  the  case  reported  by 
Lothrop  and  Pratt  the  number  of  embryos  per  cubic  centimetre  of  blood  was 
calculated  hourly  during  the  night;  it  rose  steadily  from  four  o'clock  in  the 
afternoon  till  midnight,  when  2,100  per  c.  c.  were  present,  then  fell,  none 
being  found  at  ten  o'clock  the  following  morning.  The  further  development 
of  the  embryos  is  associated  with  the  mosquito,  which  at  night  sucks  the 
blood  and  in  this  way  frees  them  from  the  body.  After  developing  a  little 
it  was  thought  that  they  were  set  free  in  the  water  by  the  death  of  the  host. 
S.  P.  James  has  found  them  in  the  tissues  of  the  proboscis  of  the  mosquito, 
and  the  infection  is  probably  direct,  as  in  malaria.  The  filariae  may  be 
present  in  the  body  without  causing  any  symptoms.  In  the  blood  of  animals 
filarise  are  very  common  and  rarely  cause  inconvenience.  It  is  only  when 
the  adult  worms  or  the  ova  block  the  lymph  channels  that  certain  definite 
symptoms  occur.  Hanson  suggests  that  it  is  the  ova  (prematurely  dis- 
charged), which  are  considerably  shorter  and  thicker  than  the  full-grown 
embryos,  which  block  the  lymph  channels  and  produce  the  conditions  of 
hsematochyluria,  elephantiasis,  and  lymph-scrotum. 

The  parasite  is  widely  distributed,  particularly  in  tropical  and  sub-tropical 
countries.  Guiteras  has  shown  that  the  disease  prevails  extensively  in  the 
Southern  States,  and  since  his  paper  appeared  contributions  have  been  made 
by  Matas,  of  New  Orleans,  Mastin,  of  Mobile,  De  Saussure,  of  Charleston, 
and  Opie. 

The  effects  produced  may  be  described  under  the  following  conditions : 

1.  PLEMATOCHYLURIA. — Without  any  external  manifestations,  and  in 
many  cases  without  special  disturbance  of  health,  the  subject  from  time  to 
time  passes  urine  of  an  opaque  white,  milky  appearance,  or  bloody,  or  a 
chylous  fluid  which  on  settling  shows  a  slightly  reddish  clot.  The  condition 
indicates  dilatation  and  rupture  of  dilated  lymphatics  in  some  part  of  the 
urinary  tract  and  obstruction  of  the  thoracic  duct.  The  urine  may  be  nor- 
mal in  quantity  or  increased.  The  condition  is  usually  intermittent,  and 
the  patient  may  pass  normal  urine  for  weeks  or  months  at  a  time.  Micro- 
scopically, the  chylous  urine  contains  minute  molecular  fat  granules,  and  usu- 
ally red  blood-corpuscles  in  various  amounts.  The  embryos  were  first  discov- 
ered by  Demarquay  at  Paris  (1863),  and  in  the  urine  by  Wucherer,  at  Bahia, 
in  1866.  It  is  remarkable  for  how  long  the  condition  may  persist  without  se- 
rious impairment  of  the  health.  A  patient,  sent  to  me  by  Dawson,  of  Charles- 
ton, had  hsmatochyluria  intermittently  for  eighteen  years.  The  only  in- 
convenience had  been  in  the  passage  of  blood-clots  which  collected  in  the 
bladder.  At  times  he  had  also  uneasy  sensations  in  the  lumbar  region.  The 
embryos  were  present  in  his  blood  at  night  in  large  numbers.  Chyluria  is  not 
always  due  to  the  filaria.  The  non-parasitic  form  of  the  disease  is  considered 
elsewhere. 

Opportunities  for  studying  the  anatomical  condition  of  these  cases  rarely 
occur.  In  the  case  described  by  Stephen  Mackenzie  the  renal  and  peritoneal 
lymph  plexuses  were  enormously  enlarged,  extending  from  the  diaphragm  to 
the  pelvis.  The  thoracic  duct  above  the  diaphragm  was  impervious. 

2.  ELEPHANTIASIS  is  common  in  all  countries  in  which  the  filaria?  pre- 
vail. The  parasites  are  not  always  found  in  the  blood.  The  condition  is 
more  common  in  the  legs,  one  or  both,  beginning  below  the  knee,  but  grad- 


DISEASES  CAUSED  BY  NEMATODES  307 

ually  involving  the  entire  limb.  Next  in  frequency  is  lymph-scrotum  and 
other  forms  involving  the  genitalia.  The  scrotal  tumor  may  reach  an  enor- 
mous size,  and  40  to  50  pounds  in  weight.  The  onset  may  be  painless  and 
slow,  or  it  may  be  sudden,  with  fever  and  rapid  swelling  and  redness  of 
the  part.  There  may  be  a  series  of  such  attacks,  each  one  -leaving1  the  part 
more  swollen. 

Sporadic  Elephantiasis. — A  non-parasitic  type  may  be  mentioned  here, 
which  is  not  very  uncommon  in  temperate  regions,  characterized  by  progres- 
sive enlargement  of  a  limb  or  portion  of  the  body,  due. to  a  hyperplasia  of 
the  skin  and  subcutaneous  tissues,  due  apparently  to  an  obstructive  inflamma- 
tion of  the  lymph-vessels.  It  may  arise  spontaneously  without  any  obvious 
cause,  or  it  may  follow  an  inflammation  of  the  skin  of  the  part,  occasionally 
removal  of  the  lymph-glands.  The  legs  are  most  frequently  involved,  begin- 
ning usually  in  one  leg,  about  the  foot  or  ankle,  and  gradually  extending 
until  the  whole  leg  is  greatly  enlarged.  The  skin  is  usually  smooth,  but  it 
may  be  hard  and  indurated  or  warty  and  nodular.  Most  of  the  cases  I 
have  seen  have  been  in  young  women,  in  whom  the  affection  has  come  on 
without  any  obvious  cause  and  progressed  slowly  until  the  leg  was  greatly 
enlarged.  In  one  case  six  or  eight  years  elapsed  before  the  other  leg  became 
involved,  and  in  another  case  more  than  ten  years  has  passed  and  the  disease 
is  still  confined  to  one  leg. 

Treatment. — So  far  as  I  know,  no  drug  destroys  the  embryos  in  the  blood. 
In  infected  districts  the  drinking-water  should  be  boiled  or  filtered.  In 
cases  of  chyluria  the  patients  should  use  a  dry  diet  and  avoid  all  excess  of 
fat.  The  chyle  may  disappear  quite  rapidly  from  the  urine  under  these  meas- 
ures, but  it  does  not  necessarily  indicate  that  the  case  is  cured.  So  long  as 
clots  and  albumin  are  present  the  leak  in  the  lymphoid  varix  is  not  healed, 
although  the  fat,  not  being  supplied  to  the  chyle,  may  not  be  present.  A 
single  tumblerful  of  milk  will  at  once  give  ocular  proof  of  the  patency  or 
otherwise  of  the  rupture  in  the  varix  (Manson). 

Elephantoid  fever  demands  rest,  liquid  diet,  free  purgation  and  sedative 
applications  to  painful  areas.  In  elephantiasis  during  periods  with  acute 
symptoms  the  patient  should  be  at  rest  and  the  legs  firmly  banuaged.  Good 
results  are  reported  from  the  use  of  fibrolysin. 

The  surgical  treatment  of  some  of  these  cases  is  most  successful,  partic- 
ularly in  the  removal  of  the  adult  filarise  from  the  enlarged  lymph-glands, 
especially  in  the  groin.  Maitland  states  that  during  seven  years  25  opera- 
tions of  this  kind  have  been  performed  without  serious  symptoms.  Surgical 
measures  may  be  advisable  in  elephantiasis. 

5.    DEACONTIASIS 
(Guinea-worm  Disease) 

Dracunculus  medinensis  is  a  widely  spread  parasite  in  parts  of  Africa 
and  the  East  Indies.  In  the  United  States  instances  occasionally  occur. 
Jarvis  reported  a  case  in  a  post  chaplain  who  had  lived  at  Fortress  Monroe, 
Va.,  for  thirty  years.  Van  Harlingen's  patient,  a  man  aged  forty-seven, 
had  never  lived  out  of  Philadelphia,  so  that  the  worm  must  be  included 


308  SPECIFIC  INFECTIOUS  DISEASES 

among  the  parasites  of  the  United  States.  A  majority  of  the  cases  reported 
in  American  journals  have  been  imported. 

The  female  develops  in  the  subcutaneous  and  intermuscular  connective 
tissues  and  produces  vesicles  and  abscesses.  In  the  large  majority  of  the  cases 
the  parasite  is  found  in  the  leg.  Of  181  cases,  in  124  the  worm  was  found 
in  the  feet,  33  times  in  the  leg,  and  11  times  in  the  thigh.  It  is  usually 
solitary,  though  there  are  cases  on  record  in  which  six  or  more  have  been 
present.  It  is  cylindrical  in  form,  about.  2  mm.  in  diameter,  and  from  50  to 
80  cm.  in  length.  The  male  has  been  found  by  Leiper  in  a  monkey,  a  very 
small  worm  only  22  mm.  in  length. 

The  worm  gains  entrance  to  the  system  through  the  stomach,  not  through 
the  skin,  as  was  formerly  supposed.  It  is  probable  that  both  male  and 
female  are  ingested;  but  the  former  dies  and  is  discharged,  while  the  latter 
after  impregnation  penetrates  the  intestine  and  attains  its  full  development 
in  the  subcutaneous  tissues,  where  it  may  remain  quiescent  for  a  long  time 
and  can  be  felt  beneath  the  skin  like  a  bundle  of  string.  The  worm  con- 
tains an  enormous  number  of  living  embryos,  and  to  enable  them  to  escape 
she  travels  slowly  downward  head  first,  and,  as  mentioned,  usually  reaches 
the  foot  or  ankle.  The  head  then  penetrates  the  skin  and  the  epidermis 
forms  a  little  vesicle,  which  ruptures,  and  a  small  ulcer  is  left,  at  the  bottom 
of  which  the  head  often  protrudes.  The  distended  uterus  ruptures  and  the 
embryos  are  discharged  in  a  whitish  fluid.  After  getting  rid  of  them  the 
worm  will  spontaneously  leave  her  host.  In  the  water  the  embryos  develop 
in  the  cyclops — a  small  crustacean — and  it  seems  likely  that  man  is  infected 
by  drinking  the  water  containing  these  developed  larvas. 

When  the  worm  first  appears  it  should  not  be  disturbed,  as  after  par- 
turition it  may  leave  spontaneously.  When  the  worm  begins  to  come  out 
a  common  procedure  is  to  roll  it  round  a  portion  of  smooth  wood  and  in 
this  way  prevent  the  retraction,  and  each  day  wind  a  little  more  until  the 
entire  worm  is  withdrawn.  It  is  stated  that  special  care  must  be  taken  to 
prevent  tearing  of  the  worm,  as  disastrous  consequences  sometimes  follow, 
probably  from  the  irritation  caused  by  the  migration  of  the  embryos. 

The  parasite  may  be  excised  entire,  or  killed  by  injections  of  bichloride 
of  mercury  (1  to  1,000).  It  is  stated  that  the  leaves  of  the  plant  called 
amarpattee  are  almost  a  specific  in.  the  disease.  Asafetida  in  full  doses  is 
said  to  kill  the  worm. 

6.     OTHER    NEMATODES 

Filariae. — Among  less  important  filarian  worms  parasitic  in  man  the  fol- 
lowing may  be  mentioned:  Filaria  loa,  a  cylindrical  worm  of  about  3  cm. 
in  length,  whose  habitat  is  beneath  the  conjunctiva.  It  has  been  found 
on  the  West  African  coast,  in  Brazil,  and  in  the  West  Indies.  Filaria 
lentis,  which  has  been  found  in  a  cataract.  Three  specimens  have  been 
found  together.  Filaria  labialis,  which  has  been  found  in  a  pustule  in  the 
upper  lip.  Filaria  hominis  oris,  which  was  described  by  Leidy,  from  the 
mouth  of  a  child.  Filaria  Ironchialis,  which  has  been  found  occasionally 
in  the  trachea  and  bronchi.  This  parasite  has  been  seen  in  a  few  cases  in 
the  bronchioles  and  in  the  lungs.  There  is  no  evidence  that  it  ever  produces 


DISEASES  CAUSED  BY  NEMATODES  309 

an  extensive  verminous  bronchitis  similar  to  that  which  I  have  described  in 
dogs.  Filaria  immitis — the  common  Filaria  sanguinis  of  the  dog — of  which 
Bowlby  has  described  two  cases  in  man.  In  one  case  with  haematuria  female 
worms  were  found  in  the  portal  vein,  and  the  ova  were  present  in  the  thick- 
ened bladder  wall  and  in  the  ureters. 

Trichocephalus  dispar  (Whip-worm). — This  parasite  is  not  infrequently 
found  in  the  caecum  and  large  intestine  of  man.  It  measures  from  4  to  5 
cm.  in  length,  the  male  being  somewhat  shorter  than  the  female.  The  worm 
is  readily  recognized  by  the  remarkable  difference  between  the  anterior  and 
posterior  portions.  The  former,  which  forms  at  least  three-fifths  of  the 
body,  is  extremely  thin  and  hair-like  in  contrast  to  the  thick  hinder  por- 
tion of  the  body,  which  in  the  female  is  conical  and  pointed,  and  in  the  male 
more  obtuse  and  usually  rolled  like  a  spring.  The  eggs  are  oval,  lemon- 
shaped,  0.05  mm.  in  length,  and  each  is  provided  with  a  button-like  pro- 
jection. 

The  number  of  the  worms  found  is  variable,  as  many  as  'a  thousand  hav- 
ing been  counted.  It  is  a  widely  spread  parasite.  In  parts  of  Europe  it 
occurs  in  from  10  to  30  per  cent,  of  all  bodies  examined,  but  in  the  United 
States  it  is  not  so  common.  In  285  West  Indian  workers  at  Panama  Darling 
found  46  per  cent,  infected.  It  is  possible,  he  thinks,  that  these  parasites 
play  a  role  in  amoabic  dysentery,  the  lesions  of  which  begin  at  the  exact  loca- 
tion of  the  points  of  their  attachment.  The  trichocephalus  rarely  causes 
symptoms.  French  and  Boycott  found  ova  in  40  of  500  Guy's  Hospital  pa- 
tients. They  found  no  etiological  relationship  of  the  parasite  to  appendicitis. 
Several  cases  have  been  reported  in  which  profound  anaemia  has  occurred 
in  connection  with  this  parasite,  usually  with  diarrhoea.  Enormous  numbers 
may  be  present,  as  in  Eudolph's  case,  without  producing  any  symptoms. 

The  diagnosis  is  readily  made  by  the  examination  of  the  faeces,  which 
contain,  sometimes  in  great  abundance,  the  characteristic  lemon-shaped,  hard, 
dark-brown  eggs. 

Dicotophyme  Tena\e(Eustrongylus  gigas). — This  enormous  nematode,  the 
male  of  which  measures  about  a  foot  in  length  and  the  female  about  three 
feet,  occurs  in  very  many  animals  and  has  occasionally  been  met  with  in 
man.  It  is  usually  found  in  the  renal  region  and  may  entirely  destroy  the 
kidney. 

Anguillula  aceti. — The  Anguillula  aceti,  or  vinegar  eel,  is  sometimes 
present  in  the  urine  (in  one  case  it  is  said  from  the  bladder).  It  is  most 
probably  a  contamination  from  a  dirty  bottle  in  which  the  urine  is  col- 
lected. 

Strongyloides  intestinalis. — The  parasite  was  discovered  in  1876  by  Nor- 
mand,  and  is  the  same  as  was  formerly  described  as  Anguillula  stercoralis 
and  Rhabdonema  intestinalis.  It  is  a  common  parasite  in  tropical  diarrhoea, 
particularly  in  Cochin  China.  It  is  found  in  about  3  per  cent,  of  the  med- 
ical patients  in  the  Isthmus  of  Panama,  and  in  from  20  to  30  per  cent,  of 
the  patients  in  the  insane  division.  When  in  large  numbers  they  cause 
diarrhoea,  but  from  his  studies  there  Darling  concludes  that  they  are  not 
the  cause  of  severe  diarrhoea,  though  they  may  produce  moderate  anaemia. 
The  mother  worm  burrows  in  the  mucous  membrane  and  deposits  ova.  The 
parasite  is  found  in  the  upper  parts  of  the  small  intestines.  They  are  met 


310  SPECIFIC  INFECTIOUS  DISEASES 

with  occasionally  in  the  temperate  regions.     Three  cases  were  reported  from 
my  clinic  by  Thayer. 

"  Acanthocephala  (Thorn-headed  Worms.) — The  Gigantorhynchus  or  Echi- 
iinrln/iirhiis  gigas  is  a  common  parasite  in  the  intestine  of  the  hog  and 
attains  a  large  size.  The  larvae  develop  in  cockchafer  grubs.  The  American 
intermediate  host  is  the  June  bug  (Stiles).  Lambl  found  a  small  Echinor- 
hynchus  in  the  intestine  of  a  boy.  Welch's  specimen,  which  was  found  en- 
cysted in  the  intestine  of  a  soldier  at  Netley,  is  stated  by  Cobbold  probably 
not  to  have  been  an  Echinorhynchus.  Recently  a  case  of  Echinorhynchv.3 
moniliformis  has  been  described  in  Italy  by  Grassi  and  Calandruccio. 


IV.    PARASITIC  ARACHNIDA  AND  TICKS 

Pentastomes. — 1.  LINGUATULA  BHINARIA  (Pentastoma  tcenioides)  has  a 
somewhat  lancet-shaped  body,  the  female  being  from  3  to  4  inches  in  length, 
the  male  about  an  inch  in  length.  The  body  is  tapering  and  marked  by 
numerous  rings.  The  adult  worm  infests  the  frontal  sinuses  and  nostrils 
of  the  dog,  more  rarely  of  the  horse.  The  larval  form,  which  is  known  as 
the  Linguatula  serrata  (Pentastomum  denticulatum) ,  is  seen  in  the  internal 
organs,  particularly  the  liver,  but  has  also  been  found  in  the  kidney.  The 
adult  worm  has  been  found  in  the  nostril  of  man,  but  is  very  rare  and  seldom 
occasions  any  inconvenience.  The  larva?  are  by  no  means  uncommon,  par- 
ticularly in  parts  of  Germany.  The  parasite  is  very  rare.  Flint  refers  to  a 
Missouri  case  in  which  from  75  to  100  of  the  parasites  were  expectorated. 
The  liver  was  enlarged  and  the  parasites  probably  occupied  this  region.  In 
1869  I  saw  a  specimen  which  had  been  passed  with  the  urine  by  a  patient  of 
James  H.  Richardson,  of  Toronto. 

2.  The  POROCEPHALUS  CONSTRICTUS  (P ' entastomum  constrictum) ,  has  the 
length  of  half  an  inch,  with  twenty-three  rings  on  the  abdomen.  It  is  found 
in  the  Congo  district  and  in  parts  of  Asia.  The  larva?,  found  in  cysts  in  the 
lungs  and  liver,  cause  disease  as  they  wander.  The  adult  form  lives  in  the 
nasal  cavities  and  lungs  of  pythons  and  other  snakes  and  man  is  infected 
probably  through  the  drinking  water. 

Demodex  (Acarus)  folliculorum  ( var.  hominis).- — A  minute  parasite, 
from  0.3  mm.  to  0.4  mm.  in  length,  which  lives  in  the  sebaceous  follicles,  par- 
ticularly of  the  face.  It  is  doubtful  whether  it  produces  any  symptoms.  Pos- 
sibly when  in  large  numbers  they  may  excite  inflammation  of  the  follicles, 
leading  to  acne. 

Sarcoptes  (Acarus)  scabiei  (Itch  Insect}. — This  is  the  most  important 
of  the  arachnid  parasites,  as  it  produces  troublesome  and  distressing  skin 
eruptions.  The  male  is  0.23  mm.  in  length  and  0.19  mm.  in  breadth;  the 
lemale  is  0.45  mm.  in  length  and  0.35  mm.  in  width.  The  female  can  be 
seen  readily  with  the  naked  eye  and  has  a  pearly-white  color.  It  is  not  so 
common  a  parasite  fn  the  United  States  and  Canada  as  in  Europe. 

The  insect  lives  in  a  small  burrow,  about  1  cm.  in  length,  which  it  makes 
for  itself  in  the  epidermis.  At  the  end  of  this  burrow  the  female  lives. 
The  male  is  seldom  found.  The  chief  seat  of  the  parasite  is  in  the  folds 
where  the  skin  is  most  delicate,  as  in  the  web  between  the  fingers  and  toes, 


PARASITIC  INSECTS  311 

the  backs  of  the  hands,  the  axilla,  and  the  front  of  the  abdomen.  The  head 
and  face  are  rarely  involved.  The  lesions  which  result  from  the  presence 
of  the  itch  insect  are  very  numerous  and  result  largely  from  the  irritation 
of  the  scratching.  The  commonest  is  a  papular  and  vesicular  rash,  or,  in 
children,  an  ecthymatous  eruption.  The  irritation  and  pus.tulation  which 
follow  the  scratching  may  completely  destroy  the  burrows,  but  in  typical 
cases  there  is  rarely  doubt  as  to  the  diagnosis. 

The  treatment  is  simple.  It  should  consist  of  warm  baths  with  a  thor- 
ough use  of  a  soft  soap,  after  which  the  skin  should  be  anointed  with  sul- 
phur ointment,  which  in  the  case  of  children  should  be  diluted.  An  oint- 
ment of  naphthol  (drachm  to  the  ounce)  is  very  efficacious. 

Leptus  autumnalis  (Harvest  Bug}. — This  reddish-colored  parasite,  about 
half  a  millimetre  in  size,  is  often  found  in  large  numbers  in  fields  and  in 
gardens.  They  attach  themselves  to  animals  and  man  with  their  sharp 
proboscides,  and  the  booklets  of  their  legs  produce  a  great  deal  of  irritation. 
They  are  most  frequently  found  on  the  legs.  They  are  readily  destroyed  by 
sulphur  ointment  or  corrosive-sublimate  lotions. 

Ixodiasis  (Tick-fever). — In  South  Africa,  particularly  in  the  western 
provinces  of  the  Uganda  Protectorate,  the  western  districts  of  German  East 
Africa  and  the  eastern  regions  of  the  Congo  Free  State,  there  is  a  disease 
known  by  this  name,  believed  to  be  transmitted  by  a  tick — the  Ornithodorus 
or  Argas  monbata.  Christy  states  that  the  bite  of  the  0.  savignyi  does  not 
produce  any  ill  effects.  The  ticks  live  in  old  houses,  and  their  habits  are 
very  much  like  those  of  the  common  bedbug.  This  tick  transmits  the  spiro- 
chceta  dutioni,  the  cause  of  the  African  form  of  relapsing  fever  already 
mentioned. 

The  Dermacentor  occidentalis  is  present  in  the  Northwestern  States  from 
California  to  Montana.  The  bites  may  cause  severe  lymphangitis.  It  appears 
to  be  the  medium  of  transmission  of  the  Rocky  Mountain  spotted  fever. 

In  Arizona  and  other  parts  of  the  Southwestern  States  a  tick — Ornitho- 
dorus megnini — is  occasionally  found  in  the  ear  and  in  the  nose,  causing 
suppuration  and  intense  suffering. 

Several  other  varieties  of  ticks  are  occasionally  found  on  man — the  Ixodes 
ricinus  and  the  Dermacentor  americanus,  which  are  met  with  in  horses  and 
oxen. 

V.    PARASITIC  INSECTS 

0 

Pediculi  (Phthiriasis ;  Pediculosis). — There  are  three  varieties  of  the 
body  louse,  which  are  found  only  in  persons  of  uncleanly  habits. 

PEDICDLUS  CAPITIS. — The  male  is  from  1  to  1.5  mm.  in  length  and  the 
female  nearly  2  mm.  The  color  varies  somewhat  with  the  different  races 
of  men.  It  is  light  gray  with  a  black  margin  in  the  European,  and  very 
much  darker  in  the  negro  and  Chinese.  They  are  oviparous,  and  the  female 
lays  about  sixty  eggs,  which  mature  in  a  week.  The  ova  are  attached  to 
the  hairs,  and  can  be  readily  seen  as  white  specks,  known  popularly  as  nits. 
The  symptoms  are  irritation  and  itching  of  the  scalp.  When  numerous,  the 
insects  may  excite  an  eczema  or  a  pustular  dermatitis,  which  causes  crusts 
and  scabs,  particularly  at  the  back  of  the  head.  In  the  most  extreme  cases 


312  SPECIFIC   INFECTIOUS    DISEASES 

the  hair  becomes  tangled  in  these  crusts  and  matted  together,  forming  at 
the  occiput  a  firm  mass  which  is  known  as  plica  polonica,  as  it  was  not  in- 
frequent among  the  Jewish  inhabitants  of  Poland. 

PEDICULUS  CORPORIS  (vestimentorum) . — This  is  considerably  larger  than 
the  head  louse.  It  lives  on  the  clothing,  and  in  sucking  the  blood  causes 
minute  hsemorrhagic  specks,  which  are  very  common  about  the  neck,  back, 
and  abdomen.  The  irritation  of  the  bites  may  cause  urticaria,  and  the 
scratching  is  usually  in  linear  lines.  In  long-standing  cases,  particularly 
in  old  dissipated  characters,  the  skin  becomes  rough  and  greatly  pigmented, 
a  condition  which  has  been  termed  the  vagabond's  disease — morbus  errorum 
—and  which  may  be  mistaken  for  the  bronzing  of  Addison's  disease.  The 
pigmentation  in  some  cases  may  be  extreme  and  extend  to  the  face  and 
buccal  mucpsa. 

PHTHIRIUS  PUBIS  differs  somewhat  from  the  other  forms,  and  is  found 
in  the  parts  of  the  body  covered  with  short  hairs,  as  the  pubes;  more  rarely 
the  axilla  and  eyebrows. 

The  taches  bleuatres  or  peliomata,  excited  by  the  irritation  of  pediculi,  are 
peculiar  subcuticular  bluish  or  slate-colored  spots  from  5  to  10  mm.  in  diam- 
eter seen  about  the  abdomen  and  thighs,  particularly  in  febrile  cases.  They 
are  very  well  pictured  in  Murchison's  work  on  Fevers.  The  spots  are  more 
marKed  on  white  thin  skins.  They  are  stains  caused  by  a  pigment  in  the 
secretion  of  the  salivary  glands  of  the  louse.  I  have  never  seen  these  macula 
ceruhoR,  as  they  are  also  called,  without  finding  the  lice  or  their  nits. 

TREATMENT. — For  the  Pediculus  capitis,  when  the  condition  is  very  bad, 
the  hair  should  be  cut  short,  as  it  is  very  difficult  to  destroy  thoroughly  all 
the  nits.  Eepeated  saturations  of  the  hair  in  coal-oil  or  in  turpentine  are 
usually  efficacious,  or  with  lotions  of  carbolic  acid,  1  to  50.  Scrupulous 
cleanliness  and  care  are  sufficient  to  prevent  recurrence.  In  the  case  of  the 
Pediculus  corporis,  the  clothing  should  be  placed  for  hours  in  a  disinfecting 
oven.  To  allay  the  itching  a  warm  bath  containing  4  or  5  ounces  of  bicar- 
bonate of  soda  is  useful.  The  skin  may  be  rubbed  -with  a  lotion  of  carbolic 
acid,  2  drachms  to  the  pint,  with  2  ounces  of  glycerin.  For  the  Phthirius 
pubis  white  precipitate  or  ordinary  mercurial  ointment  should  be  used,  and 
the  parts  should  be  thoroughly  washed  two  or  three  times  a  day  with  soft  soap 
and  water. 

Cimex  lectularius  (Common  Bedbug). — The  tropical  and  sub-tropical 
variety  is  Cimex  rotundalius  (W.  S.  Patton).  It  lives  in  the  crevices  of  the 
bedstead  and  in  the  cracks  in  the  floor  and  in  the  walls.  It  is  nocturnal  in 
its  habits.  The  peculiar  odor  of  the  insect  is  caused  by  the  secretion  of  a 
special  gland.  The  parasite  possesses  a  long  proboscis,  with  which  it  sucks 
the  blood.  Individuals  differ  remarkably  in  the  reaction  to  the  bite  of  this 
insect;  some  are  not  disturbed  in  the  slightest  by  them,  in  others  the  irrita- 
tion causes  hyperamia  and  often  intense  urticaria.  Fumigation  with  sul- 
phtir  or  scouring  with  corrosive-sublimate  solution'  or  kerosene  destroys  them. 
Iron  bedsteads  should  be  used. 

Pulex  irritans  (Common  FZea).— The  male  is  from  2  to  2.5  mm.  in 
length,  the  female  from  3  to  4  mm.  The  flea  is  a  transient  parasite  on 
man.  The  bite  causes  a  circular  red  spot  of  hypersemia  in  the  centre  of 
which  is  a  little  speck  where  the  boring  apparatus  has  entered.  The  amount 


•PAEASITIC  FLIES  313 

of  irritation  caused  by  the  bite  is  variable.  Many  persons  suffer  intensely 
and  a  diffuse  erythema  or  an. irritable  urticaria  develops;  others  suffer  no 
inconvenience  whatever. 

The  Pulex  penetrans  (sand-flea,  jigger)  is  found  in  tropical  countries, 
particularly  in  the  West  Indies  and  South  America.  It  is  much  smaller 
than  the  common  flea,  and  not  only  penetrates  the  skin,  but  burrows  and 
produces  an  inflammation  with  pustular  or  vesicular  swelling.  It  most  fre- 
quently attacks  the  feet.  It  is  readily  removed  with  a  needle.  Where  they 
exist  in  large  numbers  the  essential  oils  are  used  on  the  feet  as  a  preventive. 


VI.     PARASITIC  FLIES 

(Myiasis,  Myiosis) 

The  accidental  invasion  of  the  body  cavities  and  of  the  skin  by  the  larvae 
jf  the  diptera  is  known  as  myiasis. 

The  larvae  of  the  Lucilia  macellaria,  the  so-called  screw-worm,  have  been 
found  in  the  nose,  in  wounds,  and  in  the  vagina  after  delivery.  They  can 
be  removed  readily  with  forceps;  if  there  is  any  difficulty,  thorough 
cleansing  and  the  application  of  an  antiseptic  bandage  are  sufficient  to  kill 
them.  The  ova  of  the  blue-bottle  fly  may  be  deposited  in  the  nostrils,  the 
ears,  or  the  conjunctiva — the  myiasis  narium,  aurium,  conjunctiva.  This 
invasion  rarely  takes  place  unless  these  regions  are  the  seat  of  disease. 
In  the  nose  and  in  the  ear  the  larvae  may  cause  serious  inflammation.  Even 
the  urethra  has  not  been  spared  in  these  dipterous  invasions. 

Gastrointestinal  myiasis  may  result  from  the  swallowing  of  the  larvae  of 
the  common  house-fly  or  of  species  of  the  genus  Anthomyia.  There  are  many 
cases  on  record  in  which  the  larvae  of  the  Musca  domestica  have  been  dis- 
charged by  vomiting.  Instances  in  which  dipterous  larvae  have  been  passed 
in  the  fasces  are  less  common.  Finlayson,  of  Glasgow,  has  reported  an  inter- 
esting case  in  a  physician,  who,  after  protracted  constipation  and  pain  in 
the  back  and  sides,  passed  large  numbers  of  the  larva?  of  the  flower-fly — 
Anthomyia  canicularis.  Among  other  forms  of  larvae  or  gentles,  as  they  are 
sometimes  called,  which  have  been  found  in  the  faeces  are  those  of  the  com- 
mon house-fly,  the  blue-bottle  fly,  and  the  Techomyza  fusca.  The  larva?  of 
other  insects  are  extremely  rare.  It  is  stated  that  the  caterpillar  of  the 
taby  moth  has  been  found  in  the  faeces. 

A  specimen  of  the  Homalomyia  scalaris,  one  of  the  privy  flies,  was  sent 
to  me  by  Dr.  Hartin,  of  Kaslo  City,  British  Columbia,  the  larvae  of  which 
were  passed  in  large  numbers  in  the  stools  of  a  man  aged  twenty-four,  a 
native  of  Louisiana.  They  were  present  in  the  stools  from  May  1  to  July 
15,  1897.  There  are  cases  in  which  the  larvae  have  been  passed  for  years,  in 
one  instance  12  years ! 

Although  no  grave  results  necessarily  follow  the  invasion  of  the  alimen- 
tary tract  by  these  larvae,  yet  they  may  be  the  cause  of  serious  intestinal  ulcer- 
ation  manifesting  itself  by  a  dysenteric  disease  with  fatal  result.  Cockayne, 
who  has  recently  (1912)  studied  the  question,  states  that  there  are  four 
deaths  on  record. 
22 


314  SPECIFIC   INFECTIOUS   DISEASES 

Cutaneous  Myiasis. — The  most  common  form  of  cutaneous  myiasis  is  that 
in  which  an  external  wound  becomes  "living,"  as  it  is  called.  This  myiasis 
vulnerum  is  caused  by  the  larvae  of  either  the  blue-bottle  or  the  common 
flesh-fly. 

The  skin  may  also  be  infected  by  the  larva  of  the  Musca  vomitoria,  but 
more  commonly  by  the  bot-flies  of  the  ox  and  sheep  which  occasionally  at- 
tack man.  This  condition  is  rare  in  temperate  climates.  Matas  has  described 
a  case  in  which  cestrus  larvae  were  found  in  the  gluteal  region.  In  parts  of 
Central  America  the  eggs  of  another  bot-fly,  the  Dermatobia,  are  not  infre- 
quently deposited  in  the  skin  and  produce  a  swelling  very  like  the  ordinary 

boil. 

Dermamyiasis  linearis  migrans  cestrosa  is  a  remarkable  cutaneous  condi- 
tion, observed  particularly  in  Eussia  and  occasionally  in  other  countries,  in 
•which  the  larva  of  GastropJiilus  equi  (Samson),  the  horse  bot-fly,  makes  a 
plightly  raised  pale  red  "line"  which  travels  over  the  body  surface,  sometimes 
with  great  rapidity.  It  has  been  referred  to  as  Larva  migrans  and  as  Creep- 
ing Eruption.  (See  Hamburger,  Journal  of  Cutaneous  Diseases,  1904.) 

In  Africa  the  larvae  of  the  Cayor  fly  are  not  uncommonly  found  beneath 
the  skin  in  little  boils.  In  the  Congo  region  Dutton,  Todd,  and  Christy 
found  a  troublesome  blood-sucking  dipterous  larva,  known  as  the  floor  mag- 
got, the  fly  of  which  is  the  Anchmeromyia  luieola. 

Phlebotomous  Fever. — In  Herzegovina,  Malta  and  Crete  and  other  parts 
of  the  Mediterranean  there  is  a  fever  of  two  or  three  days'  duration,  caused 
by  the  bite  of  the  sand-fly,  Phlebotomus  papatasii.  The  manifestations  are 
those  of  fever  alone,  and  may  be  mistaken  for  abortive  typhoid,  febricula 
or  mild  Malta  fever.  The  disease  is  known  as  pappataci  fever  and  on  the 
Dalmatian  coast  it  is  severe.  The  experiments  of  Doerr  and  of  Birt  show 
that  the  disease  is  readily  caused  by  the  bite  of  infected  sand-flies. 

Caterpillar  Rash. — In  some  districts  in  Europe  the  hairs  of  the  proces- 
sion caterpillar,  particularly  of  the  species  Cnethocampa,,  cause  an  intense 
urticaria,  the  so-called  U.  epidemica.  There  are  districts  in  Switzerland 
which  have  been  rendered  uninhabitable  in  consequence  of  the  skin  rashes 
caused  by  the  caterpillars.  Of  late  years  in  New  England  and  some  other 
parts  of  the  United  States  the  caterpillar  of  the  brown-tailed  moth  has  caused 
much  discomfort.  The  hairs  are  widely  distributed  by  the  wind,  and  the 
barbs  are  so  arranged  that  they  readily  work  into  the  skin.  Whole  families 
have  been  affected  by  an  intense  eruption  which  has  been  mistaken  for  that  of 
small-pox.  In  England,  Thresh  has  called  attention  to  the  frequency  of 
these  caterpillar  rashes  due  to  the  yellow-tailed  moth,  Porihesia,  similis. 

Harvest  Rash  (Erythema  Autumnale). — In  parts  of  England  during 
the  autumn  many  people  are  attacked  by  the  harvest  bug  or  harvesters,  which 
may  cause  a  very  obstinate  and  distressing  malady.  Usually  attributed  to 
the  harvest  spider,  it  is  in  reality  caused  by  a  mite,  parasitic  upon  it,  the 
hexapod  larva  of  the  silky  trombidian.  It  is  so  small  as  to  be  scarcely  visible 
and  is  brick-red  in  color.  They  chiefly  attack  persons  with  delicate  skins 
on  the  ankles  and  legs,  but  they  may  also  attack  the  arms  and  the  neck. 
The  mite  attaches  itself  to  the  skin  by  its  claws,  sucks  the  blood,  and  the 
swollen  red  abdomen  may  sometimes  be  seen  as  a  bright-red  dot.  A  papulo- 
vesicular,  sometimes  a  pustular,  eruption  with  an  intolerable  itching  is 


SMALL-POX  315 

caused  by  it.  So  intense  may  the  eruption  be,  with  perhaps  an  entire  family 
attacked  at  once,  that  suspicion  of  poisoning  may  be  aroused.  The  parasite 
is  readily  killed  by  benzine. 


E.  INFECTIOUS  DISEASES  OF  DOUBTFUL  OE  UNKNOWN 

ETM)LOGY 

I.     SMALL-POX   (Variola) 

Definition. — An  acute  infectious  disease  characterized  by  a  cutaneous  erup- 
tion which  passes  through  the  stages  of  papule,  vesicle,  pustule,  and  crust. 

History. — The  existence  of  the  disease  in  ancient  Egypt  is  suggested  by 
the  eruption  on  the  skin  of  a  mummy  of  the  20th  dynasty — 1,200  to  1,100 
B.  C.  (Riiffer  and  Ferguson).  The  disease  existed  in  China  many  centuries 
before  Christ.  The  pesta  magna  described  by  Galen  (of  which  Marcus  Aure- 
lius  died)  is  believed  to  have  been  small-pox.  In  the  sixth  century  it  pre- 
vailed, and  subsequently,  at  the  time  of  the  Crusades,  became  widespread. 
It  was  brought  to  America  by  the  Spaniards  early  in  the  sixteenth  century. 
The  first  accurate  account  was  given  by  Rhazes,  an  Arabian  physician  who 
lived  in  the  ninth  century,  and  whose  admirable  description  is  available  in 
Greenhill's  translation  for  the  Sydenham  Society.  In  the  seventeenth  cen- 
tury the  illustrious  Sydenham  differentiated  measles  from  small-pox.  Special 
events  in  the  history  of  the  disease  are  the  introduction  of  inoculation  into 
Europe,  by  Lady  Mary  Wortley  Montagu,  in  1718,  and  the  discovery  of  vacci- 
nation by  Jenner,  in  1796. 

Etiology. — Small-pox  is  one  of  the  most  virulent  of  contagious  diseases, 
and  persons  exposed,  if  unprotected  by  vaccination,  are  almost  invariably 
attacked.  Instances  of  natural  immunity  are  rare.  It  is  said  that  Diemer- 
broeck,  a  celebrated  Utrecht  professor  in  the  seventeenth  century,  was  not 
only  himself  exempt,  but  likewise  many  members  of  his  family.  One  of  the 
nurses  in  the  small-pox  department  of  the  Montreal  General  Hospital  stated 
that  she  had  never  been  successfully  vaccinated,  and  she  certainly  had  no 
mark.  An  attack  may  not  protect  for  life.  There  are  undoubted  cases  of  a 
second,  reputed  instances,  indeed,  of  a  third  attack. 

AGE. — Small-pox  is  common  at  all  ages,  but  is  particularly  fatal  to  young 
children.  Of  3,164  deaths  in  the  Montreal  epidemic  of  1885-'86,  2,717  were 
of  children  under  ten  years  of  age.  The  fetus  in  uiero  may  be  attacked,  but 
only  if  the  mother  herself  is  the  subject  of  the  disease.  The  child  may  be 
born  with  the  rash  out  or  with  the  scars.  In  the  case  of  twins,  only  one  may 
be  attacked;  Kaltenbach  records  an  instance  of  triplets,  only  two  of  which 
were  affected  (Comby).  Children  born  in  a  small-pox  hospital,  if  vaccinated 
immediately,  may  escape  the  disease;  usually,  however,  they  die  early.  (See 
Hunter's  works,  iv,  p.  74.) 

SEX. — Males  and  females  are  equally  affected. 

RACE. — Among  aboriginal  races  small-pox  is  terribly  fatal.  When  the 
disease  was  first  introduced  into  America  the  Mexicans  died  by  thousands, 
and  the  North  American  Indians  have  also  been  frequently  decimated  by 


316  SPECIFIC   INFECTIOUS    DISEASES 

this  plague.  It  is  stated  that  the  negro  is  especially  susceptible,  and  the 
mortality  is  greater— about  42  per  cent,  in  the  black,  against  29  per  cent,  in 
the  white  (W.  M.  Welch). 

It  is  claimed  that  isolation  hospitals  increase  the  incidence  of  the  disease 
in  a  locality.  J.  Glaister,  who  has  considered  the  whole  question  very  care- 
fully, concludes  that  as  a  centre  of  traffic  such  an  institution,  through  the 
channels  of  unavoidable  human  intercourse,  naturally  favors  the  spread  of 
the  disease  locally,  but  decides  against  1fe  aerial  conveyance  of  the  disease, 
in  spite  of  the  very  strong  evidence. 

The  disease  smoulders  here  and  there  and  when  conditions  are  favorable 
becomes  epidemic.  This  was  well  illustrated  by  the  celebrated  Montreal  out- 
break of  1885.  For  several  years  there  had  been  no  small-pox  in  the  city,  and 
a  large  unprotected  population  grew  up  among  the  French-Canadians,  many 
of  whom  were  opposed  to  vaccination.  On  February  28  a  Pullman-car  con- 
ductor, who  had  traveled  from  Chicago,  was  admitted  into  the  Hotel-Dieu, 
the  civic  small-pox  hospital  being  at  the  time  closed.  Isolation  was  not  car- 
ried out,  and  on  the  1st  of  April  a  servant  in  the  hospital  died  of  small-pox. 
Following  her  decease,  the  authorities  of  the  hospital  dismissed  all  patients 
presenting  no  symptoms  of  contagion  who  could  go  home.  The  disease  spread 
like  fire  in  dry  grass,  and  within  nine  months  3,164  persons  died  in  the  city 
of  small-pox. 

VARIATIONS  IN  THE  VIRULENCE  OF  EPIDEMICS. — Sydenham  states  that 
"small-pox  also  has  its  peculiar  kinds,  which  take  one  form  during  one  series 
of  years,  and  another  during  another";  and  not  only  does  what  he  called  the 
epidemic  constitution  vary  greatly,  but  one  sometimes  sees  the  most  extra- 
ordinary variations  in  the  intensity  of  the  disease  in  members  of  a  family 
all  exposed  to  the  same  infection.  A  striking  illustration  of  this  variability 
has  been  given  in  the  recent  epidemics,  which  have  been  of  so  mild  a  character 
that  in  many  localities  it  has  been  mistaken  for  chicken-pox;  in  others,  par- 
ticularly in  the  United  States,  the  belief  prevailed  that  a  new  disease  had 
arisen,  to  which  the  name  "Cuban  itch"  or  "Philippine  itch"  has  been  given. 
Very  often  a  correct  diagnosis  has  not  been  reached  until  a  fatal  case  has 
occurred.  As  will  be  mentioned,  a  small  outbreak  occurred  in  one  of  my 
wards  for  colored  patients,  which  we  mistook  at  first  for  chicken-pox.  The 
same  peculiarities  have  been  observed  in  the  Leicester,  Nottingham,  and  Cam- 
bridge outbreaks.  Even  in  unvaccinated  children  the  disease  has  been  exceed- 
ingly mild.  Some  of  the  Leicester  cases  had  only  a  few  pocks  (Allan  gar- 
ner) ;  but  this  is  an  old  story  in  the  history  of  the  disease.  John  Mason 
Good,  in  commenting  on  this  very  point,  refers  to  the  great  variability  in  the 
epidemics,  and  states  that  he  himself  as  a  child  of  six  (1770)  passed  through 
small-pox  with  "scarcely  any  disturbance  and  not  more  than  twenty  scattered 
pustules" ! 

The  disease  described  in  some  of  the  Brazilian  states  as  Alastrin  amas, 
or  varioloid  varicella,  seen  also  in  the  West  Indies,  is  probably  a  mild  small- 
pox. 

Recent  Prevalence.— In  the  United  States  in  1909  there  were  24,099  cases 
with  150  deaths;  in  1910,  30,352  cases  and  415  deaths.  The  mild  type  of  the 
disease  continues,  but  in  places  there  have  been  virulent  outbreaks.  In 
England  and  Wales  there  were  only  19  deaths  from  the  disease  in  1910. 


SMALL-POX  317 

NATURE  OF  CONTAGION. — Protozoon-like  bodies  were  described  in  the 
skin  lesions  by  Guarnieri — the  cytoryctes  variolce.  Councilman  and  his  col- 
leagues describe  a  protozoon  with  a  double  cycle  and  cytoplasmic  stage,  with 
small  structureless  bodies  in  the  lower  layer  of  the  epithelial  cells.  The  dried 
scales  constitute  by  far  the  most  important  element,  and  as  a  dust-like  powder 
are  distributed  everywhere  in  the  room  during  convalescence,  becoming  at- 
tached to  clothing  and  various  articles  of  furniture.  The  disease  is  probably 
contagious  from  a  very  early  stage,  though  I  think  it  has  not  yet  been  de- 
termined whether  the  contagion  is  active  before  the  eruption  develops.  The 
poison  is  of  unusual  tenacity  and  clings  to  infected  localities.  It  is  conveyed 
by  persons  who  have  been  in  contact  with  the  sick  and  by  fomites.  During 
epidemics  it  is  no  doubt  widely  spread  in  street-cars  and  public  conveyances. 
It  must  not  be  forgotten  that  an  unprotected  person  may  contract  a  very 
virulent  form  of  the  disease  from  the  mild  varioloid. 

Morbid  Anatomy. — The  pustules  may  be  seen  upon  the  tongue  and  the 
buccal  mucosa,  and  on  the  palate;  sometimes  also  in  the  pharynx  and  the 
upper  part  of  the  oesophagus.  In  exceptionally  rare  cases  the  rash  extends 
down  the  oesophagus  and  even  into  the  stomach.  Swelling  of  the  Peyer's 
follicles  is  not  uncommon;  the  pustules  have  been  seen  in  the  rectum. 

In  the  larynx  the  eruption  may  be  associated  with  a  fibrinous  exudate  and 
sometimes  with  cedema.  Occasionally  the  inflammation  penetrates  deeply 
and  involves  the  cartilages.  In  the  trachea  and  bronchi  there  may  be  ulcera- 
tive  erosions,  but  true  pocks,  such  as  are  seen  on  the  skin,  do  not  occur. 

The  heart  occasionally  shows  myocardial  changes,  parenchymatous  and 
fatty;  endocarditis  and  pericarditis  are  uncommon.  French  writers  have 
described  an  endarteritis  of  the  coronary  vessels.  The  spleen  is  markedly  en- 
larged. Apart  from  the  cloudy  swelling  and  areas  of  coagulation-necrosis, 
lesions  of  the  kidneys  are  not  common.  Nephritis  may  occur. 

In  the  haemorrhagic  form  extravasations  are  found  on  the  serous  and 
mucous  surfaces,  in  the  parenchyma  of  organs,  in  the  connective  tissues, 
about  the  nerve-sheaths  and  in  the  muscles.  In  one  instance  I  found  the 
entire  retro-peritoneal  tissue  infiltrated  with  a  large  coagulum,  and  there 
were  also  extensive  extravasations  in  the  course  of  the  thoracic  aorta.  Hae- 
morrhages in  the  bone-marrow  have  also  been  described.  The  spleen  is 
firm  and  hard  in  haemorrhagic  small-pox,  and  such  was  the  case  in  seven  in- 
stances I  examined.  In  these  rapidly  fatal  forms  the  liver  has  been  described 
as  fatty,  but  in  5  of  my  7  cases  it  was  of  normal  size,  dense,  and  firm. 

Symptoms. — Three  forms  of  small-pox  are  described: 

(a)   Variola  vera;  (1)  Discrete,  (2)  Confluent. 

(6)  Variola  hamorrhagica;  (1)  Purpura  variolosa  or  black  small-pox; 
(2)  Haemorrhagic  pustular  form,  variola  haemorrhagica  pustulosa. 

(c)   Varioloid,  or  small-pox  modified  by  vaccination. 

(a)  VARIOLA  VERA. — The  affection  may  be  conveniently  described  under 
various  stages:  Incubation. — "From  nine  to  fifteen  days;  oftenest  twelve." 
I  have  seen  it  as  early  as  the  eighth  day  after  exposure,  and  there  are  well- 
authenticated  instances  in  which  this  stage  has  been  prolonged  to  twenty 
days.  It  is  unusual  for  patients  to  complain  of  any  symptoms. 

Invasion. — In  adults  a  chill  and  in  children  a  convulsion  are  common 
initial  symptoms.  There  may  be  repeated  chills  within  the  first  twenty-four 


318  SPECIFIC   INFECTIOUS   DISEASES 

hours.  Intense  frontal  headache,  severe  lumbar  pains,  and  vomiting  aifc  very 
constant  features.  The  pains  in  the  back  and  in  the  limbs  are  more  severe 
in  the  initial  stage  of  this  than  of  any  other  eruptive  fever,  and  their  combi- 
nation with  headache  and  vomiting  is  so  suggestive  that  precautionary  meas- 
ures may  often  be  taken  several  days  before  the  eruption  appears.  The  tem- 
perature rises  quickly,  and  may  on  the  first  day  be  103°  or  104°.  The  pulso 
is  rapid  and  full,  not  often  dicrotic.  In  severe  cases  there  may  be  marked 
delirium,  particularly  if  the  fever  is  high.  The  patient  is  restless  and  dis- 
tressed, the  face  is  flushed,  and  the  eyes  are  bright  and  clear.  The  skin  is 
usually  dry,  though  occasionally  there  are  profuse  sweats.  One  cannot  judge 
from  the  initial  symptoms  whether  a  case  is  likely  to  be  discrete  or  confluent, 
as  convulsions,  severe  headache,  and  high  fever  may  precede  a  very  mild 
attack. 

Initial  Rashes. — Two  forms  can  be  distinguished :  the  diffuse,  scarlatinal, 
and  the  macular  or  measly  form;  either  of  which  may  be  associated  with 
petechiae  and  occupy  a  variable  extent  of  surface.  In  some  instances  they  are 


CHART  IX. — TRUE  SMALL-POX  (Strihnpell). 

general,  but  as  a  rule  they  are  limited  either  to  the  lower  abdominal  areas, 
to  the  inner  surfaces  of  the  thighs,  and  to  the  lateral  thoracic  region,  or  to  the 
axillae.  Occasionally  they  are  found  over  the  extensor  surfaces,  particularly 
in  the  neighborhood  of  the  knees  and  elbows.  These  rashes,  usually  purpuric, 
are  often  associated  with  an  erythematous  or  erysipelatous  blush.  The  scarla- 
tinal rash  may  come  out  as  early  as  the  second  day,  and  be  as  diffuse  and 
vivid  as  in  a  true  scarlatina.  The  measly  rash  may  also  be  diffuse  and  resem- 
ble closely  that  of  measles.  Urticaria  is  only  occasionally  seen.  It  was  pres- 
ent once  in  my  Montreal  cases.  The  initial  rashes  are  more  abundant  in 
some  epidemics  than  in  others.  They  occur  in  from  10  to  16  per  cent,  of  cases. 
Eruption. — (1)  In  the  discrete  form,  usually  on  the  fourth  day,  mac- 
ules  appear  on  the  forehead,  preceded  sometimes  by  an  erythematous  flush, 
and  on  the  anterior  surfaces  of  the  wrists.  Within  the  first  twenty-four  hours 
from  their  appearance  they  occur  on  other  parts  of  the  face  and  on  the  ex- 
tremities, and  a  few  are  seen  on  the  trunk.  The  spots  are  from  2-3  milli- 
metres in  diameter,  of  a  bright  red  color,  and  disappear  completely  on  pres- 
sure. As  the  rash  comes  out  the  temperature  falls,  the  general  symptoms 
subside,  and  the  patient  feels  comfortable.  On  the  fifth  or  sixth  day  the 


SMALL-POX  319 

papules  change  into  vesicles  with  clear  summits.  Each  one  is  elevated,  circu- 
lar, and  presents  a  little  depression  or  umbilication  in  the  centre.  About  the 
eighth  day  the  vesicles  change  into  pustules,  the  umbilication  disappears,  the 
flat  top  assumes  a  globular  form  and  becomes  grayish-yellow  in  color,  owing 
to  the  contained  pus.  There  is  an  areola  of  injection  about  the  pustules  and 
the  skin  between  them  is  swollen.  This  maturation  first  takes  place  on  the 
face,  and  follows  the  order  of  the  appearance  of  the  eruption.  The  tempera- 
ture now  rises — secondary  fever — and  the  general  symptoms  return.  The 
swelling  about  the  pustules  is  attended  with  a  good  deal  of  tension  and  pain 
in  the  face;  the  eyelids  become  swollen  and  closed.  In  the  discrete  form  the 
temperature  of  maturation  does  not  usually  remain  high  for  more  than 
twenty-four  or  twenty-six  hours,  so  that  on  the  tenth  or  eleventh  day  the 
fever  disappears  and  the  stage  of  convalescence  begins.  The  pustules  rapidly 
dry,  first  on  the  face  and  then  on  the  other  parts,  and  by  the  fourteenth  or 
fifteenth  day  desquamation  may  be  far  advanced  on  the  face.  The  march 
and  distribution  of  the  rash  are  often  most  characteristic.  The  abdomen  and 
groins  and  the  legs  are  the  parts  least  affected.  The  rash  is  often  copious  on 
the  upper  part  of  the  back,  scanty  on  the  lower.  Vesicles  in  the  mouth, 
pharynx,  and  larynx  cause  soreness  and  swelling  in  these  parts,  with  loss  of 
voice.  Whether  pitting  takes  place  depends  a  good  deal  upon  the  severity  of 
the  disease.  In  a  majority  of  cases  Sydenham's  statement  holds  good,  that 
"it  is  very  rarely  the  case  that  the  distinct  small-pox  leaves  its  mark."  The 
odor  of  a  small-pox  patient  is  very  distinctive  even  in  the  early  stages,  and  I 
have  known  it  to  be  a  help  in  the  diagnosis  of  a  doubtful  case. 

(2)  The  Confluent  Form. — With  the  same  initial  symptoms,  though  usu- 
ally of  greater  severity,  the  rash  appears  on  the  fourth,  or,  according  to  Syden- 
ham,  on  the  third  day.  The  more  the  eruption  shows  itself  before  the  fourth 
day  the  more  sure  it  is  to  become  confluent  (Sydenham).  The  papules  at 
first  may  be  isolated,  and  it  is  only  later  in  the  stage  of  maturation  that  the 
eruption  is  confluent.  But  in  severer  cases  the  skin  is  swollen  and  hyperaemic 
and  the  papules  are  very  close  together.  On  the  feet  and  hands,  too,  the 
papules  are  thickly  set;  more  scattered  on  the  limbs;  and  quite  discrete  on 
the  trunk.  With  the  appearance  of  the  eruption  the  symptoms  subside  and 
the  fever  remits,  but  not  to  the  same  extent  as  in  the  discrete  form.  Oc- 
casionally the  temperature  falls  to  normal  and  the  patient  may  be  very  com- 
fortable. Then,  usually  on  the  eighth  day,  the  fever  again  rises,  the  vesicles 
change  to  pustules,  the  hypersemia  becomes  intense,  the  swelling  of  the  face 
and  hands  increases,  and  by  the  tenth  day  the  pustules  have  fully  maturated, 
many  of  them  have  coalesced,  and  the  entire  skin  of  the  head  and  extremities 
is  a  superficial  abscess.  The  fever  rises  to  103°  or  105°,  the  pulse  is  from  110 
to  120,  and  there  is  often  delirium.  As  pointed  out  by  Sydenham,  salivation 
in  adults  and  diarrhosa  in  children  are  common  symptoms  of  this  stage. 
There  is  usually  much  thirst.  The  eruption  may  also  be  present  in  the  mouth, 
and  usually  the  pharynx  and  larynx  ar,e  involved  and  the  voice  is  husky. 
Great  swelling  of  the  cervical  lymphatic  glands  occurs.  At  this  stage  the 
patient  presents  a  terrible  picture,  unequaled  in  any  other  disease  and  one 
which  fully  justifies  the  horror  and  fright  with  which  small-pox  is  associated 
in  the  public  mind.  Even  when  the  rash  is  confluent  on  the  face,  hands,  and 
feet,  the  pustules  remain  discrete  on  the  trunk.  The  danger,  as  pointed  out 


320  SPECIFIC    INFECTIOUS    DISEASES 

by  Sydenham,  is  in  proportion  to  the  number  upon  the  face.  "If  upon  the 
face  they  are  as  thick  as  sand,  it  is  no  advantage  to  have  them  few  and  far 
between  on  the  rest  of  the  body."  In  fatal  cases  by  the  tenth  or  eleventh 
day  the  pulse  gets  feebler  and  more  rapid,  the  delirium  is  marked,  there  is 
subsultus,  sometimes  diarrhoea,  and  with  these  symptoms  the  patient  dies. 
In  other  instances  between  the  eighth  and  eleventh  day  haemorrhagic  fea- 
tures occur.  When  recovery  takes  place,  the  patient  enters  on  the  eleventh 
or  twelfth  day  the  period  of  desiccation. 

Desiccation. — The  pustules  break  and  the  pus  exudes  or  they  dry  and 
form  crusts.  Throughout  the  third  week  the  desiccation  proceeds  and  in 
cases  of  moderate  severity  the  secondary  fever  subsides;  but  in  others  it  may 
persist  until  the  fourth  week.  The  crusts  in  confluent  small-pox  adhere  for 
a  long  time  and  the  process  of  scarring  may  take  three  or  four  weeks.  On 
the  face  they  fall  off  singly,  but  the  tough  epidermis  of  the  hands  and  feet 
may  be  shed  entire. 

(&)  H^MORRHAGIC  SMALL-POX  occurs  in  two  forms.  In  one,  the  pe- 
techial  or  black  small-pox — purpura  variolosa — the  special  symptoms  appear 
early  and  death  follows  in  from  two  to  six  days.  In  the  other  form  the  case 
progresses  as  one  of  ordinary  variola,  and  in  the  vesicular  or  pustular  stage 
haemorrhages  take  place  into  the  pocks  or  from  the  mucous  membranes — 
variola  hcemorrhagica  pustulosa. 

Purpura  variolosa  is  more  common  in  some  epidemics  than  in  others. 
It  is  less  frequent  in  children  than  in  adults.  Of  27  cases  admitted  to  the 
small-pox  department  of  the  Montreal  General  Hospital  there  were  3  under 
ten  years,  4  between  fifteen  and  twenty,  9  between  twenty  and  twenty-five, 
7  between  twenty-five  and  thirty-five,  3  between  thirty-five  and  forty-five,  and 
1  above  fifty.  Young  and  vigorous  persons  seem  more  liable  to  this  form. 
Several  of  my  cases  were  above  the  average  in  muscular  development.  Men 
are  more  frequently  affected  than  women;  thus  in  my  list  there  were  21  males 
and  only  6  females.  The  influence  of  vaccination  is  shown  in  the  fact  that 
of  the  cases  14  were  unvaccinated,  while  not  one  of 'the  13  who  had  scars  had 
been  revaccinated.  The  illness  starts  with  the  usual  symptoms,  but  with 
more  intense  constitutional  disturbance.  On  the  evening  of  the  second  or  on 
the  third  day  there  is  a  diffuse  hyperaemic  rash,  particularly  in  the  groins, 
with  small  punctiform  haemorrhages.  The  rash  extends,  becomes  more  dis- 
tinctly haemorrhagic,  and  the  spots  increase  in  size.  Ecchymoses  appear  on 
the  conjunctiva?,  and  as  early  as  the  third  day  there  may  be  haemorrhages 
from  the  mucous  membranes.  Death  may  take  place  before  the  papules 
appear.  In  this  truly  terrible  affection  the  patient  may  present  a  frightful 
appearance.  The  skin  may  have  a  uniformly  purplish  hue  and  the  unfortu- 
nate victim  may  even  look  plum-colored.  The  face  is  swollen  and  large  con- 
junctival  haemorrhages  with  the  deeply  sunken  corneas  give  a  ghastly  appear- 
ance to  the  features.  The  mind  may  remain  clear  to  the  end.  Death  occurs 
from  the  third  to  the  sixth  day;  thu,s  in  thirteen  of  my  cases  it  took  place 
between  these  dates.  The  earliest  death  was  on  the  third  day  and  there  were 
no  traces  of  papules.  There  may  be  no  mucous  haemorrhages;  thus  in  one 
case  of  a  most  virulent  character  death  occurred  without  bleeding  early  on 
the  fourth  day.  Haematuria  is  perhaps  most  common,  next  haematemesis,  and 
melaena  was  noticed  in  a  third  of  the  cases.  Metrorrhagia  was  present  in  one 


SMALL-POX  321 

only  of  the  six  females  on  my  list.  Haemoptysis  occurred  in  five  cases.  The 
pulse  in  this  form  of  small-pox  is  rapid  and  often  hard  and  small.  The 
respirations  are  greatly  increased  in  frequency  and  out  of  all  proportion  to 
the  intensity  of  the  fever. 

In  variola  pustulosa  Jicemorrhagica  the  disease  progresses  as  a  severe  case, 
and  the  hemorrhages  do  not  occur  until  the  vesicular  or  pustular  stage.  The 
first  indication  is  hemorrhage  into  the  areolae  of  the  pocks,  and  later  the  matu- 
rated pustules  fill  with  blood.  The  earlier  the  hemorrhage  the  greater  is  the 
danger.  Bleeding  from  the  mucous  membranes  is  also  common  in  this  form, 
and  the  great  majority  of  the  cases  prove  fatal,  usually  on  the  seventh,  eighth, 
or  ninth  day,  but  a  few  cases  recover.  In  patients  with  the  discrete  form,  if 
allowed  to  get  up  early,  hemorrhage  may  take  place  into  the  pocks  on  the  legs. 

Leucocytes. — In  variola  vera  there  is  a  marked  leucocytosis,  12-16  thou- 
sand, about  the  eighth  day,  then  a  slight  decline  and  a  rise  again  about  the 
twelfth  or  fourteenth  day,  sometimes  to  18,000  or  20,000.  There  is  an  in- 
crease in  the  mononuclear  elements,  which  may  be  the  only  marked  feature  of 
the  mild  cases  (Magrath,  Brinckerhoff,  and  Bancroft). 

(c)  VARIOLOID. — This  term  is  applied  to  the  modified  form  which  affects 
persons  who  have  been  vaccinated.  It  may  set  in  with  abruptness  and  severity, 
the  temperature  reaching  103°.  More  commonly  it  is  in  every  respect  milder 
in  its  initial  symptoms,  though  the  headache  and  backache  may  be  very  dis- 
tressing. The  papules  appear  on  the  evening  of  the  third  or  on  the  fourth 
day.  They  are  few  in  number  and  may  be  confined  to  the  face  and  hands. 
The  fever  drops  at  once  and  the  patient  feels  perfectly  comfortable.  The 
vesiculation  and  maturation  of  the  pocks  take  place  rapidly,  and  there  is  no 
secondary  fever.  There  is  rarely  any  scarring.  As  a  rule,  when  small-pox 
attacks  a  person  who  has  been  vaccinated  within  five  or  six  years  the  disease 
is  mild,  but  it  may  prove  severe,  even  fatal. 

Abortive  Types. — As  already  mentioned,  recent  epidemics  have  been  char- 
acterized by  the  large  number  of  mild  cases.  Even  in  unvaccinated  children 
only  a  few  pustules  may  appear,  and  the  disease  is  over  in  a  few  days.  Even 
with  a  thickly  set  eruption  the  vesicles  at  the  fifth  or  sixth  day,  instead  of 
filling,  dry  and  abort,  forming  the  so-called  horn-,  crystalline-,  or  wart-pox. 
Variola  sine  eruptione  is  described.  I  saw  no  cases  of  the  kind  in  Montreal. 
They  seem  to  have  been  not  uncommon  in  the  recent  epidemics.  Bancroft  ob- 
served twelve  cases  in  the  Boston  outbreak,  all  among  physicians  and  attend- 
ants. The  symptoms  are  headache,  pain  in  the  back,  fever,  and  vomiting.  As 
already  mentioned,  the  pocks  may  be  very  scanty  and  easily  overlooked,  even 
in  unvaccinated  persons.  One  of  Bancroft's  cases  was  of  special  interest — a 
pregnant  woman  who  had  slight  symptoms  after  exposure,  but  no  rash.  Her 
child  showed  a  typical  eruption  when  two  days  old. 

Complications. — Considering  the  severity  of  many  of  the  cases  and  the 
character  of  the  disease,  associated  with  multiple  foci  of  suppuration,  the 
complications  in  small-pox  are  remarkably  few. 

Laryngitis  is  serious  in  three  ways:  it  may  produce  a  fatal  oedema  of  the 
glottis;  it  is  liable  to  extend  and  involve  the  cartilages,  producing  necrosis; 
and  by  diminishing  the  sensibility  of  the  larynx  it  may  allow  irritating  par- 
ticles to  reach  the  lower  air-passages,  where  they  excite  bronchitis  or  broncho- 
pneumonia. 


322  SPECIFIC   INFECTIOUS   DISEASES 

Broncho-pneumonia  is  almost  invariably  present  in  fatal  cases.  Ldbar 
pneumonia  is  rare.  Pleurisy  is  common  in  some  epidemics. 

The  cardiac  complications  are  also  rare.  In  the  height  of  the  fever  a 
systolic  murmur  at  the  apex  is  not  uncommon;  but  endocarditis,  either  simple 
or  malignant,  is  rarely  met  with.  Pericarditis,  too,  is  very  uncommon.  Myo- 
carditis seems  to  be  more  frequent,  and  may  be  associated  with  endarteritis  of 
the  coronary  vessels. 

Of  complications  in  the  digestive  system,  parotitis  is  rare.  In  severe  cases 
there  is  extensive  pseudo-diphtheritic  angina.  Vomiting,  which  is  so  marked 
a  symptom  in  the  early  stage,  is  rarely  persistent.  Diarrhoea  is  not  uncom- 
mon, as  noted  by  Sydenham,  and  particularly  in  children. 

Albuminuria  is  frequent,  but  true  nephritis  is  rare.  Inflammation  of  the 
testes  and  of  the  ovaries  may  occur. 

Among  the  most  interesting  and  serious  complications  are  those  pertaining 
to  the  nervous  system.  In  children  convulsions  are  common.  In  adults  the 
delirium  of  the  early  stage  may  persist  and  become  violent,  and  finally  sub- 
side into  a  fatal  coma.  Post-febrile  insanity  is  occasionally  met  with  during 
convalescence,  and  very  rarely  epilepsy.  Many  of  the  old  writers  spoke  of 
paraplegia  in  connection  with  the  intense  backache  of  the  early  stage,  but  it  is 
probably  associated  with  the  severe  agonizing  lumbar  and  crural  pains  and  ia 
not  a  true  paraplegia.  It  must  be  distinguished  from  the  form  occurring  in 
convalescence,  which  may  be  due  to  peripheral  neuritis  or  to  a  diffuse  myelitis 
(Westphal).  The  neuritis  may,  as  in  diphtheria,  involve  the  pharynx  alone, 
or  it  may  be  multiple.  Of  this  nature,  in  all  probability,  is  the  so-called 
pseudo-tabes,  or  ataxie  variolique.  Hemiplegia  and  aphasia  have  been  met 
with  in  a  few  instances,  the  result  of  encephalitis. 

Among  the  most  constant  and  troublesome  complications  are  those  in- 
volving the  skin.  During  convalescence  boils  are  very  frequent  and  may  be 
severe.  Acne  and  ecthyma  are  also  met  with.  Local  gangrene  in  various 
parts  may  occur. 

Arthritis  may  occur,  usually  in  the  period  of  desquamation,  and  may  pass 
on  to  suppuration.  Acute  necrosis  of  the  bone  is  sometimes  met  with. 

A  remarkable  secondary  eruption  (recurrent  small-pox)  occasionally  oc- 
curs after  desquamation. 

SPECIAL  SENSES. — The  eye  affections  which  were  formerly  so  common  and 
serious  are  not  now  so  frequent,  owing  to  the  care  which  is  given  to  keeping 
the  conjunctiva?  clean.  A  catarrhal  and  purulent  conjunctivitis  is  common  in 
severe  cases.  The  secretions  cause  adhesions  of  the  eyelids,  and  unless  great 
care  is  taken  a  diffuse  keratitis  is  excited,  which  may  go  on  to  ulceration  and 
perforation.  Iritis  is  not  very  uncommon.  Otitis  media  is  an  occasional 
complication,  and  usually  results  from  an  extension  of  the  disease  through  the 
Eustachian  tubes. 

Prognosis.  —  In  unprotected  persons  small-pox  is  a  very  fatal  disease,  the 
death-rate  ranging  from  25  to  35  per  cent.  In  Japan  the  mortality  among 
unprotected  persons  has  been  even  higher.  In  the  recent  mild  epidemic  in 
the  United  States  the  mortality  has  been  very  slight,  e.  g.,  for  the  five  months 
ending  November  24,  1911,  4,852  cases  and  35  deaths.  At  the  Municipal 
Hospital,  Philadelphia,  of  2,831  cases  of  variola,  1,534 — i.  e.,  54.18  per  cent. 
—died,  while  of  2,169  cases  of  varioloid  only  28 — i.  e.,  1.29  per  cent. — died 


SMALL-POX  323 

(W.  M.  Welch).  Purpura  variolosa  is  invariably  fatal,  and  a  majority  of 
those  attacked  with  the  severer  confluent  forms  die.  The  intemperate  and 
debilitated  succumb  more  readily  to  the  disease.  As  Sydenham  observed,  the 
danger  is  directly  proportionate  to  the  intensity  of  the  disease  on  the  face 
and  hands.  "When  the  fever  increases  after  the  appearance  of.  the  pustules, 
it  is  a  bad  sign ;  but  if  it  is  lessened  on  their  appearance,  that  is  a  good  sign" 
(Rhazes).  Very  high  fever,  delirium  and  subsultus  are  symptoms  of  ill 
omen.  The  disease  is  particularly  fatal  in  pregnant  women  and  abortion 
usually  takes  place.  It  is  not,  however,  uniformly  so,  and  I  have  twice  known 
severe  cases  to  recover  after  miscarriage.  Moreover,  abortion  is  not  inevitable. 
Very  severe  pharyngitis  and  lar}*ngitis  are  fatal  complications. 

Death  results  in  the  early  stage  from  the  action  of  the  poison  upon  the 
nervous  system.  In  the  later  stages  it  usually  occurs  about  the  eleventh  or 
twelfth  day,  at  the  height  of  the  eruption.  In  children,  and  occasionally  in 
adults,  the  laryngeal  and  pulmonary  complications  prove  fatal. 

Diagnosis. — During  an  epidemic  the  initial  chill,  the  headache  and  back- 
ache, and  the  vomiting  at  once  put  the  physician  on  his  guard. 

The  initial  rashes  may  lead  to  error.  The  scarlatinal  rash  has  rarely  the 
extent  and  never  the  persistence  of  the  rash  in  true  scarlet  fever.  I  have 
known  the  rash  of  measles  to  be  mistaken  for  the  initial  rash  of  small-pox. 
The  general  condition  of  the  patient,  and  the  presence  of  coryza,  conjunctivitis 
and  Koplik's  sign,  may  be  better  guides  than  the  rash  itself. 

Malignant  hsemorrhagic  small-pox  may  prove  fatal  before  the  characteristic 
rash  appears.  Of  27  cases  of  purpura  variolosa,  in  only  one,  in  which  death 
occurred  on  the  third  day,  did  inspection  fail  to  show  the  papules.  In  3 
cases  dying  on  the  fourth  day  the  characteristic  papular  rash  was  noticed.  It 
may  be  difficult  or  impossible  to  recognize  this  form  of  hasmorrhagic  small- 
pox from  hcemorrhagic  scarlet  fever  or  hcemorrhagic  measles,  though  in  the 
latter  there  is  rarely  so  constant  involvement  of  the  mucous  membranes. 

Naturally  enough,  as  they  are  allied  affections,  varicella  is  the  disease 
which  most  frequently  leads  to  error.  Particularly  has  this  been  the  case  in 
the  mild  epidemic  which  has  prevailed  during  the  past  three  years.  A  negro 
patient  was  admitted  to  my  wards  on  the  fourth  day  of  the  disease.  Small- 
pox was  not  prevalent  at  the  time,  and  the  case  was  regarded  as  one  of  vari- 
cella. Subsequently  eight  cases  appeared,  several  of  exceeding  mildness,  but 
our  mistake  was  forcibly  brought,  home  to  us  by  the  occurrence,  in  a  man 
who  had  been  exposed  in  the  ward,  of  a  case  of  confluent  small-pox  of  great 
severity.  The  following  points  are  to  be  borne  in  mind:  first,  the  experience 
of  the  past  few  years  has  shown  that  very  mild  epidemics  of  true  small-pox 
may  occur;  secondly,  any  large  number  of  cases  of  a  contagious  disease  with 
a  pustular  eruption  occurring  in  adults  is  strongly  in  favor  of  small-pox. 
The  characters  of  the  rash  are  of  less  value.  Its  abundance  on  the  trunk  in 
varicella  is  important.  At  the  outset  the  papules  have  rarely  the  shotty,  hard 
feel  of  small-pox.  The  vesicles  are  more  superficial,  the  infiltrated  areola 
is  not  so  intense  nor  so  constant,  and  as  a  rule  the  pocks  may  be  seen  in  the 
same  patient  in  all  stages  of  development.  The  longer  period  of  invasion,  the 
prodromal  rashes,  the  great  intensity  of  the  onset  are  also  important  points 
in  small-pox.  But,  as  I  have  said,  there  are  mild  epidemics  in  which  it  must 
~je  confessed  that  the  recognition  of  the  nature  of  the  outbreak  is  sometimes 


324 

only  confirmed  by  the  appearance  of  a  severe  case  of  the  confluent  or  of  the 
haemorrhagic  form. 

The  disease  may  be  mistaken  for  cerebro-spinal  fever,  in  which  purpuric 
symptoms  are  not  uncommon.  A  four-year-old  child  was  taken  suddenly  ill 
with  fever,  pains  in  the  back  and  head,  and  on  the  second  or  third  day 
petechise  appeared  on  the  skin.  There  were  retraction  of  the  head  and  marked 
rigidity  of  the  limbs.  The  hemorrhages  became  more  abundant ;  and  finally 
hsematemesis  occurred  and  the  child  died  on  the  sixth  day.  At  the  post 
mortem  there  were  no  lesions  of  cerebro-spinal  fever,  and  in  the  deeply  hsemor- 
rhagic  skin  the  papules  could  be  readily  seen.  The  post  mortem  diagnosis 
of  small-pox  was  unhappily  confirmed  by  the  mother  taking  the  disease  and 
dying  of  it. 

Pustular  Syphilides. — A  very  copious  pustular  rash  in  syphilis  may  resem- 
ble variola,  particularly  if  accompanied  by  fever,  but  the  history  and  the  dis- 
tribution, particularly  the  slight  amount  on  the  face,  leave  no  question  as  to 
the  diagnosis. 

Pustular  glanders  has  been  mistaken  for  small-pox.  In  a  remarkable  in- 
stance of  the  kind  in  Montreal  there  was  a  widespread  pustular  eruption, 
which  we  thought  at  first  was  small-pox,  but  the  subsequent  course  and  the 
fact  that  there  was  glanders  among  the  horses  in  the  stable  led  to  the  correct 
diagnosis.  The  eruption  resembled  exactly  that  described  in  Eayer's  mono- 
graph (De  la  Morve,  1837). 

Impetigo  contagiosa  is  stated  to  have  been  mistaken  for  variola. 

Prophylaxis. — Thorough  vaccination  and  re-vaccination  are  the  most  im- 
portant preventive  measures.  All  those  exposed  to  infection  should  be  vacci- 
nated at  once,  as  four  days  after  exposure  a  successful  vaccination  may  pro- 
tect from  the  disease.  During  epidemics  general  vaccination  of  the  com- 
munity should  be  done  and  special  care  taken  to  recognize  mild  cases.  Those 
who  have  been  exposed  should  be  isolated  for  sixteen  days.  Isolation  of  those 
with  the  disease  should  be  rigid  and,  if  possible,  they  should  be  placed  in  a 
special  hospital.  The  attendants  should  wear  gowns'  and  caps ;  rubber  gloves 
are  an  advantage.  The  linen  should  be  placed  in  carbolic  acid  solution  (2 
per  cent.)  and  boiled  afterwards.  Dressings  should  be  burned.  The  patient 
should  not  be  discharged  until  all  the  crusts  are  removed;  a  thorough  spong- 
ing with  carbolic  solution  (2  per  cent.)  is  advisable. 

Treatment. — GENERAL  CONSIDERATIONS. — Segregation  in  special  hospitals 
is  imperative.  In  the  case  of  local  outbreaks  temporary  barracks  or  tents 
may  be  constructed. 

We  have  no  specific  treatment.  There  should  be  abundance  of  fresh  air ; 
the  diet  should  be  liquid  and  large  amounts  of  water  and  cold  drinks  given. 
A  calomel  and  saline  purge  is  advisable  at  the  onset  and  later  the  bowels 
should  be  kept  open  by  salines.  With  severe  toxemia  alcohol  should  be  given. 

In  the  early  stages  two  symptoms  call  for  treatment:  the  pain  in  the 
back,  which,  if  not  relieved  by  phenacetine  (gr.  v,  0.3  gm.),  requires  opium 
in  some  form,  as  advised  by  Sydenham;  and  the  vomiting,  which  is  very 
difficult  to  check  and  may  be  uncontrollable.  Nothing  should  be  given  except 
a  little  ice  and  champagne,  and  it  usually  stops  with  the  appearance  of  the 
eruption. 

For  the  fever,  cold  sponging  or  the  tub -bath  may  bq  used;  when  there  is 


SMALL-POX  325 

much  delirium  with  high  fever  the  latter  or  the  cold  pack  is  preferable.  In 
some  cases,  particularly  with  s°vere  toxsemia  and  marked  eruption,  the  con- 
tinuous warm  bath  is  advisable. 

The  treatment  of  the  eruption  is  important.  After  trying  all  sorts  of 
remedies,  such  as  puncturing  the  pustules  with  nitrate  of  silver,  or  treating 
them  with  iodine  and  various  ointments,  I  came  to  Sydenham's  conclusion, 
that  in  guarding  the  face  against  being  disfigured  by  the  scars  "the  only 
effect  of  oils,  liniments,  and  the  like  was  to  make  the  white  scurfs  slower  in 
coming  off."  The  constant  application  on  the  face  and  hands  of  lint  soaked 
in  cold  water,  to  which  antiseptics  such  as  carbolic  acid  (2  per  cent.) 
or  bichloride  of  mercury  (1  to  5,000)  may  be  added,  is  perhaps  the 
most  suitable  local  treatment.  It  is  very  pleasant  to  the  patient,  and  for 
the  face  it  is  well  to  make  a  mask  of  lint,  which  can  then  be  covered  with 
oiled  silk.  When  the  crusts  begin  to  form,  the  chief  point  is  to  keep  them 
thoroughly  moist,  which  may  be  done  with  oil  or  glycerin.  This  prevents  the 
desiccation  and  diffusion  of  the  flakes  of  epidermis.  Vaseline  is  particularly 
useful,  and  at  this  stage  may  be  freely  used  upon  the  face.  It  also  relieves  the 
itching.  For  the  odor,  which  is  sometimes  so  characteristic  and  disagreeable, 
the  dilute  carbolic  solutions  are  probably  best.  If  the  eruption  is  abundant  on 
the  scalp,  the  hair  should  be  cut  short  to  prevent  matting  and  decomposition 
of  the  crusts.  When  suppuration  is  marked  the  continuous  warm  bath  (95°) 
is  useful.  Boric  acid,  alum  or  potassium  permanganate  may  be  added  to  the 
water. 

The  papules  do  not  maturate  so  well  when  protected  from  the  light,  and 
for  centuries  attempts  have  been  made  to  modify  the  course  of  the  pustules  by 
either  exgluding  the  light  or  by  changing  its  character.  In  the  Middle  Ages 
John  of  Gaddesden  recommended  wrapping  the  patient  in  red  flannel,  and 
treated  in  this  way  the  son  of  Edward  I.  It  was  an  old  practice  of  the 
Egyptians  and  Arabians  to  cover  the  exposed  parts  of  small-pox  patients 
with  gold-leaf.  Lutzenberg,  a  distinguished  New  Orleans  physician,  in 
1832  treated  patients  by  exclusion  of  the  sunlight.  Eecently  the  red-light 
treatment  of  the  disease  has  been  advocated  by  Finsen.  The  statements  do 
not  agree  as  to  its  value.  Nash  states  that  the  course  of  the  rash  may  be 
modified  by  the  treatment,  but  Eicketts  and  Byles  could  see  no  influence 
whatever,  even  in  cases  taken  at  the  earliest  possible  date. 

COMPLICATIONS. — If  the  diarrhoea  is  severe  in  children,  paregoric  may  be 
given.  When  the  pulse  becomes  feeble  and  rapid,  stimulants  may  be  freely 
given.  The  maniacal  delirium  may  require  chloroform  or  morphia,  but  for 
less  intense  nervous  symptoms  the  bath  or  cold  pack  is  the  best.  For  the 
severe  hemorrhages  of  the  malignant  cases  nothing  can  be  done,  and  it  is 
only  cruel  to  drench  the  unfortunate  patient  with  iron,  ergot,  and  other  drugs. 
Symptoms  of  obstruction  in  the  larynx,  usually  from  cedema,  may  call  for 
tracheotomy.  In  the  late  stages  of  the  disease,  should  the  patient  be  extremely 
debilitated  and  the  subject  of  abscesses  and  bed-sores,  he  may  be  placed  on  a 
water-bed  or  treated  in  the  continuous  warm  bath. 

The  care  of  the  eyes  is  most  important.  The  lids  should  be  thoroughly 
cleansed  and  the  conjunctiva?  washed  with  a  warm  solution  of  salt  or  boracic 
acid.  In  the  confluent  cases  the  eyelids  are  much  swollen  and  glued  together, 
and  it  is  only  constant  watchfulness  which  prevents  keratitis.  The  edges  of 


326  SPECIFIC    INFECTIOUS    DISEASES 

the  lids  should  be  smeared  with  vaseline.  The  mouth  and  throat  should  be 
kept  clean,  a  potassium  permanganate  or  carbolic  mouth  wash  and  gargle 
used,  and  the  treatment  of  the  nose  with  glycerin  or  sweet  oil  should  be  begun 
early,  as  it  prevents  the  formation  of  hard  crusts.  Douching  the  nose  with  a 
warm  alkaline  solution  is  helpful. 

The  treatment  in  the  stage  of  convalescence  is  important.  Frequent  bath- 
ing helps  to  soften  the  crusts,  and  the  skin  may  be  oiled  daily.  Convalescence 
should  not  be  considered  established  until  the  skin  is  perfectly  smooth  and 
clean  and  free  from  any  trace  of  scabs. 

H.     VACCINIA    (Cow-pox)— VACCINATION 

Definition. — An  eruptive  disease  of  the  cow,  the  virus  of  which,  inoculated 
into  man  (vaccination),  produces  a  local  pock  with  constitutional  disturbance, 
which  affords  protection,  more  or  less  permanent,  against  small-pox. 

The  vaccine  is  got  either  directly  from  the  calf — animal  lymph — in  which 
the  disease  is  propagated  at  regular  stations,  or  is  obtained  from,  persons  vac- 
cinated (humanized  lymph). 

History. — For  centuries  it  had  been  a  popular  belief  among  farmer  folk 
that  cow-pox  protected  against  small-pox.  The  notorious  Duchess  of  Cleve- 
land, replying  to  some  joker  who  suggested  that  she  would  lose  her  occupation 
if  she  was  disfigured  with  small-pox,  said  that  she  was  not  afraid  of  the  dis- 
ease, as  she  had  had  a  disease  that  protected  her  against  small-pox.  Jesty,  a 
Dorsetshire  farmer,  had  had  cow-pox,  and  in  1774  vaccinated  successfully  his 
wife  and  two  sons.  Plett,  in  Holstein,  in  1791,  also  successfully  vaccinated 
three  children.  When  Jenner  was  a  student  at  Sodbury,  a  young  girl,  who 
came  for  advice,  when  small-pox  was  mentioned,  exclaimed,  "I  cannot  take 
that  disease,  for  I  have  had  cow-pox/'  Jenner  subsequently  mentioned  the 
subject  to  Hunter,  who  in  reply  gave  the  famous  advice :  "Do  not  think,  but 
try;  be  patient,  be  accurate."  As  early  as  1780  the  idea  of  the  protective 
power  of  vaccination  was  firmly  impressed  on  JenneVs  mind.  The  problem 
which  occupied  his  attention  for  many  years  was  brought  to  a  practical  issue 
when,  on  May  14,  1796,  he  took  matter  from  the  hand  of  a  dairy-maid,  Sarah 
Nelmes,  who  had  cow-pox,  and  inoculated  a  boy  named  James  Phipps,  aged 
eight  years.  On  July  1st,  matter  was  taken  from  a  small-pox  pustule  and 
inserted  into  the  boy,  but  no  disease  followed.  In  1798  appeared  An  Inquiry 
into  the  Causes  and  Effects  of  the  Variola  Vaccinae,  a  Disease  discovered  in 
some  of  the  Western  Counties  of  England,  particularly  Gloucestershire,  and 
known  by  the  Name  of  Cow-pox  (pp.  iv,  75,  four  plates,  4to.  London,  1798). 

In  the  United  States  cow-pox  was  introduced  by  Benjamin  Waterhouse, 
Professor  of  Physic  at  Harvard,  who  on  July  8,  1800,  vaccinated  seven  of  his 
children.  In  Boston  on  August  16,  1802,  nineteen  boys  were  inoculated  with 
the  cow-pox.  On  November  9th  twelve  of  them  were  inoculated  with  small- 
pox; nothing  followed.  A  control  experiment  was  made  by  inoculating  two 
onvaccinated  boys  with  the  same  small-pox  virus ;  both  took  the  disease.  The 
nineteen  children  of  August  16th  were  again  unsuccessfully  inoculated  with 
fresh  virus  from  these  two  boys.  This  is  one  of  the  most  crucial  experiments 
in  the  history  of  vaccination,  and  fully  justified  the  conclusion  of  the  Board 
of  Health — cow-pox  is  a  complete  security  against  the  small-pox. 


VACCINIA  (COW-POX)— VACCINATION  327 

Practitioners  should  familiarize  themselves  with  the  literature  on  vaccina- 
tion. The  centenary  number  of  the  British  Medical  Journal  is  particularly 
valuable  (1896).  The  report  of  the  Eoyal  Commission  on  vaccination  (1897), 
the  exhaustive  articles  in  Allbutt  and  Eolleston's  System  by  T.  D.  Acland, 
Copeman  and  Me  Vail,  and  Cory's  monograph  on  the  subject  afford  a  large 
body  of  material.  To  the  public  health  officials  who  wish  for  distribution 
in  handy  shape  Facts  about  Small-pox  and  Vaccination  leaflets  issued  by  the 
British  Medical  Association  will  be  of  the  greatest  value.  The  Vaccination 
Law  of  the  German  Empire,  printed  in  English  (Berlin,  B.  Paul,  1904),  con- 
tains important  information  and  statistics. 

Nature  of  Vaccinia. — Is  cow-pox  a  separate  independent  disease,  or  is  it 
only  small-pox  modified  by  passing  through  the  cow?  In  spite  of  a  host  of 
observations,  this  question  is  not  yet  settled.  The  experiments  may  be  di- 
vided into  two  groups.  First,  those  in  which  the  inoculation  of  the  small-pox 
matter  in  the  heifer  produced  pocks  corresponding  in  all  respects  to  the  vac- 
cine vesicles.  Lymph  from  the  first  calf  inoculated  into  a  second  or  third 
produced  the  characteristic  lesions  of  cow-pox,  and  from  the  first,  second,  or 
third  animal  lymph  used  to  vaccinate  a  child  produced  a  typical  localized 
vaccine  vesicle  without  any  of  the  generalized  features  of  small-pox.  The 
experiments  of  Ceely,  of  Babcock,  and  many  other  workers  seem  to  leave  no 
question  whatever  that  typical  vaccinia  may  be  produced  in  the  calf  by  the 
inoculation  of  variolous  matter.  A  great  deal  of  the  vaccine  material  at  one 
time  in  use  in  England  was  obtained  in  this  way.  Secondly,  against  this  are 
urged  Chauveau's  Lyons  experiments.  Seventeen  young  animals  were  inocu- 
lated with  the  virus  of  small-pox.  Small  reddish  papules  occurred  which  dis- 
appeared rapidly,  but  the  animals  did  not  acquire  cow-pox.  Fifteen  of  the 
seventeen  animals  were  also  vaccinated.  Of  these  only  one  showed  a  typical 
cow-pox  eruption.  To  determine  the  nature  of  the  original  papules  one  was 
excised  and  inoculated  into  a  non-vaccinated  child,  which  developed  as  a 
result  generalized  confluent  small-pox.  A  second  child  inoculated  from  the 
primary  pustule  of  the  first  child  developed  discrete  small-pox.  The  French 
still  hold  to  the  Lyons  experiments  as  demonstrating  the  duality  of  the  dis- 
eases. 

The  weight  of  evidence  favors  the  view  that  cow-pox  and  horse-pox  are 
variola  modified  by  transmission;  or,  as  has  been  suggested,  "small-pox  and 
vaccinia  are  both  of  them  descended  from  a  common  stock — from  an  ancestor, 
for  instance — which  resembled  vaccinia  far  more  than  it  resembled  small- 
pox" (Copeman). 

The  bodies  described  by  Guarnieri  have  been  very  thoroughly  studied  by 
Councilman  and  his  colleagues,  who  regard  them  as  forms  of  a  protozoon — 
Cytoryctes  vaccinia — with  a  well-characterized  development  cycle,  increasing 
in  size  until  they  undergo  segmentation. 

Normal  Vaccination. — PERIOD  OF  INCUBATION. — At  first  there  may  be  a 
little  irritation  at  the  site  of  inoculation,  which  subsides. 

PERIOD  OF  ERUPTION. — On  the  third  day,  as  a  rule,  a  papule  is  seen  sur- 
rounded by  a  reddish  zone.  This  gradually  increases,  and  on  the  fifth  or 
sixth  day  shows  a  definite  vesicle,  the  margins  of  which  are  raised  while  the 
centre  is  depressed.  By  the  eighth  day  the  vesicle  has  attained  its  maximum 
size.  It  is  round  and  distended  with  a  limpid  fluid,  the  margin  hard  and 


328  SPECIFIC   INFECTIOUS    DISEASES 

prominent,  and  the  umbilication  is  more  distinct.  By  the  tenth  day  the  vesi- 
cle is  still  large  and  is  surrounded  by  an  extensive  areola.  The  contents  have 
now  become  purulent.  The  skin  is  also  swollen,  indurated,  and  often  painful. 
On  the  eleventh  or  twelfth  day  the  hyperasmia  diminishes,  the  lymph  becomes 
more  opaque  and  begins  to  dry.  By  the  end  of  the  second  week  the  vesicle  is 
converted  into  a  brownish  scab,  which  gradually  becomes  dry  and  hard,  and  in 
about  a  week  (that  is,  about  the  twenty-first  or  twenty-fifth  day  from  the 
vaccination)  separates  and  leaves  a  circular  pitted  scar.  If  the  points  of  in- 
oculation have  been  close  together,  the  vesicles  fuse  and  may  form  a  large  com- 
bined vesicle.  Constitutional  symptoms  of  a'  more  or  less  marked  degree  fol- 
low the  vaccination.  Usually  on  the  third  or  fourth  day  the  temperature 
rises,  and  may  persist,  increasing  until  the  eighth  or  ninth  day.  There  is  a 
marked  leucocytosis.  In  children  it  is  common  to  have  with  the  fever  rest- 
lessness, particularly  at  night,  and  irritability;  but  as  a  rule  these  symptoms 
are  trivial.  If  the  inoculation  is  made  on  the  arm,  the  axillary  glands  be- 
come large  and  sore;  if  on  the  leg,  the  inguinal  glands.  Immunity  is  not 
necessarily  complete  at  once  after  vaccination;  it  may  take  as  long  as  three 
weeks;  on  the  other  hand,  a  person  exposed  to  small-pox  and  successfully 
vaccinated  at  once  may  escape  entirely,  or  the  two  diseases  may  run  concur- 
rently, with  the  small-pox  much  modified.  The  duration  of  the  immunity 
is  extremely  variable,  differing  in  different  individuals.  In  some  instances 
it  is  permanent,  but  a  majority  of  persons  within  ten  or  twelve  years  again 
become  susceptible. 

Revaccination  should  be  performed  between  the  tenth  and  fifteenth  year, 
and  whenever  small-pox  is  epidemic.  The  susceptibility  to  revaccination  is 
very  general.  In  1891-'92  vaccination  pustules  developed  in  88.7  per  cent,  of 
the  newly  enrolled  troops  of  the  German  army,  most  of  whom  had  been  vac- 
cinated twice  in  their  lives  before.  The  vesicle  in  revaccination  is  usually 
smaller,  has  less  induration  and  hyperaemia,  and  the  resulting  scar  is  less  per- 
fect. Particular  care  should  be  taken  to  watch  the  vesicle  of  revaccination,  as 
it  not  infrequently  happens  that  a  spurious  pock  is  formed,  which  reaches  its 
height  early  and  dries  to  a  scab  by  the  eighth  or  ninth  day. 

Irregular  Vaccination. — (a)  LOCAL  VARIATIONS. — We  occasionally  meet 
with  instances  in  which  the  vesicle  develops  rapidly  with  much  itching,  has 
not  the  characteristic  flattened  appearance,  the  lymph  early  becomes  opaque, 
and  the  crust  forms  by  the  seventh  or  eighth  day.  The  evolution  of  the  pocks 
may  be  abnormally  slow.  In  such  cases  the  operation  should  again  be  per- 
formed with  fresh  lymph.  The  contents  of  the  vesicles  may  be  watery  and 
bloody.  In  the  involution  the  bruising  or  irritation  of  the  pocks  may  lead  to 
ulceration  and  inflammation.  A  very  rare  event  is  the  recurrence  of  the  pock 
in  the  same  place.  Sutton  reports  four  such  recurrences  within  six  months. 

(6)  GENERALIZED  VACCINIA. — It  is  not  uncommon  to  see  vesicles  in  the 
vicinity  of  the  primary  sore.  Less  common  is  a  true  generalized  pustular  rash, 
developing  in  different  parts  of  the  body,  often  beginning  about  the  wrists  and 
on  the  back.  The  secondary  pocks  may  continue  to  make  their  appearance  for 
five  or  six  weeks  after  vaccination.  In  children  the  disease  may  prove  fatal. 
They  may  be  most  abundant  on  the  vaccinated  limb,  and  occur  usually  about 
the  eighth  to  the  tenth  day. 

(c)    COMPLICATIONS.— In  unhealthy  subjects,  or  as  a  result  of  uncleanli- 


VACCINIA  (COW-POX)— VACCINATION  329 

ness,  or  sometimes  injury,  the  vesicles  inflame  and  deep  excavated  ulcers 
result.  Sloughing  and  deep  cellulitis  may  follow.  In  debilitated  children 
there  may  be  with  this  a  purpuric  rash.  Acland  thus  arranges  the  dates  at 
which  the  possible  eruptions  and  complications  may  be  looked  for : 

1.  During  the  first  three  days:    Erythema;  urticaria;  vesicular  and  bul- 
lous  eruptions;  invaccinated  erysipelas. 

2.  After  the  third  day  and  until  the  pock  reaches  maturity:    Urticaria; 
lichen  urticatus,  erythema  multiforme;  accidental  erysipelas. 

3.  About  the  end  of  the  first  week:    Generalized  vaccinia;  impetigo;  vac- 
cinal  ulceration;  glandular  abscess;  septic  infections;  gangrene. 

4.  After  the  involution  of  the  pocks :   Invaccinated  diseases — for  example, 
syphilis. 

(d)  TRANSMISSION  OF  DISEASES  BY  VACCINATION. — Syphilis  has  un- 
doubtedly been  transmitted  by  vaccination,  but  such  instances  are  very  rare, 
and  a  large  number  of  the  cases  of  alleged  vaccino-syphilis  must  be  thrown 
out.  The  question  has  now  become  really  of  minor  importance  since  the  wide- 
spread use  of  animal  lymph.  Dr.  Cory's  sad  experiment  may  here  be  referred 
to.  He  vaccinated  himself  four  times  from  syphilitic  children.  With  the  first 
vaccination  followed,  but  no  syphilis.  Two  other  attempts  (negative)  were 
made.  The  fourth  time  he  was  vaccinated  from  a  child  the  subject  of  con- 
genital syphilis.  The  lymph  was  taken  from  the  child's  arm  with  care,  avoid- 
ing any  contamination  with  blood.  At  two  of  the  points  of  insertion  red 
papules  appeared  on  the  twenty-first  day.  On  the  thirty-eight  day  a  little 
ulcer  was  found,  which  Sir  Jonathan  Hutchinson  decided  was  syphilitic.  The 
diseased  parts  were  then  removed.  By  the  fiftieth  day  the  constitutional  symp- 
toms were  well  marked. 

Among  the  differences  between  vaccino-syphilis  and  vaccination  ulcers  the 
most  important  is  perhaps  that  the  chancre  never  appears  before  the  fifteenth 
day,  usually  not  until  from  three  to  five  weeks,  whereas  the  ulceration  of 
ordinary  vaccination  is  present  by  the  twelfth  or  fifteenth  day.  The  loss  of 
substance  in  the  chancre  is  usually  quite  superficial  and  the  induration  very 
parchment-like  and  specific,  with  but  a  slight  inflammatory  areola.  The 
glandular  swelling,  too,  is  constant  and  indolent,  while  in  the  vaccination 
ulcer  it  is  often  absent,  or,  when  present,  chiefly  inflammatory. 

Tuberculosis. — "No  undoubted  case  of  invaccinated  tubercle  was  brought 
before  the  Eoyal  Commission  on  Vaccination"  (Acland).  The  risk  of  trans- 
mitting tuberculosis  from  the  calf  is  so  slight  that  it  need  not  be  considered. 
The  transmission  of  leprosy  by  vaccination  is  doubtful. 

The  observations  on  the  presence  of  actinomyces  in  vaccine  virus  have  been 
confirmed  by  W.  T.  Howard,  Jr.,  who  found  it  24  times  in  95  cultures  from 
the  virus  of  five  producers  in  the  United  States. 

Tetanus. — McFarland  collected  95  cases,  practically  all  American.  Sixty- 
three  occurred  in  1901,  a  majority  of  which  could  be  traced  to  one  source 
of  supply,  in  which  E.  W.  Wilson  demonstrated  the  tetanus  bacillus.  Most  of 
the  cases  occurred  about  Philadelphia.  Since  that  date  very  few  cases  have 
been  reported.  The  occurrence  of  this  terrible  complication  emphasizes  the 
necessity  of  the  most  scrupulous  care  in  the  preparation  of  the  animal  virus, 
as  the  tetanus  bacillus  is  almost  constantly  present  ic  the  intestines  of 

cattle. 

23 


330  SPECIFIC   INFECTIOUS    DISEASES 

(e)  INFLUENCE  OF  VACCINATION  UPON  OTHER  DISEASES.— A  quiescent 
malady  may  be  lighted  into  activity  by  vaccination.  This  has  happened  with 
congenital  syphilis,  occasionally  with  tuberculosis.  An  old  idea  was  prevalent 
that  vaccination  had  a  beneficial  influence  upon  existing  diseases.  Thomas 
Archer,  the  first  medical  graduate  in  the  United  States,  recommended  it  in 
whooping-cough,  and  said  that  it  had  cured  six  or  eight  cases  in  his  hands. 
At  the  height  of  the  vaccination  convulsions  may  occur  and  be  followed  by 
hemiplegia. 

Technique. — That  part  of  the  arm  about  the  insertion  of  the  deltoid  is 
usually  selected  for  the  operation.  Mothers  "in  society"  prefer  to  have  girl 
babies  vaccinated  on  the  leg.  The  skin  should  be  cleansed  and  put  upon  the 
stretch.  Then,  with  a  scalpel,  needle,  or  the  ivory  point,  cross-scratches  or 
superficial  incisions  should  be  made  in  one  or  more  places.  Four  points  of 
insertion,  an  inch  apart,  are  best.  When  glycerin  lymph  is  used  the  drops 
may  be  placed  on  the  skin  first  a'nd  the  incisions  then  made.  When  the  lymph 
has  dried  on  the  points  it  is  best  to  moisten  it  in  warm  water.  The  clothing 
of  the  child  should  not  be  adjusted  until  the  spot  has  dried,  and  it  should  be 
protected  for  a  day  or  two  with  lint  or  a  soft  handkerchief.  When  the  vesicle 
forms  it  can  be  protected  by  sterile  gauze  held  in  place  by  strapping.  If  ery- 
sipelas is  prevalent,  or  if  there  are  cases  of  suppuration  in  the  same  house,  it 
is  well  to  apply  a  pad  of  antiseptic  cotton.  Vaccination  is  usually  performed 
between  the  fourth  and  sixth  month.  If  unsuccessful,  it  should  be  repeated 
from  time  to  time.  It  should  be  postponed  if  the  child  has  any  ailment  or 
suffers  from  syphilis  or  a  skin  disease.  Eevaccination  should  be  done  at  the 
age  of  nine  years.  A  person  exposed  to  the  contagion  of  small-pox  should 
always  be  revaccinated.  This,  if  successful,  will  usually  protect;  but  not 
always.  The  cases  in  which  small-pox  is  taken  within  a  few  years  after  vac- 
cination are  probably  instances  of  spurious  vaccination. 

The  Value  of  Vaccination. — Sanitation  cannot  account  for  the  diminu- 
tion in  small-pox  and  for  the  low  rate  of  mortality.  Jsolation,  of  course,  is  a 
useful  auxiliary,  but  it  is  no  substitute.  Vaccination  is  not  claimed  to  be  an 
invariable  and  permanent  preventive  of  small-pox,  but  in  an  immense  ma- 
jority of  cases  successful  inoculation  renders  the  person  for  many  years  insus- 
ceptible. Communities  in  which  vaccination  and  revaccination  are  thoroughly 
and  systematically  carried  out  are  those  in  which  small-pox  has  the  fewest 
victims.  The  German  army  since  1874,  the  date  of  the  stringent  laws,  has 
enjoyed  practical  immunity.  On  the  other  hand,  communities  in  which  vac- 
cination and  revaccination  are  persistently  neglected  are  those  in  which  epi- 
demics are  most  prevalent.  Owing  to  a  widespread  prejudice  against  vacci- 
nation in  Montreal,  there  grew  up,  between  the  years  1876  and  1884,  a  con- 
siderable unprotected  population,  and  the  materials  were  ripe  for  an  extensive 
epidemic.  The  soil  had  been  prepared  with  the  greatest  care,  and  it  only 
needed  the  introduction  of  the  seed,  which  in  due  time  came  with  the  Pullman- 
car  conductor  from  Chicago,  on  the  28th  of  February,  1885.  Within  the  next 
ten  months  thousands  of  persons  were  stricken  with  the  disease,  and  3,164 
died.  The  statistics  from  Japan,  published  by  Kitasato  (1911),  show  strik- 
ingly the  efficacy  of  vaccination  in  that  country.  In  the  Japanese  army  of 
more  than  a  million  men  in  a  war  waged  in  a  country  in  which  small-pox  was 
then  endemic  there  were  only  362  cases  and  35  deaths.  He  shows  with  great 


VAEICELLA   (CHICKEN-POX)  331 

clearness  the  gradual  lessening  of  the  intensity  of  the  epidemics  in  Japan  as 
the  system  of  vaccination  has  been  perfected. 

Although  the  effects  of  a  single  vaccination  may  wear  out,  as  we  say,  and 
the  individual  again  become  susceptible  to  small-pox,  yet  the  mortality  in 
such  cases  is  very  much  lower  than  in  persons  who  have  never  been  vaccinated. 
The  mortality  in  persons  who  have  been  vaccinated  is  from  6  to  8  per  cent., 
whereas  in  the  unvaccinated  it  is  at  least  35  per  cent.  There  is  evidence  that 
the  greater  the  number  of  marks  the  greater  the  protection  in  relation  to 
small-pox;  thus,  the  English  Vaccination  Report  states  that  out  of  4,754  cases 
the  death-rate  with  one  mark  was  7.6  per  cent. ;  with  two  marks,  7  per  cent. ; 
with  three  marks,  4.2  per  cent. ;  with  four  marks,  2.4  per  cent.  W.  M.  Welch's 
statistics  of  5,000  cases  on  this  point  give  with  good  cicatrices  8  per  cent.; 
with  fair  cicatrices,  14  per  cent.;  with  poor  cicatrices,  27  per  cent.;  post- 
vaccinal  cases,  16  per  cent. ;  unvaccinated  cases,  58  per  cent. 


III.     VARICELLA   (Chicken-pox) 

Definition. — An  acute  contagious  disease,  characterized  by  an  eruption  of 
vesicles  on  the  skin. 

History. — Ingrassias,  a  distinguished  Neapolitan  professor,  first  recognized 
the  disease  as  differing  from  small-pox  (1553).  Heberden  gave  it  the  name 
chicken-pox  (1767). 

Etiology.  — The  disease  occurs  in  epidemics,  but  sporadic  cases  are  also 
met  with.  It  may  prevail  at  the  same  time  as  small-pox  or  may  follow  oj 
precede  epidemics  of  this  disease.  It  is  a  disease  of  childhood;  a  majority  of 
the  cases  occur  between  the  second  and  sixth  years.  Adults  who  have  not  had 
the  disease  in  childhood  are  very  liable  to  be  attacked.  The  specific  germ  has 
not  yet  been  discovered. 

Varicella  is  an  affection  distinct  from  variola  and  without  at  present  any 
relation  whatever  to  it.  An  attack  of  the  one  does  not  confer  immunity  from 
an  attack  of  the  other.  A  boy,  aged  five,  was  admitted  to  St.  Thomas'  Hos- 
pital with  a  vesicular  eruption,  and  was  isolated  in  a  ward  on  the  same  floor 
as  the  small-pox  ward.  The  disease  was  pronounced  chicken-pox,  however, 
by  Risdon  Bennett  and  Bristowe.  The  patient  was  then  removed  and  Vacci- 
nated, with  a  result  of  four  vesicles  which  ran  a  pretty  normal  course.  On 
the  eighth  day  from  the  vaccination  the  child  became  feverish.  On  the  fol- 
lowing day  the  papules  appeared  and  the  child  had  a  well-developed  attack  of 
small-pox  with  secondary  fever  (Sharkey). 

Symptoms. — After  a  period  of  incubation  of  ten  or  fifteen  days  the  child 
becomes  feverish  and  in  some  instances  has  a  slight  chflk  There  may.be 
vomiting,  and  pains  in  the  back  and  legs.  Convulsions  are  rare.  The  erup- 
tion usually  occurs  within  twenty-four  hours.  It  is  first  seen  upon  the  trunk, 
either  on  the  back  or  on  the  chest.  It  may  begin  on  the  forehead  and  face. 
At  first  in  the  form  of  raised  red  papules,  these  are  in  a  few  hours  trans- 
formed into  hemispherical  vesicles  containing  a  clear  or  turbid  fluid.  As  a 
rule  there  is  no  umbilication,  but  in  rare  instances  the  pocks  are  flat- 
tened, and  a  few  may  even  be  umbilicated.  They  are  often  ovoid  in  shape  and 
look  more  superficial  than  the  variolous  vesicles.  The  skin  in  the  neighborhood 


332  SPECIFIC   INFECTIOUS   DISEASES 

is  not  often  infiltrated  or  hyperaemic.  At  the  end  of  thirty-six  or  forty-eight 
hours  the  contents  of  the  vesicles  are  purulent.  They  begin  to  shrivel,  and 
during  the  third  and  fourth  days  are  converted  into  dark  brownish  crusts, 
\\hirli  fall  off  and  as  a  rule  leave  no  scar.  Fresh  crops  appear  during  the  first 
two  or  three  days  of  the  illness,  so  that  on  the  fourth  day  one  can  usually  see 
pocks  in  all  stages  of  development  and  decay.  They  are  always  discrete,  and 
the  number  may  vary  from  eight  or  ten  to  several  hundreds.  As  in  variola, 
a  scarlatinal  rash  occasionally  precedes  the  development  of  the  eruption.  The 
eruption  may  occur  on  the  mucous  membrane  of  the  mouth,  and  occasionally 
in  the  larynx.  In  adults  the  disease  may  be  much  more  severe,  the  initial 
fever  high,  the  rash  very  widespread,  and  the  constitutional  symptoms  com- 
paratively severe,  so  that  the  diagnosis  of  variola  may  be  made — the  so-called 
varicella  variolaformes.  The  fever  in  varicella  is  slight,  but  it  does  not  as  a 
rule  disappear  with  the  appearance  of  the  rash.  The  course  of  the  disease 
is  in  a  large  majority  of  the  cases  favorable,  and  no  ill  effects  follow.  The 
disease  may  recur  in  the  same  individual.  There  are  instances  in  which  a 
person  has  had  three  attacks. 

There  are  one  or  two  modifications  of  the  rash  which  are  interesting.  The 
vesicles  may  become  very  large  and  develop  into  regular  bullae,  looking  not 
unlike  ecthyma  or  pemphigus  (varicella  bullosa).  The  irritation  of  the  rash 
may  be  excessive,  and  if  the  child  scratches  the  pocks  ulcerating  sores  may 
form,  which  on  healing  leave  ugly  scars.  Indeed,  cicatrices  after  chicken-pox 
are  more  common  than  after  varioloid. 

In  delicate  children,  particularly  the  tuberculous,  gangrene  (varicella 
escharotica)  may  occur  about  the  vesicles,  or  in  other  parts,  as  the  scrotum. 

Cases  have  been  described  of  haemorrhagic  varicella  with  cutaneous  ecchy- 
moses  and  bleeding  from  the  mucous  membranes. 

Nephritis  may  occur.  Infantile  hemiplegia  has  occurred  during  an  attack 
of  the  disease.  Death  has  followed  in  an  uncomplicated  case  from  extensive 
involvement  of  the  skin. 

Diagnosis. — The  diagnosis  is  as  a  rule  easy,  particularly  if  the  patient 
has  been  seen  from  the  onset.  When  a  case  comes  under  observation  for  the 
first  time  with  the  rash  well  out,  there  may  be  considerable  difficulty.  The 
abundance  of  the  rash  on  the  trunk  in  varicella  is  most  important.  The 
pocks  in  varicella  are  more  superficial,  more  bleb-like,  have  not  so  deeply  an 
infiltrated  areola  about  them,  and  may  usually  be  seen  in  all  stages  of  devel- 
opment. They  rarely  at  the  outset  have  the  hard,  shotty  feeling  of  those  of 
small-pox.  The  general  symptoms,  the  greater  intensity  of  the  onset,  the 
prolonged  period  of  invasion,  and  the  more  frequent  occurrence  of  prodromal 
rashes  in  small-pox  are  important  points  in  the  diagnosis. 

Death  is  verj^are,  and,  unless  from  the  complications,  raises  a  suspicion 
of  the  correctness  of  the  diagnosis.  Thus  of  the  116  deaths  in  England  and 
Wales  in  1903  ascribed  to  chicken-pox,  it  is  probable,  as  Tatham  suggests, 
that  many  of  these  were  from  unrecognized  small-pox. 

No  special  treatment  is  required.  If  the  rash  is  abundant  on  the  face, 
great  care  should  be  taken  to  prevent  the  child  from  scratching  the  pustules. 
A  soothing  lotion  should  be  applied  on  lint. 


SCARLET  FEVER  333 


IV.  SCARLET  FEVER 

Definition. — An  infectious  disease  characterized  by  a  diffuse  exanthem 
and  an  angina  of  variable  intensity. 

History. — In  the  sixteenth  century  Ingrassias  of  Naples  and  Coyttarus  of 
Poitiers  recognized  the  disease;  but  Sydenham  in  1675  gave  a  full  account  of 
it  under  the  name  febris  scarlatina. 

Etiology. — No  one  of  the  acute  infections  varies  so  greatly  in  the  intensity 
of  the  outbreaks,  a  point  to  which  both  Sydenham  and  Bretonneau  called 
attention.  In  some  years  it  is  mild ;  in  others,  with  equally  widespread  epi- 
demics, it  is  fearfully  malignant.  It  is  a  widespread  affection,  occurring  in 
nearly  all  parts  of  the  globe  and  attacking  all  races. 

Sporadic  cases  occur  from  time  to' time.  The  epidemics  are  most  intense 
in  the  autumn  and  winter.  There  is  an  extraordinary  variability  in  the 
severity  of  the  outbreaks,  which  on  the  whole  appear  to  be  lessening  in  sever- 
ity; thus,  in  Boston  from  1894  to  1903  the  ratio  of  cases  per  ten  thousand  has 
ranged  from  45.80  to  16.18,  and  the  mortality  from  3.94  to  .60.  In  England 
and  Wales  the  disease  is  declining.  In  1883  there  were  over  12,000  deaths;  in 
1903,  4,158;  in  1909,  3,215,  and  in  1910  it  was  50  per  cent,  less  than  in 
1901.  Newsholme  attributes  this  in  part  to  the  general  improvement  in  sani- 
tation in  the  home  and  to  hospital  isolation,  and  in  part  to  the  striking  decline 
in  the  severity  of  the  disease. 

Seibert's  studies  in  New  York  show  that  the  disease  increases  steadily 
from  week  to  week  until  the  middle  of  May;  the  frequency  diminishes  gradu- 
ally until  the  end  of  June,  and  gradually  increases  through  October,  Novem- 
ber, and  December.  He  associates  the  remarkable  drop  in  July,  August,  and 
September  with  the  closure  of  the  schools  and  the  cessation  of  the  daily  con- 
gregation of  infectious  material  in  small  areas — school-houses  and  play- 
grounds— for  so  many  hours  each  day. 

AGE  is  the  most  important  predisposing  factor.  Ninety  per  cent,  of  the 
fatal  cases  are  under  the  tenth  year.  Sucklings  are  rarely  attacked.  The 
general  liability  to  the  disease  in  childhood  is  less  widespread  than  in  measles. 
Many  escape  in  childhood ;  others  escape  until  adult  life ;  some  never  take  it. 

FAMILY  SUSCEPTIBILITY  is  not  infrequently  illustrated  by  the  death  in 
rapid  succession  of  four  or  five  members.  On  the  other  hand,  individual  re- 
sistance is  common,  and  many  physicians  constantly  exposed  escape.  An  at- 
tack as  a  rule  confers  subsequent  immunity.  In  rare  instances  there  have 
been  one  or  even  two  recurrences. 

The  natives  of  India  are  said  to  enjoy  comparative  immunity. 

INFECTIVITY. — It  is  not  yet  accurately  known  where  in  the  body  the  poison 
is  formed.  It  is  probably  given  off  with  the  secretions  of  the  nose,  throat,  and 
respiratory  tract.  The  mild  angina  of  the  ambulatory  cases  may  convey  the 
disease,  and  in  this  way  it  is  spread  in  schools,  and  the  "return  cases"  may 
find  in  this  way  their  explanation.  Much  more  attention  has  been  paid  of  late 
to  this  aspect  of  the  scarlatinal  infection,  and  it  has  even  been  suggested 
that  the  skin  is  only  infective  by  contamination  with  the  secretions.  The 
general  opinion,  however,  is  that  the  poison  is  given  off  chiefly  from  the  skin, 
particularly  when  desquamating.  Unlike  measles,  the  germ  is  very  resistant 


334  SPECIFIC    INFECTIOUS    DISEASES 

and  clings  tenaciously  to  clothing,  to  bedding,  the  furniture  of  the  room,  etc. 
Even  after  the  most  complete  disinfection  possible,  children  who  have  been 
removed  from  an  infected  house  may  catch  the  disease  on  their  return.  The 
possibility  here  of  throat  and  nose  infection  must  be  considered.  The  in- 
tractable character  of  the  nasal  discharge  after  scarlet  fever  is  well  recognized 
and  this  secretion  appears  to  be  highly  infectious.  The  chief  organisms  in  it 
are  streptococci.  A  third  person  may  convey' the  disease,  but  undoubted  in- 
stances are  rare.  I  recall  one  instance  in  which  I  could  have  been  the  only 
possible  medium. 

The  disease  is  stated  to  have  been  conveyed  by  milk.  Of  99  epidemics 
studied  by  Kober  the  disease  prevailed  in  68  either  at  the  dairy  or  the  milk 
farm.  There  appear  to  be  two  groups  of  cases :  first,  genuine  scarlet  fever,  in 
which  the  infection  is  conveyed  through  the  milk  having  come  in  contact  with 
infected  persons;  and,  secondly,  outbreaks  of  an  infection  resembling  scarlet 
fever,  due  to  disease  of  the  udder  of  the  cows. 

By  SURGICAL  SCARLATINA,  first  brought  to  the  attention  of  the  profession 
by  Sir  James  Paget  in  1864,  is  understood  an  erythematous  eruption  follow- 
ing an  operation  or  occurring  during  septic  infection.  It  differs  from  medical 
scarlatina  in  the  large  number  of  adults  attacked,  the  shorter  incubation,  the 
mildness  of  the  throat  symptoms,  the  starting  of  the  eruption  at  the  wound, 
and  the  precocious  desquamation.  Alice  Hamilton,  after  analyzing  174  cases 
reported  in  the  literature,  concludes  that  the  eruption  is  most  frequently  due 
to  septic  infection  and  is  not  truly  scarlatinal,  and  that  in  those  cases  in 
which  the  disease  was  undoubtedly  scarlatina  there  is  no  convincing  evidence 
that  the  relation  between  the  wound  and  the  scarlet  fever  was  anything  more 
than  one  of  coincidence. 

The  SPECIFIC  GERM  is  not  known.  It  is  claimed  to  be  only  a  modified 
streptococcus  infection.  The  streptococcus  pyogenes  has  often  been  found  in 
the  blood  during  life  and  after  death,  and  it  is  constantly  present  in  the 
throat  in  severe  cases;  but  there  is  no  agreement  on  the  subject  among  the 
best  workers. 

Morbid  Anatomy. — Except  in  the  haemorrhagic  form,  the  skin  after  death 
shows  no  traces  of  the  rash.  There  are  no  specific  lesions.  Those  which 
occur  in  the  internal  organs  are  due  partly  to  the  fever  and  partly  to  infection 
with  pus-organisms. 

The  anatomical  changes  in  the  throat  are  those  of  simple  inflammation,- 
follicular  tonsillitis,  and,  in  extreme  grades,  of  diphtheroid  angina.  In 
severe  cases  there  are  intense  lymphadenitis  and  much  inflammatory  oedema  of 
the  tissues  of  the  neck,  which  may  go  on  to  suppuration,  or  even  to  gangrene. 
Streptococci  are  found  abundantly  in  the  glands  and  in  the  foci  of  suppura- 
tion. The  lymph  glands  and  the  lymphoid  tissue  may  show  hyperplasia 
and  the  spleen,  liver,  and  other  organs  may  be  the  seat  of  widespread  focal 
necroses. 

Endocarditis  and  pericarditis  are  not  infrequent.  Myocardial  changes  are 
less  common.  The  renal  changes  will  be  considered  with  the  diseases  of  the 
kidney. 

Affections  of  the  respiratory  organs  are  not  frequent.  When  death  results 
from  the  pseudo-membranous  angina,  broncho-pneumonia  is  not  uncommon. 
Cerebro-spinal  changes  are  rare. 


SCARLET   FEVER  335 

Symptoms. — INCUBATION. — "From  one  to  seven  days,  oftenest  two  to 
four."  McCollom.  considered  the  usual  period  to  be  ten  to  fourteen  days. 

INVASION. — The  onset  is  as  a  rule  sudden.  It  may  be  preceded  by  a 
slight,  scarcely  noticeable,  indisposition.  An  actual  chill  is  rare.  Vomiting 
is  one  of  the  most  constant  initial  symptoms;  convulsions  are  common.  The 
fever  is  intense;  rising  rapidly,  it  may  on  the  first  day  reach  104°  or  even 
105°.  •  The  skin  is  unusually  dry  and  to  the  touch  gives  a  sensation  of  very 
pungent  heat.  The  tongue  is  furred,  and  as  early  as  the  first  day  there  may 
be  complaint  of  dryness  of  the  throat.  Cough  and  catarrhal  symptoms  are 
uncommon.  The  face  is  often  flushed  and  the  patient  has  all  the  objective 
features  of  an  acute  fever. 

ERUPTION. — Usually  on  the  second  day,  in  some  instances  within  the  first 
twenty-four  hours,  the  rash  appears  in  the  form  of  scattered  red  points  on  a 
deep  subcuticular  flush;  at  first  on  the  neck  and  chest,  and  spreading  so 
rapidly  that  by  the  evening  of  the  second  day  it  may  have  invaded  the  entire 
skin.  After  persisting  for  two  or  three  days  it  gradually  fades.  At  its  height 
the  rash  has  a  vivid  scarlet  hue,  quite  distinctive  and  unlike  that  seen  in  any 
other  eruptive  disease.  It  is  an  intense  hyperaemia,  and  the  anemia  produced 
by  pressure  instantly  disappears.  There  may  be  fine  punctiform  haemorrhages, 
which  do  not  disappear  on  pressure.  In  some  cases  the  rash  does  not  become 
uniform  but  remains  patchy,  and  intervals  of  normal  skin  separate  large 
hyperaemic  areas.  Tiny  papular  elevations  may  sometimes  be  seen,  but  they 
are  not  so  common  as  in  measles.  With  each  day  the  rash  becomes  of  a 
darker  color,  and  there  may  be  in  parts  even  a  bluish-red  shade.  Smooth  at 
the  beginning,  the  skin  gradually  becomes  rougher,  and  to  the  touch  feels  like 
"goose  skin."  At  the  height  of  the  eruption  sudaminal  vesicles  may  develop, 
the  fluid  of  which  may  become  turbid.  The  entire  skin  may  at  the  same 
time  be  covered  with  small  yellow  vesicles  on  a  deep  red  background — scarla- 
tina miliaris.  McCollom  lays  stress  upon  the  appearance  of  a  punctate  erup- 
tion in  the  arm-pits,  groins,  and  on  the  roof  of  the  mouth  as  positive  proof  of 
scarlet  fever.  Marked  transverse  lines  at  the  bend  of  the  elbow  sometimes 
occur  early.- 

Occasionally  there  are  petechia?,  which  in  the  malignant  type  of  the  dis- 
ease become  widespread  and  large.  The  eruption  does  not  always  appear 
upon  the  face.  There  may  be  a  good  deal  of  swelling  of  the  skin,  which  feels 
uncomfortable  and  tense.  The  itching  is  variable;  not  as  a  rule  intense  at 
the  height  of  the  eruption.  By  the  seventh  or  eighth  day  the  rash  has  dis- 
appeared. The  mucous  membrane  of  the  palate,  the  cheeks,  and  the  tonsils 
present  a  vivid  red,  punctiform  appearance.  The  tongue  at  first  is  red  at  the 
tip  and  edges,  furred  in  the  centre ;  and  through  the  white  fur  are  often  seen 
the  swollen  red  papillae,  which  give  the  so-called  "strawberry"  appearance  to 
the  tongue,  particularly  if  the  child  puts  out  the  tip  of  the  tongue  between 
the  lips.  In  a  few  days  the  "fur"  desquamates  and  leaves  the  surface  red 
and  rough,  and  it  is  this  condition  which  some  writers  call  the  "strawberry," 
or,  better,  the  "raspberry"  tongue.  Enlargement  of  the  papillae  was  the  only 
constant  sign  in  1,000  cases  (McCollom).  The  breath  often  has  a  very  heavy, 
sweet  odor. 

The  pharyngeal  symptoms  are : 

1.  Slight  redness,  with  swelling  of  the  pillars  of  the  fauces  and  of  the 


336  SPECIFIC   INFECTIOUS    DISEASES 

tonsils.  2.  A  more  intense  grade  of  swelling  and  infiltration  of  these  parts 
with  a  follicular  tonsillitis.  3.  Diphtheroid  Angina  with  intense  inflamma- 
tion of  all  the  pharyngeal  structures  and  swelling  of  the  glands  below  the  jaw, 
and  in  very  severe  cases  a  thick  brawny  induration  of  all  the  tissues  of  the 

neck. 

The  fever,  which  sets  in  with  such  suddenness  and  intensity,  may  reach 
105°  or  even' 106°  F.  It  persists  with  slight  morning  remissions,  gradually 
declining  with  the  disappearance  of  the  rash.  In  mild  cases  the  temperature 
may  not  reach  103°  F.;  on  the  other  hand,  in  very  severe  cases  there  may  be 
hyperpyrexia,  the  thermometer  registering  108°  F.,  or  before  death  even 

109°  F. 

The  pulse  ranges  from  120  to  150;  in  severe  cases  with  very  high  fever 
from  190  to  200.  The  respirations  show  an  increase  proportionate  to  the 
intensity  of  the  fever.  A  leucocytosis  is  usually  present,  which  may  be  high 


Day 

1 

£ 

s 

i 

5 

G 

7 

8       3 

106'- 
101? 
102 
100 

ss° 

^ 

\  / 

A 

A 

I 

V 

\l 

1 

V 

\ 

V 

•\ 

V 

-A 

V 

-s 

\ 

\ 

CHART  X. — SCARLET  FEVER. 

(30,000  to  50,000  per  c.  mm.)  in  the  severe  cases.  The  gastrointestinal  symp- 
toms are  not  marked  after  the  initial  vomiting,  and  food  is  usually  well  taken. 
In  some  instances  there  are  abdominal  pains.  The  edge  of  the  spleen  may 
be  palpable.  The  liver  is  not  often  enlarged.  With  the  initial  fever  nervous 
symptoms  are  present  in  a  majority  of  the  cases;  but  as  the  rash  comes  out 
the  headache  and  the  slight  nocturnal  wandering  disappear.  The  urine  has 
the  ordinary  febrile  characters,  being  scanty  and  high  colored.  Slight  albu- 
minuria  is  by  no  means  infrequent  during  the  stage  of  eruption.  Careful 
examination  of  the  urine  should  be  made  every  day.  There  is  no  cause  for 
alarm  in  the  trace  of  albumin  which  is  so  often  present,  not  even  if  it  is  asso- 
ciated with  a  few  tube  casts. 

DESQUAMATION. — With  the  disappearance  of  the  rash  and  the  fever  the 
skin  looks  somewhat  stained,  is  dry,  a  little  rough,  and  gradually  the  upper 
layer  of  the  cuticle  begins  to  separate.  The  process  usually  begins  about  the 
neck  and  chest,  and  flakes  are  gradually  detached.  The  degree  and  character 
of  the  desquamation  bear  some  relation  to  the  intensity  of  the  eruption.  When 
the  latter  has  been  very  vivid  and  of  long  standing  large  flakes  may  be  thrown 
off.  In  rare  instances  the  hair  and  even  the  nails  have  been  shed.  It  must 


SCAELET  FEVER  337 

not  be  forgotten  that  there  are  cases  in  which  the  desquamation  has  been 
prolonged,  according  to  Trousseau,  even  to  the  seventh  or  eighth  week.  The 
entire  process  lasts  from  ten  to  fifteen  or  even  twenty  days. 

Atypical  Scarlet  Fever.— MILD  AND  ABORTIVE  FORMS. — In  cases  of  excep- 
tional mildness  the  rash  may  be  scarcely  perceptible.  During  epidemics,  when 
several  children  of  a  household  are  affected,  one  child  sickens  as  if  with  scar- 
let fever,  and  has  a  sore  throat  and  the  "strawberry  tongue,"  but  the  rash 
does  not  appear — scarlatina  sine  eruptione.  In  school  epidemics  a  third  or 
more  of  the  cases  may  be  without  the  rash.  Desquamation,  however,  may 
follow,  and  in  these  very  mild  forms  nephritis  may  occur. 

MALIGNANT  SCARLET  FEVER. — Fulminant  Toxic  Variety. — With  all  the 
characteristics  of  an  acute  intoxication,  the  patient  is  overwhelmed  by  the 
intensity  of  the  poison  and  may  die  within  twenty-four  or  thirty-six  hours. 
The  disease  sets  in  with  great  severity — high  fever,  extreme  restlessness, 
headache,  and  delirium.  The  temperature  may  rise  to  107°  or  even  108°, 
in  rare  cases  even  higher.  Convulsions  may  occur  and  the  initial  delirium 
rapidly  gives  place  to  coma.  The  dyspnoea  may  be  urgent;  the  pulse  is  very 
rapid  and  feeble. 

Hcemorrhagic  Form. — Hemorrhages  occur  into  the  skin,  and  there  are 
hsematuria  and  epistaxis.  In  the  erythematous  rash  scattered  petechia?  ap- 
pear, which  gradually  become  more  extensive,  and  ultimately  the  skin  may  be 
universally  involved.  Death  may  take  place  on  the  second  or  on  the  third 
day.  While  this  form  is  perhaps  more  common  in  enfeebled  children,  I  have 
twice  known  it  to  attack  adults  apparently  in  full  health. 

ANGINOSE  FORM. — The  throat  symptoms  appear  early  and  progress  rap-, 
idly;  the  fauces  and  tonsils  swell  and  are  covered  with  a  thick  membranous 
exudate,  which  may  extend  to  the  posterior  wall  of  the  pharynx,  forward  into 
the  mouth,  and  upward  into  the  nostrils.  The  glands  of  the  neck  rapidly 
enlarge.  Necrosis  occurs  in  the  tissues  of  the  throat,  the  fetor  is  extreme, 
the  constitutional  disturbance  profound,  and  the  child  dies  with  the  clinical 
picture  of  a  malignant  diphtheria.  Occasionally  the  membrane  extends  into 
the  trachea  and  the  bronchi.  The  Eustachian  tubes  and  the  middle  ear  are 
usually  involved.  When  death  does  not  take  place  rapidly  from  toxemia 
there  may  be  extensive  abscess  formation  in  the  tissues  of  the  neck  and 
sloughing.  In  the  separation  of  deep  sloughs  about  the  tonsils  the  carotid 
artery  may  be  opened,  causing  fatal  haemorrhage. 

SEPTIC^EMIC  FORM. — In  this  there  is  a  severe  secondary  infection  and 
death  occurs  in  the  second  or  third  week  from  severe  toxemia. 

Complications  and  Sequelae. — ALBUMINURIA. — At  the  height  of  the  fever 
there  is  often  a  slight  trace  of  albumin  in  the  urine,  which  is  not  of  special 
significance.  In  a  majority  of  cases  the  kidneys  escape  without  greater  dam- 
age than  occurs  in  other  acute  febrile  affections. 

NEPHRITIS  is  most  common  in  the  second  or  third  week  and  may  follow 
a  very  mild  attack.  It  may  be  delayed  until  the  third  or  fourth  week.  As 
a  rule,  the  earlier  it  occurs  the  more  severe  the  attack.  It  occurs  in  from 
10  to  20  per  cent,  of  the  cases.  Three  grades  of  cases  may  be  recognized: 

1.  Acute  hsemorrhagic  nephritis.  There  may  be  suppression  of  urine  or 
only  a  small  quantity  of  bloody  fluid  laden  with  albumin  and  tube  casts. 
Vomiting  is  constant,  there  are  convulsions,  and  the  child  dies  with  the  symp- 


338  SPECIFIC  INFECTIOUS  DISEASES 

toms  of  acute  uraemia.  In  severe  epidemics  there  may  be  many  cases  of  this 
sort,  and  an  acute,  rapidly  fatal,  nephritis  due  to  the  scarlet  fever  poison  may 
occur  without  an  exanthem. 

2.  Less  severe  cases  without  serious  acute  symptoms.     There  is  a  puffy 
appearance  of  the  eyelids,  with  slight  oedema  of  the  feet;  the  urine  is  dimin- 
ished in  quantity,  smoky,  and  contains  albumin  and  tube  casts.     The  kidney 
symptoms  then  dominate  the  entire  case,  the  dropsy  persists,  and  there  may 
be  effusion  into  the  serous  sacs.     The  condition  may  drag  on  and  become 
chronic,  or  the  patient  may  succumb  to  urasmic  accidents.     Fortunately,  in  a 
majority  of  the  cases  recovery  takes  place. 

3.  Cases  so  mild  that  they  can  scarcely  be  termed  nephritis.     The  urine 
contains  albumin  and  a  few  tube  casts,  but  rarely  blood.     The  oedema  is  ex- 
tremely slight  or  transient,  and  the  convalescence  is  scarcely   interrupted. 
Occasionally,  however,  serious  symptoms  may  supervene.     (Edema  of  the  glot- 
tis may  prove  rapidly  fatal,  and  in  one  case  of  the  kind  a  child  under  my  care 
died  of  acute  effusion  into  the  pleural  sacs. 

In  other  cases  the  oedema  disappears  and  the  child  improves,  though  he 
remains  pale,  and  a  slight  amount  of  albumin  persists  in  the  urine  for  months 
or  even  for  years.  Recovery  may  ultimately  take  place  or  a  chronic  inter- 
stitial nephritis  may  follow. 

Occasionally  oedema  occurs  without  albuminuria  or  signs  of  nephritis. 
Possibly  it  may  be  due  to  the  anemia;  but  there  are  instances  in  which 
marked  changes  have  been  found  in  the  kidney  after  death,  even  when  the 
urine  did  not  show  the  features  characteristic  of  nephritis. 

ARTHRITIS. — There  are  two  forms:  first,  the  severe  scarlatinal  pyaemia, 
with  suppuration  of  one  or  more  joints — part  of  a  widespread  streptococcus 
infection.  This  is  an  extremely  serious  and  fatal  form.  Secondly,  scarlatinal 
arthritis,  analogous  to  that  occurring  in  gonorrhoea  and  other  infections.  It 
occurs  in  the  second  or  third  week ;  many  joints  are  attacked,  particularly  the 
small  joints  of  the  hands.  The  heart  may  be  involved.  Chorea,  subcutaneous 
fibroid  nodules,  purpura,  and  pleurisy  may  be  complications.  The  outlook  is 
usually  good. 

CARDIAC  COMPLICATIONS. — In  the  severe  septic  cases  a  malignant  endo- 
carditis, sometimes  with  purulent  pericarditis,  closes  the  scene.  Simple  endo- 
carditis is  not  uncommon.  It  may  not  be  easy  to  say  whether  the  apex  systo- 
lic murmur,  so  often  heard,  signifies  a  valvular  lesion.  The  persistence  after 
convalescence,  with  signs  of  slight  enlargement  of  the  heart,  may  alone  decide 
that  the  murmur  indicated  an  organic  change.  As  is  the  rule,  such  cases 
give  no  symptoms.  And,  lastly,  there  may  be  a  severe  toxic  myocarditis, 
sometimes  leading  to  acute  dilatation  and  sudden  death.  It  is  to  be  borne  in 
mind  that  the  cardiac  complications  of  the  disease  are  often  latent. 

ACUTE  BRONCHITIS  and  BRONCHO-PNEUMONIA  are  not  common.  Empyema 
is  an  insidious  and  serious  complication. 

EAR  COMPLICATIONS. — Common  and  serious,  due  to  extension  of  the  in- 
flammation from  the  throat  through  the  Eustachian  tubes,  they  rank  among 
the  most  frequent  causes  of  deafness  in  children.  The  severe  forms  of  mem- 
branous angina  are  almost  always  associated  with  otitis,  which  goes  on  tc 
suppuration  and  to  perforation  of  the  drum.  The  process  may  extend  to  the 
labyrinth  and  rapidly  nroduce  deafness.  In  other  instances  there  is  suppura- 


SCARLET  FEVER  339 

tion  in  the  mastoid  cells.  In  the  necrosis  which  follows  the  middle-ear  dis- 
ease the  facial  nerve  may  be  involved  and  paralysis  follow.  Later,  still  more 
serious  complications  may  follow,  such  as  thrombosis  of  the  lateral  sinus, 
meningitis,  or  abscess  of  the  brain. 

ADENITIS. — In  comparatively  mild  cases  of  scarlet  fever  the  submaxillary 
lymph-glands  may  be  swollen.  In  severer  cases  the  swelling  of  the  neck 
becomes  extreme  and  extends  beyond  the  limits  of  the  glands.  Acute  phleg- 
monous  inflammations  may  occur,  leading  to  widespread  destruction  of  tissue, 
in  which  vessels  may  be  eroded  and  fatal  haemorrhage  ensue.  The  suppura- 
tive  processes  may  also  involve  the  retro-pharyngeal  tissues. 

The  swelling  of  the  lymph-glands  usually  subsides,  and  within  a  few  weeks 
even  the  most  extensive  enlargement  gradually  disappears.  There  are  rare 
instances,  however,  in  which  the  lymphadenitis  becomes  chronic,  and  the 
neck  remains  with  a  glandular  collar  which  almost  obliterates  its  outline. 
This  may  prove  intractable  to  all  ordinary  measures  of  treatment.  A  case 
came  under  my  observation  in  which,  two  years  after  scarlet  fever,  the  neck 
was  enormously  enlarged  and  surrounded  by  a  mass  of  firm  brawny  glands. 

NERVOUS  COMPLICATIONS. — Chorea  occasionally  complicates  the  arthritis 
and  endocarditis.  Sudden  convulsions  followed  by  hemiplegia  may  occur. 
In  seven  of  my  series  of  120  cases  of  infantile  hemiplegia  the  trouble  came 
on  during  scarlet  fever.  Progressive  paralysis  of  the  limbs  with  wasting 
may  present  the  features  of  a  subacute  ascending  spinal  paralysis.  Throm- 
bosis of  the  cerebral  veins  may  occur.  Mental  symptoms,  mania,  and  melan- 
cholia have  been  described. 

Other  rare  complications  and  sequela?  are  cedema  of  the  eyelids,  with- 
out nephritis,  symmetrical  gangrene,  enteritis,  noma,  and  perforation  of  the 
soft  palate. 

The  fever  may  persist  for  several  weeks  after  the  disappearance  of  the 
rash,  and  the  child  may  remain  in  a  septic  or  typhoid  state.  This  so-called 
scarlatinal  typhoid  is  usually  the  result  of  some  chronic  suppurative  process 
about  the  throat  or  the  nose,  occasionally  the  result  of  a  chronic  adenitis,  and 
in  a  few  cases  nothing  whatever  can  be  found  to  account  for  the  fever. 

Measles  may  be  concurrent  or  follow  in  the  stage  of  convalescence. 

RELAPSE  is  rare.  It  was  noted  in  7  per  cent,  of  12,000  (Caiger),  in  1 
per  cent,  of  1,520  cases  (Newsholme),  and  in  3  per  cent,  of  5,000  cases 
(McCollom). 

Diagnosis. — The  diagnosis  of  scarlet  fever  is  not  difficult,  but  there  are 
cases  in  which  the  true  nature  of  the  disease  is  for  a  time  doubtful.  The  fol- 
lowing are  the  most  common  conditions  with  which  it  may  be  confounded: 

ACUTE  EXFOLIATING  DERMATITIS. — This  pseudo-exanthem  simulates  scar- 
let fever  very  closely.  It  has  a  sudden  onset,  with  fever.  The  eruption 
spreads  rapidly,  is  uniform,  and  after  persisting  for  five  or  six  days  begins 
to  fade.  Even  before  it  has  entirely  gone  desquamation  usually  begins. 
Some  of  these  cases  cannot  be  distinguished  from  scarlet  fever  in  the  stage 
of  eruption.  The  throat  symptoms,  however,  are  usually  absent,  and  the 
tongue  rarely  shows  the  changes  which  are  so  marked  in  scarlet  fever.  In  the 
desquamation  of  this  affection  the  hair  and  nails  are  commonly  affected.  It 
is,  too,  a  disease  liable  to  recur.  Some  of  the  instances  of  second  and  third 
attacks  of  scarlet  fever  have  been  cases  of  this  form  of  dermatitis. 


340  SPECIFIC  INFECTIOUS  DISEASES 

MEASLES,  which  is  distinguished  by  the  longer  period  of  invasion,  the 
characteristic  nature  of  the  prodromes,  and  the  later  appearance  of  the  rash. 
The  greater  intensity  of  the  measly  rash  upon  the  face,  the  more  papular 
character  and  the  irregular  crescentic  distribution  are  distinguishing  features 
in  a  majority  of  the  cases.  Other  points  are  the  absence  in  measles  of  the 
sore  throat,  the  peculiar  character  of  the  desquamation,  the  absence  of  leuco- 
cytosis,  and  the  presence  of  Koplik's  sign. 

ROTHELN. — The  rash  of  rubella  is  sometimes  strikingly  like  that  of  scar- 
let fever,  but  in  the  great  majority  of  cases  the  mistake  could  not  arise.  In 
cases  of  doubt  the  general  symptoms  are  our  best  guide. 

SEPTICAEMIA. — As  already  mentioned,  the  so-called  puerperal  or  surgical 
scarlatina  shows  an  eruption  which  may  be  identical  in  appearance  with  that 
of  true  scarlet  fever. 

DIPHTHERIA. — The  practitioner  may  be  in  doubt  whether  he  is  dealing 
with  a  case  of  scarlet  fever  with  intense  membranous  angina,  a  true  diph- 
theria with  an  erythematous  rash,  or  coexisting  scarlet  fever  and  diphtheria. 
In  the  angina  occurring  early  in  and  during  the  course  of  scarlet  fever, 
though  the  clinical  features  may  be  those  of  true  diphtheria,  Loffler's  bacilli 
are  rarely  found.  On  the  other  hand,  in  the  membranous  angina  occurring 
during  convalescence  the  bacilli  are  usually  present.  The  rash  in  diphtheria 
is,  after  all,  not  so  common,  is  limited  usually  to  the  trunk,  is  not  so  persist- 
ent, and  is  generally  darker  than  the  scarlatinal  rash. 

Scarlatina  and  diphtheria  may  coexist,  but  in  a  case  presenting  widespread 
erythema  and  extensive  membranous  angina  with  Loffler's  bacilli  it  would 
puzzle  Hippocrates  to  say  whether  the  two  diseases  coexisted,  or  whether  it 
was  only  an  intense  scarlatinal  rash  in  diphtheria.  Desquamation  occurs  in 
either  case.  The  streptococcus  angina  is  not  so  apt  to  extend  to  the  larynx, 
nor  are  recurrences  so  common;  but  it  is  well  to  bear  in  mind  that  general 
infection  may  occur,  that  the  membrane  may  spread  downward  with  great 
rapidity,  and,  lastly,  that  all  the  nervous  sequelae  of  the  Klebs-Loffler  diph- 
theria may  follow  the  streptococcus  form. 

DRUG  RASHES. — These  are  partial,  and  seldom  more  than  a  transient 
hyperamia  of  the  skin.  Occasionally  they  are  diffuse  and  intense,  and  in 
such  cases  very  deceptive.  They  are  not  associated,  however,  with  the  char- 
acteristic symptoms  of  invasion.  There  is  no  fever,  and  with  care  the  dis- 
tinction can  usually  be  made.  They  are  most  apt  to  follow  the  use  of  bella- 
donna, quinine,  and  iodide  of  potassium.  The  antitoxin  erythema  is  a  fre- 
quent cause  of  doubt,  particularly  in  hospitals  for  infectious  diseases. 

COEXISTENCE  OF  OTHER  DISEASES. — Of  48,366  cases  of  scarlet  fever  in  the 
Metropolitan  Asylum  Board  Hospitals  which  were  complicated  by  some  other 
disease,  in  1,094  cases  the  secondary  infection  was  diphtheria,  in  899  cases 
chicken-pox,  in  703  measles,  in  404  whooping-cough,  in  55  erysipelas,  in  11 
enteric  fever,  and  in  1  typhus  fever  (F.  F.  Caiger).  Farnarier  (1904)  could 
collect  only  39  undoubted  cases  of  the  coexistence  of  typhoid  and  scarlet  fever. 

How  Long  Is  a  Child  Infective? — Usually,  after  desquamation  is  com- 
plete, in  four  or  five  weeks  the  danger  is  thought  to  be  over,  but  the  occur- 
rence of  so-called  "return  cases"  shows  that  patients  remain  infective  even  at 
this  stage.  In  1894,  with  2,593  patients  from  the  Glasgow  fever  hospitals  sent 
to  their  homes  convalescent,  fresh  cases  appeared  in  70  of  the  houses  (Chal- 


SCAELET  FEVER  341 

mers).  With  15,000  cases  submitted  to  an  average  period  of  isolation  of 
forty-nine  days  or  under,  the  percentage  of  return  cases  was  1.86;  with  an 
average  period  of  fifty  to  fifty-six  days  the  percentage  was  1.12;  where  the 
isolation  extended  to  between  fifty-seven  and  sixty-five  'days  the  percentage 
of  return  cases  was  1  (Xeech).  This  author  suggests  eight  weeks  as  a  mini- 
mum and  thirteen  weeks  as  a  maximum.  Special  care  should  be  taken  of 
cases  with  rhinorrhcea  and  otorrhcea  and  throat  trouble,  as  the  secretions  from 
these  parts  are  probably  of  greater  importance  than  the  skin  in  the  conveyance 
of  the  disease. 

Prognosis. — As  stated,  the  death-rate  has  been  falling  of  late  years.  Epi- 
demics differ  remarkably  in  severity  and  the  mortality  is  extremely  variable. 
Among  the  better  classes  the  death-rate  is  much  lower  than  in  hospital  prac- 
tice. There  are  physicians  who  have  treated  consecutively  a  hundred  or  more 
cases  without  a  death.  On  the  other  hand,  in  hospitals  and  among  the  poorer 
classes  the  death-rate  is  considerable,  ranging  from  5  to  10  per  cent,  in  mild 
epidemics  to  20  or  30  per  cent,  in  the  very  severe.  In  1,000  cases  reported 
from  the  Boston  City  Hospital  by  McCollom  the  death-rate  was  9.8  per  cent. 
There  is  a  curious  variability  in  the  local  mortality  from  this  disease.  In 
England,  for  example,  in  some  years,  certain  counties  enjoy  almost  immunity 
from  fatal  scarlet  fever.  The  younger  the  child  the  greater  the  danger.  In 
infants  under  one  year  the  death-rate  is  very  high.  The  great  proportion  of 
fatal  cases  occurs  in  children  under  six  years  of  age.  The  unfavorable  symp- 
toms are  very  high  fever,  early  mental  disturbance  with  great  jactitation,  the 
occurrence  of  hemorrhages  (cutaneous  or  visceral),  intense  diphtheroid 
angina  with  cervical  bubo,  and  signs  of  laryngeal  obstruction.  Nephritis  is 
always  a  serious  complication,  and  when  setting  in  with  suppression  of  the 
urine  may  quickly  prove  fatal;  a  large  majority  of  the  cases  recover. 

Prophylaxis. — Much  may  be  done  to  prevent  the  spread  of  the  disease  if 
the  physician  exercises  scrupulous  care  in  each  case.  Much  is  to  be  expected 
from  a  rigid  system  of  school  inspection,  and  from  the  more  general  recogni- 
tion of  the  importance  of  the  latent  cases  and  the  persistence  of  the  infection 
in  the  secretions  of  the  nose  and  throat.  The  attendant  in  a  case  of  scarlet 
fever  should  take  the  most  careful  precautions  against  the  conveyance  of  the 
disease,  wearing  a  gown  in  the  room  and  thoroughly  washing  the  hands  and 
face  after  leaving  the  room.  To  the  very  busy  practitioner  the  minutia?  of 
proper  disinfection  are  very  irksome,  but  it  is  his  duty  to  carry  out  the  most 
rigid  disinfection  possible,  and  intelligent  people  now  expect  it.  The  dura- 
tion of  quarantine  varies  with  the  attack:  six  to  eight  weeks  is  the  average 
period.  Patients  with  discharge  from  the  ear  or  nose  require  longer  iso- 
lation. 

Treatment. — The  patient  may  be  treated  at  home  or  sent  to  an  isolation 
hospital.  The  difficulty  in  home  treatment  is  in  securing  complete  isolation. 
The  risks  are  well  illustrated  by  the  careful  studies  of  Chapin,  of  Providence, 
who  found  that  during  eight  years  26.1  per  cent,  of  the  4,412  persons  under 
twenty-one  years  of  age  in  infected  families  took  the  disease.  When  prac- 
ticable, it  is  better  to  send  the  other  children  out  of  the  house.  Chapin's  ex- 
perience on  this  point  is  most  interesting.  In  seventeen  years,  from  652 
families  infected  with  scarlet  fever,  1,051  children,  none  of  whom  had  had 
the  disease,  were  removed.  Only  5  per  cent,  were  attacked  while  away  from 


342  SPECIFIC  INFECTIOUS  DISEASES 

home.  Nineteen  who  had  been  sent  away  from  the  infected  houses  were 
attacked  on  their  return.  In  Great  Britain  a  very  considerable  proportion 
of  all  patients  are  removed  from  their  homes.  In  the  segregation  hospital 
groups  of  patients,  from  ten  to  twenty,  are  treated  in  separate  wards.  In 
the  true  isolation  hospital  each  patient  is  in  a  separate  room,  and  patients 
with  different  infectious  diseases  may  be  in  adjacent  rooms. 

The  disease  cannot  be  cut  short.  In  the  presence  of  the  severer  forms  we 
are  still  too  often  helpless.  There  is  no  disease,  however,  in  which  the  suc- 
cessful issue  and  the  avoidance  of  complications  depend  more  upon  the  skilled 
judgment  of  the  physician  and  the  care  with  which  his  instructions  are  carried 
out. 

The  child  should  be  isolated  and  placed  in  charge  of  a  competent  nurse. 
The  temperature  of  the  room  should  be  constant  and  the  ventilation  thorough. 
The  child  should  wear  a  light  flannel  nightgown,  and  the  bedclothing  should 
not  be  too  heavy.  The  diet  should  consist  of  milk,  buttermilk,  whey,  and  ice 
cream;  water  and  fruit  juices  should  be  freely  given.  With  the  fall  of  the 
temperature  the  diet  may  be  increased  and  the  child  may  gradually  return 
to  ordinary  fare.  When  desquamation  begins  the  child  should  be  thoroughly 
rubbed  every  day,  or  every  second  day,  with  sweet  oil,  or  carbolated  vaseline, 
or  a  5-per-cent.  hydro-naphthol  soap,  which  prevents  the  drying  and  the  dif- 
fusion of  the  scales.  A  5-  or  10-per-cent.  solution  of  ichthyol  in  lanolin 
may  be  used.  An  occasional  warm  bath  may  then  be  given.  At  any  time 
during  the  attack  the  skin  may  be  sponged  with  warm  water.  The  patient 
may  be  allowed  to  get  up  after  the  temperature  has  been  normal  for  ten  days, 
but  for  at  least  three  weeks  from  this  time  great  care  should  be  exercised  to 
prevent  exposure  to  cold.  It  must  not  be  forgotten,  also,  that  the  renal  com- 
plications are  very  apt  to  occur  during  the  convalescence,  and  after  all  danger 
is  apparently  past.  Ordinary  cases  do  not  require  any  medicine,  or  at  the 
most  a  simple  fever  mixture,  and  during  convalescence  a  bitter  tonic.  The 
bowels  should  be  carefully  regulated. 

Special  symptoms  in  the  severe  cases  call  for  treatment. 

When  the  fever  is  above  103°  F.  the  extremities  may  be  sponged  with 
tepid  water.  In  severe  cases,  with  the  temperature  rapidly  rising,  this  will 
not  suffice,  and  more  thorough  measures  of  hydrotherapy  should  be  practiced. 
With  pronounced  delirium  and  nervous  symptoms  the  cold  pack  should  be 
used.  When  the  fever  is  rising  rapidly  but  the  child  is  not  delirious,  he 
should  be  placed  in  a  warm  bath,  the  temperature  of  which  can  be  gradually 
lowered.  The  bath  with  the  water  at  80°  is  beneficial.  In  giving  the  cold 
pack  a  rubber  sheet  and  a  thick  layer  of  blankets  should  be  spread  upon  a 
sofa  or  a  bed,  and  over  them  a  sheet  wrung  out  of  cold  water.  The  naked 
child  is  then  laid  upon  it  and  wrapped  in  the  blankets.  An  intense  glow  of 
heat  quickly  follows  the  preliminary  chilling,  and  from  time  to  time  the 
blankets  may  be  unfolded  and  the  child  sprinkled  with  cold  water.  The 
good  effects  which  follow  this  plan  of  treatment  are  often  striking,  particu- 
larly in  allaying  the  delirium  and  jactitation,  and  procuring  quiet  and  re- 
freshing sleep.  Parents  will  object  less,  as  a  rule,  to  the  warm  bath  gradually 
cooled  than  to  any  other  form  of  hydrotherapy.  The  child  may  be  removed 
from  the  warm  bath,  placed  upon  a  sheet  wrung  out  of  tolerably  cold  water, 
and  then  folded  in  blankets.  The  ice-cap  is  very  useful  and  may  be  kept 


MEASLES  343 

constantly  applied  in  cases  in  which  there  is  high  fever.  Medicinal  anti- 
pyretics are  not  of  much  service  in  comparison  with  cold  water. 

The  throat  symptoms,  if  mild,  do  not  require  much  treatment.  If  severe, 
the  local  measures  mentioned  under  diphtheria  should  be  used.  The  nose 
should  be  kept  clean,  for  which  a  simple  alkaline  douche,  given  gently,  is  best. 
Cold  applications  to  the  neck  are  to  be  preferred  to  hot,  though  it  is  some- 
times difficult  to  get  a  child  to  submit  to  them.  If  cervical  adenitis  occurs, 
an  ice  bag  should  be  applied,  and  with  the  first  signs  of  suppuration  an  in- 
cision made.  In  connection  with  the  throat,  the  ears  should  be  specially 
looked  after,  and  a  careful  disinfection  of  the  mouth  and  fauces  by  suitable 
antiseptic  solutions  should  be  practiced.  When  the  inflammation  extends 
through  the  tubes  to  the  middle  ear,  the  practitioner  should  either  himself 
examine  daily  the  condition  of  the  drum,  or,  when  available,  a  specialist 
should  be  called  in  to  assist  him  in  the  case.  The  careful  watching  of  this 
membrane  day  by  day  and  the  puncturing  of  it  if  the  tension  becomes  too 
great  may  save  the  hearing  of  the  child.  With  the  aid  of  cocaine  the  drum 
is  readily  punctured.  The  operation  may  be  repeated  at  intervals  if  the  pain 
and  distention  return.  No  complication  of  the  disease  is  more  serious  than 
this  extension  of  the  inflammatory  process  to  the  ear. 

The  nephritis  should  be  dealt  with  as  in  ordinary  cases;  indications  for 
treatment  will  be  found  under  the  appropriate  section.  It  is  worth  men- 
tioning, however,  that  Jaccoud  insists  upon  the  great  value  of  milk  diet  in 
scarlet  fever  as  a  preventive  of  nephritis. 

Among  other  indications  for  treatment  in  the  disease  is  cardiac  weakness, 
which  is  usually  the  result  of  the  direct  action  of  the  poison,  and  is  best  met 
by  stimulants. 

SERUM  TREATMENT. — As  a  streptococcus  infection  frequently  complicates 
scarlet  fever  and  is  responsible  for  the  secondary  infections,  the  use  of  anti- 
streptococcus  serum  seems  rational,  but  it  has  not  proved  of  great  value  in 
the  acute  stages.  More  is  to  be  expected  from  it  in  the  more  chronic  infec- 
tions, in  which  also  an  autogenous  vaccine  may  be  useful.  The  dosage  should 
be  small  at  first  and  increased  gradually. 


V.     MEASLES 

(Morbilli) 

Definition. — An  acute,  highly  contagious  fever  with  specific  localization 
in  the  upper  air  passages  and  in  the  skin. 

History. — Rhazes,  an  Arabian  physician,  in  the  ninth  century  described 
the  disease  with  small-pox,  of  which  it  was  believed  to  be  a  mild  form  until 
Sydenham  separated  them  in  the  seventeenth  century. 

Etiology.  — As  a  cause  of  death  measles  ranks  first  among  the  acute  fevers 
of  children.  In  1909  there  were  12,618  deaths  from  this  disease  in  England 
and  Wales.  The  death  rate  is  highest  in  the  second  year. 

The  liability  to  infection  is  almost  universal  in  persons  unprotected  by  a 
previous  attack.  It  is  a  disease  of  childhood,  but,  as  shown  in  the  widespread 
epidemics  in  the  Farroe  Islands  and  in  the  Fiji  Islands,  unprotected  adults  of 


344  SPECIFIC  INFECTIOUS  DISEASES 

all  ages  are  attacked.  Within  the  first  three  months  of  life  there  is  a  relative 
immunity.  Occasionally  infants  of  a  month  or  six  weeks  take  the  disease. 
Intra-uterine  cases  have  been  described,  and  a  mother  with  measles  may  give 
birth  to  a  child  with  the  eruption,  or  the  rash  may  appear  in  a  few  days. 

The  disease  is  endemic  in  cities,  and  becomes  epidemic  at  intervals,  pre- 
vailing most  extensively  in  the  cooler  months,  though  this  is  by  no  means  a 
fixed  rule. 

The  germ  of  the  disease  is  unknown.  J.  F.  Anderson  has  shown  that  the 
blood  of  a  patient  inoculated  into  the  Rhesus  monkey  produces  after  eight 
days  a  fever  of  short  duration  with  a  well-marked  slight  exanthem.  The 
contagion  is  present  in  the  blood,  the  secretions  of  the  mouth  and  nose,  and 
in  the  skin.  In  the  eighteenth  century  Monro  and  others  demonstrated  the 
inoculability  of  the  disease.  Direct  contagion  is  the  most  common.  The 
poison  is  probably  not  in  the  expired  air,  but  in  the  particles  of  mucus  and 
in  the  sputum  and  the  secretions  of  the  mouth  and  nose,  which,  dried,  are 
conveyed  with  the  dust.  An  important  point  is  the  contagiousness  of  the 
disease  in  the  pre-eruptive  stage.  A  child  with  only  the  catarrhal  symptoms 
may  be  at  school  and  a  source  of  active  infection.  Indirect  contagion  by 
means  of  fomites  is  very  common.  Measles  may  be  .-thus  conveyed  by  a  third 
person,  by  clothes,  and  by  infected  toys.  The  germ  soon  loses  its  virulence. 

Recurrence  is  rare.  Very  many  cases  of  the  supposed  second  and  third 
attack  represent  mistakes  in  diagnosis.  Relapse  is  occasionally  seen,  the  symp- 
toms recurring  at  intervals  from  ten  to  forty  days;  but  it  is  not  always  easy 
to  say  in  a  given  case  whether  there  may  not  have  been  new  infection  from 
without. 

Morbid  Anatomy. — The  catarrhal  and  inflammatory  appearances  seen 
post  mortem  have  nothing  characteristic.  Fatal  cases  show,  as  a  rule,  bron- 
cho-pneumonia and  an  intense  bronchial  catarrh.  The  lymphatic  elements  all 
over  the  body  are  swollen,  the  tonsils,  the  lymph-glands,  and  the  solitary  and 
agminated  follicles  of  the  intestines.  The  spleen  is  rarely  much  enlarged. 
During  convalescence  latent  tuberculous  foci  are  very  apt  to  become  active. 

Symptoms. — INCUBATION. — "From  seven  to  eighteen  days;  oftenest  four- 
teen." The  child  shows  no  special  changes,  but  coryza  and  swelling  of  the 
cervical  lymph-glands  may  be  present.  A  leucocytosis  has  been  observed,  and 
the  pulse  is  said  to  be  slow. 

INVASION. — In  this  period,  lasting  from  three  to  four  days,  very  rarely 
five  or  six,  the  child  presents  the  symptoms  of  a  feverish  cold.  The  onset 
may  be  insidious,  or  it  may  start  with  great  abruptness,  even  with  a  con- 
vulsion. There  is  not  often  a  definite  chill.  Headache,  nausea,  and  vomit- 
ing may  usher  in  the  severe  cases.  The  common  catarrhal  symptoms  are 
sneezing  and  running  at  the  nose,  redness  of  the  eyes  and  lids,  and  cough. 
The  fever  is  slight  at  first,  but  gradually  there  is  pungent  heat  of  the  skin 
with  turgescence  of  the  face.  Prodromal  rashes  precede  the  true  eruption  in 
a  few  cases,  usually  a  blotchy  erythema  or,  scattered  macules.  The  tongue  is 
furred  and  the  mucous  membranes  of  the  mouth  and  throat  are  hyperaemic, 
and  frequently  show  a  distinct  punctiform  rash.  The  fever  of  the  stage  of 
invasion  may  rise  abruptly;  more  frequently  it  takes  twenty-four  or  forty- 
eight  hours  to  reach  the  fastigium.  The  pulse-rate  increases  with  the  fever, 
and  may  rea^h  140  or  160  per  minute,  gradually  falling  with  defervescence. 


MEASLES 


345 


ERUPTION. — "The  symptoms  increase  till  the  fourth  day.  At  that  period 
(although  sometimes  a  day  later)  little  red  spots,  just  like  flea-bites,  begin  to 
come  out  on  the  forehead  and  the  rest  of  the  face.  These  increase  both  in 
size  and  number,  group  themselves  in  clusters,  and  mark  the  face  with  largish 
red  spots  of  different  figures.  These  red  spots  are  formed  by  small  red  pap- 
ules, thick  set,  and  just  raised  above  the  level  of  the  skin.  The  fact  that 
they  really  protrude  can  scarcely  be  determined  by  the  eye.  It  can,  however, 
be  ascertained  by  feeling  the  surface  with  the  fingers.  From  the  face — 
where  they  first  appear — these  spots  spread  downward  to  the  breast  and  belly; 
afterward  to  the  thighs  and  legs  "  (Sydenham).  The  papules  may  feel  quite 
shotty,  but  do  not  extend  deeply.  On  the  trunk  and  extremities  the  swelling 
of  the  skin  is  not  so  noticeable,  the  color  of  the  rash  not  so  intense  and  often 


Day     1        S 


IOC 


10k 


102 


100 


98 


CHART  XI. — MEASLES. 

less  uniform.  The  mottled,  blotchy  character  is  seen  most  clearly  on  the 
chest  and  the  abdomen.  It  is  hyperasmic  and  disappears  on  pressure,  but  in 
the  malignant  cases  it  may  become  of  a  deep  rose,  inclining  to  purple.  These 
general  symptoms  do  not  abate  with  the  occurrence  of  the  eruption,  but  persist 
until  the  end  of  the  fifth  or  the  sixth  day,  when  they  lessen.  Among  peculi- 
arities of  the  rash  may  be  mentioned  the  development  of  numerous  miliary 
vesicles  and  the  occurrence  of  petechiaB,  which  are  seen  occasionally  even  in 
cases  of  moderate  severity.  Eecession  of  the  rash,  so  much  dwelt  upon  by 
older  writers,  is  rarely  seen.  When  the  "measles  sink  in  suddenly  after  they 
have  begun  to  come  out,  and  then  the  patient  is  seized  with  anxiety  and  a 
swooning  comes  on,  it  is  a  sign  of  speedy  death"  (Rhazes).  In  reality  it  is 
the  failing  circulation  which  causes  the  rash  to  fade. 

BUCCAL  SPOTS  were  described  by  Filatow  in  1895,  and  by  Koplik  in  1896. 
They  are  seen  on  a  level  with  the  bases  of  the  lower  milk  molars  on  either 
side,  or  at  the  line  of  junction  of  the  molars  when  the  jaws  are  closed.  They 
are  white  or  bluish-white  specks,  surrounded  by  red  areolas.  Their  importance 
depends  upon  the  fact  of  their  early  appearance  and  remarkable  constancy  in 
the  disease — six-sevenths  of  all  cases  (Heubner),  97.7  per  cent,  of  214  cases 

(Balme). 

24 


346  SPECIFIC  INFECTIOUS  DISEASES 

The  fauces  may  be  injected,  and  there  is  sometimes  an  eruption  of  scat- 
tered spots  over  the  entire  mucous  membrane  of  the  mouth.  Ringer  was  in 
the  habit  of  calling  attention  to  opaque  white  spots  on  the  mucous  membrane 
of  the  lips. 

DESQUAMATION. — After  the  rash  fades  desquamation  begins,  usually  in 
the  form  of  fine  scales,  more  rarely  in  large  flakes.  It  bears  a  definite  rela- 
tionship to  the  extent  and  intensity  of  the  rash.  In  mild  cases  desquamation 
may  take  only  a  few  days,  in  severe  cases  several  weeks. 

The  tonsils  and  the  cervical  lymph  glands  may  be  slightly  swollen  and 
sore;  sometimes  there  is  a  polyadenitis. 

During  the  course  leucocytosis  is  absent.  Its  presence  generally  points 
to  a  complication.  Myelocytes  are  often  present  in  small  numbers  during  the 
eruption  (Tileston). 

Atypical  Measles. — Variations  in  the  course  of  the  disease  are  not  com 
mon.    There  is  an  attenuated  form,  in  which  the  child  may  be  veil  by  the 
fourth  or  fifth  day.     An  abortive  form,  in  which  the  initial  symptoms  may 
be  present,  but  no  eruption  appears — morbilli  sine  morbillis. 

Malignant  or  black  measles  is  seen  most  frequently  in  the  widespread 
epidemics,  but  it  is  also  met  with  in  institutions,  and  occasionally  in  general 
practice  among  children,  more  rarely  in  adults.  Hemorrhages  occur  into  the 
skin  and  from  the  mucous  membranes;  there  is  very  high  fever,  and  all  the 
features  of  a  profound  toxamia,  often  with  cyanosis,  dyspnoea,  and  extreme 
cardiac  weakness.  Death  may  occur  from  the  second  to  the  sixth  day. 

Complications. — Those  of  the  air  passages  are  the  most  serious.  The 
coryza  may  become  chronic  and  lead  to  irritation  of  the  lymphoid  tissues  of 
the  naso-pharynx,  leaving  enlarged  tonsils  and  adenoids,  and  not  improbably 
leaving  these  parts  less  able  to  resist  tuberculous  invasion.  Epistaxis  may 
sometimes  be  serious.  Laryngitis  is  not  uncommon:  the  voice  becomes  husky 
and  the  cough  croupy  in  character.  (Edema  of  the  glottis  and  pseudo-mem- 
branous inflammation  are  rare.  Ulceration,  abscess,  and  even  perichondritis 
may  occur. 

Bronchitis  and  Broncho-pneumonia. — In  every  case  of  severe  measles  the 
possibility  of  the  existing  bronchitis  extending  to  the  small  tubes  and  caus- 
ing lobular  pneumonia  has  to  be  considered.  It  is  more  apt  to  occur  at  the 
height  of  the  eruption  or  as  desquamation  begins.  The  high  mortality  in 
institutions  is  due  to  this  complication,  which,  as  Sydenham  remarked,  kills 
more  than  the  small-pox.  (For  the  symptoms, ^ee  the  section  on  the  subject.) 

Lobar  pneumonia  is  less  common.   Thrombosis  in  veins  has  been  described. 

Severe  stomatitis  may  follow  the  slight  catarrhal  form.  In  institutions 
cancrum  oris  or  gangrenous  stomatitis  is  a  terrible  complication,  attacking 
sometimes  many  children.  Parotitis  occasionally  occurs.  Intestinal  catarrh 
and  acute  colitis  are  special  complications  of  some  epidemics. 

Nephritis  is  less  rare  than  is  stated.  It  is  not  very  uncommon  to  see  cases 
of  chronic  Bright's  disease  which  date  from  an  attack  of  measles.  Vulvitis 
may  be  present  as  part  of  the  general  catarrhal  condition. 

Endocarditis  is  rare.  Arthritis  may  follow  the  fever,  or  come  on  at  its 
height.  It  may  be  general  and  severe.  I  saw  an  instance  in  which  anchylosis 
of  the  jaw  followed  an  attack  of  measles  in  a  child  of  four  years.  The  con- 
junctivitis may  be  followed  by  Jceratitis.'  Otitis  media  is  not  at  all  uncom- 


MEASLES  347 

mon  and  may  lead  to  perforation  of  the  drum  or  mastoid  disease.  Hemiplegia 
is  a  most  serious  complication.  In  4  of  my  series  of  120  cases  the  hemiplegia 
came  on  during  measles.  It  usually  persists.  Paraplegia  due  to  acute  myeli- 
tis has  been  described.  Polyneuritis  may  occur  with  widespread  atrophy. 
Acute  mania,  meningitis,  abscess  of  the  brain,  and  multiple  •  sclerosis  are 
among  the  rare  complications  or  sequelae.  Scarlet  fever  may  occur  with 
measles.  Whooping-cough  not  infrequently  follows  measles. 

Diagnosis. — During  the  prevalence  of  an  epidemic  the  disease  is  easily 
recognized.  Physicians  to  isolation  hospitals  appreciate  the  practical  difficul- 
ties. On  several  occasions  I  had  patients  with  measles  sent  to  the  small-pox 
hospital,  and  it  is  well  to  bear  in  mind  that  in  adults  the  beginning  of  the 
eruption  on  the  face,  its  nodular  character,  and  the  isolation  of  the  spots  may 
be  suggestive  of  variola.  From  scarlet  fever  measles  is  distinguished  by  the 
longer  initial  stage  with  characteristic  symptoms,  and  the  blotchy  irregular 
character  of  the  rash,  so  unlike  the  diffu&e  uniform  erythema.  In  measles 
the  mouth  (with  the  early  Koplik  sign),  in  scarlet  fever  the  throat,  is  chiefly 
affected.  Occasionally  in  measles,  when  the  throat  is  very  sore  and  the  erup- 
tion pretty  diffuse,  there  may  at  first  be  difficulty  in  determining  which  dis- 
ease is  present,  but  a  few  days  should  suffice  to  make  the  diagnosis  clear.  A8 
a  rule  there  is  no  leucocytosis.  It  may  be  extremely  difficult  to  distinguish 
from  rotheln.  I  have  more  than  once  known  practitioners  of  large  experi- 
ence unable  to  agree  upon  a  diagnosis.  The  shorter  prodromal  stage,  the 
absence  of  oculo-nasal  catarrh,  and  the  slighter  fever  in  many  cases  are  per- 
haps the  most  important  features.  It  is  difficult  to  speak  definitely  about  the 
distinctions  in  the  rash,  though  perhaps  the  more  uniform  distribution  and 
the  absence  of  the  crescentic  arrangement  are  more  constant  in  rotheln.  In 
Africans  the  disease  is  easily  recognized;  the  papules  stand  out  with  great 
plainness,  often  in  groups;  the  hyperaemia  is  to  be  seen  on  all  but  the  very 
black  skins.  The  distribution  of  the  rash,  the  coryza,  and  the  rash  in  the 
mouth  are  important  points.  Of  drug  eruptions,  that  induced  by  copaiba  is 
very  like  measles,  but  is  readily  distinguished  by  the  absence  of  fever  and 
catarrh.  Antipyrin,  chloral,  and  quinine  rashes  rarely  cause  any  difficulty  in 
diagnosis.  The  serum  exanthem  of  a  diphtheria  antitoxin  may  be  difficult  to 
recognize.  In  adults  the  acute  malignant  measles  may  resemble  typhus  fever. 
Occasionally  erythema  multiforme  may  simulate  measles. 

Prognosis. — The  mortality  from  the  disease  itself  is  not  high,  but  the 
pulmonary  complications  render  it  one  of  the  most  serious  of  the  diseases  of 
children.  In  some  epidemics,  particularly  in  institutions  and  in  armies,  the 
death-rate  may  be  high,  not  so  much  from  the  fever  itself  as  from  the  exten- 
sion of  the  catarrhal  symptoms  to  the  finer  bronchial  tubes.  Imported  in 
1875  from  Sydney  by  H.M.S.  Dido  to  the  Fiji  Islands,  40,000  out  of  150,000 
of  the  inhabitants  died  in  four  months.  Panum,  the  distinguished  Danish 
physician,  described  the  widespread  and  fatal  epidemic  which  decimated  the 
inhabitants  of  the  Faroe  Islands  in  1846.  In  private  practice  the  mortality 
is  from  2  to  3  per  cent. ;  in  hospitals  from  6  to  8  or  10  per  cent. 

Prophylaxis. —The  difficulty  is  inherent  in  the  prolonged  incubation  and 
the  four  days  of  invasion,  during  which  the  catarrhal  symptoms  are  marked, 
and  the  disease  is  contagious,  and  one  often  finds  that  the  quarantine  which 
has  been  carried  out  so  efficiently  has  been  in  vain.  From  contact  with  cases 


348  SPECIFIC  INFECTIOUS  DISEASES 

in  the  stage  of  invasion  and  mild  cases  with  scarcely  any  fever  the  disease  is 
readily  disseminated  through  schools  and  conveyed  to  healthy  children  in  the 
every-day  contact  with  each  other  on  the  streets,  in  the  squares  and  play- 
grounds. Once  manifested,  the  child  should  be  carefully  quarantined  and 
all  possible  precautions  taken  against  the  spread  of  the  disease  in  the  house. 
As  the  germ  of  measles  seems  to  have  a  feeble  vitality  the  quarantine  need 
not  be  so  protracted  as  in  scarlet  fever,  four  weeks  usually  being  sufficient. 

Treatment. — Confinement  to  bed  in  a  well-ventilated  room  and  a  light  diet 
with  abundance  of  water  are  the  only  measures  necessary  in  cases  of  uncom- 
plicated measles.  The  fever  rarely  reaches  a  dangerous  height.  If  it  does  it 
may  be  lowered  by  sponging  or  by  the  tepid  bath  gradually  reduced.  If  the 
rash  does  not  come  out  well,  warm  drinks  and  a  hot  bath  will  hasten  its 
maturation.  The  bowels  should  be  freely  opened.  If  the  cough  is  distress- 
ing compresses  should  be  applied  to  the  chest  and  inhalations  of  the  com- 
pound tincture  of  benzoin  given.  Small  doses  of  paregoric  or  codein  may  be 
given.  The  patient  should  be  kept  in  bed  for  a  few  days  after  the  fever  sub- 
sides. During  desquamation  the  skin  should  be  oiled  daily,  and  warm  baths 
given  to  facilitate  the  process.  The  mouth  and  nostrils  should  be  carefully 
cleansed,  even  in  mild  cases.  The  convalescence  from  measles  is  the  most 
important  stage  of  the  disease.  Watchfulness  and  care  may  prevent  serious 
pulmonary  complications.  The  frequency  with  which  the  mothers  of  children 
with  simple  or  tuberculous  broncho-pneumonia  tell  us  that  "the  child  caught 
cold  after  measles,"  and  the  contemplation  of  the  mortality  bills,  should 
make  us  extremely  careful  in  our  management  of  this  affection. 


VI.     RUBELLA 

(Roiheln,  German  Measles) 

This  exanthem  has  also  the  names  of  rubeola  tiotha,  or  epidemic  roseola, 
and,  as  it  is  supposed  to  present  features  common  to  both,  has  been  also 
known  as  hybrid  measles  or  hybrid  scarlet  fever.  It  is  now  generally  re- 
garded, however,  as  a  separate  and  distinct  affection. 

Etiology. — It  is  propagated  by  contagion  and  spreads  with  great  rapidity. 
It  frequently  attacks  adults,  and  the  occurrence  of  either  measles  or  scarlet 
fever  in  childhood  is  no  protection  against  it.  The  epidemics  of  it  are  often 
very  extensive. 

Symptoms. — These  are  usually  mild,  and  it  is  altogether  a  less  serious 
affection  than  measles.  Very  exceptionally,  as  in  the  epidemics  studied  by 
Cheadle,  the  symptoms  are  severe. 

The  stage  of  incubation  is  two  weeks  or  even  longer. 

In  the  stage  of  invasion  there  are  chilliness,  headache,  pains  in  the  back 
and  legs,  and  coryza.  A  macular,  rose-red  eruption  on  the  throat  is  a  constant 
symptom,  and,  indeed,  it  was  on  this  account  that  it  was  originally  regarded 
as  a  hybrid,  having  the  sore  throat  of  scarlet  fever  and  the  rash  of  measles 
There  may  be  very  slight  fever.  In  30  per  cent,  of  Edwards's  cases  the  tem- 
perature did  not  rise  above  100°.  The  duration  of  this  stage  is  somewhat 
variable.  The  rash  usually  appears  on  the  first  day,  some  writers  say  on  the 


EPIDEMIC  PAROTITIS  349 

second,  and  others  again  give  the  duration  of  the  stage  of  invasion  as  three 
days.  Griffith  places  it  at  two  days.  The  eruption  comes  out  first  on  the 
face,  then  on  the  chest,  and  gradually  extends  so  that  within  twenty-four 
hours  it  is  scattered  over  the  whole  body.  It  may  be  the  first  symptom  noted 
by  the  mother.  The  eruption  consists  of  a  number  of  round  or  oval,  slightly 
raised  spots,  pinkish-red  in  color,  usually  discrete,  but  sometimes  confluent. 

The  color  of  the  rash  is  somewhat  brighter  than  in  measles.  The  patches 
are  less  distinctly  crescentic.  After  persisting  for  two  or  three  days  (some- 
times longer),  it  gradually  fades  and  there  is  a  slight  furfuraceous  desquama- 
tion.  The  rash  persists  as  a  rule  longer  than  in  scarlet  fever  or  measles,  and 
the  skin  is  slightly  stained  after  it.  In  some  cases  the  rash  is  scarlatiniform, 
which  may  even  follow  a  measly  eruption.  The  lymphatic  glands  of  the 
neck  are  frequently  swollen,  and,  when  the  eruption  is  very  intense  and  dif- 
fuse, the  lymph-glands  in  the  other  parts  of  the  body. 

There  are  no  special  complications.  The  disease  usually  progresses  favor- 
ably ;  but  in  rare  instances,  as  in  those  reported  by  Cheadle,  the  symptoms  are 
of  greater  severity.  Albuminuria,  arthritis,  or  even  nephritis  may  occur. 
Pneumonia  and  colitis  have  been  present  in  some  epidemics.  Icterus  has  been 
seen. 

Diagnosis. — The  slightness  of  the  prodromal  symptoms,  the  mildness  or 
the  absence  of  the  fever,  the  more  diffuse  character  of  the  rash,  its  rose-red 
color,  and  the  early  enlargement  of  the  cervical  glands,  are  the  chief  points  of 
distinction  between  rotheln  and  measles. 

The  treatment  is  that  of  a  simple  febrile  affection. 

"Fourth  Disease." — Clement  Dukes,  in  a  paper  on  the  confusion  of  two 
different  diseases  under  the  name  rubella,  describes  what  he  calls  a  "fourth 
disease,"  in  which  the  body  is  covered  in  a  few  hours  with^a  diffuse  exanthem 
of  a  bright  red  color,  almost  scarlatiniform  in  appearance.  The  face  may 
remain  quite  free.  The  desquamation  is  more  marked  than  in  rotheln. 

Erythema  Infectiosum. — Under  this  term  there  has  been  described  in 
Germany,  particularly  by  Escherich,  a  feebly  contagious  disease,  characterized 
by  a  rose-red,  maculo-papular  rash,  appearing  chiefly  between  the  ages  of  four 
and  twelve.  It  has  occurred  in  epidemic  form  in  the  spring  and  summer. 
It  has  followed  outbreaks  of  measles  or  of  rotheln.  The  most  characteristic 
feature  is  the  morbilliform  eruption  on  the  extremities,  chiefly  on  the  extensor 
surfaces.  The  trunk  as  a  rule  remains  free. 


VII.     EPIDEMIC   PAROTITIS 

(Mumps) 

Definition. — A  specific  infectious  disease,  characterized  by  swelling  of  the 
Salivary  glands  and  a  special  liability  to  orchitis  in  males. 

Hippocrates  described  the  disease  and  its  peculiarities — an  affection  of 
children  and  young  male  adults,  the  absence  of  suppuration,  and  the  orchitis. 

Etiology. — The  nature  of  the  virus  is  unknown. 

It  is  endemic  in  large  centres  of  population,  and  at  certain  seasons,  par- 
ticularly spring  and  autumn,  the  cases  increase  rapidly.  It  is  met  most  fre- 


350  SPECIFIC  INFECTIOUS  DISEASES 

quently  in  childhood  and  adolescence.  Very  young  infants  and  adults  are 
seldom  attacked.  Males  are  somewhat  more  frequently  affected  than  females. 
In  institutions,  barracks,  and  schools  the  disease  has  been  known  to  attack 
over  90  per  cent,  of  the  residents.  It  may  be  curiously  localized  in  a  city  or 
district,  or  even  in  one  part  of  a  school  or  barrack.  The  disease  is  contagious 
and  spreads  from  patient  to  patient.  The  infection  may  persist  for  as  long 
as  six  weeks.  It  may  be  congenital,  and  Hale  White  has  reported  a  case  in 
which  the  mother  and  her  new-born  child  were  attacked  at  the  same  time. 

A  remarkable  idiopathic,  non-specific  parotitis  may  follow  injury  or  dis- 
ease of  the  abdominal  or  pelvic  organs  (see  Diseases  of  the  Salivary  Glands). 

Symptoms. — The  period  of  incubation  is  from  two  to  three  weeks,  and 
there  are  rarely  any  symptoms  during  this  stage.  The  invasion  is  marked 
by  fever,  which  is  usually  slight,  rarely  rising  above  101°,  but  in  exceptionally 
severe  cases  reaches  103°  or  104°.  The  child  complains  of  pain  just  below 
the  ear  on  one  side,  where  a  slight  swelling  is  noticed,  which  increases  grad- 
ually, and  within  forty-eight  hours  there  is  great  enlargement  of  the  neck 
and  side  of  the  cheek.  The  swelling  passes  forward  in  front  of  the  ear,  the 
lobe  of  which  is  lifted,  and  back  beneath  the  sterno-mastoid  muscle.  The 
other  side  usually  becomes  affected  within  a  day  or  two,  and  the  whole  neck 
is  surrounded  by  a  collar  of  doughy  infiltration.  Only  one  gland  may  be 
involved,  or  an  interval  of  four  or  five  days  may  elapse  before  the  other  side 
is  involved.  The  submaxillary  and  sublingual  glands  become  swollen,  though 
not  always;  in  a  few  cases  they  may  be  alone  attacked.  The  lachrymal 
glands  may  be  involved.  The  greatest  inconvenience  is  experienced  in  taking 
food,  for  the  patient  is  unable  to  open  the  mouth,  and  even  speech  and  de- 
glutition become  difficult.  There  may  be  an  increase  in  the  secretion  of 
the  saliva,  but  the  reverse  is  sometimes  the  case.  The  mucous  membrane 
of  the  mouth  and"  throat  may  be  slightly  inflamed.  There  is  seldom  great 
pain,  but  an  unpleasant  feeling  of  tension  and  tightness.  There  may  be 
earache,  even  otitis  media,  and  slight  impairment  of  hearing. 

After  persisting  for  from  seven  to  ten  days,  the  swelling  gradually  sub- 
sides and  the  child  rapidly  regains  his  strength  and  health  and  is  none  the 
worse  for  the  attack. 

Occasionally  the  disease  is  very  severe  and  characterized  by  high  fever, 
delirium,  and  great  prostration.  The  patient  may  even  lapse  into  a  typhoid 
condition. 

Relapse  is  rare,  but  there  may  be  within  a  few  weeks  two  or  three  slight 
recurrences,  in  which  I  have  known  the  cervical  glands  to  enlarge.  A  second 
or  even  a  third  attack  may  occur. 

Orchitis. — Excessively  rare  before  puberty,  it  occurs  usually  about  the 
eighth  day,  and  more  particularly  if  the  boy  is  allowed  to  leave  his  bed.  One 
or  both  testicles  may  be  involved.  The  swelling  may  be  great,  and  occasionally 
effusion  takes  place  into  the  tunica  vaginalis.  The  orchitis  may  occur  before 
the  parotitis,  or  in  rare  instances  may  be  the  only  manifestation  of  the  infec- 
tion (orchitis  parotidea).  The  inflammation  increases  for  three  or  four  days, 
and  resolution  takes  place  gradually.  There  may  be  a  muco-purulent  dis- 
charge from  the  urethra.  In  severe  cases  atrophy  may  follow,  fortunately  as 
a  rule  only  in  one  organ;  occurring  in  both  before  puberty  the  natural  de- 
velopment is  usually  checked.  Even  when  both  testicles  are  atrophied  and 


TYPHUS  FEVEK  351 

small,  sexual  vigor  may  be  retained.  The  proportion  of  cases  of  orchitis 
varies  in  different  epidemics;  211  cases  occurred  in  699  cases,  and  103  cases 
of  atrophy  followed  163  instances  of  orchitis  (Comby).  No  satisfactory  ex- 
planation of  this  remarkable  metastasis  has  been  given.  Military  surgeons, 
who  see  so  much  of  the  disease  in  young  recruits,  have  suggested  the  transfer- 
ence of  the  virus  to  the  penis  with  the  fingers  and  its  transmission  along 
the  urethra. 

A  vulvo-vaginitis  sometimes  occurs  in  girls,  and  the  breasts  may  become 
enlarged  and  tender.  Mastitis  has  been  seen  in  boys.  Involvement  of  the 
ovaries  is  rare.  The  thyroid  gland  may  enlarge  in  the  attack,  and  there  have 
been  features  suggestive  of  acute  pancreatitis. 

Complications  and  Sequelae. — Of  these  the  cerebral  affections  are  perhaps 
the  most  serious.  As  already  mentioned,  there  may  be  delirium  and  high 
fever.  In  rare  instances  meningitis  has  been  found.  Hemiplegia  and  coma 
may  also  occur.  A  majority  of  the  fatal  cases  are  associated  with  meningeal 
symptoms.  These,  of  course,  are  very  rare  in  comparison  with  the  frequency 
of  the  disease;  yet,  in  the  Index  Catalogue,  under  this  caption,  there  are  six 
fatal  cases  mentioned.  In  some  epidemics  the  cerebral  complications  are 
much  more  marked  than  in  others.  Acute  mania  has  occurred,  and  there  are 
instances  on  record  of  insanity  following  the  disease. 

Arthritis,  albuminuria,  nephritis,  with  acute  uraemia  and  convulsions,  en- 
docarditis, pleurisy,  facial  paralysis,  hemiplegia,  and  peripheral  neuritis  are 
occasional  complications. 

Suppuration  of  the  gland  is  an  extremely  rare  complication.  Gangrene 
has  occasionally  occurred.  The  special  senses  may  be  seriously  involved. 
Deafness  may  occur,  and  may  be  permanent.  Affections  of  the  eye  are  rare, 
but  optic  neuritis  with  atrophy  has  been  described. 

Chronic  hypertrophy  of  the  gland  may  follow. 

Diagnosis. — The  diagnosis  of  the  disease  is  usually  easy.  The  position  of 
the  swelling  in  front  of  and  below  the  ear  and  the  elevation  of  the  lobe  on 
the  affected  side  definitely  fix  the  locality  of  the  swelling.  In  children  inflam- 
mation of  the  parotid,  apart  from  ordinary  mumps,  is  excessively  rare. 

Treatment. — It  is  well  to  keep  the  patient  in  bed  during  the  height  of  the 
disease.  The  bowels  should  be  freely  opened,  and  the  patient  given  a  light 
liquid  diet.  No  medicine  is  required  unless  the  fever  is  high,  in  which  case 
aconite  may  be  given.  Cold  compresses  may  be  placed  on  the  gland,  but  chil- 
dren, as  a  rule,  prefer  hot  applications.  A  pad  of  cotton  wadding  covered 
with  oil  silk  is  the  best  application.  Suppuration  is  hardly  ever  to  be  dreaded, 
even  though  the  gland  become  very  tense.  Should  redness  and  tenderness 
develop,  leeches  may  be  used.  With  delirium  and  head  symptoms  the  ice-cap 
may  be  applied.  For  the  orchitis,  rest,  with  support  and  protection  of  the 
swollen  gland  with  cotton-wool,  is  usually  sufficient. 


VHI.     TYPHUS  FEVER 

Definition. — An  acute  infectious  disease  of  unknown  origin,  highly  con- 
tagious, characterized  by  sudden  onset,  maculated  and  hamorrhagic  rash, 
marked  nervous  symptoms,  and  a  cyclical  course  terminating  by  crisis,  usually 


352  SPECIFIC  INFECTIOUS  DISEASES 

about  the  end  of  the  second  week.  Post  mortem  there  are  no  special  lesions 
other  than  those  associated  with  fever. 

The  disease  is  known  by  the  names  of  hospital  fever,  spotted  fever,  jail 
fever,  camp  fever,  and  ship  fever,  and  in  Germany  is  called  exanthematic 
typhus,  in  contradistinction  to  abdominal  typhus.  The  word  signifies  "smoke" 
or  "mist"  in  Greek  and  was  used  by  Hippocrates  to  describe  any  condition 
with  a  tendency  to  stupor.  In  the  eighteenth  century  the  name  was  given  by 
de  Sauvages  to  the  common  putrid  or  pestilential  fever,  and  the  general  use 
came  in  through  its  adoption  by  Cullen. 

Etiology. — Typhus  has  been  one  of  the  great  epidemics  of  the  world, 
whose  history,  as  Hirsch  remarks,  is  written  in  those  dark  pages  which  tell 
of  the  grievous  visitations  of  mankind  by  war,  famine,  and  misery.  It  now 
exists  in  a  few  endemic  areas,  where  from  time  to  time  sporadic  cases  occur. 
Ireland  was  terribly  scourged  by  the  disease  between  the  years  1817  and  1819, 
and  again  in  1846.  It  prevailed  extensively  in  all  the  large  cities  of  Great 
Britain  and  the  Continent.  Its  gradual  disappearance  has  been  one  of  the 
great  triumphs  of  sanitation.  In  1875  in  England  and  Wales  there  were  1,499 
deaths  from  the  disease.  Of  late  years  the  name  typhus  has  rarely  appeared 
in  the  Registrar-General's  report.  In  the  United  States  and  Canada  it  pre- 
vailed extensively  in  the  early  years  of  the  nineteenth  century,  and  there 
were  severe  epidemics  in  the  wake  of  the  Irish  immigrations  in  '46  and  '47. 
It  is  endemic  in  parts  of  Russia  and  in  the  Slav  countries,  and  there  have  been 
extensive  epidemics  in  the  present  war. 

Sporadic  typhus  fever  offers  peculiarities  which  are  apt  to  make  its  recog- 
nition difficult.  There  may  be  outbreaks  of  a  few  cases,  the  origin  of  which 
may  be  very  difficult  to  trace,  though,  as  Kelsch  long  ago  suggested,  tramps 
may  convey  the  disease,  while  they  themselves  are  healthy.  Two  such  limited 
outbreaks  came  under  my  observation,  one  at  the  House  of  Refuge,  Montreal, 
in  1877,  in  which  eleven  persons  were  affected,  and  the  second  in  1901  at 
the  Johns  Hopkins  Hospital,  where  three  cases  occurred. 

A  question  of  interest  has  arisen  as  to  the  relation  of  typhus  fever  to  the 
cases  of  fever,  255  in  number,  studied  by  Brill  in  New  Yqrk.  In  all  probabil- 
ity it  is  a  sporadic  type  of  typhus,  an  opinion  to  which  Brill  himself  leans, 
and  which  has  been  confirmed  by  the  studies  of  Anderson  and  Goldberger. 
Beginning  with  the  usual  prodromes,  the  fever  increases  rapidly  and  reaches  a 
maximum  about  the  third  or  fourth  day,  where  it  remains  fairly  constant 
between  103°  and  104°.  On  the  5th  or  6th  day  an  eruption  appears, 
maculo-papular  in  type,  dull  red  in  color,  rarely  haemorrhagic,  not  ap- 
pearing in  crops,  not  disappearing  on  pressure,  and  neither  profuse  as 
in  measles  nor  diffuse  as  in  typical  typhus;  there  may  be  only  a  few  hun- 
dred spots.  The  rash  persists  until  the  crisis  and  then  fades  rapidly. 
The  patients  are  much  prostrated,  with  severe  headache,  but  no  abdominal 
symptoms.  Constipation  is  usually  a  marked  feature.  After  persisting  for 
12  to  15  days,  the  fever  declines  rapidly,  usually  with  a  critical  fall,  and 
there  is  a  speedy  convalescence.  The  blood  cultures  are  negative  and  there 
is  no  agglutination  with  any  of  the  organisms  of  the  typhoid  group.  The 
disease  does  not  spread  to  other  patients  in  the  wards  or  in  the  home.  It  is 
very  rarely  fatal,  and  post  mortem  results  show  no  lesions  of  the  intestines. 

The  so-called  Manchurian  type  met  with  in  the  far  East  is  very  similar, 


TYPHUS  FEVER  353 

and  has  the  same  low  mortality  and  slight  degree  of  infectiousness.  On  the 
other  hand,  the  typhus  fever  prevailing  in  Mexico  City,  where  it  is  known 
as  Tabardillo,  is  more  severe,  and  in  its  study  Eicketts  of  Chicago  fell  a  vic- 
tim. Neither  the  Rocky  Mountain  spotted  fever,  nor  the  Flood  or  River 
fever  of  Japan  is  identical  with  typhus. 

The  disease  is  associated  with  filth  and  overcrowding.  In  epidemics  it 
is  one  of  the  most  highly  contagious  of  all  diseases,  and  those  in  attendance 
upon  patients  are  almost  invariably  attacked  unless  special  precautions  are 
taken  to  guard  against  lice.  In  a  period  of  twenty-five  years  in  Ireland, 
among  1,230  physicians  attached  to  institutions,  550  died  of  this  disease. 
The  disease  is  transmitted  by  the  body  louse  and  possibly  by  the  head  louse. 
Various  organisms  have  been  described  but  none  can  be  regarded  as  positively 
established  as  the  cause.  Nicole,  Anderson  and  Goldberger  have  been  able  to 
transmit  the  disease  to  monkeys,  and  Nicole  has  shown  that  lice  fed  on  the 
typhus-infected  chimpanzee  can  transmit  the  disease  to  monkeys. 

Morbid  Anatomy. — The  anatomical  changes  are  those  which  result  from 
intense  fever.  The  blood  is  dark  and  fluid;  the  muscles  are  of  a  deep  red 
color,  and  often  show  a  granular  degeneration,  particularly  in  the  heart;  the 
liver  is  enlarged  and  soft  and  may  have  a  dull  clay-like  lustre;  the  kidneys 
are  swollen ;  there  is  moderate  enlargement  of  the  spleen,  and  a  general  hyper- 
plasia  of  the  lymph-follicles.  Peyer's  glands  are  not  ulcerated.  Bronchial 
catarrh  is  usually,  and  hypostatic  congestion  of  the  lungs  often,  present.  The 
skin  shows  the  petechial  rash. 

Symptoms.  — INCUBATION. — This  is  placed  at  about  twelve  days,  but  it  may 
be  less.  There  may  be  ill-defined  feelings  of  discomfort.  As  a  rule,  however, 
the  invasion  is  abrupt  and  marked  by  chills  or  a  single  rigor,  followed  by 
fever.  The  chills  may  recur  during  the  first  few  days,  and  there  is  headache 
with  pains  in  the  back  and  legs.  There  is  early  prostration,  and  the  patient 
is  glad  to  take  to  his  bed  at  once.  The  temperature  is  high  at  first,  and  may 
attain  its  maximum  on  the  second  or  third  day.  The  pulse  is  full,  rapid,  and 
not  so  frequently  dicrotic  as  in  typhoid.  The  tongue  is  furred  and  white, 
and  there  is  an  early  tendency  to  dryness.  The  face  is  flushed,  the  eyes  con- 
gested, and  the  expression  dull  and  stupid.  Vomiting  may  be  a  distressing 
symptom.  In  severe  cases  mental  symptoms  are  present  from  the  outset, 
either  a  mild  febrile  delirium  or  an  excited,  active,  almost  maniacal  condition. 
Bronchial  catarrh  is  common. 

STAGE  or  ERUPTION. — From  the  third  to  the  fifth  day  the  eruption  ap- 
pears— first  upon  the  abdomen  and  upper  part  of  the  chest,  and  then  upon  the 
extremities  and  face;  occurring  so  rapidly  that  in  two  or  three  days  it  is  all 
out.  There  are  two  elements  in  the  eruption:  a  subcuticular  mottling,  "a 
fine,  irregular,  dusky  red  mottling,  as  if  below  the  surface  of  the  skin  some 
little  distance,  and  seen  through  a  semi-opaque  medium"  (Buchanan) ;  and 
distinct  papular  rose-spots  which  change  to  petechiag.  In  some  instances  the 
petechial  rash  comes  out  with  the  rose-spots.  Collie  describes  the  rash  as  con- 
sisting of  three  parts:  rose-colored  spots  which  disappear  on  pressure,  dark- 
red  spots  which  are  modified  by  pressure,  and  petechiae  upon  which  pressure 
produces  no  effect.  In  children  the  rash  at  first  may  present  a  striking  resem- 
blance to  that  of  measles  and  give  as  a  whole  a  curiously  mottled  appearance 
to  the  skin.  The  term  mulberry  rash  is  sometimes  applied  to  it.  In  mild 


354 


SPECIFIC  INFECTIOUS  DISEASES 


cases  the  eruption  is  slight,  but  even  then  is  largely  petechial  in  character. 
As  the  rash  is  haemorrhagic,  it  does  not  disappear  after  death.  Usually  the. 
skin  is  dry,  so  that  sudaminal  vesicles  are  not  common.  It  is  stated  by  some 
authors  that  a  distinctive  odor  is  present.  During  the  second  week  the  gen- 
eral symptoms  are  much  aggravated.  The  prostration  becomes  more  marked, 
the  delirium  more  intense,  and  the  fever  rises.  The  patient  lies  on  his  back 
with  a  dull,  expressionless  face,  flushed  cheeks,  injected  conjunctivas,  and 
contracted  pupils.  The  pulse  increases  in  frequency  and  is  feebler;  the  face 


105 


104 


103 


102 


101 


100 


99 


10 


1  1 


12 


CHAET  XII. — TYPHUS  FEVER   (Murchison). 

is  dusky,  and  the  condition  becomes  more  serious.  Retention  of  urine  is  com- 
mon. Coma-vigil  is  frequent,  a  condition  in  which  the  patient  lies  with  open 
eyes,  but  quite  unconscious;  with  it  there  may  be  subsultus  tendinum  and 
picking  at  the  bedclothes.  The  tongue  is  dry,  brown,  and  cracked,  and  there 
are  sordes  on  the  teeth.  Respiration  is  accelerated,  the  heart's  action  becomes 
more  and  more  enfeebled,  and  death  takes  place  from  exhaustion.  In  favora- 
ble cases  about  the  end  of  the  second  week  occurs  the  crisis,  in  which,  often 
after  a  deep  sleep,  the  patient  awakes  feeling  much  better  and,  with  a  clear 
mind.  The  temperature  falls,  and  although  the  prostration  may  be  extreme 
convalescence  is  rapid  and  relapse  very  rare.  This  abrupt  termination  by 
crisis  is  in  striking  contrast  to  the  mode  of  termination  in  typhoid  fever. 

FEVER. — The  temperature  rises  steadily  during  the  first  four  or  five  days, 
and  the  morning  remissions  are  not  marked.  The  maximum  is  usually  at- 
tained by  the  fifth  day,  when  the  temperature  may  be  105°,  106%  or  107°  F. 


TYPHUS  FEVER  355 

In  mild  cases  it  seldom  rises  above  103°  F.  After  reaching  its  maximum  the 
fever  generally  continues  with  slight  morning  remissions  until  the  twelfth  or 
fourteenth  day,  when  the  crisis  occurs,  during  which  the  temperature  may 
fall  below  normal  within  twelve  or  twenty-four  hours.  Preceding  a  fatal 
termination,  there  is  usually  a  rapid  rise  in  the  fever  to  108°  or  even  109°  F. 

The  heart  may  early  show  signs  of  weakness.  The  first  sound  becomes 
feeble  and  almost  inaudible,  and  a  systolic  murmur  at  the  apex  is  not  infre- 
quent. Hypostatic  congestion  of  the  lungs  occurs  in  all  severe  cases.  The 
brain  symptoms  are  usually  more  pronounced  than  in  typhoid,  and  the  de- 
lirium is  more  constant.  A  slight  leucocytosis  is  more  common  than  in 
typhoid. 

The  urine  in  typhus  shows  the  usual  febrile  increase  of  urea  and  uric 
acid.  The  chlorides  diminish  or  disappear.  Albumin  is  present  in  a  large 
proportion  of  the  cases,  but  nephritis  seldom  occurs. 

Variations  in  the  course  of  the  disease  are  naturally  common.  There  are 
malignant  cases  which  rapidly  prove  fatal  within  two  or  three  days;  the 
so-called  typhus  siderans.  On  the  other  hand,  during  epidemics  there  are 
extremely  mild  cases  in  which  the  fever  is  slight,  the  delirium  absent,  and 
convalescence  is  established  by  the  tenth  day. 

Complications  and  Sequelae. — Broncho-pneumonia  is  perhaps  the  most 
common  complication.  It  may  pass  on  to  gangrene.  In  certain  epidemics 
gangrene  of  the  toes,  the  hands,  or  the  nose,  and  in  children  noma  or  cancrum 
oris,  have  occurred.  Meningitis  is  rare.  Paralyses,  which  are  probably  due 
to  a  post-febrile  neuritis,  are  not  very  uncommon.  Septic  processes,  such  as 
parotitis  and  abscesses  in  the  subcutaneous  tissues  and  in  the  joints,  are  occa- 
sionally met  with.  Nephritis  is  rare.  Haamatemesis  may  occur. 

Prognosis. — The  mortality  ranges  in  different  epidemics  from  12  to  20 
per  cent.  It  is  very  slight  in  the  young.  Children,  who  are  quite  as  fre- 
quently attacked  as  adults,  rarely  die.  After  middle  age  the  mortality  is 
high,  in  some  epidemics  50  per  cent.  Death  usually  occurs  toward  the  close 
of  the  second  week  and  is  due  to  the  toxaemia.  In  the  third  week  it  more 
commonly  results  from  pneumonia. 

Diagnosis. — During  an  epidemic  there  is  rarely  any  doubt,  for  the  disease 
presents  distinctive  general  characters.  Isolated  cases  and  the  form  de- 
scribed by  Brill  may  be  very  difficult  to  distinguish  from  typhoid  fever. 
While  in  typical  instances  the  eruption  in  the  two  affections  is  very  dif- 
ferent, yet  taken  alone  it  may  be  deceptive,  since  in  typhoid  fever  a  roseo- 
lous  rash  may  be  abundant  and  there  may  be  occasionally  a  subcuticular 
mottling  and  even  petechiae.  The  difference  in  the  onset,  particularly  in 
the  temperature,  is  marked;  but  cases  in  which  it  is  important  to  make 
an  accurate  diagnosis  are  not  usually  seen  until  the  fourth  or  fifth  day. 
The  suddenness  of  the  onset,  the  greater  frequency  of  the  chill,  and  the 
early  prostration  are  the  distinctive  features  in  typhus.  The  brain  symptoms, 
too,  are  earlier.  'It  is  easy  to  put  down  on  paper  elaborate  differential  distinc- 
tions, which  are  practically  useless  at  the  bedside.  The  Widal  reaction  and 
blood  cultures  are  important  aids,  but  in  sporadic  cases  the  diagnosis  is  some- 
times extremely  difficult.  I  have  seen  Murchison  himself  in  doubt,  and  more 
than  once  I  have  known  the  diagnosis  to  be  deferred  until  the  sectio  cadaveris. 
Severe  cerebro-spinal  fever  may  closely  simulate  typhus  at  the  outset,  but  the 


356  SPECIFIC  INFECTIOUS  DISEASES 

diagnosis  is  usually  clear  within  a  few  days.  Malignant  variola  also  has  cer- 
tain features  in  common  with  severe  typhus,  but  the  greater  extent  of  the 
haemorrhages  and  the  bleeding  from  the  mucous  membranes  make  the  diag- 
nosis clear  within  a  short  time.  The  rash  at  first  resembles  that  of  measles, 
but  in  the  latter  the  eruption  is  brighter  red  in  color,  often  crescentic  or  irreg- 
ular in  arrangement,  and  appears  first  on  the  face. 

The  frequency  with  which  other  diseases  are  mistaken  for  typhus  is  shown 
by  the  fact  that  during  and  following  the  epidemic  of  1881  in  New  York 
108  cases  were  wrongly  diagnosed — one-eighth  of  the  entire  number — and 
sent  to  the  Eiverside  Hospital  (F.  W.  Chapin). 

Treatment. — The  general  management  of  the  disease  is  like  that  of 
typhoid  fever.  Hydrotherapy  should  be  thoroughly  and  systematically  em- 
ployed. Judging  from  the  good  results  which  we  have  obtained  by  this 
method  in  typhoid  cases  with  nervous  symptoms,  much  may  be  expected 
from  it.  Medicinal  antipyretics  are  even  less  suitable  than  in  typhoid,  as  the 
tendency  to  heart-weakness  is  often  more  pronounced.  As  a  rule,  the  patients 
require  from  the  outset  a  supporting  treatment ;  water  should  be  freely  given, 
and  alcohol  in  suitable  doses,  according  to  the  condition  of  the  pulse. 

The  bowels  may  be  kept  open  by  mild  aperients.  The  so-called  specific 
medication,  by  sulphocarbolates,  the  sulphides,  carbolic  acid,  etc.,  is  not  com- 
mended by  those  who  have  had  the  largest  experience.  The  special  nervous 
symptoms  and  the  pulmonary  symptoms  should  be  dealt  with  as  in  typhoid 
fever.  In  epidemics,  when  the  conditions  of  the  climate  are  suitable,  the 
patients  are  best  treated  in  tents  in  the  open  air. 


IX.     YELLOW  FEVER 

Definition. — A  fever  of  tropical  and  subtropical  countries,  characterized  by 
A  toxaemia  of  varying  intensity,  with  jaundice,  albuminuria,  and  a  marked 
tendency  to  haemorrhage,  especially  from  the  stomach,  causing  the  "black 
vomit."  The  specific  organism  has  not  yet  been  found,  but  the  disease  is 
capable  of  being  transmitted  through  the  bite  of  a  mosquito,  the  Stegomyia 
fasciata. 

Etiology. — The  disease  prevails  endemically  in  certain  sections  of  the 
Spanish  Main.  Until  recently  it  has  existed  in  Cuba.  From  these  regions 
it  occasionally  extended  and,  under  suitable  conditions,  prevailed  epidemically 
in  the  Southern  States.  Now  and  then  it  was  brought  to  the  large  seaports  of 
the  Atlantic  coast.  Formerly  it  occurred  extensively  in  the  United  States. 
In  the  latter  part  of  the  eighteenth  century  and  the  beginning  of  the  nine- 
teenth frightful  epidemics  prevailed  in  Philadelphia  and  other  Northern 
cities.  The  epidemic  of  1793,  in  Philadelphia,  so  graphically  described  by 
Matthew  Carey,  was  the  most  serious  that  has  ever  visited  any  city  of  the 
Middle  States.  The  mortality,  as  given  by  Carey,  during  the  months  of 
August,  September,  October,  and  November,  was  4,041,  of  whom  3,435  died 
in  the  months  of  September  and  October.  The  population  of  the  city  at  the 
time  was  only  40,000.  Epidemics  occurred  in  the  United  States  in  1797, 
1798,  1799,  and  in  1802,  when  the  disease  prevailed  slightly  in  Boston  and 
extensively  in  Baltimore.  In  1803  and  1805  it  again  appeared;  then  for 


YELLOW  FEVER  357 

many  years  the  outbreaks  were  slight  and  localized.  In  1853  the  disease 
raged  throughout  the  Southern  States.  There  were  moderately  severe  epi- 
demics in  1867,  1873,  and  1878,  and  still  milder  ones  in  1897,  1898,  and  1899. 
In  July,  1899,  a  local  outbreak  occurred  in  the  Soldiers'  Home  at  Hampton, 
Va.  There  were  45  cases,  with  13  deaths.  In  September,  1903,  yellow  fever 
became  epidemic  along  the  Mexican  side  of  the  Rio 'Grande.  It  crossed  into 
Texas  and  prevailed  in  several  of  the  border  towns.  In  Laredo  there  were 
1,014  cases,  with  107  deaths.  The  efficient  work  of  the  public  health  service 
is  shown  by  the  differences  between  New  Laredo  on  the  Mexican  border,  just 
across  the  river,  where  50  per  cent,  of  the  population  contracted  the  disease, 
and  Laredo,  Texas,  in  which  only  10  per  cent,  out  of  a  population  of  10,000 
were  attacked.  In  Europe  it  has  occasionally  gained  a  foothold,  but  there 
have  been  no  widespread  epidemics  in  the  Spanish  ports.  The  disease  has 
existed  on  the  west  coast  of  Africa,  and  the  late  Rubert  Boyce  claimed  that  it 
is  still  widely  prevalent.  It  is  sometimes  carried  to  ports  in  Great  Britain  and 
France,  but  it  has  never  extended  into  these  countries.  The  Stegomyia  fas- 
ciata  exists  here,  but  it  is  not  very  abundant  and,  as  Ross  points  out,  yellow 
fever  is  a  disease  in  which  the  parasites  live  a  very  short  time  in  the  human 
host,  unlike  malaria.  The  infective  period  in  a  case  lasts  only  about  three 
days,  so  that,  unless  the  stegomyia  index  is  high,  as  in  Havana,  the  disease 
has  no  chance  to  reach  epidemic  form. 

The  epidemics  in  the  United  States  have  always  been  in  the  summer  and 
autumn  months,  disappearing  rapidly  with  the  onset  of  cold  weather. 

Guiteras  recognizes  three  areas  of  infection:  (1)  The  focal  zone  in  which 
the  disease  is  never  absent,  including  Vera  Cruz,  Rio,  and  other  Spanish- 
American  ports.  (2)  The  perifocal  zone  or  regions  of  periodic  epidemics, 
including  the  ports  of  the  tropical  Atlantic  in  America  and  Africa.  (3)  The 
zone  of  accidental  epidemics,  lying  between  the  35th  and  15th  parallels  of 
north  latitude. 

Mode  of  Transmission. — No  belief  has  been  more  strong  among  the  laity 
than  that  the  disease  is  transmitted  by  infected  clothing,  and  quarantine 
efforts  are  chiefly  directed  to  the  disinfection  of  fomites  of  all  sorts  shipped 
from  infected  ports.  The  remarkable  series  of  experiments  carried  out  by 
the  Yellow  Fever  Commission  of  the  United  States  Army,  consisting  of  Drs. 
Walter  Reed,  Carroll,  Lazear,  and  Agramonte,  have  demonstrated  conclu- 
sively that  the  disease  cannot  be  conveyed  in  this  way.  At  Camp  Lazear, 
Cuba,  a  frame  house  was  so  constructed  as  to  shut  out  the  sunlight  and  fresh 
air,  and  the  vestibule  was  thoroughly  screened.  The  average  temperature  for 
sixty-three  days  was  kept  about  76°  F.  Boxes  filled  with  sheets,  pillow-slips, 
blankets,  etc.,  contaminated  by  contact  with  cases  of  yellow  fever  and  the 
discharges,  were  placed  in  the  house.  Dr.  R.  P.  Cooke  and  two  privates  of 
the  hospital  corps,  all  non-immunes,  entered  this  building  and  unpacked  the 
boxes,  and  for  a  period  of  twenty  days  occupied  the  room,  each  morning  pack- 
ing the  infected  articles  in  the  boxes,  and  at  night  unpacking  them.  In  their 
experiments  with  the  fomites,  seven,  in  all,  non-immune  subjects  during  the 
period  of  sixty-three  days  lived  in  contact  with  the  fomites  and  remained 
perfectly  well.  These  experiments,  conducted  in  the  most  rigid  and  scientific 
manner,  completely  discredit  the  belief  in  the  transmission  of  the  disease  by 
fomites. 


358  SPECIFIC  INFECTIOUS  DISEASES 

Carlos  Finlay,  of  Havana,  in  1881  suggested  that  the  disease  was  trans- 
mitted by  mosquitoes.  Stimulated  by  the  work  of  Ross  on  malaria,  the  Ameri- 
can Commission  above  named  has  demonstrated  conclusively  that  yellow  fever 
is  transferred  by  a  mosquito,  Stegomyia  fasciata,  previously  fed  on  the  blood 
of  infected  persons.  The  Commission  showed  also  that  in  non-immunes  the 
disease  could  be  produced  by  either  the  subcutaneous  or  the  intravenous  in- 
jection of  blood  taken  from  patients  suffering  with  the  disease. 

An  interval  of  about  twelve  days  or  more  after  contamination  appears 
to  be  necessary  before  the  mosquito  is  capable  of  introducing  the  infection. 
The  bite  at  an  early  period  after  contamination  does  not  confer  immunity 
against  a  subsequent  attack.  The  period  of  incubation  in  13  cases  of  experi- 
mental yellow  fever  varied  from  forty-one  hours  to  five  days  and  seventeen 
hours. 

We  must  bear  testimony  to  the  heroism  of  the  young  soldiers  who  volun- 
tarily, without  compensation  and  purely  in  the  interests  of  humanity,  sub- 
mitted to  the  experiments,  and  also  to  the  zeal  with  which  members  of  our 
profession  have,  at  great  personal  risk,  attempted  to  solve  the  riddle  of  this 
most  serious  disease.  The  death  of  Dr.  Lazear,  of  the  American  Commission, 
and  of  Dr.  Myers,  of  the  Liverpool  Commission,  adds  two  more  names  to  the 
already  long  roll  of  the  martyrs  of  science. 

As  Reed  pointed  out,  the  mosquito  theory  fits  in  with  well-recognized  facts 
in  connection  with  the  epidemics.  After  the  importation  of  a  case  into  an 
uninfected  region,  a  definite  period  elapses,  rarely  less  than  two  weeks,  before 
a  second  case  occurs.  Like  malaria,  the  disease  prevails  most  during  the  mos- 
quito season,  and  disappears  with  the  appearance  of  frost.  Probably,  too,  as 
in  very  malarious  districts,  the  disease  is  kept  up  by  its  prevalence  in  a  very 
mild  form  among  children.  As  Guiteras  remarks,  "the  foci  of  endemicity  are 
essentially  maintained  by  the  Creole  infant  population,  which  is  subject  to 
the  disease  in  a  very  mild  form."  In  all  probability  the  immunity  which  is 
acquired  by  prolonged  residence  in  a  locality  in  which  the  disease  is  endemic 
is  due  to  the  occurrence  of  very  slight  attacks. 

One  attack  does  not  always  confer  immunity.  Rosenau  reports  two  at- 
tacks within  a  period  of  eight  years,  and  Libby  two  attacks  within  a  period  of 
two  years. 

The  specific  germ  has  not  yet  been  discovered. 

Morbid  Anatomy. — The  skin  is  more  or  less  jaundiced,  even  though  the 
patient  did  not  appear  yellow  before  death.  Cutaneous  haemorrhages  may  be 
present.  No  specific  or  distinctive  internal  lesions  have  been  found.  The 
blood-serum  may  contain  haemoglobin,  owing  to  destruction  of  the  red  cells, 
just  as  in  pernicious  malaria.  The  heart  sometimes,  not  invariably,  shows 
fatty  change;  the  stomach  presents  more  or  less  hyperaemia  of  the  mucosa 
with  catarrhal  swelling.  It  contains  the  material  which,  ejected  during  life, 
is  known  as  the  black  vomit.  The  essential  ingredient  in  this  is  transformed 
blood-pigment.  There  is  often  general  glandular  enlargement;  the  cervical, 
axillary  and  mesenteric  groups  are  most  involved.  The  liver  is  usually  of  a 
pale  yellow  or  brownish-yellow  color,  and  the  cells  are  in  various  stages  of 
fatty  degeneration.  From  the  date  of  Louis'  observations  at  Gibraltar  in 
1828,  the  appearances  of  this  organ  have  been  very  carefully  studied,  and 
some  have  thought  the  changes  in  it  to  be 'characteristic.  Fatty  degeneration 


YELLOW  FEVER  359 

and  regions  of  necrosis  are  present  in  all  cases.  The  kidneys  always  show 
traces  of  diffuse  nephritis.  The  epithelium  of  the  convoluted  tubules  is  swol- 
len and  very  granular;  there  may  also  be  necrotic  changes. 

Symptoms. — The  incubation  is  usually  three  or  four  days;  in  13  experi- 
mental cases  it  ranged  from  forty-one  hours  to  five  days,  seventeen  hours.  The 
onset  is  sudden,  as  a  rule,  without  premonitory  symptoms,  and  in  the  early 
hours  of  the  morning.  Chilly  feelings  are  common,  and  are  usually  associated 
with  headache  and  very  severe  pains  in  the  back  and  limbs.  The  fever  rises 
rapidly  and  the  skin  feels  very  hot  and  dry.  The  tongue  is  furred,  but  moist; 
the  throat  sore.  Nausea  and  vomiting  are  not  constant,  and  become  more 
intense  on  the  second  or  third  day.  The  bowels  are  usually  constipated.  Thb 
following,  in  detail,  are  the  more  important  characteristics: 

FACIES. — Even  as  early  as  the  first  morning  the  patient  may  present  a 
characteristic  fades,  one  of  the  three  distinguishing  features  of  the  disease, 
which  Guiteras  describes  as  follows :  The  face  is  flushed,  more  so  than  in  any 
other  acute  infectious  disease  at  such  an  early  period.  The  eyes  are  injected, 
the  color  is  a  brigl.^  red,  and  there  may  be  a  slight  tumefaction  of  the  eyelids 
and  of  the  lips.  Even  at  this  early  date  there  is  to  be  noticed  in  connection 
with  the  injection  of  the  superficial  capillaries  of  the  face  and  conjunctivas  a 
slight  icteroid  tint,  and  "the  early  manifestation  of  jaundice  is  undoubtedly 
the  most  characteristic  feature  of  the  facies  of  yellow  fever/' 

THE  FEVER. — On  the  morning  of  the  first  day  the  temperature  may  range 
from  100°  to  106°  F.,  usually  it  is  between  102°  and  103°  F.  During  the 
evening  of  the  first  day  and  the  morning  of  the  second  day  the  temperature 
keeps  about  the  same.  There  is  a  slight  diurnal  variation  on  the  second  and 
third  day.  In  very  mild  cases  the  fever  may  fall  on  the  evening  of  the  second 
or  on  the  morning  of  the  third  day,  or  in  abortive  cases  even  at  the  end  of 
twenty-four  hours.  In  cases  that  are  to  terminate  favorably  the  defervescence 
takes  place  by  lysis  during  a  period  of  two  or  three  days.  The  remission  or 
stage  of  calm,  as  it  has  been  called,  is  succeeded  by  a  febrile  reaction  or  sec- 
ondary fever,  which  lasts  one,  two,  or  three  days,  and  in  favorable  cases  falls 
by  a  short  lysis.  On  the  other  hand,  in  fatal  cases  the  temperature  is  continu- 
ous, becomes  higher  than  in  the  initial  fever,  and  death  follows  shortly. 

THE  PULSE. — On  the  first  day  the  pulse  is  rarely  more  than  100  or  110. 
On  the  second  or  third  day,  while  the  fever  still  keeps  up,  the  pulse  begins 
to  fall,  as  much  perhaps  as  20  beats,  while  the  temperature  has  risen  1.5°  or 
2°.  On  the  evening  of  the  third  day  there  may  be  a  temperature  range  of 
103°  and  a  pulse  of  only  75,  or  "a  temperature  between  103°  and  104°  with 
a  pulse  running  from  70  to  80."  This  important  diagnostic  feature  was  first 
described  by  Faget,  of  New  Orleans.  During  defervescence  the  pulse  may 
become  still  lower,  down  to  50,  48,  or  45,  or  even  as  low  as  30;  a  slow  pulse 
at  this  period  is  not  the  special  circulatory  feature  of  the  disease,  but  the 
slowing  of  the  pulse  with  a  steady  or  even  rising  temperature. 

ALBUMINURIA. — This,  the  third  characteristic  symptom  of  the  disease, 
occurs  as  early  as  the  evening  of  the  third  day.  Guiteras  says  very  truly  that 
it  is  very  rare  so  early  in  other  fevers  except  those  of  an  unusually  severe 
type.  "Even  in  the  mild  cases  that  do  not  go  to  bed — cases  of  'walking  yel- 
low fever' — on  the  second,  third,  or  fourth  day  of  the  disease  albuminuria  will 
show  itself."  It  may  be  quite  transient.  In  the  severer  cases  the  amount  of 


360  SPECIFIC  INFECTIOUS  DISEASES 

albumin  is  very  large,  and  there  may  be  numerous  tube  casts  and  all  the  signs 
of  an  acute  nephritis;  or  complete  suppression  may  supervene,  and  death  oc- 
curs in  ursemic  convulsions  or  coma  within  twenty-four  or  thirty-six  hours. 

GASTRIC  FEATURES. — "Black  Vomit" — Irritability  of  the  stomach  is  pres- 
ent from  the  very  outset,  and  the  vomited  matter  consists  of  the  contents  of 
the  stomach,  and  subsequently  of  mucus  and  a  grayish  fluid.  In  the  third 
stage  of  the  disease  the  vomiting  becomes  more  pronounced  and  in  the  severe 
cases  is  characterized  by  the  presence  of  blood.  It  may  be  copious  and  forci- 
ble, producing  much  pain  in  the  abdomen  and  along  the  gullet.  There  is 
nothing  specific  in  this  "black  vomit,"  which  consists  of  altered  blood,  and 
it  is  not  necessarily  a  fatal  symptom,  though  occurring  only  in  the  severer 
forms  of  the  disease.  Other  hagmorrhagic  features  may  be  present — petechiae 
on  the  skin  and  bleeding  from  the  gums  or  from  other  mucous  membranes. 
The  bowels  are  usually  constipated,  the  stools  not  clay-colored,  except  late  in 
the  disease.  They  are  sometimes  tarry  from  the  presence  of  altered  blood. 

MENTAL  FEATURES. — In  very  severe  cases  the  onset  may  be  with  active 
delirium.  "As  a  rule,  in  a  majority  of  cases,  even  when  there  is  black  vomit, 
there  is  a  peculiar  alertness;  the  patient  watches  everything  going  on  about 
him  with  a  peculiar  intensity  and  liveliness.  This  may  be  due  in  part  to  the 
terror  the  disease  inspires"  (Guiteras). 

Relapses  occasionally  occur.  Among  the  varieties  of  the  disease  it  is  im- 
portant to  recognize  the  mild  cases,  characterized  by  slight  fever,  continuing 
for  one  or  two  days,  and  succeeded  by  a  rapid  convalescence.  In  the  absence 
of  a  prevailing  epidemic  they  would  scarcely  be  recognized  as  yellow  fever. 
Cases  of  greater  severity  have  high  fever  and  the  features  of  the  disease  are 
well  marked — vomiting,  extreme  prostration,  and  haemorrhages.  And,  lastly, 
in  the  malignant  form  the  patient  is  overwhelmed  by  the  intensity  of  the 
fever,  and  death  takes  place  in  two  or  three  days. 

In  severe  cases  convalescence  may  be  complicated  by  parotitis,  abscesses 
in  various  parts  of  the  body,  and  diarrhrea. 

Diagnosis. —  (a)  FROM  DENGUE. — The  difficulty 'in  the  differential  diag- 
nosis of  these  two  diseases  lies  in  their  frequent  coexistence,  as  during  the  epi- 
demic of  1897  in  parts  of  the  Southern  States.  During  the  autumn  of  1897 
the  profession  of  Texas  was  divided  on  the  question  of  the  existence  of  yellow 
fever  in  the  State,  some  claiming  that  the  disease  was  dengue,  others,  includ- 
ing Guiteras  and  West,  that  yellow  fever  also  existed.  In  a  majority  of  the 
cases  the  three  diagnostic  points-  upon  which  Guiteras  lays  stress — the  fades, 
the  albuminuria,  and  the  slowing  of  the  pulse  with  maintenance  or  elevation 
of  the  fever — are  sufficient  for  the  diagnosis.  He  states,  too,  that  jaundice, 
which  does  sometimes  occur  in  dengue,  rarely  appears  as  early  as  the  second 
or  third  day  of  the  disease,  and  on  this  much  stress  should  be  laid.  Hae- 
morrhages are  much  less  common  in  dengue,  but  that  they  do  occur  has  been 
recognized  by  authorities  ever  since  the  time  of  Rush. 

(6)  FROM  MALARIAL  FEVER. — In  the  early  stages  of  an  epidemic  cases 
are  very  apt  to  be  mistaken  for  malarial  fever.  In  the  Southern  States  the 
outbreaks  have  usually  been  in  the  late  summer  months,  the  very  season  in 
which  the  aestivo-autumnal  fever  prevails.  Among  the  points  to  be  specially 
noted  is  the  absence  of  early  jaundice.  Even  in  the  most  intense  types  of 
malarial  infection  the  color  of  the  skin  is  rarely  changed  within  four  or  five 


YELLOW  FEVER  361 

days.  To  the  experienced  eye  the  facies  would  be  of  considerable  help  if  the 
case  was  seen  from  the  outset.  Albumin  is  rarely  present  in  the  urine  so 
early  as  the  second  day  in  a  malarial  infection.  Other  important  points  are 
the  marked  swelling  of  the  spleen  in  malaria,  while  in  yellow  fever  it  is  not 
much  enlarged.  Haemorrhages,  and  particularly  the  black  vomit,  epistaxis, 
and  bleeding  gums  are  very  rare  in  malarial  infection.  In  the  so-called  hse- 
morrhagic  malarial  fever  the  patient  has  usually  had  previous  attacks  of 
malaria.  Hsematuria  is  a  prominent  feature,  while  in  yellow  fever  it  is  by  no 
means  frequent.  A  special  point  of  greater  importance,  perhaps,  than  any 
of  these  general  symptomatic  features  is  the  examination  of  the  blood  for 
malarial  parasites.  The  work  of  the  army  surgeons  in  Cuba  showed  that  in 
a  large  proportion  of  cases  there  is  not  much  difficulty  in  recognizing  the 
sestivo-autumnal  fever  from  yellow  fever. 

Prognosis. — In  its  graver  forms  yellow  fever  is  one  of  the  most  fatal  of 
epidemic  diseases.  The  mortality  has  ranged,  in  various  epidemics,  from  15 
to  85  per  cent.  In  heavy  drinkers  and  those  who  have  been  exposed  to  hard- 
ships the  death-rate  is  much  higher  than  among  the  better  classes.  In  the 
epidemic  of  1878,  in  New  Orleans,  while  the  mortality  in  hospitals  was  over 
50  per  cent,  of  the  white  and  21  per  cent,  of  the  colored  patients,  in  private 
practice  it  was  not  more  than  10  per  cent,  among  the  white  patients.  The 
death-rate  was  very  low  in  the  epidemic  of  1897. 

Prophylaxis. — The  clearing  of  Havana  by  Colonel  Gorgas  was  a  direct 
outcome  of  the  work  of  Eeed  and  his  colleagues.  The  city,  with  250,000  peo- 
ple, had  been  infected  continuously  for  130  years.  Non-immunes  came  in  at 
the  rate  of  20,000  a  year,  and  there  were  6,000  children  born.  The  city  was 
divided  into  districts,  each  under  the  charge  of  an  inspector,  whose  work  was 
arranged  under  three  heads:  (1)  To  prevent  the  breeding  of  stegomyia  mos- 
quitoes. (2)  To  destroy  those  that  had  become  infected.  (3)  To  prevent 
mosquitoes  becoming  infected  by  protecting  the  sick  so  that  they  could  not  be 
bitten  by  mosquitoes. 

The  work  was  begun  in  February,  1901,  and  the  last  case  of  yellow  fever 
occurred  in  September  of  that  year,  since  which  date,  with  the  exception  of  a 
slight  return,  the  city  has  been  free. 

At  Panama  in  1904,  the  date  of  the  American  occupation,  the  serious 
problem  was  how  to  fight  yellow  fever.  Conditions  were  such  that  it  took 
sixteen  months  before  the  disease  disappeared.  There  has  been  no  return. 
It  is  interesting  to  note  that  in  the  yellow  fever  wards  at  Ancon  during  1905 
all  the  physicians  and  nurses  were  non-immune,  but  not  one  of  them  con- 
tracted the  disease,  as  the  wards  were  so  screened  that  no  stegomyia  mosqui- 
toes could  get  at  the  patients  to  become  infected.  • 

Treatment. — Careful  nursing  and  a  symptomatic  plan  of  treatment  prob- 
ably give  the  best  results.  The  patient  should  be  at  rest  in  bed  and  for  the 
first  few  days  the  diet  should  consist  of  very  simple  fluids.  Elimination  is  an 
important  part  of  treatment.  Water  should  be  given  as  freely  as  possible,  best 
in  the  form  of  cold  carbonated  alkaline  water.  The  bowels  should  be  opened  by 
a  calomel  and  saline  purge  and  enemata  used  if  necessary.  If  there  is  vomit- 
ing, fluid  should  be  given  by  the  bowel  or  by  infusion.  Ice  in  small  quantities, 
iced  champagne  or  cocaine  (gr.  %,  0.016  gm.)  may  be  tried.  The  fever  should 
be  treated  by  hydrotherapy,  sponges,  packs  or  baths  being  used.  The  alkaline 
25 


362  SPECIFIC  INFECTIOUS  DISEASES 

treatment  is  favorably  regarded,  sodium  bicarbonate  in  full  doses  being  given 
at  short  intervals  and  as  much  alkaline  water  as  possible.  For  gastric  and 
intestinal  hemorrhage  the  perchloride  of  iron  or  oil  of  turpentine  may  be 
given  in  doses  of  15  minims  (1  c.  c.).  Uraemic  symptoms  are  best  treated 
by  the  hot  baths  or  packs,  the  free  administration  of  fluid  and  hot  bowel 
irrigations.  Stimulants,  especially  strychnine,  should  be  used  during  the  sec- 
ond stage  when  the  heart  becomes  feeble  and  rapid. 


X.     DENGUE 

Definition. — An  acute  infectious  disease  of  tropical  and  subtropical  re- 
gions, characterized  by  febrile  paroxysms,  pains  in  the  joints  and  muscles,  an 
initial  erythematous  and  a  terminal  polymorphous  eruption. 

It  is  known  as  break-bone  fever  from  the  atrocious  character  of  the  pain, 
and  dandy  fever  from  the  stiff,  dandified  gait.  The  word  dengue  is  supposed 
to  be  derived  from  a  Spanish,  or  possibly  Hindostanee,  equivalent  of  the  word 
dandy. 

History  and  Geographical  Distribution.— The  disease  was  first  recognized 
in  1779  in  Cairo  and  in  Java,  where  Bylon  described  the  outbreak  in  Batavia. 
There  have  been  widespread  epidemics  in  India  and  China.  The  description 
by  Benjamin  Eush  of  the  epidemic  in  Philadelphia  in  1780  is  one  of  the  first 
and  one  of  the  very  best  accounts  of  the  disease.  Between  1824  and  1828  it 
was  prevalent  at  intervals  in  India  and  in  the  Southern  States.  S.  H.  Dick- 
son  gives  a  graphic  description  of  the  disease  as  it  appeared  in  Charleston  in 
1828.  Since  that  date  there  have  been  four  or  five  widespread  epidemics  in 
tropical  countries  and  on  this  continent  along  the  Gulf  States,  the  last  in 
the  summer  of  1897.  None  of  the  recent  epidemics  have  extended  into  the 
Northern  States,  but  in  1888  it  prevailed  as  far  north  as  Virginia.  It  has 
prevailed  in  the  Philippine  Islands  among  the  United  States  troops  and 
among  the  natives. 

Etiology. — The  rapidity  of  diffusion  and  the  pandemic  character  are  the 
two  most  important  features  of  dengue.  There  is  no  disease,  not  even  influ- 
enza, which  attacks  so  large  a  proportion  of  the  population.  In  Galveston,  in 
1897,  20,000  people  were  attacked  within  two  months.  In  1903  Graham 
showed  that  the  disease  could  be  transmitted  to  healthy  persons  by  the  bite  of 
the  mosquito  Culex  fatigans,  an  observation  confirmed  by  Ashburn  and  Craig. 
The  specific  germ  is  still  undetermined,  but  is  probably  ultramicroscopic. 

As  the  disease  is  rarely  fatal,  no  observations  have  been  made  upon  its 
pathological  anatomy. 

Symptoms.  — The  period  of  incubation  is  from  three  to  five  days,  during 
which  the  patient  feels  well.  The  attack  sets  in  suddenly  with  headache,  chilly 
feelings,  and  intense  aching  pains  in  the  joints  and  muscles.  The  tempera- 
ture rises  gradually,  and  may  reach  106°  or  107°.  The  pulse  is  rapid,  and 
there  are  the  other  phenomena  associated  with  acute  fever — loss  of  appetite, 
coated  tongue,  slight  nocturnal  delirium,  and  concentrated  urine.  The  face 
has  a  suffused,  bloated  appearance,  the  eyes  are  injected,  and  the  visible  mu- 
cous membranes  are  flushed.  There  is  a  congested  erythematous  state  of  the 
skin.  Bush's  description  of  the  pains  is  worth  quoting,  as  in  it  the  epithet 


DENGUE  363 

break-bone  occurs  in  the  literature  for  the  first  time.  "The  pains  which 
accompanied  this  fever  were  exquisitely  severe  in  the  head,  back,  and  limbs. 
The  pains  in  the  head  were  sometimes  in  the  back  parts  of  it,  and  at  other 
times  they  occupied  only  the  eyeballs.  In  some  people  the  pains  were  so  acute 
in  their  backs  and  hips  that  they  could  not  lie  in  bed.  In  others  the  pains 
affected  the  neck  and  arms,  so  as  to  produce  in  one  instance  a  difficulty  of 
moving  the  fingers  of  the  right  hand.  They  all  complained  more  or  less  of  a 
soreness  in  the  seats  of  these  pains,  particularly  when  they  occupied  the  head 
and  eyeballs.  A  few  complained  of  their  flesh  being  sore  to  the  touch  in  every 
part  of  the  body.  From  these  circumstances  the  disease  was  sometimes  be- 
lieved to  be  a  rheumatism,  but  its  more  general  name  among  all  classes  of 
people  was  the  break-bone  fever."  The  large  and  small  joints  are  affected, 
sometimes  in  succession,  and  become  swollen,  red,  and  painful.  In  some  cases 
cutaneous  hyperaesthesia  has  been  noted.  Haemorrhage  from  the  mucous 
membranes  was  noted  by  Rush,  and  black  vomit  has  also  been  described. 

The  fever  gradually  reaches  its  maximum  by  the  third  or  fourth  day;  the 
patient  then  enters  upon  the  apyretic  period,  which  may  last  from  two  to 
four  days,  and  in  which  he  feels  prostrated  and  stiff.  A  second  paroxysm 
of  fever  then  occurs,  and  the  pains  return.  In  a  large  number  of  cases  an 
eruption  is  common,  which,  judging  from  the  description,  has  nothing  dis- 
tinctive, being  sometimes  macular,  like  that  of  measles,  sometimes  diffuse  and 
scarlatiniform,  or  papular,  or  lichen-like.  In  other  instances  the  rash  has 
been  described  as  urticarial,  or  even  vesicular.  The  rash  may  persist  for  a 
month  after  the  symptoms  have  disappeared.  Certain  writers  describe  in- 
flammation and  hyperasmia  of  the  mucous  membrane  of  the  nose,  mouth  and 
pharynx.  Enlargement  of  the  lymph-glands  is  not  uncommon,  and  may  per- 
sist for  weeks  after  the  disappearance  of  the  fever.  Convalescence  is  often 
protracted,  and  there  is  a  degree  of  mental  and  physical  prostration  out  of  all 
proportion  to  the  severity  of  the  primary  attack.  The  pains  in  the  joints  or 
muscles,  sometimes  very  local,  may  persist  for  weeks.  Rush  refers  to  the 
former,  stating  that  a  young  lady  after  recovery  said  it  should  be  called 
break-heart,  not  break-bone,  fever.  The  average  duration  of  a  moderate  at- 
tack is  from  seven  to  eight  days.  Dengue  is  very  seldom  fatal.  Dickson  saw 
three  deaths  in  the  Charleston  epidemic. 

Complications  are  rare.  Insomnia  and  occasionally  delirium,  resembling 
somewhat  the  alcoholic  form,  have  been  observed,  and  convulsions  in  children. 
Atrophy  of  the  muscles  may  occur  after  the  attack.  A  relapse  may  occur  even 
as  late  as  two  weeks. 

Diagnosis. — The  diagnosis  of  the  disease,  prevailing  as  it  does  in  epidemic 
form  and  attacking  all  classes  indiscriminately,  rarely  offers  any  special  diffi- 
culty. Isolated  cases  might  be  mistaken  at  first  for  rheumatic  fever.  The 
seven-day  fever  of  East  Indian  ports  is  believed  to  be  dengue.  It  is  a  sporadic 
fever  of  the  hot  weather,  attacking  a  large  proportion  of  Europeans  within 
the  first  year  or  two  of  their  arrival.  Possibly,  as  Rogers  thinks,  it  may  be  a 
distinct  disease,  and  it  is  variously  known  in  India  as  ephemeral  fever,  mild 
malaria,  or  simple  continued  fever.  It  is  characterized  by  early  and  severe 
pains  in  the  back  and  limbs,  and  a  fever  of  six  to  seven  days'  duration. 

Treatment. — This  is  entirely  symptomatic.  Quinine  is  stated  to  be  a  pro- 
phylactic, but  on  insufficient  grounds.  Hydrotherapy  may  be  employed  to 


364  SPECIFTC  INFECTIOUS  DISEASES 

reduce  the  fever.  The  salicylates  or  antipyrin  may  be  tried  for  the  pains, 
which  usually,  however,  require  opium.  During  convalescence  iodide  of  potas- 
sium is  recommended  for  the  arthritic  pains,  and  tonics  are  indicated. 


XL    ACUTE  POLIO-MYELITIS 

(Heine-Me din's  Disease) 

Definition. — An  acute  infection  occurring  in  both  epidemic  and  sporadic 
forms,  characterized  anatomically  by  widespread  lesions  of  the  nervous  sys- 
tem, with  special  localization  in  a  majority  of  the  cases  in  the  anterior  horns 
of  the  gray  matter  in  the  spinal  cord — hence  the  common  name,  polio-mye- 
litis anterior. 

History. — In  1840  von  Heine  separated  this  type  from  other  forms  of 
paralysis  and  in  1887  Medin  called  attention  to  its  occurrence  in  widespread 
epidemics,  which  have  been  specially  studied  in  Sweden  by  Wickham,  Har- 
bitz,  and  others.  Within  the  past  ten  years  serious  outbreaks  have  occurred 
in  many  parts  of  the  United  States  and  Canada.  The  incidence  of  the  dis- 
ease has  also  slightly  increased  in  Great  Britain  and  on  the  Continent  of 
Europe,  while  in  Sweden  and  Norway  and  parts  of  Austria  the  disease  has 
assumed  epidemic  proportions.  In  New  York  City  in  1907-8  there  were 
about  2,000  cases,  with  a  mortality  of  6  to  7  per  cent.;  in  1910  throughout 
the  United  States  there  were  between  eight  and  nine  thousand  cases  reported. 

Etiology. — In  its  epidemic  behavior  the  disease  resembles  closely  cere- 
bro-spinal  fever.  Sporadic  cases  occur  in  all  communities  and  under  at 
present  unknown  conditions  increase  at  times  to  epidemic  proportions.  It 
prevails  in  the  late  summer  and  autumn. 

Age  is  a  most  important  predisposing  element;  a  great  majority  of  all 
cases  occur  in  children  in  the  first  dentition.  The  more  prevalent  the  epi- 
demic form  the  greater  the  proportion  of  young  adults  attacked.  Males  and 
females  are  about  equally  attacked.  Overexertion,  injury,  exposure  are  men- 
tioned as  possible  factors. 

The  degree  of  contagiousness  from  person  to  person  is  slight,  and  in  this 
the  disease  resembles  cerebro-spinal  fever  and  pneumonia,  but  the  precise 
mode  of  transmission  has  not  yet  been  determined. 

The  organism  has  been  isolated  by  Flexner  and  his  co-workers.  The 
colonies  consist  of  globular  bodies  averaging  0.15  to  0.3  micron  in  size.  Mon- 
keys inoculated  with  the  twentieth  generation  of  the  culture  developed  typical 
experimental  polio-myelitis.  The  infective  agent  is  present  in  the  brain  and 
spinal  cord,  in  the  naso-pharyngeal  secretions  and  in  the  blood.  The  disease 
is  inoculable  into  monkeys  and  may  be  transmitted  from  one  animal  to  another. 
It  has  been  transmitted  also  by  intracerebral  injection  of  an  emulsion  made 
from  flies  which  had  fed  on  the  spinal  cord  of  a  monkey  dead  of  the  disease. 
An  important  point  is  that  the  virus  passes  from  the  central  nervous  system 
in  the  monkey  to  the  nasal  mucosa  and  vice  versa,  and  the  application  of  the 
virus  to  this  part  is  a  ready  means  of  inoculation.  It  has  also  been  found  in  the 
tonsils  and  pharvngeal  mucosa  of  children. 

So  far  as  we  know,  the  disease  is  transmitted  either  directly  by  contact 


ACUTE    POLIO-MYELITIS  365 

or  possibly  by  the  intervention  of  healthy  carriers.  The  distribution  is  more 
independent  of  sanitary  conditions  than  in  the  common  children's  diseases. 
The  biting  flies  may  convey  the  virus. 

Morbid  Anatomy. — One  of  the  most  striking  results  of  recent  researches 
has  been  to  demonstrate  how  widespread  the  lesions  are  in  the  nervous  sys- 
tem. We  can  no  longer  regard  it  as  an  affection  limited  to  the  anterior  horns 
of  the  gray  matter  of  the  spinal  cord,  but  a  widespread  poliomyelo-encephali- 
tis  with  meningeal  complications. 

Swelling  of  the  spleen  and  a  marked  general  hyperplasia  of  the  lymphoid 
apparatus  have  been  found.  The  cerebro-spinal  fluid  is  usually  increased  but 
clear.  The  pia  mater  is  hypersemic  and  moist,  but  without  exudate.  Cases 
in  which  the  cerebral  s}rmptoms  have  been  pronounced  show  swelling  and 
flattening  of  the  convolutions,  with  hyperasmia  of  the  gray  matter  and  here 
and  there  small  haemorrhages.  The  changes  in  the  spinal  cord  are  very  char- 
acteristic. The  meninges  are  moist,  the  pia  is  hyperaemic,  sometimes  with 
small  capillary  haemorrhages.  On  section  the  cut  surface  bulges,  the  grey 
matter  is  hypera?mic,  appearing  as  a  reddened  H,  or  the  redness  is  limited  to 
the  anterior  horns,  which  may  show  spots  of  haemorrhage.  These  changes 
may  be  localized  to  the  swellings  of  the  cord  or  extend  throughout  its  entire 
extent.  Microscopically  there  is  small-celled  infiltration  about  the  vessels 
of  the  meninges,  most  marked  in  the  lumbar  and  cervical  swellings.  The 
infiltration  extends  into  the  fissures  of  the  cord  and  follows  the  blood-vessels. 
The  amount  of  meningeal  implication  is  much  more  intense  than  is  indicated 
macroscopically.  In  the  cord  itself  the  smaller  blood-vessels  are  distended, 
haemorrhages  occur  in  the  gray  matter,  there  is  marked  perivascular  infiltra- 
tion, chiefly  of  lymphocytes,  which  collect  about  the  vessels,  forming  definite 
foci.  Sometimes  the  majority  of  the  cells  are  polynuclear  leucocytes.  The 
ganglion  cells,  usually  those  of  the  anterior  horns,  degenerate  and  gradually 
disappear,  changes  probably  secondary  to  the  acute  vascular  alterations.  Foci 
of  infiltration  and  widespread  cedema  may  be  present  in  the  white  matter 
of  the  cord.  In  the  fatal  cases  there  are  changes  in  the  medulla  and  pons  of 
much  the  same  nature,  but  the  ganglion  cells  rarely  show  such  widespread 
destruction. 

The  path  of  invasion  is  apparently  by  the  organism  gaining  access  to  the 
upper  respiratory  tract.  Flexner  and  Lewis  have  shown  that  the  infection 
can  travel  by  the  sheath  of  the  sciatic  nerve  to  the  cord. 

Symptoms. — The  incubation  period  is  from  5  to  10  days,  during  which 
the  patient  may  complain  of  headache  and  pains  and  stiffness  of  the  limbs. 
Naso-pharyngeal  symptoms  are  common.  Twitchings,  even  convulsions,  and 
pain  in  the  back  and  bones  may  be  present.  More  commonly  a  child  who  has 
gone  to  bed  well  awakens  in  the  morning  with  the  paralysis  and  slight  fever. 
Prodromal  symptoms  are  more  common  in  the  epidemic  form. 

The  studies  of  the  past  two  or  three  years  have  shown  a  number  of  well- 
characterized  types,  of  which  the  following  are  the  most  important: 

(a)  ABORTIVE  FORM. — In  epidemics,  just  as  in  cerebro-spinal  fever,  there 
are  cases  of  illness  with  the  general  symptoms  of  infection,  and  indications 
of  cerebro-spinal  irritation,  but  without  any  motor  disturbances.  The  symp- 
toms pass  away  and  the  nature  of  the  trouble  remains  doubtful,  jior  would 
suspicion  be  aroused  were  it  not  for  the  existence  of  other  cases.  It  is  inter- 


366  SPECIFIC  INFECTIOUS  DISEASES 

esting  to  note  that  Anderson  and  Frost  have  shown  the  presence  of  specific 
immune  bodies  in  the  blood  of  these  cases. 

(6)  COMMON  POLIOMYELITIC  OR  SPORADIC  TYPE. — The  paralysis  is  ab- 
rupt in  its  onset,  reaches  its  maximum  in  a  very  short  time,  showing  the 
irregularity  and  lack  of  symmetry  which  is  characteristic  of  the  disease.  One 
or  both  arms  may  be  affected,  or  one  arm  and  one  leg,  or  both  legs,  or  it  may 
be  the  right  leg  and  left  arm,  or  vice  versa.  In  the  arm  the  paralysis  is 
rarely  complete,  the  upper-arm  muscles  may  be  most  affected  or  the  lower- 
arm  group;  muscles  acting  functionally  together,  with  centres  near  each 
other  in  the  spinal  cord,  are  paralyzed  together.  In  this  type  the  bladder  and 
rectum  are  rarely  involved. 

(c)  PROGRESSIVE  ASCENDING  TYPE. — A  certain  number  of  cases,  par- 
ticularly in  epidemics,  run  a  course  similar  to  Landry's  paralysis,  with  which, 
no  doubt,  some  of  them  have  been  confounded.     The  disease  begins  in  the 
legs  with  the  usual  initial  symptoms,  the  paralysis  extends  upward,  involv- 
ing the  arms  and  the  trunk,  and  death  may  occur  with  bulbar  symptoms  from 
the  third  to  the  fifth  day.     In  the  Swedish  epidemic  of  1905  of  the  159  cases 
which  died  within  the  first  two  weeks,  45  presented  this  type. 

(d)  BULBAR  FORM. — It  has  long  been  known  that  occasionally  in  the 
ordinary  spinal  paralysis  of  children  the  cerebral  nerves  are  involved,  but 
in  the  epidemic  form  the  disease  may  begin  with  paralysis  of  the  ocular, 
facial,  lingual,  or  pharyngeal  muscles.     The  patient  has  fever,  and  the  local 
picture  depends  upon  the  extent  and  distribution  of  the  lesions  in  the  medulla 
and  pons.  In  the  1905  Swedish  epidemic  there  were  34  cases  in  which  the  cere- 
bral nerves  were  alone  involved,  and  in  the  New  York  epidemic  this  localiza- 
tion was  not  very  uncommon.     A  fatal  result  may  follow  extension  of  the 
bulbar  symptoms. 

(e)  MENINGITIC  FORM. — This  is  important,  as  the  cases  simulate  closely 
and  are  apt  to  be  mistaken  for  cerebro-spinal  fever.     The  picture  is  one  of 
an  acute  meningitis — headache,  pain  and  stiffness  in  the  neck,  vomiting,  pain 
and  rigidity  in  the  back,  drowsiness  and  unconsciousness.     The  disease  may 
begin  with  the  paralytic  features  and  subsequently  show  the  meningeal  com- 
plications.    Convulsions  and  Kernig's  sign  may  be  present.     A  serious  diffi- 
culty is  that  the  two  diseases  may  prevail  together,  and  only  the  careful  ex- 
amination of  the  cerebro-spinal  fluid  may  give  a  differential  diagnosis. 

(/)  CEREBRAL  TYPE. — Here  the  picture  is  that  which  we  have  learned  to 
recognize  as  the  acute  encephalitis  or  polio-encephalitis  of  children,  a  descrip- 
tion of  which  we  owe  to  von  Striimpell.  The  disease  sets  in  suddenly,  with 
fever,  vomiting  and  convulsions,  followed  by  paralysis  of  one  side  of  the  body 
or  one  limb.  Many  of  the  patients  die,  others  recover  and  present  the  usual 
after-picture  of  the  cerebral  hemiplegia  of  children.  A  large  proportion  of 
the  cases  of  this  disease  probably  represent  this  type  of  the  sporadic  form  of 
acute  infectious  polio-myelo-encephalitis. 

(g)  POLYNEURITIC  FORM. — Many  cases  of  the  ordinary  type,  a  majority, 
I  should  say,  of  the  sporadic  form,  are  painless.  It  is  one  of  the  features 
of  the  epidemic  form  that  the  patients  complain  much  more  of  pain.  This 
is  particularly  the  case  in  a  form  which  stimulates  a  polyneuritis.  There  is 
pain  in  the  affected  limbs,  particularly  on  movement,  with  tenderness  on 
pressure  along  the  nerves  and  on  pressing  the  muscles ;  the  paralysis  may 


ACUTE  POLIO-MYELITIS  3G7 

extend  like  neuritis,  involving  chiefly  the  peripheral  extensor  muscle  groups, 
and  be  followed  by  rapid  wasting. 

Diagnosis. — In  the  ordinary  spinal  sporadic  cases  there  is  rarely  any  diffi- 
culty. An  important  point  to  remember  is  that  in  periods  of  epidemic  preva- 
lence the  disease  presents  an  extraordinary  number  of  clinical  types.  Some 
cases  run  a  course  like  an  acute  infection,  others  have  the  picture  of  Landry's 
paralysis,  in  others  again  meningeal  symptoms  predominate,  or  there  may  be 
hyperaesthesia  and  pain,  with  the  picture  of  a  polyneuritis. 

It  seems  not  improbable  that  some  obscure  cases  of  meningitis  are  really 
instances  of  sporadic  poliomyelitis.  The  same  may  be  said  of  the  acute  en- 
cephalitis in  children  causing  hemiplegia.  The  extraordinary  complexity  of 
the  symptoms  makes  the  diagnosis  very  difficult,  so  that  we  must  look  for 
help  in  the  examination  of  the  blood  and  spinal  fluid  and  the  testing  the 
biological  reactions  of  immunity. 

If  lumbar  puncture  is  done  early  the  cerebro-spinal  fluid  may  be  slightly 
turbid.  The  fluid  contains  a  large  amount  of  protein  and  gives  a  positive 
reaction  to  Noguchi's  butyric  acid  test  for  globulin.  This  is  one  of  the 
earliest  features  and  reaches  its  maximum  just  before  paralysis  appears.  By 
this  some  abortive  cases  of  poliomyelitis  have  been  recognized.  In  general 
characters,  cytology  and  in  globulin  content  the  spinal  fluid  of  the  disease 
resembles  closely  that  in  tuberculous  meningitis  and  in  syphilitic  myelitis. 

Anomalous  forms  and  symptoms  are  common  during  the  prevalence  of  an 
epidemic.  The  muscles  of  respiration  may  be  involved  earl}',  the  diaphragm 
alone  may  be  paralyzed,  or  the  intercostals  or  the  muscles  of  the  palate  and 
pharynx.  Involvement  of  the  facial  muscles,  usually  a  slight  weakness,  may 
be  present,  but  in  5  out  of  90  cases  studied  by  F.  R.  Fraser  the  facial  muscles 
alone  were  involved.  In  one  instance  ptosis  was  the  only  paralytic  symptom 
on  admission.  Eemarkable  types  may  occur  quite  unlike  the  classical  picture. 
In  one  case  there  was  paralysis  of  one  side  of  the  soft  palate  with  slight  fever, 
the  serum  of  this  patient  protected  a  monkey  from  intra-cerebral  injection  of 
the  polio-myelitic  virus.  There  may  be  slight  fever  with  general  spasticity  of 
the  muscles  and  tremor  or  rigidity  of  the  muscles  with  coma. 

The  diagnosis  from  peripheral  neuritis  may  be  very  difficult;  in  both  the 
paralysis  is  of  the  legs,  with  wasting,  loss  of  reflexes,  and  the  bladder  and 
rectum  may  be  involved.  Loss  of  the  vibrating  sensation  tested  with  a  large 
tuning  fork  is  more  common  in  peripheral  neuritis,  and  later  the  electrical 
changes  and  the  action  of  degeneration  may  be  distinctive. 

Course. — After  the  acute  features  have  subsided  there  is  little  change  for 
two  or  three  weeks,  after  which  improvement  begins.  This  may  continue  for 
two  or  three  months.  The  atrophy  becomes  evident  in  a  few  weeks  from  the 
onset  of  the  attack.  The  affected  limbs  show  less  development  as  the  patient 
grows  older,  and  the  deformity  is  usually  most  marked  in  the  leg.  The  re- 
action of  degeneration  is  present  in  the  atrophied  muscles.  Early  in  the  course 
the  muscles  lose  the  faradic  response. 

Prognosis. — The  mortality  is  low,  ranging  in  different  epidemics  from 
4  to  15  per  cent.  The  fatal  cases  are  usually  of  the  ascending,  bulbar  and 
meningeal  types.  As  regards  the  muscles,  complete  loss  of  response  to 
faradism  means  severe  atrophy.  If  it  is  never  completely  lost  the  outlook  ig 
good  and  even  extensive  paralyses  may  disappear. 


368  SPECIFIC    INFECTIOUS    DISEASES 

Prophylaxis.— The  disease  has  been  made  notifiable.  The  patient  should 
be  isolated,  the  discharges  and  articles  used  by  patients  and  nurses  carefully 
disinfected,  and  special  care  should  be  taken  of  the  nasal  and  pharyngeal  dis- 
charges. It  does  not  seem  necessary  to  enforce  a  quarantine  against  those 
who  come  into  relation  with  the  patients,  but  the  throat  and  nose  of  such 
persons  should  be  disinfected  with  a  menthol  spray.  There  is  some  warrant 
for  the  administration  of  prophylactic  doses  of  hexamine. 

Treatment. — Hexamine  may  be  given  in  doses  of  gr.  v  to  xv  (0.3  to  1  gm.). 

When  the  fever  is  high  the  general  treatment  is  that  of  an  acute  infection. 
Aspirin  and  sedatives  for  the  pain  may  be  given.  Lumbar  puncture  has 
been  advised,  and  if  the  pressure  is  found  to  be  high  it  should  be  repeated. 
The  affected  limb  should  be  wrapped  in  cotton  wool,  and,  if  there  is  much 
pain,  local  sedative  applications  may  be  used.  In  the  meningeal  type  of  the 
disease  warm  baths  and  hot  packs  will  be  helpful.  In  the  early  stages  it  is 
well  not  to  attempt  to  do  much  to  the  muscles,  but  within  ten  days  careful 
massage  may  be  practiced,  using  either  lanolin  or  sweet  oil.  Strychnine 
hypodermically  has  been  extensively  used,  but  how  far  it  has  any  influence 
may  be  questioned.  It  should  not  be  given  early.  Electricity  may  be  used 
and  it  has  a  value  in  keeping  up  the  mitrition  of  the  muscles.  The  faradic 
current  should  be  employed  if  there  is  response,  if  not,  the  galvanic.  The 
damage  always  looks  to  be  much  worse  than  it  really  is,  as  many  of  the  symp- 
toms depend  on  meningeal  and  vascular  changes  which  undergo  resolution. 
A  curative  serum  has  not  yet  been  obtained. 

The  muscle  itself  as  a  factor  has  been  emphasized  by  William  MacKenzie 
of  Melbourne  (Brit.  Med.  Jour.  1915,  i)  as  biologically  it  is  all  important  in 
treatment.  The  disease  really  destroys  muscle  adjustments,  and  one  of  the 
first  things  to  do  is  to  place  the  muscle  at  physiological  rest  in  the  zero 
position,  in  which  it  is  itself  relaxed,  and  both  its  own  action,  and  that  of  its 
opponent  prevented.  Massage,  he  urges,  should  not  be  given  too  early,  until, 
for  example,  the  patient  can  elevate  the  upper  limb  when  sitting  up,  and  the 
heel  when  lying  on  the  back.  Persistent  gradual  re'-education  of  the  muscles 
yields  remarkable  results.  Passive  movements  may  be  used  and  with  toys  a 
child  may  be  encouraged  to  use  the  muscles  of  any  group  which  still  act.  The 
treatment  of  residual  deformities  is  a  question  of  orthopaedic  surgery. 


XII.    HYDROPHOBIA 

(Lyssa;  Rabies) 

Definition. — An  acute  disease  of  warm-blooded  animals,  dependent  upon 
a  virus  which  is  communicated  by  inoculation  to  man. 

Distribution. — Rabies  is  very  variously  distributed.  In  Eussia  it  is  com- 
mon. In  North  Germany  it  is  relatively  rare,  owing  to  the  wise  provision 
that  all  dogs  must  be  muzzled.  In  France  it  is  much  more  common.  In 
England  the  muzzling  order  has  been  followed  by  a  complete  disappearance 
of  the  disease  and  there  has  been  no  death  from  hydrophobia  since  1903.  In 
the  decennium- ending  with  1890  the  deaths  averaged  29  annually  (Tatham). 
In  the  United  States  the  disease  occurs  more  often  than  is  generally  supposed. 

Etiology. — Dogs  are  especially  liable  to  the  disease.     It  also  occurs  in 


HYDBOPHOBIA  369 

the  wolf,  fox,  skunk,  cat,  horse  and  cow.  Most  animals  are  susceptible ;  and 
it  is  communicable  by  inoculation  to  the  rabbit  and  pig.  The  disease  is  propa- 
gated chiefly  by  the  dog.  The  nature  of  the  poison  is  as  yet  unknown.  It  is  con- 
tained chiefly  in  the  nervous  system  and  is  met  with  in  some  of  the  secretions, 
particularly  in  the  saliva.  Bartarelli  has  shown  that  the  virus  reaches  the 
dog's  salivary  glands  by  way  of  the  nerves  and  not  through  the  blood-vessels. 

A  variable  time  elapses  between  the  introduction  of  the  virus  and  the 
appearance  of  the  symptoms.  Horsley  states  that  this  depends  upon  the  fol- 
lowing factors:  "(a)  Age.  The  incubation  is  shorter  in  children  than  in 
adults.  For  obvious  reasons  the  former  are  more  frequently  attacked.  (6) 
Part  infected.  The  rapidity  of  onset  of  the  symptoms  is  greatly  determined 
by  the  part  of  the  body  which  may  happen  to  have  been  bitten.  Wounds  about 
the  face  and  head  are  especially  dangerous;  next  in  order  in  degrees  of  mor- 
tality come  bites  on  the  hands,  then  injuries  on  the  other  parts  of  the  body. 
This  relative  order  is,  no  doubt,  greatly  dependent  upon  the  fact  that  the 
face,  head,  and  hands  are  usually  naked,  while  the  other  parts  are  clothed;  it 
would  also  appear  to  depend  somewhat  upon  the  richness  in  nerves  of  the 
part,  (c)  The  extent  and  severity  of  the  wound.  Puncture  wounds  are  the 
most  dangerous;  the  lacerations  are  fatal  in  proportion  to  the  extent  of  the 
surface  afforded  for  absorption  of  the  virus,  (d)  The  animal  conveying  the 
infection.  In  order  of  decreasing  severity  come:  first,  the  wolf;  second,  the 
cat;  third,  the  dog;  and  fourth,  other  animals."  Only  a  limited  number  of 
those  bitten  by  rabid  dogs  become  affected  by  the  disease;  according  to  Hors- 
ley, not  more  than  15  per  cent.  On  the  other  hand,  the  death-rate  of  those 
persons  bitten  by  wolves  is  higher,  not  less  than  40  per  cent.  Babes  gives 
the  mortality  as  from  60  to  80  per  cent. 

The  incubation  period  in  man  is  extremely  variable.  The  average  is  from 
six  weeks  to  two  months.  In  a  few  cases  it  has  been  under  two  weeks.  It 
may  be  prolonged  to  three  months.  It  is  stated  that  the  incubation  may  be 
prolonged  for  a  year  or  even  two  years,  but  this  has  not  been  definitely  settled. 

Morbid  Anatomy. — The  important  lesions  consist  in  the  accumulation  of 
leucocytes  around  the  blood-vessels  and  the  nerve-cells,  particularly  the  motor 
ganglion  cells,  of  the  central  nervous  system  (rabic  tubercles  of  Babes).  Es- 
pecial importance  in  the  rapid  diagnosis  of  rabies  is  attached  by  van  Gehuch- 
ten  and  Nelis  to  the  accumulation  of  lymphoid  and  endothelioid  cells  around 
nerve-cells  of  the  sympathetic  and  cerebro-spinal  ganglia.  Negri  described 
in  the  central  nervous  system  irregular  bodies  varying  from  4  to  10  microns  in 
size,  widespread,  frequently  in  the  cells  of  the  cerebellum,  cerebral  cortex  and 
pons,  and  in  the  spinal  cord.  They  are  probably  protozoa,  and  it  is  stated 
that  they  furnish  a  rapid  and  trustworthy  means  of  diagnosis.  The  inocula- 
tion experiments  show  that  the  virus  is  not  present  in  the  liver,  spleen,  or 
kidneys,  but  is  abundant  in  the  spinal  cord,  brain,  and  peripheral  nerves. 

Symptoms. — Three  stages  of  the  disease  are  recognized: 

(a)  PREMONITORY  STAGE,  in  which  there  may  be  irritation  about  the  bite, 
pain,  or  numbness.  The  patient  is  depressed  and  melancholy;  and  complains 
of  headache  and  loss  of  appetite.  He  is  very  irritable  and  sleepless,  and  has 
a  constant  sense  of  impending  danger.  There  is  often  greatly  increased  sensi- 
bility. A  bright  light  or  a  loud  voice  is  distressing.  The  larynx  may  be 
injected  and  the  first  symptoms  of  difficulty  in  swallowing  are  experienced. 


370  SPECIFIC  INFECTIOUS  DISEASES 

The  voice  also  becomes  husky.  There  is  a  slight  rise  in  the  temperature  and 
the  pulse. 

(6)  STAGE  OF  EXCITEMENT. — This  is  characterized  by  great  excitability 
and  restlessness,  and  an  extreme  degree  of  hypersesthesia.  "Any  afferent 
stimulant — i.  e.,  a  sound  or  a  draught  of  air,  or  the  mere  association  of  a 
verbal  suggestion — will  cause  a  violent  reflex  spasm.  In  man  this  symptom 
constitutes  the  most  distressing  feature  of  the  malady.  The  spasms,  which 
affect  particularly  the  muscles  of  the  larynx  and  mouth,  are  exceedingly  pain- 
ful and  are  accompanied  by  an  intense  sense  of  dyspnoea,  even  when  the  glottis 
is  widely  opened  or  tracheotomy  has  been  performed"  (Horsley).  Any 
attempt  to  take  water  is  followed  by  an  intensely  painful  spasm  of  the  mus- 
cles of  the  larynx  and  of  the  elevators  of  the  hyoid  bone.  It  is  this  which 
makes  the  patient  dread  the  very  sight  of  water  and  gives  the  name  hydro- 
phobia to  the  disease.  These  spasmodic  attacks  may  be  associated  with  mania- 
cal symptoms.  In  the  intervals  the  patient  is  quiet  and  the  mind  un- 
clouded. The  temperature  in  this  stage  is  usually  elevated  and  may  reach 
from  100°  to  103°.  In  some  instances  the  disease  is  afebrile.  The  patient 
rarely  attempts  to  injure  his  attendants,  and  in  the  intense  spasms  may  be 
particularly  anxious  to  avoid  hurting  any  one.  There  are,  however,  occa- 
sional fits  of  furious  mania,  and  the  patient  may,  in  the  contractions  of  the 
muscles  of  the  larynx  and  pharynx,  give  utterance  to  odd  sounds.  This 
stage  lasts  from  a  day  and  a  half  to  three  days  and  gradually  passes  into  the — 

(c)  PARALYTIC  STAGE. — In  rodents  the  preliminary  and  furious  stages 
are  absent,  as  a  rule,  and  the  paralytic  stage  may  be  marked  from  the  outset 
—the  so-called  dumb  rabies.  This  stage  rarely  lasts  longer  than  from  six  to 
eighteen  hours.  The  patient  then  becomes  quiet ;  the  spasms  no  longer  occur ; 
unconsciousness  gradually  supervenes;  the  heart's  action  becomes  more  and 
more  enfeebled,  and  death  occurs  by  syncope. 

Diagnosis. — In  man  the  diagnosis  offers  no  special  difficulties.  It  is  ad- 
visable, in  cases  attended  with  any  doubts,  as  soon  as  possible  after  the  in- 
jury has  been  inflicted,  to  secure  the  medulla  oblongata  of  the  supposed  rabid 
animal  for  the  purpose  of  inoculating  rabbits.  The  subdural  inoculation  of 
rabbits  with  a  small  quantity  of  the  central  nervous  system  of  a  rabid  animal 
will  be  followed  by  the  occurrence  of  the  paralytic  form  of  the  disease  in 
from  fifteen  to  twenty  days. 

Treatment. — Prophylaxis  is  of  the  greatest  importance,  and  by  a  system- 
atic muzzling  of  dogs  the  disease  can  be  practically  eradicated. 

In  case  of  a  bite  from  a  suspicious  animal,  bleeding  should  be  encouraged, 
the  wound  freely  opened  and  washed  with  bichloride  of  mercury  solution  (1 
to  1,000).  Thorough  cauterization  should  be  done  as  soon  as  possible,  for 
which  pure  carbolic  or  nitric  acid  should  be  used,  being  applied  to  every  part 
of  the  wound.  The  wound  is  washed  with  a  saturated  solution  of  bicarbonate 
of  soda  and  then  with  alcohol.  When  once  established  the  disease  is  hope- 
lessly incurable.  No  measures  have  been  found  of  the  slightest  avail,  conse- 
quently the  treatment  must  be  palliative.  The  patient  should  be  kept  in  a 
darkened  room,  in  charge  of  not  more  than  two  attendants.  To  allay  the 
spasm,  chloroform  may  be  administered  and  morphia  given  hypodermically. 
It  is  best  to  use  these  powerful  remedies  from  the  outset,  and  not  to  tem- 
porize with  chloral,  bromide  of  potassium,  and  other  less  potent  drugs.  By 


RHEUMATIC  FEVER  371 

the  local  application  of  cocaine,  the  sensitiveness  of  the  throat  may  be  dimin- 
ished sufficiently  to  enable  the  patient  to  take  liquid  nourishment.  Some- 
times he  can  swallow  readily.  Nutrient  enemata  should  be  administered. 

PREVENTIVE  INOCULATION. — Pasteur  found  that  the  virus,  when  propa- 
gated through  a  series  of  rabbits,  increases  in  its  virulence;  so  that  where- 
as subdural  inoculation  of  the  brain  of  a  mad  dog  takes  from  fifteen  to 
twenty  days  to  produce  the  disease,  in  successive  inoculation  in  a  series  of 
rabbits  the  incubation  period  is  gradually  reduced  to  seven  days  (virus  fixe). 
The  spinal  cords  of  these  rabbits  contain  the  virus  in  great  intensity,  but  when 
they  are  preserved  in  dry  air  this  gradually  diminishes.  If  now  dogs  are 
inoculated  from  cords  preserved  for  from  twelve  to  fifteen  days,  and  then 
from  cords  preserved  for  a  shorter  period,  i.  e.,  with  a  progressively  stronger 
virus,  they  gradually  acquire  immunity  against  the  disease.  A  dog  treated 
in  this  way  will  resist  inoculation  with  the  virus  fixe,  which  otherwise  would 
inevitably  have  proved  fatal.  Relying  upon  these  experiments,  Pasteur  began 
inoculations  in  the  human  subject,  using,  on  successive  days,  material  from 
cords  in  which  the  virus  was  of  varying  degrees  of  intensity. 

In  1910,  410  patients  were  treated  at  the  Pasteur  Institute  'of  Paris  with- 
out a  death;  in  1909,  467 'cases  and  one  death,  in  1908,  524  cases  and  one 
death.  There  has  been  a  progressive  decline  in  the  number  of  cases  and  in 
the  mortality. 

Pseudo-hydrophobia  (Lyssopliobia) . — This  is  a  very  interesting  affection, 
which  may  closely  resemble  hydrophobia,  but  is  really  nothing  more  than  a 
neurotic  or  hysterical  manifestation.  A  nervous  person  bitten  by  a  dog, 
either  rabid  or  supposed  to  be  rabid,  has  within  a  few  months,  or  even  later, 
symptoms  somewhat  resembling  the  true  disease.  He  is  irritable  and  de- 
pressed. He  constantly  declares  his  condition  to  be  serious  and  that  he  will 
inevitably  become  mad.  He  may  have  paroxysms  in  which  he  says  he  is 
unable  to  drink,  grasps  at  his  throat,  and  becomes  emotional.  The  temper- 
ature is  not  elevated  and  the  disease  does  not  progress.  It  lasts  much  longer 
than  the  true  rabies,  and  is  amenable  to  treatment.  It  is  not  improbable 
that  a  majority  of  the  cases  of  alleged  recovery  in  this  disease  have  been  of 
this  hysterical  form.  Certain  cases  of  acute  bulbar  paralysis  may  resemble 
hydrophobia,  and,  as  already  mentioned,  there  is  a  form  of  tetanus  with 
hydrophobic  symptoms. 

XIII.    RHEUMATIC  FEVER 

Definition. — An  acute  infection,  dependent  upon  an  unknown  infective 
agent,  and  characterized  by  multiple  arthritis  and  a  marked  tendency  to  in- 
flammation of  the  endocardium  of  the  valves  of  the  heart. 

Etiology. — DISTRIBUTION  AND  PREVALENCE. — It  prevails  in  temperate 
and  humid  climates.  Church  has  collected  interesting  statistics  on  this  point. 
Oddly  enough,  the.  two  countries  with  the  highest  admission  in  the  British 
army  per  thousand  of  strength — Egypt,  7.02,  and  Canada,  6.26 — have  climates 
the  most  diverse.  In  the  Registrar  General's  report  for  England  and  "Wales 
for  1909  there  were  1,970  deaths  from  the  disease,  but  rheumatic  fever  has 
a  long  arm  and  no  small  proportion  of  the  50,918  deaths  from  diseases  of  the 
heart  is  to  be  laid  at  its  door.  The  disease  prevails  more  in  the  northern  lati- 


372  SPECIFIC  INFECTIOUS  DISEASES 

tildes.  In  the  Montreal  General  Hospital  there  were,  for  the  twelve  years 
ending  1903,  2  deaths  in  482  cases  among  12,044  admissions;  at  the  Royal 
Victoria  Hospital,  Montreal,  for  ten  years  ending  1903,  3  deaths  in  285  cases 
among  9,286  admissions  (John  McCrae).  At  the  Johns  Hopkins  Hospital 
for  the  fifteen  years  ending  1904  there  were  360  admissions  (330  patients) 
and  9  deaths  (T.  McCrae)).  The  general  impression  is  that  the  disease  pre- 
vails more  in  the  British  Isles  than  elsewhere;  hut,  as  Church  remarks,  the 
returns  are  very  imperfect  (this  holds  good  everywhere).  In  Norway,  where 
cases  of  rheumatic  fever  are  notified.,  there  were,  for  the  four  years  1888-'92, 
13,654  cases,  with  250  deaths. 

SEASON. — In  London  the  cases  reach  the  maximum  in  the  months  of  Sep- 
tember and  October.  In  the  Montreal  General  Hospital  Bell's  statistics  of 
456  cases  show  that  the  largest  number  was  admitted  in  February,  March, 
and  April.  And  the  same  is  true  in  Baltimore ;  55  per  cent,  of  our  cases  were 
admitted  in  the  first  four  months  of  the  year  (McCrae).  The  disease  pre- 
vails most  in  the  dry  years  or  a  succession  of  such,  and  is  specially  prevalent 
when  the  subsoil  water  is  abnormally  low  and  the  temperature  of  the  earth 
high  (Newsholme). 

AGE. — Young  adults  are  most  frequently  affected,  but  the  disease  is  by 
no  means  uncommon  in  children.  In  England  the  incidence  in  children  is 
very  high.  In  2,556  examined  by  Langmead,  133  were  definitely  rheumatic 
and  in  all  but  18  the  heart  was  involved.  In  43  per  cent,  of  these  cases  there 
was  some  abnormality  of  the  tonsils  or  pharyngeal  mucosa.  Sucklings  are 
rarely  attacked.  Milton  Miller  has  analyzed  19  undoubted  cases.  The 
cases  have  to  be  distinguished  from  a  totally  different  affection,  the  pyo- 
genic  arthritis  of  infants.  Of  456  cases  admitted  to  the  Montreal  General 
Hospital  there  were,  under  fifteen  years,  4.38  per  cent. ;  from  fifteen  to  twenty- 
five  years,  48.68  per  cent.;  from  twenty-five  to  thirty-five  years,  25.87  per 
cent.;  from  thirty-five  to  forty-five  years,  13.6  per  cent.;  above  forty-five 
years,  7.4  per  cent.  Of  our  360  admissions,  110  werje  in  the  third  decade  and 
65  per  cent,  below  the  thirtieth  year  of  age  (McCrae).  Ten  per  cent,  of  the 
cases  had  the  first  attack  in  the  first  decade.  Of  the  655  cases  analyzed  by 
Whipham  for  the  Collective  Investigation  Committee  of  the  British  Medi- 
cal Association,  only  32  cases  occurred  under  the  tenth  year  and  80  per 
cent,  between  the  twentieth  and  fortieth  years.  These  figures  do  not  give 
the  ratio  of  cases  in  children,  in  whom  the  milder  types  of  arthritis  are  very 
common. 

SEX. — If  all  ages  are  taken,  males  are  affected  oftener  than  females.  Of 
our  patients,  239  were  males,  91  females.  In  the  Collective  Investigation  Re- 
port there  were  375  males  and  279  females.  Up  to  the  age  of  twenty,  how- 
ever, females  predominate.  Between  the  ages  of  ten  and  fifteen  girls  are  more 
prone  to  the  disease. 

HEREDITY. — It  is  a  deeply  grounded  belief  with  the  public  and  the  pro- 
fession that  rheumatism  is  a  family  disease,  but  Church  thinks  the  evidence 
is  still  imperfect.  In  25  per  cent,  of  our  cases  there  was  a  history  of  the  dis- 
ease in  the  family.  The  not  rare  occurrence  in  several  members  of  the  same 
family  is  used  by  those  who  believe  in  the  infectious  origin  as  an  argument 
in  favor  of  its  being  a  house  disease. 

CHILL. — Exposure  to  cold,  a  wetting,  or  a  sudden  change  of  temperature 


RHEUMATIC  FEVER  373 

are  among  the  factors  in  determining  the  onset  of 'an  attack,  but  they  were 
present  in  only  12  per  cent,  of  our  cases. 

Not  only  does  an  attack  not  confer  IMMUNITY,  but,  as  in  pneumonia,  pre- 
disposes the  subject  to  the  disease. 

Rheumatic  Fever  as  an  Acute  Infectious  Disease.— Rheumatic  fever,  as 
Newsholme  has  shown,  has  epidemic  prevalence  with  irregular  periodicity,  re- 
curring at  intervals  of  three,  four,  or  six  years,  and  varying  much  in  inten- 
sity. A  severe  epidemic  is  usually  followed  by  two  or  three  years  of  slight 
prevalence. 

The  disease  has  many  features  suggestive  of  septic  infection.  As  Church 
points  out,  the  curves  of  the  mortality  statistics  approximate  nearly  to  those 
of  pyaemia,  puerperal  fever,  and  erysipelas.  In  the  character  of  the  fever, 
the  mode  of  involvement  of  the  joints,  the  tendency  to  relapse,  the  sweats,  the 
anaemia,  the  leucocytosis,  and,  above  all,  in  the  great  liability  to  endocarditis, 
and  to  involvement  of  the  serous  membranes,  the  disease  resembles  pyaemia 
very  closely. 

The  nature  of  the  specific  germ  is  still  under  discussion.  Mantle  in  1887 
obtained  a  micrococcus  from  the  fluid  of  the  joints  and  from  the  blood;  since 
which  time  many  observers  have  described  forms  of  staphyloeoeci,  strepto- 
cocci and  various  organisms.  The  work  of  Poynton  and  Payne,  Walker, 
Beattie  and  others  shows  that  from  the  joint  fluid,  the  throat  and  the  endo- 
cardial  vegetations,  and  sometimes  from  the  blood,  organisms  may  be  ob- 
tained which,  inoculated  into  animals,  cause  a  condition  very  similar 
to  that  of  acute  rheumatic  fever,  with  arthritis,  endocarditis,  and  even  the 
fibrous  nodules.  The  difficulty  is  that  the  organisms  described  do  not  coin- 
cide, and  Cole  in  a  series  of  cases  in  my  clinic  at  the  Johns  Hopkins  Hospital 
with  the  strains  of  streptococci  from  various  sources  was  able  to  produce 
experimentally  endocarditis  and  arthritis.  But  Beattie  claims  that  the  lesions 
produced  by  his  Micrococcus  rheumaticus  are  different.  A  point  of  interest 
is  the  fact  that  with  his  germ  Ainley  Walker  obtained  formic  acid  in  the 
cultures. 

The  tonsils  are  culture  centres  for  many  septic  organisms,  particularly 
of  the  streptococcus  type.  The  association  of  rheumatic  fever  and  rheumatic 
affections  generally  with  infected  tonsils  is  a  prevailing  view,  but  it  is  an 
old  story  insisted  on  by  Lasague  and  other  French  writers  years  ago.  A  not 
inconsiderable  number  of  cases  of  rheumatic  fever  begin  with  tonsillitis.  With 
organisms  isolated  from  the  tonsils  experimental  arthritis  and  endocarditis 
have  been  caused.  The  removal  of  the  tonsils  has  been  followed  by  a  com- 
plete recovery  of  sub-acute  and  chronic  forms  of  arthritis.  This  is  as  far 
as  the  evidence  goes. 

There  is  considerable  evidence  against  the  view  that  it  is  simply  a  mild 
pyogenic  infection.  Salicylates  have  no  effect  on  the  ordinary  streptococcus 
infections,  and  the  clinical  course  in  the  streptococcus  arthritis  is  very  differ- 
ent; moreover,  rheumatic  joints  never  suppurate.  The  isolation  of  strepto- 
cocci may  simply  indicate  the  presence  of  secondary  invaders  such  as  occur 
in  scarlet  fever  and  small-pox. 

Morbid  Anatomy. — There  are  no  characteristic  changes.  The  affected 
joints  show  hypersemia  and  swelling  of  the  synovial  membranes  and  of  the 
ligimentous  tissues.  The  fluid  in  the  joint  is  turbid,  albuminous  in  char- 


374  SPECIFIC  INFECTIOUS  DISEASES 

acter,  and  contains  leucocytes  and  a  few  fibrin  flakes.  Rheumatic  fever 
rarely  proves  fatal,  except  when  there  are  serious  complications,  such  as  peri- 
carditis, endocarditis,  myocarditis,  pleurisy,  or  pneumonia.  The  conditions 
found  show  nothing  to  distinguish  them  from  other  forms  of  inflammation. 
In  death  from  hyperpyrexia  no  special  changes  are  found.  The  blood  usu- 
ally contains  an  excessive  amount  of  fibrin. 

Symptoms. — As  a  rule,  the  disease  sets  in  abruptly,  but  it  may  be  preceded 
by  irregular  pains  in  the  joints,  slight  malaise,,  sore  throat,  and  particularly  by 
tonsillitis.  A  definite  rigor  is  uncommon;  more  often  there  is  slight  chilli- 
ness. The  fever  rises  quickly,  and  with  it  one  or  more  of  the  joints  become 
painful.  Within  twenty-four  hours  from  the  onset  the  disease  is  fully  mani- 
fest. The  temperature  range  is  from  102°  to  104°.  The  pulse  is  frequent, 
soft,  and  usually  above  100.  The  tongue  is  moist,  and  rapidly  becomes  cov- 
ered with  a  white  fur.  There  are  the  ordinary  symptoms  associated  with  an 
acute  fever,  such  as  loss  of  appetite,  thirst,  constipation,  and  a  scanty,  highly 
acid,  highly  colored  urine.  In  a  majority  of  the  cases  there  are  profuse,  very 
acid  sweats,  'of  a  peculiar  sour  odor.  Sudaminal  and  miliary  vesicles  are 
abundant,  the  latter  usually  surrounded  by  a  minute  ring  of  hyperaemia.  The 
mind  is  clear,  except  in  the  cases  with  hyperpyrexia.  The  affected  joints  are 
painful  to  move,  soon  become  swollen  and  hot,  and  present  a  reddish  flush. 
The  order  of  frequency  of  involvement  of  the  joints  in  our  series  was  knee, 
ankle,  shoulder,  wrist,  elbow,  hip,  hand,  foot.  The  joints  are  not  attacked 
together,  but  successively.  For  example,  if  the  knee  is  first  affected,  the  red- 
ness may  disappear  from  it  as  the  wrists  become  painful  and  hot.  The  dis- 
ease is  seldom  limited  to  a  single  articulation.  The  amount  of  swelling  is 
variable.  Extensive  effusion  into  a  joint  is  rare,  and  much  of  the  enlarge- 
ment is  due  to  the  infiltration  of  the  periarticular  tissues  with  serum.  The 
swelling  may  be  limited  to  the  joint  proper,  but  in  the  wrists  and  ankles  it 
sometimes  involves  the  sheaths  of  the  tendons  and  produces  great  enlargement 
of  the  hands  and  feet.  Corresponding  joints  are  often  affected.  In  attacks 
of  great  severity  every  one  of  the  larger  joints  maybe  involved.  The  verte- 
bral, sterno-clavicular,  and  phalangeal  articulations  are  less  often  inflamed 
than  in  gonorrhceal  arthritis.  Perhaps  no  disease  is  more  painful;  the  inabil- 
ity to  change  the  posture  without  agonizing  pain,  the  drenching  sweats,  the 
prostration  and  utter  helplessness,  combine  to  make  it  one  of  the  most  dis- 
tressing of  febrile  affections.  A  special  feature  is  the  tendency  of  the  in- 
flammation to  subside  in  one  joint  while  increasing  with  great  intensity  in 
another. 

The  temperature  range  in  an  ordinary  attack  is  between  102°  and  104°  F. 
In  only  18  of  our  cases  did  the  temperature  rise  above  104°  F.  In  100  it 
reached  103°  F.  or  over.  It  is  peculiarly  irregular,  with  marked  remissions 
and  exacerbations,  and  defervescence  is  usually  gradual.  The  profuse  sweats 
materially  influence  the  temperature  curve.  If  a  two-hourly  chart  is  made 
and  observations  upon  the  sweats  are  noted,  the  remissions  will  usually  be 
found  coincident  with  them.  The  perspiration  is  sour-smelling  and  acid  at 
first;  but,  when  persistent,  becomes  neutral  or  even  alkaline. 

The  blood  is  profoundly  altered  and  there  is  no  acute  febrile  disease  in 
which  an  ana?mia  occurs  with  greater  rapidity.  The  average  leucocyte  count 
in  our  cases  was  about  12,000  per  c.  mm.  • 


RHEUMATIC  FEVER  375 

With  the  high  fever  a  murmur  may  often  be  heard  at  the  apex  region. 
Endocarditis  is  also  a  common  cause  of  an  apex  bruit.  The  heart  should  be 
carefully  examined  at  the  first  visit  and  subsequently  each  day. 

The  urine  is,  as  a  rule,  reduced  in  amount,  of  high  density  and  high  color. 
It  is  very  acid,  and,  on  cooling,  deposits  urates.  The  chlorides  may  be  greatly 
diminished  or  even  absent.  Formic  acid  is  present  (Walker).  Febrile  albu- 
minuria  is  not  uncommon. 

The  so-called  subacute  rheumatism  represents  a  milder  form  of  the  dis- 
ease, in  which  all  the  symptoms  are  less  pronounced.  The  fever  rarely  rises 
above  101°;  fewer  joints  are  involved;  and  the  arthritis  is  less  intense.  The 
cases  may  drag  on  for  weeks  or  months.  It  should  not  be  forgotten  that  this 
mild  or  subacute  form  may  be  associated  with  endocarditis  or  pericarditis. 

The  influence  of  age  on  the  manifestations  of  the  disease  is  marked. 
While  the  usual  description  applies  to  the  disease  as  seen  in  adults,  in  young 
children  there  may  not  be  any  pronounced  arthritis,  and  the  discovery  of 
endocarditis  often  suggests  the  diagnosis.  Endocarditis  is  as  much  a  feature 
in  children  as  arthritis  in  adults. 

Complications. — These  are  important  and  serious. 

(a)  HYPEEPYREXIA. — The  temperature  may  rise  rapidly  a  few  days  after 
the  onset,  and  be  associated  with  delirium;  but  not  necessarily,  for  the  tem- 
perature may  rise  to  108°  or,  as  in  one  of  Da  Costa's  cases,  110°,  without 
cerebral  symptoms.  Hyperpyrexia  is  most  common  in  first  attacks,  57  of  107 
cases  (Church).  It  is  most  apt  to  occur  during  the  second  week.  Delirium 
may  precede  or  follow  its  onset.  As  a  rule,  with  the  high  fever,  the  pulse  is 
feeble  and  frequent,  the  prostration  is  extreme,  and  finally  stupor  super- 
venes. In  our  series  there  was  no  instance  of  hyperpyrexia,  which  seems  rare 
in  the  United  States. 

(&)  CARDIAC  AFFECTIONS. —  (1)  Endocarditis,  the  most  frequent  and 
serious  complication,  occurs  in  a  considerable  percentage  of  all  cases.  Of  889 
cases,  494  had  signs  of  old  or  recent  endocarditis  (Church).  The  liability  to 
endocarditis  diminishes  as  age  advances.  The  incidence  of  organic  disease  in 
our  cases  was  more  than  double  in  patients  who  had  their  first  attack  before 
the  age  of  twenty  years,  compared  with  those  with  the  first  attack  after 
twenty  years  of  age.  It  increases  directly  with  the  number  of  attacks.  Of 
116  cases,  in  the  first  attack  58.1  per  cent,  had  endocarditis,  63  per  cent,  in 
the  second  attack,  and  71  per  cent,  in  the  third  attack  (Stephen  Mackenzie). 
Thirty-five  per  cent,  of  our  cases  showed  organic  valve  lesions,  in  96  per  cent, 
the  mitral  was  involved,  in  27  per  cent,  the  aortic,  and  in  23  per  cent,  the 
lesions  were  combined.  The  mitral  segments  are  most  frequently  involved 
and  the  affection  is  usually  of  the  simple,  verrucose  variety.  Ulcerative  endo- 
carditis is  very  rare.  Of  209  cases  of  this  disease  which  I  analyzed,  in  only 
24  did  the  symptoms  of  a  severe  endocarditis  arise  during  the  progress  of 
acute  or  subacute  rheumatism.  The  valvulitis  in  itself  is  rarely  dangerous, 
producing  few  symptoms,  and  is  often  overlooked.  Unhappily,  though  the 
valve  at  the  time  may  not  be  seriously  damaged,  the  inflammation  starts 
changes  which  lead  to  sclerosis  and  retraction  of  the  segments,  and  so  to 
chronic  valvular  disease.  Venous  thrombosis  is  an  occasional  complication. 

(2)  Pericarditis  may  occur  independently  of  or  together  with  endocar- 
ditis. It  may  be  simple  fibrinous,  sero-fibrinous,  or  in  children  purulent. 


376  SPECIFIC  INFECTIOUS  DISEASES 

Clinically  we  meet  it  more  frequently  in  connection  with  this  disease  than 
in  any  other  acute  affection.  It  was  present  in  20  cases  of  our  series — 6  per 
cent. — in  only  four  of  which  did  effusion  occur.  The  physical  signs  are  very 
characteristic.  The  condition  will  be  fully  described  under  its  appropriate 
section.  A  peculiar  form  of  delirium  may  accompany  rheumatic  pericar- 
ditis. 

(3)  Myocarditis  occurs  frequently  and  especially  in  connection  with  endo- 
pericardial  changes.  As  Sturges  insisted,  the  term  carditis  is  applicable  to 
many  cases.  The  anatomical  condition  is  a  granular  or  fatty  degeneration  of 
the  heart-muscle,  which  leads  to  weakening  of  the  walls  and  to  dilatation. 
S.  West  has  reported  instances  of  acute  dilatation  of  the  heart  in  rheumatic 
fever,  in  one  of  which  marked  fatty  changes  were  found  in  the  heart-fibres. 

(c)  PULMONARY  AFFECTIONS. — Pneumonia  and  pleurisy  occurred  in  9.94 
per  cent,  of  3,433  cases  (Stephen  Mackenzie).     They  frequently  accompany 
the  cases  of  endo-pericarditis.     According  to  Howard's  analysis  of  a  large 
number  of  cases,  there  were  pulmonary  complications  in  only  10.5  per  cent, 
of  cases  of  rheumatic  endocarditis;  in  58  per  cent,  of  cases  of  pericarditis;  and 
in  71  per  cent,  of  cases  of  endo-pericarditis.     Congestion  of  the  lung  is  occa- 
sionally found,  and  in  several  cases  has  proved  rapidly  fatal. 

(d)  NERVOUS  COMPLICATIONS. — These  are  due,  in  part,  to  the  hyper- 
pyrexia  and  in  part  to  the  special  action  of  the  toxic  agent  of  the  disease. 
They  may  be  grouped  as  follows:    (i)  Cerebral  rheumatism,  as  it  is  called, 
which  is  characterized  by  (a)  Delirium,  which  is  associated  with  the  hyper- 
pyrexia  or  the  toxaemia,  may  be  active  and  noisy  in  character;  more  rarely  it 
is  a  low,  muttering  delirium,  passing  into  stupor  and  coma.     It  may  be  ex- 
cited by  the  salicylate  of  soda,  either  shortly  after  its  administration,  or  more 
commonly  a  few  days  later.    It  was  present  in  only  five  of  our  360  cases,  and 
in  four  of  these  we  thought  the  salicylates  at  fault.     A  peculiar  delirium  occurs 
in  connection  with  rheumatic  pericarditis.     (j8)  Coma,  which  is  more  serious, 
may  occur  without  preliminary  delirium  or  convulsions,  and  may  prove  Tapidly 
fatal.     Certain  of  these  cases  are  associated  with  hyperpyrexia ;  but  Southey 
has  reported  the  case  of  a  girl  who,  without  previous  delirium  or  high  fever, 
became  comatose,  and  died  in  less  than  an  hour.     A  certain  number  of  such 
cases,  as  those  reported  by  Da  Costa,  have  been  associated  with  marked  renal 
changes  and  were  evidently  uraemic.     The  coma  may  supervene  during  the 
attack,  or  after  convalescence  has  set  in.     (y)  Convulsions  are  less  common, 
though  they  may  precede  the  coma.     Of  127  observations  cited  by  Besnier, 
there  were  37  of  delirium,  only  7  of  convulsions,  17  of  coma  and  convulsions, 
54  of  delirium,  coma,  and  convulsions,  and  3  of  other  varieties  (Howard). 
"Cerebral  rheumatism"  is  a  very  serious  complication;  among  107  cases  col- 
lected by  the  Clinical  Society  of  London  there  were  57  deaths,     (ii)  Chorea. 
The  relations  of  this  disease  and  rheumatism  will  be  subsequently  discussed. 
It  is  sufficient  here  to  say  that  in  only  88  out  of  554  cases  which  I  have  an- 
alyzed from  the  Infirmary  for  Diseases  of  the  Nervous  System,  Philadelphia, 
were  chorea  and  rheumatism  associated.     It  is  most  apt  to  develop  in  the 
slighter  attacks  in  childhood.     (Hi)  Meningitis  is  extremely  rare,  though  un- 
doubtedly it  does  occur.     It  must  not  be  forgotten  that  in  ulcerative  endo- 
carditis, which  is  occasionally  associated  with  rheumatic  fever,  meningitis  is 
frequent,     (iv)   Poly  neuritis  has  been  described.     I  saw  a  remarkable  case 


RHEUMATIC  FEVER  377 

which  followed  hyperpyrexia.  Free  venesection  saved  the  patient's  life.  After 
many  months  the  patient  recovered,  but  with  ataxia. 

(e)  CUTANEOUS  AFFECTIONS. — Sweat-vesicles  have  already  been  men- 
tioned as  extremely  common.  A  red  miliary  rash  may  also  develop.  Scarla- 
tiniform  eruptions  are  occasionally  seen.  Purpura,  with  or  without  urticaria, 
may  occur,  and  various  forms  of  erythema.  It  is  doubtful  whether  the  cases 
of  extensive  purpura  with  urticaria  and  arthritis — peliosis  rheumatica — belong 
truly  to  rheumatic  fever. 

(/)  RHEUMATIC  MODULES. — These  curious  structures,  described  originally 
by  Meynet,  occur  in  the  form  of  small  subcutaneous  nodules  attached  to  the 
tendons  and  fascia?.  Barlow  and  Warner,  in  England,  and  T.  B.  Futcher,  in 
the  United  States,  have  paid  special  attention  to  their  varieties  and  impor- 
tance. They  vary  in  size  from  a  small  shot  to  a  large  pea,  and  are  most 
numerous  on  the  fingers,  hands,  and  wrists.  They  also  occur  about  the  elbows, 
knees,  the  spines  of  the  vertebra?,  and  the  scapulae.  They  are  not  often  tender. 
They  are  more  common  after  the  decline  of  the  fever  and  in  the  children  with 
mitral  valve  disease.  In  only  5  of  our  patients  were  they  present  during  the 
acute  attack.  The  nodules  may  grow  with  great  rapidity  and  usually  last  for 
weeks  or  months.  They  are  more  common  in  children  than  in  adults,  and  in 
the  former  their  presence  may  be  regarded  as  a  positive  indication  of  rheuma- 
tism. They  have  been  noted  particularly  in  association  with  chronic  rheumatic 
endocarditis.  Subcutaneous  nodules  occur  also  in  migraine,  gout,  and  arthri- 
tis deformans.  Histologically  they  are  made  up  of  round  and  spindle-shaped 
cells.  In  addition  to  these  firm,  hard  nodules,  there  occur  in  rheumatism  and 
in  chronic  vegetative  endocarditis  remarkable  bodies,  which  have  been  called 
by  Fereol  "nodosites  cutanees  ephemeres." 

Course. — The  course  of  rheumatic  fever  is  extremely  variable.  It  is,  as 
Austin  Flint  first  showed,  a  self-limited  disease,  and  it  is  not  probable  that 
medicines  have  any  special  influence  upon  its  duration  or  course.  Gull  and 
Sutton,  who  likewise  studied  a  series  of  62  cases  without  special  treatment, 
arrived  at  the  same  conclusion. 

Prognosis.  — Rheumatic  fever  is  the  most  serious  of  all  diseases  with  a  low 
death-rate.  The  mortality  is  rarely  above  2  or  3  per  cent.  Only  9  of  our  330 
patients  died,  2.7  per  cent.,  all  with  endocarditis  and  6  with  pericarditis. 

Sudden  death  in  rheumatic  fever  is  due  most  frequently  to  myocarditis. 
Herringham  has  reported  a  case  in  which  on  the  fourteenth  day  there  was 
fatty  degeneration  and  acute  inflammation  of  the  myocardium.  In  a  few  rare 
cases  it  results  from  embolism.  Alarming  symptoms  of  depression  sometimes 
follow  excessive  doses  of  the  salicylate  of  soda. 

Diagnosis. — Practically,  the  recognition  of  rheumatic  fever  is  usually  easy; 
but  there  are  several  affections  which,  in  some  particulars,  closely  resemble  it. 

(a)  MULTIPLE  SECONDARY  ARTHRITIS. — Under  this  term  may  be  em- 
braced the  various  forms  of  arthritis  which  come  on  or  follow  in  the  course  of 
gonorrhoea,  tonsillitis,  scarlet  fever,  dysentery,  and  cerebro-spinal  menin- 
gitis. 

(&)  SEPTIC  ARTHRITIS,  which  occurs  in  the  course  of  pyaemia  from  any 
cause,  and  particularly  in  puerperal  fever.  No  hard  and  fast  line  can 
be  drawn  between  these  and  the  cases  in  the  first  group:  but  the  in- 
flammation rapidly  passes  on  to  suppuration  and  there  is  more  or  less  destruc- 
26 


378  SPECIFIC  INFECTIOUS  DISEASES 

tion  of  the  joints.  The  conditions  under  which  the  arthritis  occurs  give  a 
clew  at  once  to  the  nature  of  the  case.  Under  this  section  may  also  be  men- 
tioned : 

(1)  Acute  necrosis  or  acute  osteo-myelitis,  occurring  in  the  lower  end  of 
the  femur,  or  in  the  tibia,  and  which  may  be  mistaken  for  rheumatic  fever 
Sometimes,  too,  it  is  multiple.     The  greater  intensity  of  the  local  symptoms, 
the  involvement  of  the  epiphyses  rather  than  the  joints,  and  the  more  serious 
constitutional  disturbances  are  points  to  be  considered.     The  condition  is 
unfortunately  often  mistaken  for  acute  arthritis,  and,  as  the  treatment  is 
essentially  surgical,  the  error  may  cost  the  life  of  the  patient. 

(2)  The  acute  arthritis  of  infants  is  usually  confined  to  one  joint  (the  hip 
or  knee),  the  effusion  in  which  rapidly  becomes  purulent.     The  affection  is 
most  common  in  sucklings  and  undoubtedly  pyaemic  in  character.    It  may  also 
occur  with  the  gonorrhoeal  ophthalmia  or  vaginitis  of  the  new-born,  as  pointed 
out  by  Clement  Lucas. 

(c)  GOUT. — While  the  localization  in  a  single,  usually  a  small,  joint,  the 
age,  the  history,  and  the  mode  of  onset  are  features  which  enable  us  to  recog- 
nize acute  gout,  there  are  everywhere  many  cases  of  acute  arthritis,  called 
rheumatic  fever,  which  are  in  reality  gout.     The  involvement  of  several  of 
the  larger  joints  is  not  so  infrequent  in  gout,  and  unless  tophi  are  present, 
or  unless  a  very  accurate  analysis  of  the  urine  is  made,  the  diagnosis  may  be 
difficult. 

(d)  ACUTE  ARTHRITIS  DEFORMANS. — In  several  cases  I  have  mistaken 
this  form  for  rheumatic  fever.     It  may  come  on  with  fever  and  multiple  arthri- 
tis, and  for  weeks  there  may  be  no  suspicion  of  the  true  nature  of  the  disease. 
Gradually  the  fever  subsides,  but  the  periarticular  thickening  persists.     As  a 
rule,  however,  in  the  acute  febrile  cases  the  involvement  of  the  smaller  joints, 
the  persistence  and  the  early  changes  in  the  articulations  suggest  arthritis 
deformans. 

In  children  the  diagnosis  may  be  very  difficult,  as  arthritis  may  be  slight 
or  entirely  absent.  The  possibility  of  rheumatic  fever  should  be  considered  in 
all  febrile  attacks  in  children  for  which  no  definite  cause  can  be  found.  Spe- 
cial care  should  be  given  to  the  examination  of  the  heart. 

Treatment. — The  main  object  should  be  to  bring  the  patient  through  the 
attack  with  an  undamaged  heart  or  with  as  little  injury  as  possible.  The  first 
essential  is  complete  rest,  which  should  be  begun  at  once  and  insisted  upon 
for  as  long  as  is  necessary.  This  is  especially  important  for  children.  The 
bed  should  have  a  smooth,  soft,  yet  elastic,  mattress.  The  patient  should 
wear  a  flannel  nightgown,  which  may  be  opened  all  the  way  down  the  front 
and  slit  along  the  outer  margin  of  the  sleeves.  Three  or  four  of  these  should 
be  made,  so  as  to  facilitate  the  frequent  changes  required  after  the  sweats. 
He  may  wear  also  a  light  flannel  cape  about  the  shoulders.  He  should  sleep 
in  blankets,  not  in  sheets,  so  as  to  reduce  the  liability  to  catch  cold  and  obviate 
the  unpleasant  clamminess  consequent  upon  heavy  sweating.  Chambers  in- 
sisted that  the  liability  to  endocarditis  and  pericarditis  was  much  reduced 
when  the  patients  were  in  blankets. 

Milk  is  the  most  suitable  diet  and  may  be  diluted  with  alkaline  mineral 
•waters.  Lemonade  and  oatmeal  or  barley  water  should  be  freely  given.  The 
thirst  is  usually  great  and  may  be  fully  satisfied.  There  is  no  objection  to 


RHEUMATIC  FEVER  379 

broths  and  soups  if  the  milk  is  not  well  borne.  As  convalescence  is  established 
a  fuller  diet  may  be  allowed,  but  meat  should  be  used  sparingly. 

Local  treatment  is  usually  necessary.  It  often  suffices  to  wrap  the  affected 
joints  in  cotton.  If  the  pain  is  severe,  hot  cloths  may  be  applied,  saturated 
with  Fuller's  lotion  (carbonate  of  soda,  6  drachms;  laudanum,  1  oz. ;  glycerine, 
2  oz. ;  and  water,  9  oz.)  or  the  lead  and  opium  lotion.  Oil  of  wintergreen  is 
useful,  the  joint  being  gently  rubbed  with  it  or  small  amounts  sprinkled  over 
flannel,  which  is  then  applied.  Chloroform  liniment  is  also  a  good  applica- 
tion. Fixation  of  the  joints  is  of  great  service  in  allaying  the  pain.  Splints, 
padded  and  bandaged  with  moderate  firmness,  will  often  be  found  to  give 
comfort.  Friction  is  rarely  well  borne  in  an  acutely  inflamed  joint.  Cold 
compresses  are  much  used  in  Germany.  The  application  of  blisters  above  and 
below  the  joint  often  relieves  the  pain.  This  method,  which  was  used  so  much 
a  few  years  ago,  is  not  to  be  compared  with  the  light  application  of  the  Paque- 
lin  cautery.  If  there  is  much  effusion,  aspiration  of  the  joint  is  useful. 

The  drug  treatment  is  still  far  from  satisfactory,  though  the  introduction 
of  the  salicyl  compounds  has  been  a  great  boon. 

TREATMENT  WITH  THE  SALICYL  COMPOUNDS. — Salicin,  introduced  in  1876 
by  Maclagan,  may  be  used  in  doses  of  20  grains  every  hour  or  two  until  the 
pain  is  relieved.  It  has  the  advantage  of  being  less  depressing  than  the 
salicylate  of  soda.  It  is  also  perhaps  the  best  drug  to  use  for  children.  Sali- 
cylic acid,  15  grains  (1  gm.),  may  be  given  every  two  hours  in  acute  cases 
until  the  pain  is  relieved.  It  is  best  given  in  capsules.  Salicylate  of  soda,  15 
grain  doses  every  three  hours,  is  perhaps  the  best  for  general  use  in  adults. 
After  the  pain  has  been  relieved,  the  drug  should  be  given  every  four  or  five 
hours  until  the  temperature  begins  to  fall.  The  potassium  bicarbonate  may 
be  given  with  it.  Oil  of  wintergreen,  20  minims  every  two  hours  in  milk,  or 
aspirin  (gr.  xv,  1  gm.),  may  be  used  if  the  salicylate  of  soda  disagrees.  There 
are  many  other  salicyl  compounds,  but  the  best  results  are  obtained  from  the 
use  of  one  or  the  other  of  the  above-named  preparations.  There  can  be  no  ques- 
tion as  to  their  efficacy  in  relieving  the  pain.  Some  observers  consider  that 
they  also  protect  the  heart,  shorten  the  course,  and  render  relapse  less  likely. 

THE  ALKALINE  TREATMENT. — The  urine  should  be  rendered  alkaline  as 
soon  as  possible.  Potassium  acetate  and  citrate  in  doses  of  15  grains  (1  gm.) 
each  are  given  every  three  hours  until  the  urine  is  alkaline  and  then  often 
enough  to  keep  it  so.  Potassium  bicarbonate  may  be  given  in  half-drachm 
doses  every  three  hours  with  the  salicylic  acid  or  salicin.  Fuller's  plan  was 
to  give  a  drachm  and  a  half  of  sodium  bicarbonate  with  half  a  drachm  of 
potassium  acetate  in  three  ounces  of  water,  rendered  effervescent  at  the  time 
of  administration  by  half  a  drachm  of  citric  acid  or  an  ounce  of  lemon-juice. 

A  widespread  popular  belief  attributes  marvelous  efficacy  to  bee-stings 
in  all  sorts  of  rheumatism,  and  a  formic-acid  treatment  has  been  introduced. 
A  21/2  per  cent,  solution  is  injected  in  the  neighborhood  of  the  painful  joints. 
Ainley  Walker  has  collected  (B.  M.  J.,  October  10,  1908)  an  interesting  lit- 
erature on  the  subject. 

To  allay  the  pain  opium  may  be  given  in  the  form  of  Dover's  powder,  or 
morphia  hypodermically.  Antipyrin,  antifebrin,  and  phenacetin  are  useful 
sometimes  for  the  purpose.  During  convalescence  iron  is  indicated  in  full 
doses,  and  quinine  is  a  useful  tonic.  Of  the  complications,  hyperpyrexi& 


380  SPECIFIC  INFECTIOUS  DISEASES 

should  be  treated  by  the  cold  bath  or  the  cold  pack.  The  treatment  of  endo- 
carditis and  pericarditis  and  the  pulmonary  complications  will  be  considered 
under  their  respective  sections.  In  all  the  cardiac  complications  the  im- 
portance of  prolonged  rest  must  be  remembered. 

To  prevent  and  arrest  endocarditis  Caton  urges  the  use  of  a  series  of  small 
blisters  along  the  course  of  the  third,  fourth,  fifth,  and  sixth  intercostal  nerves 
of  the  left  side,  applied  one  at  a  time  and  repeated  at  different  points.  Potas- 
sium or  sodium  iodide  is  given  in  addition  to  the  salicylates.  The  patients 
are  kept  in  bed  for  about  six  weeks. 

TONSILS. — With  disease  of  these  and  the  possibility  that  they  are  the  por- 
tals of  entry  for  the  infective  agent,  the  question  arises  as  to  their  removal. 
In  patients  with  diseased  tonsils  in  whom  rheumatic  fever  has  occurred  re- 
moval is  advisable  and  should  always  be  complete.  In  patients  with  endo- 
carditis and  fever  this  may  be  done  apparently  without  risk.  It  is  comparable 
to  the  removal  of  any  local  focus  of  infection  which  is  causing  general  symp- 
toms. 

XIV.     ACUTE  TONSILLITIS 

Definition. — An  acute  infection,  sporadic  or  epidemic,  involving  the  struc- 
tures of  the  tonsillar  ring,  usually  due  to  organisms  of  the  streptococcus  class. 

Etiology. — Acute  tonsillitis  occurs  in  sporadic  and  epidemic  forms.  The 
SPORADIC  variety,  one  of  the  most  common  of  diseases,  is  met  with  in  young 
persons  particularly  at  the  school  age.  Infants  are  rarely  attacked.  Chronic 
enlargement  of  the  lymphatic  structures  of  the  throat  is  an  important  predis- 
posing cause.  Exposure  to  cold  and  wet  may  bring  on  an  attack.  It  is  di- 
rectly communicated  from  one  child  to  another.  A  not  infrequent  precursor  of 
rheumatic  fever,  Cheadle  very  properly  described  it  as  one  link  in  the  rheu- 
matic chain.  It  may  be  directly  followed  by  endocarditis,  eiythema  nodosum, 
chorea,  and  acute  nephritis.  In  Great  Britain  it  prevails  in  the  autumn 
months,  in  the  United  States  in  the  spring.  An  old  notion  held  that  there 
was  a  close  relation  between  the  tonsils  and  the  testes  and  ovaries,  and  F.  J. 
Shepherd  has  called  attention  to  the  frequency  of  acute  tonsillitis  in  newly 
married  persons. 

EPIDEMIC  TONSILLITIS  is  not  infrequent,  the  cases  increasing  in  the  com- 
munity to  epidemic  proportions.  As  a  rule  it  is  impossible  to  trace  it  to  any 
special  cause.  There  are  remarkable  localized  outbreaks,  sometimes  in  institu- 
tions, which  have  been  traced  to  milk  infection.  The  recent  one  in  Boston 
(1911)  was  exceptionally  severe,  involving  more  than  1,000  persons,  and  the 
connection  with  the  use  of  the  milk  from  one  dairy  seems  to  have  been  clearly 
traced.  More  females  than  males  were  attacked,  and  a  large  proportion  of 
the  cases  were  adults. 

The  bacteriology  of  both  forms  has  been  carefully  studied.  The  tonsils, 
swarming  with  saprophytic  and  pathogenic  germs,  are  the  main  gates  through 
which  the  invaders  try  to  storm  the  town.  Normally  the  protecting  forces 
suffice  to  keep  them  at  bay,  but  now  and  again  a  fiercer  battle  than  usual 
rages,  barricades  have  to  be  set  up  in  the  shape  of  exudates  and  necroses — and 
a  local  tonsillitis  is  the  outward  and  visible  sign  of  the  struggle.  Too  often 
the  enemy  gains  entrance,  and  streptococci,  staphylccocci,  pneumococci,  etc., 


ACUTE  TONSILLITIS  381 

pass  to  distant  parts  and  excite  arthritis,  endocarditis,  and  serous  membrane 
inflammations.  In  the  recent  Boston  epidemic  the  streptococcus  was  the  com- 
mon germ,  and  the  same  holds  good  in  the  sporadic  cases. 

Morbid  Anatomy. — The  lacunae  of  the  tonsils  become  filled  with  exuda- 
tion products,  which  form  cheesy-looking  masses,  projecting  from  the  orifices 
of  the  crypts.  Not  infrequently  the  exudations  from  contiguous  Iacuna3  coal- 
esce. The  intervening  mucosa  is  usually  swollen,  deep  red  in  color,  and  may 
present  herpetic  vesicles,  or,  in  some  instances,  even  membranous  exudation, 
in  which  case  it  may  be  difficult  to  distinguish  the  condition  from  diphtheria. 
The  creamy  contents  of  the  crypt  are  made  up  of  micrococci  and  epithelial 
debris. 

Symptoms. — Chilly  feelings,  or  even  a  definite  chill,  and  aching  pains  in 
the  back  and  limbs  may  precede  the  onset.  The  fever  rises  rapidly  and  in 
the  case  of  a  young  child  may  reach  105°  F.  on  the  evening  of  the  first  day. 
The  patient  complains  of  soreness  of  the  throat  and  difficuty  in  swallowing. 
On  examination  the  tonsils  are  seen  to  be  swollen  and  the  crypts  present  the 
characteristic  creamy  exudate.  The  tongue  is  furred,  the  breath  is  heavy  and 
foul,  and  the  urine  is  highly  colored  and  loaded  with  urates.  In  children  the 
respirations  are  usually  very  hurried  and  the  pulse  is  greatly  increased  in 
rapidity.  Swallowing  is  painful  and  the  voice  often  becomes  nasal.  Slight 
swelling  of  the  cervical  glands  is  present. 

In  epidemic  cases  the  fever  may  be  very  high,  the  secondary  enlargement 
of  the  glands  considerable,  and  even  the  deeper  tissues  may  be  involved.  The 
complications  are  very  serious:  endocarditis,  pericarditis,  pneumococcic  peri- 
tonitis, and  pneumonia.  In  the  Boston  epidemic  the  clinical  sequence  was  not 
unlike  that  seen  in  rheumatic  fever — sore  throat,  adenitis,  multiple  arthritis, 
endocarditis,  and  pneumonia.  Febrile  albuminuria  is  common  and  in  a  few 
cases  acute  nephritis  follows.  A  diffuse  erythema  may  simulate  scarlet  fever. 
Acute  otitis  media  is  a  frequent  complication  in  children.  Eelapses  are  not 
uncommon  and  the  tonsils  may  remain  enlarged. 

In  the  sporadic  and  mild  epidemic  form  it  is  rare  to  see  a  fatal  case,  but 
in  severe  outbreaks  the  mortality  from  complications  may  be  three  or  four 
per  cent.  There  were  about  50  deaths  in  the  Boston  epidemic. 

Occasionally  paralyses  follow  the  streptococcus  tonsillitis  which  are  iden- 
tical with  those  of  diphtheria. 

Diagnosis. — It  may  be  difficult  to  distinguish  tonsillitis  from  diphtheria. 
It  would  seem,  indeed,  as  if  there  were  intermediate  forms  between  the  milder 
lacunar  and  the  severer  pseudo-membranous  tonsillitis.  In  the  follicular  form, 
the  individual  yellowish-gray  masses,  separated  by  the  reddish  tonsillar  tissue, 
are  very  characteristic;  whereas  in  diphtheria  the  membrane  is  ashy-gray 
and  uniform,  not  patchy.  A  point  of  the  greatest  importance  in  diphtheria 
is  that  the  membrane  is  not  limited  to  the  tonsils,  but  creeps  up  the  pillars 
of  the  fauces  and  appears  on  the  uvula.  The  diphtheritic  membrane,  when 
removed,  leaves  a  bleeding,  eroded  surface;  whereas  the  exudation  of  lacunar 
tonsillitis  is  easily  separated,  and  there  is  no  erosion  beneath  it.  In  all  doubt- 
ful cases  cultures  should  be  made  to  determine  the  presence  or  absence  of 
Loffler's  bacillus. 

Treatment.  — In  the  follicular  form  aconite  may  be  given  in  full  doses  and 
it  acts  very  beneficially  in  children.  The  salicylates,  given  freely  at  the  outset, 


382  SPECIFIC  INFECTIOUS  DISEASES 

are  regarded  by  some  as  specific,  but  I  have  seen  no  evidence  of  such  prompt 
and  decisive  action.  At  night  a  full  dose  of  Dover's  powder  may  be  given. 
The  use  of  guaiacum,  in  the  form  of  2-grain  lozenges,  is  warmly  recommended. 
Iron  and  quinine  should  be  reserved  until  the  fever  has  subsided.  An  ice- 
bag  or  cold  compresses  may  be  applied  to  the  neck.  Locally  the  tonsils  may 
be  treated  with  the  dry  sodium  bicarbonate.  The  moistened  finger-tip  is 
dipped  into  the  soda,  which  is  then  rubbed  gently  on  the  gland,  and  this  is 
repeated  every  hour.  Astringent  preparations,  such  as  iron  and  glycerine, 
alum,  zinc,  and  nitrate  of  silver,  may  be  tried.  To  cleanse  and  disinfect  the 
throat,  solutions  of  borax  or  thymol  in  glycerine  and  water  may  be  used.  In 
severe  forms  vaccines  may  be  tried,  prepared  from  the  throat  cultures,  or, 
failing  these,  the  ordinary  anti-streptococcic  serum. 


XV.     ACUTE  CATARRHAL  FEVER 

(Acute  Coryza) 

Definition. — An  acute  infection  of  the  mucous  membrane  of  the  upper  air 
passages  associated  with  the  presence  of  the  Micrococcus  catarrhalis  alone,  or 
with  other  organisms. 

Etiology. — The  micrococcus  described  by  E.  Pfeiffer  is  a  diplococcus  with 
close  resemblance  to  the  meningococcus  and  the  pneumococcus.  It  is  a  nor- 
mal habitant  of  the  throat  and  bronchial  secretions  of  many  persons.  In 
acute  inflammatory  conditions  of  the  upper  air  passages  it  is  found,  some- 
times in  almost  pure  culture,  in  the  sputum.  It  is  readily  cultivated. 

Prevailing  most  extensively  in  the  changeable  weather  of  the  spring  and 
early  winter,  coryza  may  occur  in  epidemic  form,  many  cases  arising  in  a 
community  within  a  few  weeks,  outbreaks  which  are  very  like  though  less 
intense  than  the  epidemic  influenza.  More  often  it  is  a  local  outbreak  among 
the  members  of  a  house  or  of  a  school. 

Symptoms. —The  patient  feels  indisposed,  perhaps  chilly,  has  slight  head- 
ache, and  sneezes  frequently.  In  severe  cases  there  are  pains  in  the  back  and 
limbs.  There  is  usually  slight  fever,  the  temperature  rising  to  101°  F.  The 
pulse  is  quick,  the  skin  is  dry,  and  there  are  all  the  features  of  a  feverish 
attack.  At  first  the  mucous  membrane  of  the  nose  is  swollen,  "stuffed  up," 
and  the  patient  has  to  breathe  through  the  mouth.  A  thin,  clear,  irritating 
secretion  flows,  and  makes  the  edges  of  the  nostrils  sore.  The  mucous  mem- 
brane of  the  tear-ducts  is  swollen,  so  that  the  eyes  weep  and  the  conjunctiva? 
are  injected.  The  sense  of  smell  and,  in  part,  the  sense  of  taste  are  lost.  With 
the  nasal  catarrh  there  is  slight  soreness  of  the  throat  and  stiffness  of  the 
neck ;  the  pharynx  looks  red  and  swollen,  and  sometimes  the  act  of  swallowing 
is  painful.  The  larynx  also  may  be  involved  and  the  voice  becomes  husky  or 
is  even  lost.  If  the  inflammation  extends  to  the  Eustachian  tubes  the  hearing 
may  be  impaired.  In  more  severe  cases  there  are  bronchial  irritation  and 
tough.  Occasionally  there  is  an  outbreak  of  labial  or  nasal  herpes.  Usually 
within  thirty-six  hours  the  nasal  secretion  becomes  turbid  and  more  profuse, 
the  swelling  of  the  mucosa  subsides,  the  patient  gradually  becomes  able  to 
breathe  through  the  nostrils,  and  within  four  or  five  days  the  symptoms  dis- 


FEBRICULA— EPHEMERAL  FEVER  383 

appear,  with  the  exception  of  the  increased  discharge  from  the  nose  and  upper 
pharynx.  There  are  rarely  any  bad  effects  from  a  simple  coryza.  When  the 
attacks  are  frequently  repeated  the  disease  may  become  chronic. 

Diagnosis. — The  diagnosis  is  always  easy,  but  caution  must  be  exercised 
lest  the  initial  catarrh  of  measles  or  severe  influenza  should  be  mistaken  for 
the  simple  coryza. 

Treatment. — Many  attacks  are  so  mild  that  the  patients  are  able  to  be 
about  and  attend  to  their  work.  If  there  are  fever  and  constitutional  dis- 
turbance, the  patient  should  be  kept  in  bed  and  should  take  a  simple  fever 
mixture,  and  at  night  a  drink  of  hot  lemonade  and  a  full  dose  of  Dover's 
powder.  Many  persons  find  great  benefit  from  the  Turkish  bath.  For  the 
distressing  sense  of  tightness  and  pain  over  the  frontal  sinuses,  cocaine  is  very 
useful  and  sometimes  gives  immediate  relief.  The  4-per-cent.  solution  may 
be  injected  into  the  nostrils  or  cotton  wool  soaked  in  it  may  be  inserted  into 
them.  Later  the  snuff  recommended  by  Ferrier  is  advantageous,  composed 
of  morphia  (gr.  ij),  bismuth  (3  iv),  acacia  powder  (3  ij).  This  may  occa- 
sionally be  blown  or  snuffed  into  the  nostrils.  The  fluid  extract  of  hamamelis, 
"snuffed"  from  the  hand  every  two  or  three  hours,  is  much  better. 

A  vaccine  treatment  has  been  introduced  and  may  be  tried  in  persons  sub- 
ject to  recurring  colds. 


XVI.     FEBRICULA— EPHEMERAL  FEVER 

Definition. — Fever  of  slight  duration,  probably  depending  upon  a  variety 
of  causes,  some  autogenous,  others  extrinsic  and  bacterial. 

A  febrile  paroxysm  lasting  for  twenty-four  hours  and  disappearing  com- 
pletely is  spoken  of  as  ephemeral  fever.  If  it  persists  for  three,  four,  or 
more  days  without  local  affection  it  is  referred  to  as  febricula. 

The  cases  may  be  divided  into  several  groups: 

(a)  Those  which  represent  mild  or  abortive  types  of  the  infectious  dis- 
eases. It  is  not  very  unusual,  during  an  epidemic  of  typhoid,  scarlet  fever, 
or  measles,  to  see  patients  with  some  of  the  prodromal  symptoms  and  slight 
fever,  which  persist  for  two  or  three  days  without  any  distinctive  features. 
Possibly,  as  Kahler  suggests,  some  of  the  cases  of  transient  fever  are  due  to 
the  rheumatic  poison. 

(&)  In  a  larger  and  perhaps  more  important  group  of  cases  the  symp- 
toms develop  with  dyspepsia.  In  children  indigestion  and  gastro-intestinal 
catarrh  are  often  accompanied  by  fever.  Possibly  some  instances  of  longer 
duration  may  be  due  to  the  absorption  of  certain  toxic  substances.  Slight 
fever  has  been  known  to  follow  the  eating  of  decomposing  substances  or  the 
drinking  of  stale  beer;  but  the  gastric  juice  has  remarkable  antiseptic  prop- 
erties, and  the  frequency  with  which  persons  take  from  choice  articles  which 
are  "high"  shows  that  poisoning  is  not  likely  to  occur  unless  there  is  existing 
gastro-intestinal  disturbance. 

(c)  Cases  which  follow  exposure  to  foul  odors  or  sewer  gas.  That  a  febrile 
paroxysm  may  follow  a  prolonged  exposure  to  noxious  odors  has  long  been 
recognized.  The  cases  which  have  been  described  under  this  heading  are  of 
two  kinds:  an  acute,  severe  form  with  nausea,  vomiting,  colic,  and  fever, 


;?M  SPECIFIC  INFECTIOUS  DISEASES 

followed  perhaps  by  a  condition  of  collapse  or  coma;  secondly,  a  form  of 
low  fever  with  or  without  chills.  A  good  deal  of  doubt  still  exists  in  the 
minds  of  the  profession  about  these  cases  of  so-called  sewer-gas  poisoning. 
It  is  a  notorious  fact  that  workers  in  sewers  are  remarkably  free  from  disease, 
and  in  many  of  the  cases  which  have  been  reported  the  illness  may  have  been 
only  a  coincidence.  There  are  instances  in  which  persons  have  been  taken, 
ill  with  vomiting  and  slight  fever  after  exposure  to  the  odor  of  a  very  offensive 
post  mortem.  Whether  true  or  not,  the  idea  is  firmly  implanted  in  the  minds 
of  the  laity  that  very  powerful  odors  from  decomposing  matters  may  produce 
sickness. 

(d)  Many  cases  doubtless  depend  upon  slight  unrecognized  lesions,  such  as 
tonsillitis  or  occasionally  an  abortive  or  larval  pneumonia.  Children  are 
much  more  frequently  affected  than  adults. 

The  symptoms  set  in,  as  a  rule,  abruptly,  though  in  some  instances  there 
may  have  been  preliminary  malaise  and  indisposition.  Headache,  loss  of  ap- 
petite, and  furred  tongue  are  present.  The  urine  is  scanty  and  high-colored, 
the  fever  ranges  from  101°  to  103°,  sometimes  in  children  it  rises  higher. 
The  cheeks  may  be  flushed  and  the  patient  has  the  outward  manifestations  of 
fever.  In  children  there  may  be  bronchial  catarrh  with  slight  cough.  Herpes 
on  the  lips  is  a  common  symptom.  Occasionally  in  children  the  cerebral 
symptoms  are  marked  at  the  outset,  and  there  may  be  irritation,  restlessness, 
and  nocturnal  delirium.  The  fever  terminates  abruptly  by  crisis  from  the 
second  to  the  fourth  day;  in  some  instances  it  may  continue  for  a  week. 

The  diagnosis  generally  rests  upon  the  absence  of  local  manifestations, 
particularly  the  characteristic  skin  rashes  of  the  eruptive  fevers,  and,  most 
important  of  all,  the  rapid  disappearance  of  the  pyrexia.  The  cases  most 
readily  recognized  are  those  with  acute  gastro-intestinal  disturbance. 

The  treatment  is  that  of  mild  pyrexia — rest  in  bed,  a  laxative,  and  a  fever 
mixture  containing  nitrate  of  potassium  and  sweet  spirits  of  nitre. 


XVII.     INFECTIOUS  JAUNDICE 

(Epidemic  Catarrhal  Jaundice;  Weil's  Disease) 

Local  and  widespread  outbreaks  of  jaundice  have  been  known  for  years. 
Three  or  four  cases  may  occur  in  one  house,  or  many  persons  in  an  institu- 
tion are  attacked,  or  the  disease  becomes  widespread  in  a  community.  In 
Great  Britain  this  epidemic  form  is  rare.  In  the  United  States  many  out- 
breaks have  occurred.  It  prevailed  extensively  in  North  Carolina  in  1899- 
1900,  and  a  fatal  case  of  that  epidemic  came  under  my  observation.  In  Syria, 
in  Greece,  in  Egypt  (Sandwith),  in  India  (S.  Anderson),  and  in  South  Africa 
during  the  Boer  war  (H.  B.  Matheas)  epidemics  have  been  described.  It 
has  prevailed  most  frequently  in  the  summer  months.  The  symptoms  are  at 
first  gastric,  then  fever  follows  (with  the  usual  concomitants)  and  jaundice, 
which  may  be  slight  or  very  intense,  and  as  a  rule  albuminuria.  The  liver 
and  spleen  enlarge,  and  in  severe  forms  there  are  nervous  symptoms  and 
haemorrhages.  There  is  often  a  secondary  fever.  The  attack  lasts  from  ten 
days  to  three  weeks.  The  course  is  usually  favorable ;  fatal  cases  are  rare  in 


MILK-SICKNESS  385 

the  United  States  and  in  India  and  South  Africa,  but  in  the  Greek  Hospital 
at  Alexandria  the  death-rate  was  32  among  300  cases  (Sandwith). 

In  1886  Weil  described  a  disease  characterized  by  the  features  just  men- 
tioned, but  the  cases  occurred  in  groups,  and  a  very  large  proportion  in 
butchers.  It  is  probable  there  are  several  types  of  acute  infectious  jaundice. 
The  etiology  is  unknown.  Some  epidemics  have  been  associated  with  para- 
typhoid bacillus  infection.  The  proteus  has  been  described  in  connection  with 
Weil's  disease.  In  the  fatal  case  from  North  Carolina  the  autopsy  threw  no 
light  on  the  nature  of  the  disease.  The  proteus  was  isolated  from  the  liver 
and  kidney,  and  four  other  organisms  from  various  parts.  It  is  possible  that 
acute  catarrhal  jaundice  is  a  mild  infection,  representing  the  sporadic  form 
of  the  disease. 

XVIII.     MILK-SICKNESS 

This  remarkable  disease  prevails  in  certain  districts  of  the  United  States, 
west  of  the  Alleghany  Mountains,  and  is  connected  with  the  affection  in  cattle 
known  as  the  trembles.  It  prevailed  extensively  in  the  early  settlements 
in  certain  of  the  Western  States  and  proved  very  fatal.  The  general  opinion 
is  that  it  is  communicated  to  man  only  by  eating  the  flesh  or  drinking  the 
milk  of  diseased  animals.  The  butter  and  cheese  are  also  poisonous.  In  ani- 
mals, cattle  and  the  young  of  horses  and  sheep  are  most  susceptible.  It  is 
stated  that  cows  giving  milk  do  not  themselves  show  marked  sympteij.s  unless 
driven  rapidly,  and,  according  to  Graff,  the  secretion  may  be  infective  when 
the  disease  is  latent.  When  a  cow  is  very  ill,  food  is  refused,  the  eyes  are 
injected,  the  animal  staggers,  the  entire  muscular  system  trembles,  anol  death 
occurs  in  convulsions,  sometimes  with  great  suddenness.  The  disease  is  most 
frequent  in  new  settlements, 

In  man  the  symptoms  are  those  of  a  more  or  less  acute  intoxication.  After 
a  few  days  of  uneasiness  and  distress  the  patient  is  seized  with  pains  in  the 
stomach,  nausea  and  vomiting,  fever  and  intense  thirst.  There  is  usually 
obstinate  constipation.  The  tongue  is  swollen  and  tremulous,  the  breath  is 
extremely  foul,  and,  according  to  Graff,  is  as  characteristic  of  the  disease  as 
is  the  odor  in  small-pox.  Cerebral  symptoms — restlessness,  irritability,  coma, 
and  convulsions — are  sometimes  marked,  and  there  may  gradually  be  pro- 
duced a  typhoid  state  in  which  the  patient  dies. 

The  duration  of  the  disease  is  variable.  In  the  most  acute  form  death 
occurs  within  two  or  three  days.  It  may  last  for  ten  days,  or  even  for  three 
or  four  weeks.  Graff  states  that  insanity  occurred  in  one  case.  The  poisonous 
nature  of  the  flesh  and  of  the  milk  has  been  demonstrated  experimentally. 
An  ounce  of  butter  or  cheese,  or  four  ounces  of  the  beef,  raw  or  boiled,  given 
three  times  a  day,  will  kill  a  dog  within  six  days.  Fortunately,  the  disease 
has  become  rare.  No  definite  pathological  lesions  are  known.  Jordan  and 
Harris  have  studied  a  New  Mexico  epidemic  (1908)  and  have  found  a  bacillus 
(B.  lactimorbi)  with  cultures  of  which  the  disease  may  be  reproduced  in  other 
animals. 


386  SPECIFIC  INFECTIOUS  DISEASES 


XIX.     GLANDULAR  FEVER 

Definition. — An  infectious  disease  of  children,  developing,  as  a  rule,  with- 
out premonitory  signs,  and  characterized  by  slight  redness  of  the  throat,  high 
fever,  swelling  and  tenderness  of  the  lymph-glands  of  the  neck,  particularly 
those  behind  the  sterno-cleido-mastoid  muscles.  The  fever  is  of  short  dura- 
tion, but  the  enlargement  of  the  glands  persists  for  from  ten  days  to  three 
weeks. 

In  children  acute  adenitis  of  the  cervical  and  other  glands  with  fever  has 
been  noted  by  many  observers,  but  Pfeiffer  in  1889  called  special  attention 
to  it  under  the  name  of  Druesenfieber.  He  described  it  as  an  infectious  dis- 
ease of  young  children  between  the' ages  of  five  and  eight  years,  characterized 
by  the  above-mentioned  symptoms.  Since  Pfeiffer's  paper  a  good  deal  of  work 
has  been  done  in  connection  with  the  subject,  and  in  the  United  States  West 
and  Hamill,  and  in  England  Dawson  Williams,  have  more  particularly  empha- 
sized the  condition. 

Etiology. — It  -may  occur  in  epidemic  form.  West,  of  Bellaire,  Ohio, 
described  an  epidemic  of  96  cases  in  children  between  the  ages  of  seven  months 
and  thirteen  years.  Bilateral  swelling  of  the  carotid  lymph-glands  was  a  most 
marked  feature.  In  three-fourths  of  the  cases  the  post-cervical,  inguinal,  and 
axillary  glands  were  involved.  The  mesenteric  glands  were  felt  in  37  cases, 
the  spleen  was  enlarged  in  57,  and  the  liver  in  87  cases.  Coryza  was  not  pres- 
ent, and  there  were  no  bronchial  or  pulmonary  symptoms.  Cases  occurred 
between  the  months  of  October  and  June.  The  nature  of  the  infection  has 
not  been  determined. 

Symptoms. — The  onset  is  sudden  and  the  first  complaint  is  of  pain  on 
moving  the  head  and  neck.  There  may  be  nausea  and  vomiting  and  abdomi- 
nal pain.  The  temperature  ranges  from  101°  to  103°.  The  tonsils  may  be 
a  little  red  and  the  lymphatic  tissues  swollen,  but  the  throat  symptoms  are 
quite  transient  and  unimportant.  On  the  second  or  third  day  the  enlarged 
glands  appear,  and  during  the  course  they  vary  in  size  from  a  pea  to  a  goose- 
egg.  They  are  painful  to  the  touch,  but  there  is  rarely  any  redness  or  swell- 
ing of  the  skin,  though  at  times  there  is  some  puffiness  of  the  subcutaneous 
tissues  of  the  neck,  and  there  may  be  a  little  difficulty  in  swallowing.  In 
some  instances  there  has  been  discomfort  in  the  chest  and  a  paroxysmal  cough, 
indicating  involvement  of  the  tracheal  and  bronchial  glands.  The  swelling 
of  the  glands  persists  for  from  two  to  three  weeks.  Among  the  serious  fea- 
tures of  the  disease  are  the  termination  of  the  adenitis  in  suppuration,  which 
seems  rare  (though  Neumann  has  met  with  it  in  13  cases),  and  haemorrhagic 
nephritis.  Acute  otitis  media  and  retro-pharyngeal  abscess  have  also  been 
reported. 

The  outlook  is  favorable.  West  suggests  the  use  of  small  doses  of  calomel 
during  the  height  of  the  trouble. 

XX.    MILIARY  FEVER— SWEATING  SICKNESS 

The  disease  is  characterized  by  fever,  profuse  sweats,  and  an  eruption  of 
miliary  vesicles.  It  prevailed  and  was  very  fatal  in  England  in  the  fifteenth 


FOOT-AND-MOUTH  DISEASE  387 

and  sixteenth  centuries,  and  was  made  the  subject  of  an  important  memoir 
by  Johannes  Caius,  1552.  Of.  late  years  it  has  been  confined  entirely  to  cer- 
tain districts  in  France  (Picardy)  and  Italy.  An  epidemic  of  some  extent 
occurred  in  France  in  1887.  Hirsch  gives  a  chronological  account  of  194 
epidemics  between  1718  and  1879,  many  of  which  were  limited  to  a  single 
village  or  to  a  few  localities.  Occasionally  the  disease  has  become  widely 
spread.  Slight  epidemics  have  occurred  in  Germany  and  Switzerland.  Within 
the  past  few  years  there  have  been  several  small  outbreaks  in  Austria.  They 
are  usually  of  short  duration,  lasting  only  for  three  or  four  weeks — sometimes 
not  more  than  seven  or  eight  days.  As  in  influenza,  a  very  large  number  of 
persons  are  attacked  in  rapid  succession.  In  the  mild  cases  there  is  only  slight 
fever,  with  loss  of  appetite,  and  erythematous  eruption,  profuse  perspiration, 
and  an  outbreak  of  miliary  vesicles.  The  severe  cases  present  the  symptoms 
of  intense  infection — delirium,  high  fever,  profound  prostration,  and  haemor- 
rhage. The  death-rate  at  the  outset  of  the  disease  is  usually  high,  and,  as 
is  so  graphically  described  in  the  account  of  some  of  the  epidemics  of  the 
middle  ages,  death  may  occur  in  a  few  hours. 

XXI.     FOOT-AND-MOUTH    DISEASE— EPIDEMIC    STOMATITIS— 

APHTHOUS  FEVER 

Foot-and-mouth  disease  is  an  acute  infectious  disorder  met  with  chiefly 
in  cattle,  sheep,  and  pigs,  but  attacking  other  domestic  animals.  It  is  of 
extraordinary  activity,  and  spreads  with  "lightning  rapidity"  over  vast  terri- 
tories, causing  very  serious  losses.  In  cattle,  after  a  period  of  incubation  of 
three  or  five  days,  the  animal  becomes  feverish,  the  mucous  membrane  of  the 
mouth  swells,  and  little  grayish  vesicles  the  size  of  a  hemp  seed  begin  to  de- 
velop on  the  edges  and  lower  portion  of  the  tongue,  on  the  gums,  and  on  the 
mucous  membrane  of  the  lips.  They  contain  at  first  a  clear  fluid,  which 
becomes  turbid,  and  then  they  enlarge  and  gradually  become  converted  into 
superficial  ulcers.  There  is  ptyalism,  and  the  animals  lose  flesh  rapidly.  In 
the  cow  the  disease  is  also  frequently  seen  about  the  udder  and  teats,  and  the 
milk  becomes  yellowish-white  in  color  and  of  a  mucoid  consistency. 

The  transmission  to  man  is  by  no  means  uncommon,  and  several  impor- 
tant epidemics  have  been  studied  in  the  neighborhood  of  Berlin.  In  Zuill's 
translation  of  Friedberger  and  Frb'hner's  Pathology  and  Therapeutics  of 
Domestic  Animals  (Philadelphia,  1895)  the  disease  is  thus  described:  "In 
man  the  symptoms  are :  fever,  digestive  troubles,  and  vesicular  eruption  upon 
the  lips,  the  buccal  and  pharyngeal  mucous  membranes  (angina).  The  dis- 
ease does  not  seem  to  be  transmissible  through  the  meat  of  diseased  animals." 

In  widespread  epidemics  there  has  been  sometimes  a  marked  tendency 
to  haemorrhages.  The  disease  runs,  as  a  rule,  a  favorable  course,  but  in 
Siegel's  report  of  an  epidemic  the  mortality  was  8  per  cent. 

When  epidemics  are  prevailing  in  cattle  the  milk  should  be  boiled,  and 
the  proper  prophylactic  measures  taken  to  isolate  both  the  cattle  and  the 
individuals  who  come  in  contact  with  them. 


388  SPECIFIC  INFECTIOUS  DISEASES 


XXII.     PSITTACOSIS 

A  disease  in  birds,  characterized  by  loss  of  appetite,  weakness,  diarrhoea, 
convulsions,  and  death.  In  Germany,  France,  and  Italy  a  disease  in  man 
characterized  by  an  atypical  pneumonia,  great  weakness  and  depression,  and 
sign/s  of  a  profound  infection  has  been  ascribed  to  contagion  from  birds,  par- 
ticularly parrots.  There  have  usually  been  house  epidemics  with  a  very  high 
rate  of  mortality.  A  few  cases  have  been  reported  in  England,  and  Vickery, 
of  Boston,  has  reported  three  probable  cases.  The  bacteriology  is  still  doubtful. 


XXIII.     ROCKY  MOUNTAIN  SPOTTED  FEVER;  TICK  FEVER 

In  the  Bitter-root  Valley  of  Montana  and  in  the  mountains  of  Idaho, 
Nevada,  and  Wyoming  there  is  an  acute  infection  characterized  by  chill,  fever, 
pains  in  back  and  bones,  and  a  macular  rash,  becoming  hasmorrhagic.  It  is 
estimated  that  seven  or  eight  hundred  cases  occur  annually,  with  75  or  80 
deaths.  It  was  reported  upon  occasionally  by  army  surgeons — e.  g.,  Wood — 
but  nothing  definite  was  known  until  the  careful  studies  of  Wilson  and  Chow- 
ning  (1902),  who  described  a  piroplasma  in  the  blood,  and  believed  the  dis- 
ease to  be  transmitted  by  ticks.  This  latter  point  has  been  confirmed,  but  the 
existence  of  the  piroplasma  is  doubtful.  The  studies  of  King  and  Eicketts 
have  demonstrated  beyond  doubt  the  transmission  of  the  disease  by  the  tick, 
Dermacentor  occidentalis,  but  the  true  parasite  has  not  been  determined.  The 
tick  is  widely  distributed  over  the  Rocky  Mountain  regions  as  far  south  as 
New  Mexico.  It  lives  on  the  larger  domestic  animals,  cattle  and  horses,  and 
is  in  this  way  brought  into  close  proximity  with  human  beings.  The  disease 
is  readily  given  to  the  guinea-pig  and  monkey,  and  is  transmissible  from  one 
animal  to  another  by  the  bite  of  the  tick.  Immunity  is  given  by  an  attack, 
and  in  animals  this  is  transmitted  to  the  young.  After  an  incubation  of  from 
three  to  ten  days  the  disease  begins  with  a  chill,  fever,  and  severe  pains  in  the 
limbs.  The  rash  appears  from  the  second  to  the  seventh  day,  is  macular, 
dark,  and  becomes  hasmorrhagic.  Illustrations  of  it  show  a  rash  not  unlike 
that  of  typhus.  The  skin  is  often  swollen.  Haemorrhages  from  the  mucous 
membranes  are  not  uncommon.  The  temperature  range  is  from  103°  to 
105°  F.,  and  at  the  height  of  the  disease  there  is  delirium  and  stupor.  Con- 
valescence begins  in  the  fourth  week.  The  death-rate  is  high  for  an  eruptive 
fever,  reaching  70  per  cent,  in  Montana,  but  in  Idaho  it  is  not  more  than 
2  or  3  per  cent.  As  a  prophylactic  measure,  destruction  of  the  ticks  by  dip- 
ping or  scouring  the  horses  and  cattle  should  be  carried  out.  The  treatment 
is  that  of  an  acute  infection. 

XXIV.     SWINE  FEVER 

A  few  cases  have  been  described  from  accidental  inoculation  in  the  prepa- 
ration of  cultures  and  in  making  post  mortems  upon  pigs.  In  the  course 
of  from  twelve  hours  to  three  days  there  is  swelling  of  the  fingers  of  the 
affected  hand,  which  have  a  blue-red  color,  and  small  nodules  form.  In  some 


RAT-BITE  FEVEE  389 

of  the  instances  the  course  has  been  like  that  of  a  painful  erythema  migrans, 
with  swelling  of  the  lymph-glands..  A  specific  serum  has  been  used  with  suc- 
cess in  several  cases. 

XXV.     RAT-BITE  FEVER 

A  remarkable  infection,  following  rat-bite,  characterized  by  brief  febrile 
paroxysms  which  may  recur  at  intervals  for  months. 

The  disease  has  been  known  in  China  and  Japan  for  several  centuries. 
Attention  has  been  called  to  it  in  this  country  by  Horder  and  in  the  United 
States  by  Proescher.  In  a  recent  statistical  account  from  the  Institution  for 
Infectious  Diseases  it  appears  that  there  have  been  49  cases  in  Japan  in  the 
past  thirteen  years.  The  features  are  very  unusual.  There  is  a  prolonged 
period  of  incubation,  lasting  in  some  cases  for  many  months.  The  wound, 
which  has  run  the  ordinary  course  and  perhaps  healed,  becomes  swollen,  red, 
and  eroded;  an  ulcer  forms  and  the  regional  lymph-glands  are  involved.  The 
fever  sets  in  suddenly  with  a  chill  and  lasts  three  or  four  days.  With  its  onset 
there  is  a  skin  rash,  either  erythema  or  a  blotchy  eruption  somewhat  re- 
sembling measles.  The  patient  feels  very  ill,  there  may  be  pains  in  the 
muscles  and  joints  and  sometimes  delirium.  After  persisting  for  a  few  days, 
the  temperature  falls  and  the  patient  feels  quite  well  again.  After  a  varying 
interval  of  from  a  few  days  to  a  couple  of  weeks  the  attack  is  repeated,  and 
this  may  go  on  for  several  months  or,  according  to  the  Japanese  reports,  for 
several  years.  The  outlook  is  favorable;  among  the  49  Japanese  cases  only 
1  died. 

In  Horder's  last  case  the  boy  was  bitten  on  September  15th.  From  Octo- 
ber 6th  to  llth,  on  the  13th,  14th,  17th,  18th,  19th,  23d,  24th,  25th,  28th  to 
30th,  and  November  4th,  5th,  and  6th,  he  had  attacks  of  fever,  the  temper- 
ature rising  to  between  104°  and  105°  F.,  and  once  reaching  nearly  106°. 
Each  attack  was  associated  with  a  rash. 

Various  organisms  have  been  described.  In  one  of  Horder's  cases  spirilla 
were  seen.  Ogata  describes  a  sporozoan  parasite,  and  Proescher  a  bacillus. 
Japanese  observers  have  reported  spirochaetes  in  two  cases.  One  was  treated 
by  mercury  and  the  other  by  salvarsan;  both  recovered.  Schotmuller,  Blake 
and  Tileston  each  found  a  streptothrix  in  their  cases.  In  Tileston's  case  the 
organisms  were  found  in  fresh  smears  by  dark-field  illumination.  Blake  iso- 
lated a  streptothrix  in  a  case  which  at  autopsy  showed  endocarditis,  in  the 
vegetations  of  which  the  same  organism  was  found. 

TREATMENT. — The  wound  should  be  cauterized,  salvarsan  given  intraven- 
ously, and  the  febrile  paroxysms  treated  symptomatically. 


SECTION    II 

DISEASES   DUE    TO   PHYSICAL   AGENTS 
I.     SUNSTROKE;  HEAT  EXHAUSTION 

(Insolation,  Thermic  Fever,  Siriasis) 

Definition. — Under  these  terms  are  comprised  certain  manifestations  fol- 
lowing exposure  to  excessive  heat,  of  which  thermic  fever,  or  sunstroke,  heat 
exhaustion,  and  heat  cramps  are  the  common  forms. 

History. — It  is  one  of  the  oldest  of  recognized  diseases.  The  case  of  the 
son  of  the  Shunammite  woman  (2  Kings,  IV)  is  perhaps  the  oldest  on 
record.  The  Arabians  called  the  symptoms  due  to  excessive  heart  "Siriasis," 
after  Sirius  the  Dog  Star.  Cardan  recognized  it  in  the  sixteenth  century  and 
thought  it  was  apoplexy  due  to  heat — morbus  attonitus.  In  the  eighteenth 
century  Boerhaave  regarded  it  as  phrenitis.  It  was  not  until  the  nineteenth 
century  that  the  Anglo-Indian  surgeons  and  the  physicians  of  the  United 
States  gave  us  a  full  knowledge  of  the  different  affections  due  to  excessive 
heat.  Various  classifications  have  been  suggested,  but  two  chief  forms  are 
everywhere  recognized — heat  exhaustion  and  thermic  fever  or  sunstroke — to 
which  recently  Edsall  has  added  the  remarkable  heat  cramps  which  occur  in 
persons  working  under  very  high  external  temperatures. 

Distribution. — Sunstroke  occurs  in  the  tropics  and  in  temperate  regions 
during  protracted  heat  waves.  It  is  very  common  in  the  Atlantic  Coast 
cities  of  the  United  States  during  the  hot  spells  of  summer.  In  New  York 
and  Philadelphia  many  hundreds  of  cases  may  occur  daily.  It  has  not  been 
common  in  Panama.  During  1910  no  death  from  it  was  recorded  among 
nearly  50,000  employees.  Heat  exhaustion  is  frequently  met  with  in 
conditions  similar  to  those  in  which  sunstroke  takes  place,  and  it  is  also  a  not 
infrequent  affection  in  the  engine-rooms  of  the  large  modern  steamships,  less 
often  in  foundries. 

Heat  Exhaustion. — In  the  tropics  and  in  temperate  regions  during  pro- 
tracted heat  waves  many  persons  become  depressed  physically  and  are  unable 
to  work  or  take  nourishment.  In  children  the  condition  is  very  often  asso- 
ciated with  gastro-intestinal  disturbances  and  fever.  The  true  heat  syncope 
is  specially  seen  in  persons  who  have  not  been  in  good  health  or  who  are  in- 
temperate. The  heat  may  be  that  of  the  sun  or  artificial  heat,  as  in  the 
engine-rooms  of  the  large  steamers.  The  symptoms  begin  with  giddiness, 
nausea,  an  uncertain,  staggering  gait;  there  is  pallor,  the  pulse  is  small,  the 
heart's  action  weak,  and  the  patient  may  quickly  become  unconscious.  Ex- 
390 


SUNSTROKE ;  HEAT  EXHAUSTION  391 

ternaliy  the  body  may  be  clammy,  with  sweat,  but  as  a  rule  the  rectal  temper- 
ature is  decreased.  In  the  axilla  it  may  be  as  low  as  95°  or  96°  F.  From 
slight  attacks,  such  as  are  seen  in  the  steamships,  the  patients  recover  rapidly 
when  brought  on  deck;  in  other  cases  the  unconsciousness  may  end  in  deep 
coma  and  death. 

Thermic  Fever. — This  is  more  common  in  men  than  in  women  and  chil- 
dren, and  is  principally  seen  in  persons  who  work  in  very  high  external  tem- 
peratures, and  who  are  too  heavily  clad,  or  who  are  addicted  to  alcohol.  In 
India  regiments  on  the  march  are  not  infrequently  attacked.  It  is  more  com- 
mon in  Europeans  than  in  the  dark  races,  but  in  the  United  States  negroes 
are  often  attacked. 

MORBID  ANATOMY  AND  PATHOLOGY. — Rigor  mortis  occurs  early.  Putre- 
factive changes  may  come  on  with  great  rapidity.  The  venous  engorgement 
is  extreme,  particularly  in  the  cerebrum.  The  left  ventricle  is  contracted 
(Wood)  and  the  right  chamber  dilated.  The  blood  is  usually  fluid;  the  lungs 
are  intensely  congested.  Parenchymatous  changes  occur  in  the  liver  and 
kidneys. 

SYMPTOMS. — Many  observers  have  called  attention  to  a  fever  in  the  tropics 
which  lasts  for  a  few  days,  with  no  special  symptoms  other  than  those  of 
pyrexia  and  weakness.  As  already  mentioned,  this  may  be  simply  heat  ex- 
haustion. It  is  not  uncommon  in  the  Southern  States,  particularly  in  Flor- 
ida and  the  Carolinas,  when  it  may  be  mistaken  for  malaria  or  mild  typhoid 
fever.  John  Guiteras,  who  has  unrivalled  knowledge  of  tropical  affections, 
regards  these  conditions  as  directly  due  to  prolonged  high  external  tem- 
peratures. 

The  patient  may  be  struck  down  and  die  within  an  hour,  with  symptoms 
of  heart-failure,  dyspnoea,  and  coma.  This  form,  sometimes  known  as  the 
asphyxial,  occurs  chiefly  in  soldiers  and  is  graphically  described  by  Parkes. 
Death  indeed  may  be  almost  instantaneous,  the  victims  falling  as  if  struck 
upon  the  head.  The  more  usual  form  comes  on  during  exposure,  with  pain 
in  the  head,  dizziness,  a  feeling  of  oppression,  and  sometimes  nausea  and 
vomiting.  Visual  disturbances  are  common,  and  a  patient  may  have  col- 
ored vision.  Diarrhoea  or  frequent  micturition  may  supervene.  Insensi- 
bility follows,  which  may  be  transient  or  which  deepens  into  a  profound  coma. 
The  patients  are  usually  admitted  to  hospital  in  an  unconscious  state,  with 
the  face  flushed,  the  skin  hot,  the  pulse  rapid  and  full,  and  the  tempera- 
ture ranging  from  107°  to  110°  F.,  or  even  higher.  F.  A.  Packard  states 
that,  of  the  31  cases  admitted  to  the  Pennsylvania  Hospital  in  the  summer  of 
1887,  in  a  majority  of  them  the  temperature  was  between  110°  and  111°  F. 
In  one  case  the  temperature  was  112°  F.  The  breathing  is  labored  and  deep, 
sometimes  stertorous.  Usually  there  is  complete  relaxation  of  the  muscles, 
but  twitchings,  jactitation,  or  very  rarely  convulsions  may  occur.  The  pupils 
may  at  first  be  dilated,  but  by  the  time  the  patients  are  admitted  to  hospital 
they  are  (in  a  majority)  extremely  contracted.  Pc-techiaB  may  be  present  upon 
the  skin.  In  the  fatal  cases  the  coma  deepens,  the  cardiac  pulsations  become 
more  rapid  and  feeble,  the  breathing  becomes  hurried  and  shallow  and  of  the 
Cheyne-Stokes  type.  The  fatal  termination  may  occur  within  twenty-four  or 
thirty-six  hours.  Favorable  indications  are  the  return  of  consciousness  and 
a  fall  in  the  fever.  The  recovery  in  these  eases  may  be  complete.  In  other 


392 


DISEASES  DUE  TO  PHYSICAL  AGENTS 


instances  there  are  remarkable  after-effects,  the  most  constant  of  which  is  a 
permanent  inability  to  bear  high  temperatures.  Such  patients  become  very 
uneasy  when  the  thermometer  reaches  80°  F.  in  the  shade.  Loss  of  the 
power  of  mental  concentration  and  failure  of  memory  are  more  constant  and 
very  troublesome  sequelae.  Such  patients  are  always  worse  in  the  hot  weather. 
Occasionally  there  are  convulsions,  followed  by  marked  mental  disturbance. 
Dercum  has  described  peripheral  neuritis  as  a  sequence. 

DIAGNOSIS. — It  is  rarely  difficult  to  distinguish  thermic  fever  from  the 
malignant  types  of  malaria  and  from  the  various  other  forms  of  coma.  The 
diagnosis  in  heat  exhaustion  or  thermic  fever  is  readily  made.  In  the  one 


JUNE  2 


CHABT  XIII. — CASE  OF  SUN-STEOKE  TREATED  BY  THE  ICE-BATH;   EECOVERY. 

the  skin  is  moist,  pale,  and  cool,  the  pulse  small  and  soft,  and  consciousness 
may  remain  till  near  the  end;  whereas  in  the  other  there  is  high  fever  with 
early  unconsciousness. 

PROGNOSIS. — In  the  old,  the  infirm,  and  in  alcoholic  subjects  the  case  mor- 
tality during  a  very  hot  wave  may  be  as  high  as  30  or  40  per  cent.  In  New 
York  and  Philadelphia  the  death-rate  varies  very  much  at  different  seasons. 

Treatment. — In  heat  exhaustion  stimulants  should  be  given  freely,  and 
if  the  temperature  is  below  normal  the  hot  bath  should  be  used.  Ammonia 
may  be  given  if  necessary.  In  thermic  fever  the  indications  are  to  reduce 
the  temperature  as  rapidly  as  possible.  This  may  be  done  by  packing  the 
patient  in  a  bath  with  ice.  Rubbing  the  body  with  ice  was  practiced  at  the 
New  York  Hospital  by  Darrach  in  1857,  and  is  an  excellent  procedure  t<? 


CAISSON  DISEASE  393 

lower  the  temperature  rapidly.  Ice-water  enemata  may  also  be  employed. 
At  the  Pennsylvania  Hospital  in  the  summer  of  1887  the  ice-pack  was  used 
with  great  advantage.  Of  31  cases  only  12  died,  results  probably  as  satis- 
factory as  can  be  obtained,  considering  that  many  of  the  patients  are  almost 
moribund  when  brought  to  hospital.  They  should  be  compared  with  Swift's 
statistics,  in  which,  of  150  cases,  78  died.  In  the  cases  in  which  the  symp- 
toms are  those  of  intense  asphyxia,  and  in  which  death  may  take  place  in  a 
few  minutes,  free  bleeding  should  be  practiced,  a  procedure  which  saved  Weir 
Mitchell  when  a  young  man.  For  the  convulsions,  chloroform  should  be 
given  at  once.  Of  other  remedies,  the  antipyretics  have  been  employed,  and 
may  be  given  when  there  is  any  special  objection  to  hydrotherapy,  for  which, 
however,  they  cannot  be  substituted. 

Heat  Cramps. — Persons  who  use  the  muscles  while  exposed  to  a  very  high 
temperature  are  liable  to  attacks  of  severe  cramp.  The  condition,  which  has 
been  described  very  thoroughly  by  Edsall,  occurs  principally  in  stokers  in  the 
furnace-rooms  of  steamships  and  in  workers  in  iron  foundries.  The  spasma 
occur  spontaneously,  chiefly  in  the  muscles  of  the  calves,  the  arms,  and  some- 
times in  the  abdomen;  they  are  often  of  great  intensity  and  very  painful. 
A  movement,  pressure,  or  any  stimulus,  as  electricity,  may  send  the  muscle 
into  spasm  at  once.  In  addition  to  ordinary  cramps  there  are  sometimes 
fibrillary  contractions.  The  attacks  may  last  for  from  12  to  34  hours  and 
are  followed  by  muscular  soreness  and  sometimes  by  great  weakness. 


II.     CAISSON  DISEASE 

(Compressed  Air  Disease;  Diver  s  Paralysis) 

Definition. — A  disease  of  caisson  workers  and  divers,  due  to  a  saturation 
of  the  tissues  with  N  under  the  increased  pressure.  If  the  decompression 
takes  place  quickly,  a  too-rapid  escape  of  the  N  as  bubbles  into  the  blood 
causes  air  embolism. 

History. — The  French  writers,  Bucquoy,  Foley,and  Bert,  first  studied  the 
disease.  Leyden  recognized  the  anatomical  changes.  A.  H.  Smith  and  others 
in  the  United  States  contributed  important  papers,  and  the  recent  studies 
of  Haldane,  Leonard  Hill,  and  Boycott  have  thrown  light  upon  the  etiology 
and  means  of  prevention. 

Etiology. — The  cases  are  met  with  chiefly  in  workers  in  caissons  and  tun- 
nels and  in  divers.  "The  higher  the  pressure  and  the  shorter  the  period  of 
decompression  the  greater  is  the  risk"  (Hill).  In  caissons  the  pressure  is 
rarely  30  to  35  pounds,  but  in  the  St.  Louis  bridge  the  pressure  reached  as 
high  as  45  to  50  pounds.  Divers  go  down  to  20  fathoms  with  a  pressure  of 
53  pounds;  the  record  depth  attained  by.  divers  is  210  feet  (Hill).  The  dis- 
ease may  also  occur  in  very  deep  mines. 

In  building  the  St.  Louis  bridge  across  the  Mississippi,  among  352  workers 
there  were  50  cases  of  paralysis  and  14  deaths.  In  making  the  Hudson 
Eiver  tunnel  the  cases  were  very  numerous,  and  until  the  conditions  were  im- 
proved there  were  two  or  three  deaths  a  month. 

Pathology. — To  Hoppe-Seyler,  Bucquoy,  and  Paul  Bert  we  owe  a  rational 
27 


394  DISEASES  DUE  TO  PHYSICAL  AGENTS 

explanation  of  the  disease  as  due  to  gas  absorption.  During  compression  the 
blood  passing  through  the  lungs  becomes  saturated  with  nitrogen,  which  is 
carried  to  the  tissues  until  the  whole  body  is  saturated.  "The  mass  of  blood 
is  about  5  per  cent,  of  the  body,  and  the  capacity  of  the  tissues  to  dissolve  N" 
is  estimated  by  Boycott  as  35  times  that  of  the  blood — in  a  fat  man  con- 
siderably more"  (Hill).  With  active  work  it  does  not  take  long  to  effect  com- 
plete saturation.  During  'decompression  the  process  is  just  the  reverse.  "The 
blood  gives  up  N  to  the  alveolar  air  and  returns  to  the  tissues  for  more. 
Those  organs  in  which  the  circulation  is  rapid  will  yield  up  their  N"  quickly, 

and  those  with  a  sluggish  circulation  slowly and  at  the  end 

of  decompression  a  condition  may  be  set  up  in  which  the  slow  tissues  still 
hold,  say  3  per  cent,  of  N,  while  the  blood  can  dissolve  only  1  per  cent.  Herein 
we  have  a  danger  of  bubbles  forming"  (Hill).  They  are  set  free  chiefly  in 
the  fatty  tissues  and  in  the  venous  blood.  Experimentally  all  the  symptoms 
can  be  produced  in  goats,  and  the  spinal  cord  may  contain  numerous  air 
emboli.  This  was  the  anatomical  lesion  determined  by  Leyden,  who  found 
fissuring  and  laceration  of  the  cord,  which  explains  the  paraplegia.  Pul- 
monary air  embolism  also  occurs  and  is  responsible  for  certain  features  of 
the  disease. 

Symptoms. — Within  from  half  an  hour  to  one  hour  after  leaving  the 
caisson,  the  patient  may  have  headache,  giddiness  and  feel  faint,  symptoms 
which  may  pass  off  and  leave  no  further  trouble.  In  other  instances  the 
patients  have  severe  pains  in  the  extremities,  usually  the  legs  and  the  abdo- 
men, sometimes  associated  with  nausea  and  vomiting — attacks  which  the 
workmen  usually  speak  of  as  "the  bends."  The  pains  may  be  of  the  greatest 
intensity  and  associated  with  giddiness  and  vomiting.  The  paralysis,  usually 
of  the  legs,  comes  on  rapidly,  and  varies  in  degree  from  a  slight  paralysis  to 
complete  loss  both  of  motion  and  sensation.  This  occurred  in  15  per  cent,  of 
A.  H.  Smith's  cases  and  in  61  per  cent,  of  the  St.  Louis  cases.  Monoplegia 
and  hemiplegia'are  rare.  In  extreme  instances  the  attacks  resemble  apoplexy; 
the  patient  rapidly  becomes  comatose  and  death  occurs  in  a  few  hours.  The 
paraplegia  may  be  permanent,  but  in  slight  cases  it  gradually  disappears  and 
recovery  may  be  complete. 

Prophylaxis. — The  only  safeguard  is  a  gradual  decompression,  which 
obviates  the  risk  of  rapidly  setting  free  the  nitrogen  from  the  tissues.  Hal- 
dane  and  his  colleagues  have  introduced  what  they  call  the  "Stage  Method," 
which  is  now  widely  adopted  with  the  most  beneficial  results.  For  work  in 
very  high  pressures  the  shifts  should  be  short,  not  more  than  two  hours. 

Treatment.  — The  caisson  workers  found  very  early  that  the  best  remedy  for 
"the  bends"  was  immediate  recompression,  and  Andrew  H.  Smith  of  New 
York  introduced  a  medical  air-lock  for  the  Brooklyn  bridge  workers.  The 
workers  should  live  and  sleep  not  far  from  the  works,  where  such  an  air- 
lock should  be  provided  for  immediate  treatment.  Cases  with  severe  symp- 
toms may  be  saved  by  recompression.  Hot  fomentations,  massage  and  hypo- 
dermics of  morphia  may  be  necessary  for  the  extreme  pains. 


MOUNTAIN  SICKNESS  395 


m.     MOUNTAIN  SICKNESS 

Definition.  —  An  illness  associated  with  adaptation  to  low  atmospheric 
pressures,  characterized  by  cyanosis,  nausea,  headache,  intestinal  disturbances, 
hyperpncea  and  sometimes  fainting. 

Pathology.  —  The  symptoms  are  directly  referable  to  want  of  oxygen  pro- 
duced by  the  diminished  pressure  of  the  atmosphere.  Haldane,  Douglas  and 
Henderson  have  recently  made  an  exhaustive  study  of  the  process  of  accom- 
modation in  a  five  weeks'  residence  at  the  top  of  Pike's  Peak.  After  acclima- 
tization the  symptoms  above  mentioned  disappeared,  but  dyspnoea,  blueness 
and  periodic  breathing  are  apt  to  follow  exertion.  The  alveolar  carbon  di- 
oxide pressure  was  reduced  from  about  40  mm.  to  about  27  mm.  during 
rest,  which  corresponded  to  an  increase  of  about  50  per  cent,  in  the  ventila- 
tion of  the  lung  alveoli.  As  has  long  been  known,  this  process  of  accommo- 
dation is  associated  with  a  remarkable  increase  in  the  red  blood  corpuscles 
and  haemoglobin  to  120  to  150  per  cent.  These  authors  conclude  that  the 
acclimatization  is  largely  due  to  increased  secretory  activity  of  the  alveolar  epi- 
thelium, to  the  greater  lung  ventilation  and  to  the  increased  hemoglobin 
production. 

Symptoms.  —  The  symptoms  just  given,  which  are  the  most  important,  pass 
away  gradually,  but  may  return  on  exertion.  In  feeble  persons  the  heart's 
action  may  be  weak  and  intermittent,  and  syncope  may  follow  any  effort. 
\Yhymper  in  the  ascent  of  Chimborazo  at  a  height  of  16,000  feet  had  head- 
ache, fever,  gasping  respiration  and  great  weakness.  Nausea,  vomiting,  bleed- 
ing at  the  nose,  ringing  in  the  ears  and  palpitation  are  not  infrequent  symp- 
toms. 


SECTION    III 
THE  -INTOXICATIONS 

I.     ALCOHOLISM 

(a)  Acute  Alcoholism. — When  a  large  quantity  of  alcohol  is  taken,  the 
influence  is  chiefly  on  the  nervous  system,  and  is  manifested  in  muscular  inco- 
ordination,  mental  disturbance,  and,  finally,  narcosis.     The  individual  pre- 
sents a  flushed,  sometimes  slightly  cyanosed  face,  the  pulse  is  full,  respira- 
tions deep  but  rarely  stertorous.     The  pupils  are  dilated.     The  temperature 
is  frequently  below  normal,  particularly  if  the  patient  has  been  exposed  to 
cold.     Perhaps  the  lowest  reported  temperatures  have  been  in  cases  of  this 
sort.    An  instance  is  on  record  in  which  the  patient  on  admission  to  hospital 
had  a  temperature  of  24°  C.  (ca.  75°  F.),  and  ten  hours  later  the  temperature 
had  not  risen  to  91°  F.     The  unconsciousness  is  rarely  so  deep  that  the  pa- 
tient cannot  be  roused  to  some  extent,  and  in  reply  to  questions  he  mutters 
incoherently.     Muscular  twitchings  may  occur,  but  rarely  convulsions.     The 
breath  has  a  heavy  alcoholic  odor.     The  respirations  may  be  slow;  in  one 
case  they  were  only  six  in  the  minute. 

The  diagnosis  is  not  difficult,  yet  mistakes  are  frequently  made.  Persons 
are  brought  to  a  hospital  by  the  police  supposed  to  be  drunk  when  in  reality 
they  are  dying  from  apoplexy.  Too  great  care  cannot  be  exercised,  and  the 
patient  should  receive  the  benefit  of  the  doubt.  In  'some  instances  the  mis- 
take has  arisen  from  the  fact  that  a  person  who  has  been  drinking  heavily 
has  been  stricken  with  apoplexy.  In  this  condition  the  coma  is  usually  deeper, 
stertor  is  present,  and  there  may  be  evidence  of  hemiplegia  in  the  greater 
flaccidity  of  the  limbs  on  one  side.  The  diagnosis  will  be  considered  in  the 
section  upon  ursemic  coma. 

Dipsomania  is  a  form  of  acute  alcoholism  seen  in  persons  with  a  strong 
hereditary  tendency  to  drink.  Periodically  the  victims  go  "on  a  spree,"  but 
in  the  intervals  they  are  entirely  free  from  any  craving  for  alcohol. 

(b)  Chronic  Alcoholism. — In  moderation,  wine,  beer,  and  spirits  may  be 
taken  throughout  a  long  life  without  impairing  the  general  health. 

The  poisonous  effects  of  alcohol  are  manifested  (1)  as  a  functional  poison, 
as  in  acute  narcosis;  (2)  as  a  tissue  poison,  in  which  its  effects  are  seen  on 
the  parenchymatous  elements,  particularly  epithelium  and  nerve,  producing 
a  slow  degeneration,  and  on  the  blood  vessels,  causing  thickening  and  ulti- 
mately fibroid  changes;  and  (3)  as  a  checker  of  tissue  oxidation,  since  the  alco- 
hol is  consumed  in  place  of  the  fat.  This  leads  to  fatty  changes  and  some- 
times to  a  condition  of  general  steatosis. 
396 


ALCOHOLISM  397 

The  chief  effects  of  chronic  alcohol  poisoning  may  be  thus  summarized: 

Nervous  System. — Functional  disturbance  is  common.  Unsteadiness  of 
the  muscles  in  performing  any  action  is  a  constant  feature.  The  tremor  is 
best  seen  in  the  hands  and  in  the  tongue.  The  mental  processes*  may  be  dull, 
particularly  in  the  early  morning  hours,  and  the  patient  is  unable  to  transact 
any  business  until  he  has  had  his  accustomed  stimulant.  Irritability  of  tem- 
per, forgetfulness,  and  a  change  in  the  moral  character  of  the  individual 
gradually  come  on.  The  judgment  is  seriously  impaired,  the  will  enfeebled, 
and  in  the  final  stages  dementia  may  supervene.  An  interesting  combination 
of  symptoms  in  chronic  alcoholics  is  characterized  by  peripheral  neuritis,  loss 
of  memory,  and  pseudo-reminiscences — that  is,  false  notions  as  to  the  patient's 
position  in  time  and  space,  and  fabulous  explanations  of  real  occurrences. 
The  peripheral  neuritis  is  not  always  present;  there  may  be  only  tremor  and 
jactitation  of  the  lips,  and  thickness  of  the  speech,  with  visual  hallucinations. 
The  mental  condition  was  described  by  Jackson  and  by  Wilks.  Korsakoff 
speaks  of  it  as  a  psychosis  polyneuritica,  and  the  symptom-complex  is  some- 
times called  by  his  name.  The  relation  of  chronic  alcoholism  to  insanity  has 
been  much  discussed.  According  to  Savage,  of  4,000  patients  admitted  to  the 
Bethlehem  Hospital,  133  gave  drink  as  the  cause  of  their  insanity.  Chronic 
alcoholism  is  certainly  one  of  the  important  elements  in  the  strain  which  leads 
to  mental  breakdown.  Epilepsy  may  result  directly  from  chronic  drinking. 
It  is  a  hopeful  form,  and  may  disappear  entirely  with  a  return  to  habits  of 
temperance. 

There  is  a  remarkable  condition  in  chronic  alcoholism  termed  "wet  brain" 
in  which  a  heavy  drinker,  who  may  perhaps  have  had  attacks  of  delirium 
tremens,  begins  to  get  drowsy  or  a  little  more  befuddled  than  usual ;  gradually 
the  stupor  deepens  until  he  becomes  comatose,  in  which  state  he  may  remain 
for  weeks.  There  may  be  slight  fever,  but  there  are  no  signs  of  paralysis,  and 
no  optic  neuritis.  The  urine  may  be  normal.  The  lumbar  puncture  yields 
a  clear  fluid,  but  under  high  pressure.  In  one  case,  which  died  at  the  end  of 
six  weeks,  there  were  the  anatomical  features  of  a  serous  meningitis. 

No  characteristic  changes  are  found  in  the  nervous  system.  Haemorrhagic 
pachymeningitis  is  not  very  uncommon.  There  are  opacity  and  thickening  of 
the  pia-arachnoid  membranes,  with  more  or  less  wasting  of  the  convolutions. 
These  are  in  no  way  peculiar  to  chronic  alcoholism,  but  are  found  in  old 
persons  and  in  chronic  wasting  diseases.  In  the  very  protracted  cases  there 
may  be  chronic  encephalo-meningitis  with  adhesions  of  the  membranes.  Finer 
changes  in  the  nerve-cells,  their  processes,  and  the  neuroglia  have  been  de- 
scribed. By  far  the  most  striking  effect  of  alcohol  on  the  nervous  system  is 
the  production  of  the  alcoholic  neuritis,  which  will  be  considered  later. 

Digestive  System. — Catarrh  of  the  stomach  is  the  most  common  symptom. 
The  toper  has  a  furred  tongue,  heavy  breath,  and  in  the  morning  a  sensation 
of  sinking  at  the  stomach  until  he  has  had  his  dram.  The  appetite  is  usu- 
ally impaired  and  the  bowels  are  constipated.  In  beer-drinkers  dilatation  of 
the  stomach  is  common. 

Alcohol  produces  definite  changes  in  the  liver,  leading  ultimately  to  the 
various  forms  of  cirrhosis,  to  be  described.  In  Welch's  laboratory  J.  Frieden- 
wald  has  caused  typical  cirrhosis  in  rabbits  by  the  administration  of  alcohol. 
The  effect  is  a  primary  degenerative  change  in  the  liver-cells.  A  special  vul- 


398  THE  INTOXICATIONS 

nerability  of  the  liver-cells  is  necessary  in  the  etiology  of  alcoholic  cirrhosis. 
There  are  cases  in  which  comparatively  moderate  drinking  for  a  few  years 
has  been  followed  by  cirrhosis;  on  the  other  hand,  the  livers  of  persons  who 
have  been  steady  drinkers  for  thirty  or  forty  years  may  show  only  a  moderate 
grade  of  sclerosis.  For 'years  before  cirrhosis  develops  heavy  drinkers  may 
present  an  enlarged  and  tender  liver,  with  at  times  swelling  of  the  spleen. 
With  the  gastric  and  hepatic  disorders  the  facies  often  becomes  very  charac- 
teristic. The  venules  of  the  cheeks  and  nose  are  dilated;  the  latter  becomes 
enlarged,  red,  and  may  present  the  condition  known  as  acne  rosacea.  The 
eyes  are  watery,  and  conjunctiva?  hyperasniic  and  sometimes  bile-tinged. 

The  heart  and  arteries  in  chronic  topers  show  degenerative  changes,  and 
alcoholism  is  a  factor  in  causing  arterio-sclerosis.  Steell  has  pointed  out  the 
frequency  of  cardiac  dilatation  in  these  cases. 

Kidneys. — The  influence  of  chronic  alcoholism  upon  these  organs  is  by  no 
means  so  marked.  According  to  Dickinson  the  total  of  renal  disease  is  not 
greater  in  the  drinking  class,  and  he  holds  that  the  effect  of  alcohol  on  the 
kidneys  has  been  much  overrated.  Formad  has  directed  attention  to  the  fact 
that  in  a  large  proportion  of  chronic  alcoholics  the  kidneys  are  increased  in 
size.  The  Guy's  Hospital  statistics  support  this  statement,  and  Pitt  notes  that 
in  43  per  cent,  of  the  bodies  of  hard  drinkers  the  kidneys  were  hypertrophied 
without  showing  morbid  change.  A  granular  kidney  may  result  indirectly 
through  the  arterial  changes. 

It  was  formerly  thought  that  alcohol  was  in  some  way  antagonistic  to 
tuberculous  disease,  but  the  observations  of  late  years  indicate  clearly  that 
the  reverse  is  the  case  and  that  chronic  drinkers  are  much  more  liable  to 
both  acute  and  pulmonary  tuberculosis.  It  is  probably  altogether  a  question 
of  altered  tissue-soil,  the  alcohol  lowering  the  vitality  and  enabling  the  bacilli 
more  readily  to  develop  and  grow. 

(c)  Delirium  tremens  (mania  a  potu),  an  incident  in  the  history  of 
chronic  alcoholism,  results  from  the  long-continued  action  of  the  poison  on 
the  brain.  The  condition  was  first  accurately  described  early  in  the  19th 
century  by  Sutton,  of  Greenwich,  who  had  numerous  opportunities  for  study- 
ing the  different  forms  among  sailors.  One  of  the  most  careful  studies  of  the 
disease  was  made  by  Ware,  of  Boston.  A  spree  in  a  temperate  person,  no 
matter  how  prolonged,  is  rarely  if  ever  followed  by  delirium  tremens;  but  in 
the  case  of  an  habitual  drinker  a  temporary  excess  is  apt  to  bring  on  an  attack. 
It  sometimes  follows  in  consequence  of  the  sudden  withdrawal  of  the  alcohol. 
An  accident,  a  sudden  fright  or  shock,  or  an  acute  inflammation,  particularly 
pneumonia,  may  determine  the  onset.  It  is  especially  apt  to  occur  in  drinkers 
admitted  to  hospitals  for  injuries,  especially  fractures,  and,  as  this  seems  most 
likely  to  occur  when  the  alcohol  is  withdrawn,  it  is  well  to  give  such  patients 
a  moderate  amount  of  alcohol.  At  the  outset  of  the  attack  the  patient  is 
restless  and  depressed  and  sleeps  badly,  symptoms  which  cause  him  to  take 
alcohol  more  freely.  After  a  day  or  two  the  characteristic  delirium  sets  in. 
The  patient  talks  constantly  and  incoherently;  he  is  incessantly  in  motion, 
and  desires  to  go  out  and  attend  to  some  imaginary  business.  Hallucinations 
of  sight  and  hearing  develop.  He  sees  objects  in  the  room,  such  as  rats,  mice, 
or  snakes,  and  fancies  that  they  are  crawling  over  his  body.  The  terror  in- 
spired by  these  imaginary  objects  is  great,  and  has  given  the  popular  nam« 


ALCOHOLISM  399 

"horrors"  to  the  disease.  The  patients  need  to  he  watched  constantly,  for 
in  their  delusions  they  may  jump  out  of  the  window  or  escape.  Auditory 
hallucinations  are  not  so  common,  but  the  patient  may  complain  of  hearing 
the  roar  of  animals  or  the  threats  of  imaginary  enemies.  There  is  much  mus- 
cular tremor;  the  tongue  is  covered  with  a  thick  white  fur,  and  when  pro- 
truded is  tremulous.  The  pulse  is  soft,  rapid,  and  readily  compressed.  There 
is  usually  fever,  but  the  temperature  rarely  registers  above  102°  or  103°.  In 
fatal  cases  it  may  be  higher.  Insomnia  is  a  constant  feature.  On  the  third 
or  fourth  day  in  favorable  cases  the  restlessness  abates,  the  patient  sleeps, 
and  improvement  gradually  sets  in.  The  tremor  persists  for  some  days,  the 
hallucinations  gradually  disappear,  and  the  appetite  returns.  In  more  serious 
cases  the  insomnia  persists,  the  delirium  is  incessant,  the  pulse  becomes  more 
frequent  and  feeble,  the  tongue  dry,  the  prostration  extreme,  and  death  takes 
place  from  gradual  heart-failure. 

There  is  a  condition  termed  acute  hallucinosis,  in  which  auditory  halluci- 
nations are  marked,  orientation  is  retained,  and  the  mental  disturbances  are 
fixed.  Ideas  of  persecution  are  common.  There  are  intermediate  forms  be- 
tween this  and  the  ordinary  delirium  tremens. 

Diagnosis. — The  clinical  picture  of  the  disease  can  scarcely  be  confounded 
with  any  other.  Cases  with  fever,  however,  may  be  mistaken  for  meningitis. 
By  far  the  most  common  error  is  to  overlook  some  local  disease,  such  as  pneu- 
monia or  erysipelas,  or  an  accident,  as  a  fractured  rib,  which  in  a  chronic 
drinker  may  precipitate  an  attack  of  delirium  tremens.  In  every  instance  a 
careful  examination  should  be  made,  particularly  of  the  lungs.  It  is  to  be 
remembered  that  in  the  severer  forms,  particularly  the  febrile  cases,  conges- 
tion of  the  bases  of  the  lungs  is  by  no  means  uncommon.  Another  point  to 
be  borne  in  mind  is  the  fact  that  pneumonia  of  the  apex  is  apt  to  be  accom- 
panied by  delirium  similar  to  mania-  a  potu. 

Prognosis.  — Recovery  takes  place  in  a  large  proportion  of  the  cases  in  pri- 
vate practice.  In  hospital  practice,  particularly  in  the  large  city  hospitals 
to  which  the  debilitated  patients  are  taken,  the  death-rate  is  higher.  Gerhard 
states  that  of  1,241  cases  admitted  to  the  Philadelphia  Hospital  121  proved 
fatal.  Recurrence  is  frequent,  almost,  indeed,  the  rule,  if  the  drinking  is 
kept  up. 

Treatment. — Acute  alcoholism  rarely  requires  any  special  measures,  as  the 
patient  sleeps  off  the  effects  of  the  debauch.  In  the  case  of  profound  alco- 
holic coma  it  may  be  advisable  to  wash  out  the  stomach,  and  if  collapse  symp- 
toms occur  the  limbs  should  be  rubbed  and  hot  applications  made  to  the  body. 
Should  convulsions  supervene,  chloroform  may  be  carefully  administered.  In 
the  acute,  violent  alcoholic  mania  the  hypodermic  injection  of  apomorphia, 
one-eighth  or  one-sixth  of  a  grain,  is  usually  very  effectual,  causing  nausea 
and  vomiting,  and  rapid  disappearance  of  the  maniacal  symptoms. 

Chronic  alcoholism  is  a  condition  very  difficult  to  treat,  and  once  fully 
established  the  habit  is  rarely  abandoned.  The  most  obstinate  cases  are  those 
with  marked  hereditary  tendency.  Withdrawal  of  the  alcohol  is  the  first 
essential.  This  is  most  effectually  accomplished  by  placing  the  patient  in  an 
institution,  in  which  he  can  be  carefully  watched  during  the  trying  period 
of  the  first  week  or  ten  days  of  abstention.  The  absence  of  temptation  in 
institution  life  is  of  special  advantage.  For  the  sleeplessness  the  bromides 


400  THE  INTOXICATIONS 

or  hyoscine  may  be  employed.  Quinine  and  strychnine  in  tonic  doses  may  be 
given.  Cocaine  or  tbe  fluid  extract  of  coca  has  been  recommended  as  a  sub- 
stitute for  alcohol,  but  it  is  not  of  much  service.  Prolonged  seclusion  in  a 
suitable  institution  is  in  reality  the  only  effectual  means  of  cure.  When  an 
hereditary  tendency  exists  a  lapse  into  the  drinking  habit  is  almost  inevitable. 

In  delirium  tremens  the  patient  should  be  confined  to  bed  and  carefully 
watched  night  and  day.  The  danger  of  escape  in  these  cases  is  very  great,  as 
the  patient  imagines  himself  pursued  by  enemies  or  demons.  Flint  mentions 
the  case  of  a  man  who  escaped  in  his  nightclothes  and  ran  barefooted  for  fif- 
teen miles  on  the  frozen  ground  before  he  was  overtaken.  The  patient  should 
not  be  strapped  in  bed,  as  this  aggravates  the  delirium ;  sometimes,  however,  it 
may  be  necessary,  in  which  case  a  sheet  tied  across  the  bed  may  be  sufficient,  and 
this  is  certainly  better  than  violent  restraint  by  three  or  four  men.  Alcohol 
should  be  withdrawn  at  once  unless  the  pulse  is  feeble. 

Delirium  tremens  is  a  disease  which,  in  a  large  majority  of  cases,  runs  a 
course  very  slightly  influenced  by  medicine.  The  indications  for  treatment 
are  to  procure  sleep  and  to  support  the  strength.  In  mild  cases  half  a  drachm 
(2  gm.)  of  bromide  of  potassium  combined  with  tincture  of  capsicum  may  be 
given  every  three  hours.  Chloral  is  often  of  great  service,  and  may  be  given 
without  hesitation  unless  the  heart's  action  is  feeble.  Good  results  sometimes 
follow  the  hypodermic  use  of  hyoscine,  one  one-hundredth  of  a  grain.  Opium 
must  be  used  cautiously.  A  special  merit  of  Ware's  work  was  the  demonstra- 
tion that  on  a  rational  or  expectant  plan  of  treatment  the  percentage  of  re- 
coveries was  greater  than  with  the  indiscriminate  use  of  sedatives,  which  had 
been  in  vogue  for  many  years.  When  opium  is  indicated  it  should  be  given 
as  morphia,  hypodermically.  The  effect  should  be  carefully  watched,  and,  if 
after  three  or  four  quarter-grain  doses  have  been  given  the  patient  is  still 
restless  and  excited,  it  is  best  not  to  push  it  farther.  Eepeated  doses  of  trional 
(grs.  xv-xx)  every  four  hours  may  be  tried.  Lambert  advises  ergotin  hypo- 
dermically in  both  the  acute  and  chronic  alcoholism.  When  fever  is  present 
the  tranquilizing  effects  of  a  cold  douche  or  cold  ba'th  may  be  tried,  or  the 
cold  or  warm  packs.  The  large  doses  of  digitalis  formerly  employed  are  not 
advisable. 

Careful  feeding  is  the  most  important  element  in  the  treatment  of  these 
cases.  Milk  and  concentrated  broths  should  be  given  at  stated  intervals.  If 
the  pulse  becomes  rapid  and  shows  signs  of  flagging,  alcohol  may  be  given  in 
combination  with  the  aromatic  spirits  of  ammonia. 


H.     MORPHIA  HABIT 

(Morphinomania;  Morphinism) 

Taken  at  first  to  allay  pain,  a  craving  for  the  drug  is  gradually  engendered. 
and  the  habit  in  this  way  acquired.  The  effects  of  the  constant  use  of  opium 
vary  very  much.  In  the  East,  where  opium-smoking  is  as  common  as  tobacco- 
smoking  with  us,  the  ill  effects  are,  according  to  good  observers,  not  very  strik- 
ing. Taken  as  morphia  and  hypodermically,  as  is  the  rule,  it  is  very  injurious. 
but  a  moderate  amount  may  be  taken  for  years  without  serious  damage. 


MORPHIA  HABIT  401 

The  habit  is  particularly  prevalent  among  women  and  physicians  who  use 
the  hypodermic  syringe  for  the  alleviation  of  pain,  as  in  neuralgia  or  sciatica. 
The  acquisition  of  the  habit  as  a  pure  luxury  is  rare. 

Symptoms. — The  symptoms  at  first  are  slight  and  for  months  there  may  be 
no  disturbance  of  health.  There  are  exceptional  instances  in  which  for  a 
period  of  years  excessive  amounts  have  been  taken  without  deterioration  of  the 
mental  or  bodily  functions.  As  a  rule,  the  dose  necessary  to  obtain  the  desired 
sensation  has  gradually  to  be  increased.  As  the  effects  wear  off  the  victim 
experiences  sensations  of  lassitude  and  mental  depression,  accompanied  often 
with  slight  nausea  and  epigastric  distress,  or  even  recurring  colic,  which  may 
be  mistaken  for  appendicitis.  The  confirmed  opium-eater  usually  has  a  sallow, 
pasty  complexion,  is  emaciated,  and  becomes  prematurely  gray.  He  is  restless, 
irritable,  and  unable  to  remain  quiet  for  any  time.  Itching  is  a  common 
symptom.  The  sleep  is  disturbed,  the  appetite  and  digestion  are  deranged, 
and  except  when  directly  under  the  influence  of  the  drug  the  mental  condi- 
tion is  one  of  depression.  Occasionally  there  are  profuse  sweats,  which  may 
be  preceded  by  chills.  The  pupils,  except  when  under  the  direct  influence  of 
the  drug,  are  dilated,  sometimes  unequal.  In  one  case  there  was  a  persistent 
oedema  of  the  legs  without  sufficient  renal  changes  or  anaemia  to  account  for  it. 
Persons  addicted  to  morphia  are  inveterate  liars,  and  no  reliance  whatever  can 
be  placed  upon  their  statements.  In  many  instances  this  is  not  confined  to 
matters  relating  to  the  vice.  In  women  the  symptoms  may  be  associated  with 
those  of  pronounced  hysteria  or  neurasthenia.  The  practice  may  be  con- 
tinued for  an  indefinite  time,  usually  requiring  increase  in  the  dose  until  ulti- 
mately enormous  quantities  may  be  needed  to  obtain  the  desired  effect. 
Finally  a  condition  of  asthenia  is  induced,  in  which  the  victim  takes  little  or 
no  food  and  dies  from  the  extreme  bodily  debility.  An  increase  in  the  dose 
is  not  always  necessary,  and  there  are  habitues  who  reach  the  point  of  satis- 
faction with  a  daily  amount  of  2  or  3  grains  of  morphia,  and  who  are  able 
to  carry  on  successfully  for  many  years  the  ordinary  business  of  life.  They 
may  remain  in  good  physical  condition,  and  indeed  often  look  ruddy. 

Treatment. — The  treatment  of  the  morphia  habit  is  extremely  difficult,  and 
can  rarely  be  successfully  carried  out  by  the  general  practitioner.  Isolation, 
systematic  feeding,  and  gradual  withdrawal  of  the  drug  are  the  essential  ele- 
ments. As  a  rule,  the  patients  must  be  under  control  in  an  institution  and 
should  be  in  bed  for  the  first  ten  days.  It  is  best  in  a  majority  of  cases  to 
reduce  the  morphia  gradually.  The  diet  should  consist  of  beef -juice,  milk,  and 
egg-white,  which  should  be  given  at  short  intervals.  The  sufferings  of  the  pa- 
tients are  usually  very  great,  more  particularly  the  abdominal  pains,  some- 
times nausea  and  vomiting,  and  the  distressing  restlessness.  Usually  within  a 
week  or  ten  days  the  opium  may  be  entirely  withdrawn.  In  all  cases  the  pulse 
should  be  carefully  watched  and,  if  feeble,  stimulants  should  be  given,  with 
the  aromatic  spirit  of  ammonia  and  digitalis.  For  the  extreme  restlessness 
a  hot  bath  is  serviceable.  The  sleeplessness  is  the  most  distressing  symptom, 
and  various  drugs  may  have  to  be  resorted  to,  particularly  hyoscine  and  sul- 
phonal  and  sometimes,  if  the  insomnia  persists,  morphia  itself. 

It  is  essential  in  the  treatment  of  a  case  to  be  certain  that  the  patient  has 
no  means  of  obtaining  morphia.  Even  under  the  favorable  circumstances  of 
seclusion  in  an  institution,  and  constant  watching  by  a  night  and  a  day  nurse, 


402  THE  INTOXICATIONS 

I  have  known  a  patient  to  practice  deception  for  a  period  of  three  months. 
After  an  apparent  cure  the  patients  are  only  too  apt  to  lapse  into  the  habit. 
The  condition  is  one  which  has  become  so  common,  and  is  so  much  on 
the  increase,  that  physicians  should  exercise  the  utmost  caution  in  prescrib- 
ing morphia,  particularly  to  female  patients.  Under  no  circumstances  should 
a  patient  be  allowed  to  use  the  hypodermic  syringe,  and  it  is  even  safer  not 
to  intrust  this  dangerous  instrument  to  the  hands  of  the  nurse. 


in.    LEAD  POISONING 

(Plumbism,  Saturnism) 

Etiology. — 'The  disease  is  widespread,  particularly  in  the  lead  industries 
and  among  plumbers,  painters,  and  glaziers.  For  the  ten  years  ending  1909, 
8,973  cases  with  667  deaths  were  reported  to  the  Home  Office  (England)  as  oc- 
curring in  18  industries,  but  Legge  points  out  there  has  been  in  this  period  a 
reduction  of  more  than  50  per  cent,  of  cases.  In  the  United  States  it  is  not 
easy  to  get  accurate  statistics.  Alice  Hamilton  reports  358  cases  with  16 
deaths  in  23  white  lead  factories  during  the  16  months  to  May  1,  1911.  In 
New  York  State  in  1909  and  1910,  60  deaths  were  certified  from  lead  poison- 
ing. The  metal  is  introduced  into  the  system  in  many  forms.  Miners  usu- 
ally escape,  but  those  engaged  in  the  smelting  of  lead-ores  are  often  attacked. 
Animals  in  the  neighborhood  of  smelting  furnaces  have  suffered  with  the  dis- 
ease, and  even  the  birds  that  feed  on  the  berries  in  the  neighborhood  may  be 
affected.  Men  engaged  in  the  white-lead  factories  are  particularly  prone  to 
plumbism.  Accidental  poisoning  may  come  in  many  ways;  most  commonly 
by  drinking  water  which  has  passed  through  lead  pipes  or  been  stored  in  lead- 
lined  cisterns.  Wines  and  cider  which  contain  acids  quickly  become  con- 
taminated in  contact  with  lead.  It  was  the  frequency  of  colic  in  certain  of 
the  cider  districts  of  Devonshire  which  gave  the  name  of  Devonshire  colic,  as 
the  frequency  of  it  in  Poitou  gave  the  name  colica  Pictonum.  Among  the  in- 
numerable sources  of  accidental  poisoning  may  be  mentioned  milk,  various 
sorts  of  beverages,  hair  dyes,  false  teeth,  and  thread.  A  few  cases  have  fol- 
lowed the  retention  of  lead  bullets  in  gun-shot  wounds.  Given  medicinally, 
lead  rarely  causes  poisoning,  but  we  had  in  the  Johns  Hopkins  Hospital  four 
cases  following  the  use  of  lead  and  opium  pills  for  dysentery,  of  which  cause 
Miller  has  collected  many  cases  from  the  literature.  It  has  also  followed  the 
use  of  Emplastrum  Diachylon  to  produce  abortion,  and  there  is  a  case  reported 
in  an  infant  from  the  application  of  lead-water  on  the  mother's  nipples.  One 
grain  every  three  hours  for  three  days,  and  two  grains  every  three  hours  for 
one  day,  have  caused  signs  of  poisoning.  A  serious  outbreak  of  lead-poisoning, 
investigated  by  David  D.  Stewart,  occurred  in  Philadelphia,  owing  to  adul- 
teration of  a  baking-powder  with  chromate  of  lead,  which  was  used  to  give  a 
yellow  tint  to  the  cakes. 

All  ages  are  attacked,  but  children  are  relatively  less  liable.  The  largest 
number  of  cases  occur  between  thirty  and  forty.  According  to  Oliver,  females 
are  more  susceptible  than  males.  They  are  much  more  quickly  brought  under 
its  influence,  and  in  a  recent  epidemic  in  which  a  thousand  cases  were  in- 


LEAD  POISONIHG  403 

volved  the  proportion  of  females  to  males  was  four  to  one.  Miscarriage  is 
common,  and  it  is  rare  for  a  woman  working  in  lead  to  carry  a  child  to  term. 
It  also  destroys  the  reproductive  power  in  man. 

The  lead  gains  entrance  to  the  system  through  the  lungs,  the  digestive 
organs,  or  the  skin.  Poisoning  may  follow  the  use  of  cosmetics  containing 
lead.  Through  the  lungs  it  is  freely  absorbed.  The  chief  channel,  according 
to  Oliver,  is  the  digestive  system.  It  is  rapidly  eliminated  by  the  kidneys  and 
skin,  and  is  present  in  the  urine  of  lead-workers.  The  susceptibility  is  re- 
markably varied.  The  symptoms  may  be  manifest  within  a  month  of  ex- 
posure. On  the  other  hand,  Tanquerel  (des  Planches)  met  with  a  case  in  a 
man  who  had  been  a  lead-worker  for  fifty-two  years. 

•  Morbid  Anatomy.  — Small  quantities  of  lead  occur  in  the  body  in  health. 
J.  J.  Putnam's  reports  show  that  of  150  persons  not  presenting  symptoms  of 
lead-poisoning  traces  of  lead  occurred  in  the  urine  of  25  per  cent.  Of  264 
deaths  in  persons  subjects  of  plumbism  32  were  due  to  an  encephalopathy,  43 
to  Bright's  disease,  47  to  cerebral  haemorrhage,  43  to  paralysis,  44  to  lead 
poisoning,  38  to  phthisis,  and  40  to  various  maladies,  pneumonia,  heart  dis- 
ease, aneurism,  etc.  (Legge). 

In  chronic  poisoning  lead  is  found  in  the  various  organs.  The  affected 
muscles  are  yellow,  fatty,  and  fibroid.  The  nerves  present  the  features  of  a 
peripheral  degenerative  neuritis.  The  cord  and  the  nerve-roots  are,  as  a  rule, 
uninvolved.  In  the  primary  atrophic  form  the  ganglion  cells  of  the  anterior 
horns  are  probably  implicated.  In  the  acute  fatal  cases  there  may  be  the  most 
intense  entero-colitis. 

Symptoms. — ACUTE  FORM. — We  do  not  refer  here  to  the  accidental  or 
suicidal  cases,  which  present  vomiting,  pain  in  the  abdomen,  and  collapse 
symptoms.  In  workers  in  lead  there  are  several  manifestations  which  follow 
a  short  time  after  exposure  and  set  in  acutely.  There  may  be,  in  the  first 
place,  a  rapidly  developing  anaemia.  Acute  neuritis  has  been  described,  and 
convulsions,  epilepsy,  and  a  delirium,  which  may  be  not  unlike  that  produced 
by  alcohol.  There  are  also  cases  in  which  the  gastro-intestinal  symptoms  are 
most  intense  and  rapidly  prove  fatal.  These  acute  forms  occur  more  fre- 
quently in  persons  recently  exposed,  and  are  more  frequent  in  winter  than  in 
summer.  Da  Costa  has  reported  the  onset  of  hemiplegia  after  three  days' 
exposure  to  the  poison. 

CHRONIC  POISONING. —  (a)  Blood  Changes. — A  moderate  grade  of  anosmia, 
the  so-called  saturnine  cachexia,  is  usually  present.  The  corpuscles  do  not 
often  fall  below  50  per  cent.  Many  of  the  red  cells  show  a  remarkable  granu- 
lar, basophilic  degeneration  when  stained  with  Jenner's  stain,  or  with  poly- 
chrome methylene  blue.  Grawitz  first  demonstrated  their  presence  in  casea 
of  pernicious  anaemia,  and  Pepper  (tertius)  and  White  showed  that  they  were 
constantly  present  in  lead-poisoning.  Further  observations  by  Vaughan  and 
others  have  shown  that  such  granulations  are  found  in  the  blood  in  a  great 
variety  of  conditions,  even  in  normal  blood,  but  that  they  are  most  numerous 
in  lead-poisoning,  in  which  their  occurrence  in  very  large  numbers  is  of  con- 
siderable value  in  diagnosis.  Cadwalader  has  shown  the  constant  presence  of 
nucleated  red  blood-corpuscles  even  when  the  anaemia  is  of  very  slight  grade. 

(6)  Blue  line  on  the  gums,  which  is  a  valuable  indication,  but  not  in- 
variably present.  Two  lines  must  be  distinguished:  one,  at  the  margin  be- 


404  THE  INTOXICATIONS 

tween  the  gums  and  teeth,  is  on,  not  in  the  gums,  and  is  readily  removed  by 
rinsing  the  mouth  and  cleansing  the  teeth.  The  other  is  the  well-known  char- 
acteristic blue-black  line  at  the  margin  of  the  gum.  The  color  is  not  uniform, 
but  being  in  the  papillae  of  the  gums  the  line  is,  as  seen  with  a  magnifying- 
glass,  interrupted.  The  lead  is  absorbed  and  converted  in  the  tissues  into  a 
black  sulphide  by  the  action  of  sulphuretted  hydrogen  from  the  tartar  of  the 
teeth.  The  line  may  form,  in  a  few  days  after  exposure  (Oliver)  and  disap- 
pear within  a  few  weeks,  or  may  persist  for  many  months.  Philipson  has 
noted  the  occurrence  of  a  black  line  in  miners,  due  to  the  deposition  of  carbon. 
The  most  important  symptoms  of  chronic  lead-poisoning  are  colic,  lead- 
palsy,  and  the  encephalopathy.  Of  these,  the  colic  is  the  most  frequent.  Of 
Tanquerel's  cases,  there  were  1,217  of  colic,  101  of  paralysis,  and  72  of 
encephalopathy. 

(c)  Colic  is  the  most  common  symptom  of  chronic  lead-poisoning.     It 
is  often  preceded  by  gastric  or  intestinal  symptoms,  particularly  constipation. 
The  pain  is  over  the  whole  abdomen.     The  colic  is  usually  paroxysmal,  like 
true  colic,  and  is  relieved  by  pressure.     There  is  often,  in  addition,  between 
the  paroxysms  a  dull,  heavy  pain.     There  may  be  vomiting.     During  the 
attack,  as  Riegel  noted,  the  pulse  is  increased  in  tension  and  the  heart's  action 
is  retarded.    Attacks  of  pain  with  acute  diarrhoea  may  recur  for  weeks  or  even 
for  three  or  four  years. 

Certain  of  the  cases  with  colic  may  present  the  features  of  an  acute  intra- 
abdominal  inflammatory  condition.  A  case  may  be  admitted  to  the  surgical 
wards  with  a  diagnosis  of  appendicitis,  or  simulate  intestinal  obstruction. 
Localized  pain,  slight  fever,  and  moderate  leucocytosis  may  be  present.  The 
history,  the  presence  of  a  blue  line  on  the'gums,  and  the  blood  changes  are  of 
importance  in  differential  diagnosis. 

(d)  Lead-palsy. — This   is  rarely   a  primary  manifestation.     Among  54 
cases  of  lead-poisoning  treated  in  the  J.  H.  H.  and  dispensary  there  were 
30  cases  of  lead-paralysis  (H.  M.  Thomas).     The  upper  limbs  are  most  fre- 
quently affected.    In  26  cases  the  arms  alone  were 'affected,  and  18  of  these 
showed  the  typical  double  wrist-drop.    In  7  the  right  arm  alone  was  involved, 
and  in  one  the  left.    In  4  cases  both  arms  and  legs  were  attacked.    The  onset 
may  be  acute,  subacute,  or  chronic.    It  usually  occurs  without  fever.     In  its 
distribution  it  may  be  partial,  limited  to  a  muscle  or  to  certain  muscle  groups, 
or  generalized,  involving  in  a  short  time  the  muscles  of  the  extremities  and 
the  trunk.     Madame  Dejerine-Klumpke  recognizes  the  following  localized 
forms:     (1)  Antebrachial  type,  paralysis  of  the  extensors  of  the  fingers  and 
of  the  wrist.    In  this  the  musculo-spiral  nerve  is  involved,  causing  the  char- 
acteristic wrist-drop.     The  supinator  longus  usually  escapes.     In  the  long- 
continued  flexion  of  the  carpus  there  may  be  slight  displacement  backward 
of  the  bones,  with  distention  of  the  synovial  sheaths,  so  that  there  is  a  promi- 
nent swelling  over  the  wrist  known  as  Gruebler's  tumor.     (2)  Brachial  type, 
which  involves  the  deltoid,  the  biceps,  the  brachialis  anticus,  and  the  supinator 
longus,  rarely  the  pectorals.    The  atrophy  is  of  the  scapulo-humeral  form.    It 
is  bilateral,  and  sometimes  follows  the  first  form,  but  it  may  be  primary.     (3) 
The  Aran-Duchenne  type,  in  which  the  small  muscles  of  the  hand  and  of  the 
thenar  and  hypothenar  eminences  are  involved.    The  atrophy  is  marked,  and 
may  be  the  first  manifestation  of  the  lead-palsy.    Mobius  has  shown  that  this 


LEAD  POISONING  405 

form  is  particularly  marked  in  tailors.  (4)  The  peroneal  type.  According 
to  Tanquerel.  the  lower  limbs  are  involved  in  the  proportion  of  13  to  100  of 
the  upper  limbs.  The  lateral  peroneal  muscles,  the  extensor  communis  of  the. 
toes,  and  the  extensor  proprius  of  the  big  toe  are  involved,  producing  the 
steppage  gait.  (5)  Laryngeal  form.  Adductor  paralysis  has  been  noted  by 
Morell  Mackenzie  and  others  in  lead-palsy. 

Generalized  Palsies. — There  may  be  a  slow,  chronic  paralysis,  gradually 
involving  the  extremities,  beginning  with  the  classical  picture  of  wrist-drop. 
More  frequently  there  is  a  rapid  generalization,  producing  complete  paralysis 
in  all  the  muscles  of  the  parts  in  a  few  days.  It  may  pursue  a  course  like 
an  ascending  paralysis,  associated  with  rapid  wasting  of  all  four  limbs.  Such 
cases,  however,  are  very  rare.  Death  has  occurred  by  involvement  of  the  dia- 
phragm. Oliver  reports  a  case  of  Philipson's  in  which  complete  paralysis 
supervened.  A  patient  with  generalized  paralysis  was  admitted  in  the  winter 
of  1904  in  whom  the  paralysis  began  in  the  legs  after  but  two  weeks'  work 
as  an  enameler.  It  spread  rapidly,  so  that  in  a  little  over  a  week  he  was  bed- 
ridden, and  on  admission  to  the  hospital  nearly  every  muscle  below  the  neck 
was  involved.  The  diaphragm  was  completely  paralyzed.  EDe  was  walking 
about  when  he  left  the  hospital,  though  there  was  still  some  weakness  remain- 
ing. Dejerine-Klumpke  also  recognizes  a  febrile  form  of  general  paralysis 
in  lead-poisoning,  which  may  closely  resemble  the  subacute  spinal  paralysis 
of  Duchenne. 

There  is  also  a  primary  saturnine  muscular  atrophy  in  which  the  weak- 
ness and  wasting  come  on  together.  It  is  this  form,  according  to  Gowers, 
which  most  frequently  assumes  the  Aran-Duchenne  type. 

The  electrical  reactions  are  those  of  lesions  of  the  lower  motor  segment. 
The  reaction  of  degeneration  in  its  different  grades  may  be  present,  depending 
upon  the  severity  of  the  disease.  Usually  with  the  onset  of  the  paralysis  there 
are  pains  in  the  legs  and  joints,  the  so-called  saturnine  arthralgias.  Sensation 
may,  however,  be  unaffected. 

(e)  The  cerebral  symptoms  are  numerous.  Seven  of  our  cases  showed 
marked  cerebral  involvement.  One  had  delusions  and  maniacal  excitement 
and  had  to  be  removed  to  an  asylum.  In  other  cases  there  occurred  transient 
delirium,  attacks  of  unconsciousness,  and  in  one  case  convulsions.  Optic 
neuritis  or  neuro-retinitis  may  occur.  Hysterical  symptoms  occasionally  occur 
in  girls.  Convulsions  are  not  uncommon,  and  in  an  adult  the  possibility  of 
lead-poisoning  should  always  be  considered.  True  epilepsy  may  follow  the 
convulsions.  An  acute  delirium  may  occur  with  hallucinations.  The  patients 
may  have  trance-like  attacks,  which  follow  or  alternate  with  convulsions.  A 
few  cases  of  lead  encephalopathy  finally  drift  into  lunatic  asylums.  Tremor 
is  one  of  the  commonest  manifestations  of  lead-poisoning. 

(/)  Arterio-sclerosis. — Lead-workers  are  notoriously  subject  to  arterio- 
sclerosis with  contracted  kidneys  and  hypertrophy  of  the  heart.  The  cases 
usually  show  distinct  gouty  deposits,  particularly  in  the  big-toe  joint;  but 
in  the  United  States  acute  gout  in  lead-workers  is  rare.  According  to  Sir 
William  Eoberts,  the  lead  favors  the  precipitation  of  the  crystalline  urates  of 
the  tissues. 

Prognosis. — In  the  minor  manifestations  this  is  good.  According  to  Gow- 
ers, the  outlook  is  bad  in  the  primary  atrophic  form  of  paralysis.  Convulsions 


406  THE  INTOXICATIONS 

are,  as  a  rule,  serious,  and  the  mental  symptoms  which  succeed  may  be  perma- 
nent    Occasionally  the  wrist-drop  persists. 

Treatment. —Prophylactic  measures  should  be  taken  at  all  lead-works,  but, 
unless  employees  are  careful,  poisoning  is  apt  to  occur  even  under  the  most 
favorable  conditions.  Cleanliness  of  the  hands  and  of  the  finger-nails,  fre- 
quent bathing,  and  the  use  of  respirators  when  necessary  should  be  insisted 
upon.  When  the  lead  is  in  the  system  the  iodide  of  potassium  should  be  given 
in  from  5-  to  10-grain  (0.3-0.6  gm.)  doses  three  times  a  day.  For  the 
colic  local  applications  and,  if  severe,  morphia  may  be  used.  An  occasional 
morning  purge  of  magnesium  sulphate  may  be  given.  For  the  anaemia  iron 
should  be  used.  In  the  very  acute  cases  it  is  well  not  to  give  the  iodide,  as, 
according  to  some  writers,  the  liberation  of  the  lead  which  has  been  deposited 
in  the  tissues  may  increase  the  severity  of  the  symptoms.  For  the  local  palsies 
massage  and  the  constant  current  should  be  used.  Bulletin  No.  95  (1911) 
of  the  Bureau  of  Labor,  Washington,  contains  an  elaborate  study  of  industrial 
lead-poisoning  in  Europe  by  Oliver,  and  of  the  conditions  in  the  United  States 
by  Alice  Hamilton  and  John  B.  Andrews. 


IV.    ARSENICAL  POISONING 

Acute  poisoning  by  arsenic  is  common,  particularly  by  Paris  green  and 
such  mixtures  as  "Rough  on  Rats,"  which  are  used  to  destroy  vermin  and 
insects.  The  chief  symptoms  are  intense  pain  in  the  stomach,  vomiting,  and, 
later,  colic,  with  diarrhoea  and  tenesmus;  occasionally  the  symptoms  are  those 
of  collapse.  If  recovery  takes  place,  paralysis  may  follow.  The  treatment 
should  be  similar  to  that  of  other  irritant  poisons — rapid  removal  with  the 
stomach  pump,  the  promotion  of  vomiting,  and  the  use  of  milk  and  eggs. 
If  the  poison  has  been  taken  in  solution,  dialyzed  iron  may  be  used  in  doses 
of  from  6  to  8  drachms. 

Chronic  Arsenical  Poisoning. — Arsenic  is  used  extensively  in  the  arts, 
particularly  in  the  manufacture  of  colored  papers,  artificial  flowers,  and  in 
many  of  the  fabrics  employed  as  clothing.  The  glazed  green  and  red  papers 
used  in  kindergartens  also  contain  arsenic.  It  is  present,  too,  in  many  wall- 
papers and  carpets.  Much  attention  has  been  paid  to  this  question  of  late 
years,  as  instances  of  poisoning  have  been  thought  to  depend  upon  wall-papers 
and  other  household  fabrics.  The  arsenic  compounds  may  be  either  in  the 
form  of  solid  particles  detached  from  the  paper  or  as  gaseous  volatile  bodies 
formed  from  arsenical  organic  matter  by  the  action  of  several  moulds,  notably 
Penicilium  brevicaule,  Mucor  mucedo,  etc.  (Gosio).  In  moisture,  and  at  a 
temperature  of  from  60°  to  95°  F.,  a  volatile  compound  is  set  free,  probably 
"an  organic  derivative  of  arsenic  pentoxide"  (Sanger).  The  chronic  poison- 
ing from  fabrics  and  wall-papers  may  be  due,  according  to  this  author,  to  the 
ingestion  of  minute  continued  doses  of  this  derivative.  Contaminated  glucose, 
used  in  manufacturing  beer,  caused  a  widespread  epidemic  of  poisoning  at 
Manchester.  The  associated  presence  of  selenium  compounds  may  have  played 
a  part  in  the  production  of  the  poisoning  (Tunnicliffe  and  Rosenheim). 
Arsenic  is  eliminated  in  all  the  secretions,  and  has  been  found  in  the  milk. 
J.  J.  Putnam,  it  should  be  remembered,  has  shown  that  it  is  not  uncommon 


FOOD  POISONING  407 

to  find  traces  of  arsenic  in  the  urine  of  many  persons  in  apparent  health.  The 
effects  of  moderate  quantities  of  arsenic  are  not  infrequently  seen  in  medical 
practice.  In  chorea  and  in  pernicious  'anaemia  steadily  increasing  doses  are 
often  given  until  the  patient  takes  from  15  to  20  drops  of  Fowler's  solution 
three  times  a  day.  Flushing  and  hypersemia  of  the  skin,  puffiness  of  the  eye- 
lids or  above  the  eyebrows,  nausea,  vomiting,  and  diarrhoea  are  the  most  com- 
mon symptoms.  Eedness  and  sometimes  bleeding  of  the  gums  and  salivation 
occur.  In  the  protracted  administration  of  arsenic  patients  may  complain  of 
numbness  and  tingling  in  the  fingers.  Cutaneous  pigmentation  and  keratosis 
are  very  characteristic,  and,  as  a  late  rare  sequence  of  the  latter,  epithelioma. 
In  chorea  neuritis  has  occurred,  and  a  patient  of  mine  with  Hodgkin's  disease 
had  multiple  neuritis  after  taking  §  iv  3  j  of  Fowler's  solution  in  seventy-five 
days,  during  which  time  there  were  fourteen  days  on  which  the  drug  was 
omitted. 

In  the  Manchester  epidemic  nearly  all  cases  presented  signs  of  neuritis 
and  lesions  of  the  skin.  In  some  the  sensory  disturbances  predominated, 
in  others  the  motor,  the  individuals  being  unable  to  walk  or  to  use  their  hands. 
In  a  certain  number  there  was  muscular  incoordination,  resembling  that  of 
locomotor  ataxia.  Rapid  muscular  atrophy  characterized  some  cases.  In  not  a 
few  patients  a  condition  of  erythromelalgia  was  present.  Occasionally  a 
catarrh  of  the  respiratory  and  alimentary  tracts  was  the  chief  feature.  Pig- 
mentation, keratosis,  and  herpes  were  the  most  characteristic  cutaneous  mani- 
festations. 

How  far  similar  symptoms  are  to  be  attributed  to  the  small  quantities  of 
arsenic  absorbed  from  wall-papers  and  fabrics  is  by  some  considered  doubt- 
ful. That  children  and  adults  may  take  with  impunity  large  doses  for  months 
without  unpleasant  effects,  and  the  fact  of  the  gradual  establishment  of  a 
toleration  which -enables  Styrian  peasants  to  take  as  much  as  8  grains  of  arse- 
nious  acid  in  a  day,  speak  strongly  against  it.  On  the  other  hand,  as  Sanger 
states,  we  do  not  know  accurately  the  effects  of  many  of  the  compounds  in 
minute  and  long-continued  doses,  notably  the  arsenates. 

Arsenical  paralysis  has  the  same  characteristics  as  lead-palsy,  but  the  legs 
are  more  affected  than  the  arms,  particularly  the  extensors  and  peroneal 
group,  so  that  the  patient  has  the  characteristic  steppage  gait  of  peripheral 
neuritis. 

The  electrical  reaction  in  the  muscles  may  be  disturbed  before  there  is 
any  loss  of  power,  and  when  the  patient  is  asked  to  extend  the  wrist  fully  and 
to  spread  the  fingers  slight  weakness  may  be  detected  early. 


V.     FOOD  POISONING 

There  may  be  "death  in  the  pot"  from  many  causes.  .Food  poisons  may 
be  endogenous  or  exogenous.  Those  articles  in  which  the  poison  is  of  endoge- 
nous origin  can  scarcely  be  designated  as  foods.  The  poisonous  mushroom, 
for  example,  is  often  mistaken  for  the  edible  form.  The  former  is  injurious 
because  it  normally  produces  a  highly  poisonous  alkaloid,  muscarine.  Cer- 
tain fish  also  produce  normal  physiological  but  toxic  products.  When  eaten 
by  mistake,  as  frequently  occurs  in  the  West  Indies  and  Japan,  these  fish  may 


408  THE  INTOXICATIONS 

cause  poisonous  symptoms.  The  exogenous  origin  of  food  poisons  is  by  far 
the  commonest.  Under  this  head  come  those  foods  which  are  rendered  poison- 
ous hy  accidental  contamination  from  outside  sources.  Food  may  contain 
the  specific  organisms  of  disease,  as  of  tuberculosis  or  trichinosis;  milk  and 
other  foods  may  become  infected  with  typhoid  bacilli,  and  so  convey  the  dis- 
ease. 

Animals  (or  insects,  as  bees)  may  feed  on  substances  which  cause  their 
flesh  or  products  to  be  poisonous  to  man. 

The  grains  used  as  food  may  be  infected  with  fungi  and  cause  the  epi- 
demics of  ergotism,  etc. 

Foods  of  all  sorts  may  become  contaminated  with  the  bacteria  of  putre- 
faction, the  products  of  which  may  be  highly  poisonous. 

The  term  "ptomaine  poisoning"  has  been  popularized  to  such  an  extent 
that  it  is  used  synonymously  with  food  poisoning.  The  term  ptomaine  was 
introduced  by  the  Italian  chemist,  Selmi,  to  designate  basic  alkaloidal  products 
formed  in  putrefaction.  It  is  largely  through  the  labors  of  Brieger  that  our 
knowledge  of  ptomaines  was  gained.  Mytilotoxin,  found  in  poisonous  mus- 
sels, is  of  this  class,  and  is  by  far  the  most  poisonous  of  the  known  ptomaines. 

Among  the  more  common  forms  are  the  following: 

Meat  Poisoning. — Outbreaks  of  disease  due  to  poisons  of  bacterial  origin 
or  due  to  chemical  changes  in  meat  are  not  uncommon.  Several  groups  of 
cases  have  been  recognized. 

(a)  From  the  colon  bacillus  or  the  typho-coli  group  of  organisms,  which 
occupy  a  position  intermediate  between  the  typhoid  and  colon  bacillus.  In 
severe  forms  symptoms  come  on  a  few  hours  after  eating  the  meat;  violent 
vomiting,  purging,  pains  in  the  abdomen  and  collapse  and  death  may  occur 
within  twenty-four  hours.  Individuals  react  very  differently,  as  shown  in  the 
remarkable  outbreak  investigated  by  McWeeney  in  the  Industrial  School, 
Limerick.  Among  73  cases  every  grade  of  severity  was  seen,  from  severe 
cholera  nostras  to  headache  with  slight  fever.  Indeed,  there  were  cases  with- 
out symptoms,  but  with  the  typhoid  blood  reaction.' 

Some  of -these  cases  have  a  close  resemblance  to  the  paratyphoid  infection, 
and,  as  Durham  pointed  out,  the  bacilli  are  divisible  into  two  groups:  The 
Gaertner  type  (B.  enteritidis)  and  the  Aertryk  type. 

The  important  matter  in  connection  with  this  type  of  poisoning  is  the 
unaltered  appearance  of  the  meat.  The  danger  seems  greatest  from  beef  and 
veal,  and  in  Germany  has  particularly  followed  the  use  of  meat  from  cattle 
ill  with  some  septic  or  diarrhceal  condition.  Pork  is  a  not  infrequent  cause 
in  England,  and  severe  attacks  have  followed  the  eating  of  pork  pies. 

(&)  Meat  poisoning  associated  with  putrefaction.  Here  alterations  of  ap- 
pearance, of  smell  and  taste  are  usually  present.  The  products  are  those  of 
protein  hydrolysis,  various  aromatic  compounds,  but  more  particularly  the 
bodies  known  as  putrescine,  cadaverine  and  sepsin.  How  far  these  bodies 
themselves  are  responsible  for  the  symptoms,  how  far  they  are  due  to  infection 
with  associated  organisms,  particularly  the  proteus  and  the  colon  bacilli,  has 
not  yet  been  definitely  settled.  Many  cases  of  food  poisoning  have  been  re- 
ported as  due  to  proteus  and  its  toxins.  A  point  of  interest  is  the  fact  that 
this  organism  was  found  to  be  the  cause  of  a  severe  outbreak  due  to  eating 
potato  salad. 


FOOD  POISOfflNXJ  409 

(c)  Meat  poisoning  due  to  Bacillus  botulinus.  This  is  a  raie  form,  the 
organism  of  which  was  discovered  by  van  Ermengem  in  a  ham,  the  eating  of 
which  had  given  rise  to  50  cases  of  botulism.  The  symptoms  resemble  those 
of  atropine  poisoning — dryness  of  the  throat,  dilatation  of  the  pupil,  deafness, 
facial  and  cardio-respiratory  paralysis. 

Certain  game  birds,  particularly  the  grouse,  are  poisonous  in  special  dis- 
tricts and  at  certain  seasons.  It  is  interesting  to  note  that  mutton  and  lamb 
have  thus  far  not  been  implicated  as  a  cause  of  food  poisoning. 

Poisoning  by  Meat  Products. — (a)  The  poisonous  effects  which  follow 
the  drinking  of  milk  infected  with  saprophytic  bacteria  are  considered  in  the 
section  on  the  diarrhoea  of  infants. 

(5)  Cheese  Poisoning. — Various  milk  products,  ice  cream,  custard,  and 
cheese,  may  prove  highly  poisonous.  Among  the  poisons  Vaughan  now  states 
that  the  tyrotoxicon  "is  not  the  one  most  frequently  present,  nor  is  it  the 
most  active  one."  In  one  epidemic  he  and  Novy  have  isolated  from  cheese  a 
substance  belonging  to  the  poisonous  albumins,  and  in  an  extensive  ice-cream 
epidemic  Vaughan  and  Perkins  found  in  the  ice  cream  a  highly  pathogenic 
bacillus,  but  its  toxin  has  not  been  separated.  The  symptoms  are  those  of 
acute  gastro-intestinal  irritation. 

Poisoning  by  Shell-fish  and  Fish. — (a)  Mussel  Poisoning. — Brieger  has 
separated  a  ptomaine — mytilotoxin — which  exists  chiefly  in  the  liver  of  the 
mussel.  The  observations  of  Schmidtmann  and  Cameron  have  shown  that  the 
mussel  from  the  open  sea  only  becomes  poisonous  when  placed  in  filthy  waters, 
as  at  Wilhelmshafen. 

Dangerous,  even  fatal,  effects  may  follow  the  eating  of  either  raw  or  cooked 
mussels.  The  symptoms  are  those  of  an  acute  poisoning  with  profound  action 
on  the  nervous  system,  and  without  gastro-intestinal  manifestations.  There 
are  numbness  and  coldness,  no  fever,  dilated  pupils,  and  rapid  pulse;  death 
occurs  sometimes  within  two  hours  with  collapse  symptoms.  In  an  epidemic 
at  Wilhelmshafen,  Germany,  in  1885,  nineteen  persons  were  attacked,  four 
of  whom  died.  Salkowski  and  Brieger  isolated  the  mytilotoxin  from  speci- 
mens of  the  mussels.  Poisoning  occasionally  follows  the  eating  of  oysters 
which  are  stale  or  decomposed.  The  symptoms  are  usually  gastro-intestinal. 

(£)  Fish  Poisoning. — There  are  two  distinct  varieties;  in  one  the  poison 
is  a  physiological  product  of  certain  glands  of  the  fish,  in  the  other  it  is  a 
product  of  bacterial  growth.  The  salted  sturgeon  used  in  parts  of  Eussia 
has  sometimes  proved  fatal  to  large  numbers  of  persons.  In  the  middle  parts 
of  Europe  the  barb  is  stated  to  be  sometimes  poisonous,  producing  the  so-called 
"barben  cholera."  In  China  and  Japan  various  species  of  the  tetrodon  are 
also  toxic,  sometimes  causing  death  within  an  hour,  with  symptoms  of  intense 
disturbance  of  the  nervous  system. 

Grain  and  Vegetable  Food  Poisoning.— (a)  Ergotism. — The  prolonged  use 
of  meal  made  from  grains  contaminated  with  the  ergot  fungus  (claviceps  pur- 
purea)  causes  a  series  of  symptoms  known  as  ergotism,  epidemics  of  which 
have  prevailed  in  different  parts  of  Europe.  Two  forms  of  this  chronic 
erotism  are .  described — the  one,  gangrenous,  is  believed  to  be  due  to  the 
sphacelinic  acid,  the  other,  convulsive  or  spasmodic,  is  due  to  the  cornutin. 
In  the  former  mortification  affects  the  extremities — usually  the  toes  and  fia- 
gers,  less  commonly  the  ears  and  nose.  Preceding  the  onset  of  the  gangrene 


410  THE  INTOXICATIONS 

there  are  usually  anaesthesia,  tingling,  pains,  spasmodic  movements  of  the 
muscles,  and  gradual  blood  stasis  in  certain  vascular  territories. 

The  nervous  manifestations  are  very  remarkable.  After  a  prodromal  stage 
of  ten  to  fourteen  days,  in  which  the  patient  complains  of  weakness,  headache, 
and  tingling  sensations  in  different  parts  of  the  body,  perhaps  accompanied 
with  slight  fever,  symptoms  of  spasm  develop,  producing  cramps  in  the  mus- 
cles and  contractures.  The  arms  are  flexed  and  the  legs  and  toes  extended. 
These  spasms  may  last  from  a  few  hours  to  many  days  and  relapses  are  fre- 
quent. In  severer  cases  epilepsy  develops  and  the  patient  may  die  in  convul- 
sions. Mental  symptoms  are  common,  manifested  sometimes  in  a  prelimi- 
nary delirium,  but  more  commonly,  in  the  chronic  poisoning,  as  melancholia 
or  dementia.  Posterior  spinal  sclerosis  occurs  in  chronic  ergotism.  In  the 
interesting  group  of  29  cases  studied  by  Tuczek  and  Siemens  9  died  at  various 
periods  after  the  infection,  and  four  post  mortems  showed  degeneration  of  the 
posterior  columns.  A  condition  similar  to  tabes  dorsalis  is  gradually  pro- 
duced by  this  slow  degeneration  in  the  spinal  cord. 

(&)  Lathyrism  (Lupinosis). — An  affection  produced  by  the  use  of  meal 
from  varieties  of  vetches,  chiefly  the  Lathyrus  sativus  and  L.  cicera.  The 
grain  is  popularly  known  as  the  chick-pea.  The  grains  are  usually  powdered 
and  mixed  with  the  meal  from  other  cereals  in  the  preparation  of  bread.  As 
early  as  the  seventeenth  century  it  was  noticed  that  the  use  of  flour  with  which 
the  seeds  of  the  Lathyrus  were  mixed  caused  stiffness  of  the  legs.  The  subject 
did  not,  however,  attract  much  attention  before  the  studies  of  James  Irving, 
in  India,  who  between  1859  and  1868  published  several  important  communi- 
cations, describing  a  form  of  spastic  paraplegia  affecting  large  numbers  of 
the  inhabitants  in  certain  regions  of  India  and  due  to  the  use  of  meal  made 
from  the  Lathyrus  seeds.  It  also  produces  a  spastic  paraplegia  in  animals. 
The  Italian  observers  describe  a  similar  form  of  paraplegia,  and  it  has  been 
observed  in  Algiers  by  the  French  physicians.  The  condition  is  that  of  a 
spastic  paralysis,  involving  chiefly  the  legs,  which  may  proceed  to  complete 
paraplegia.  The  arms-  are  rarely,  if  ever,  affected. ,  It  is  evidently  a  slow 
sclerosis  induced  under  the  influence  of  this  toxic  agent.  The  precise  ana- 
tomical condition,  so  far  as  I  can  ascertain,  has  not  yet  been  determined. 

(c)  Potato-poisoning. — It  has  long  been  known  that  potatoes  contain 
normally  a  very  small  amount  (about  0.06  per  cent.)  of  the  poisonous  prin- 
ciple solanin,  but  it  is  only  quite  recently  that  it  has  been  discovered  that, 
under  certain  circumstances,  they  may  contain  the  poison  in  amounts  sufficient 
to  cause  grave  disturbance  of  the  system.  The  increase  is  due  to  the  action 
of  at  least  two  species  of  bacteria,  Bacterium  solaniferum  non-colorabih  and 
Bacterium  solaniferum  colorabile,  and  occurs  in  those  tubers  which,  during 
growth,  have  lain  partially  exposed  above  ground,  and  in  those  which,  during 
storage,  have  become  well  sprouted.  The  most  extensive  outbreak  of  potato- 
poisoning  recorded  occurred  in  1899  in  a  German  regiment,  fifty-six  members 
of  which,  after  eating  sprouted  potatoes,  were  seized  with  chills,  fever,  head- 
ache, vomiting,  diarrhoea,  colic,  and  great  prostration.  Many  were  jaundiced 
and  several  collapsed,  but  all  recovered.  Samples  of  the  remaining  potatoes 
yielded  0.38  per  cent,  of  solanin,  and  this  .would  indicate  that  a  full  portion 
must  have  contained  about  5  grains. 

Treatment. — The  source  of  the  infection  must  be  ascertained  and  the  of- 


PELLAGRA  411 

fending  food  destroyed.  The  stomach  should  be  washed  out  and  the  bowels 
evacuated  by  a  brisk  saline  purge.  Saline  infusions,  hypodermic  or  intra- 
venous, may  promote  the  elimination  of  the  toxins. 


VI.     PELLAGRA 

Definition. — A  disorder  of  metabolism,  with  periodical  manifestations  char- 
acterized by  gastro-intestinal  disturbances,  skin  lesions,  and  a  tendency  to 
changes  in  the  nervous  system. 

Historical. — The  disease  appears  to  have  been  endemic  in  Spain  by  1735 
and  the  first  description  is  by  Cazal  (1762),  who  named  it  mal  de  la  rosa. 
It  existed  in  Italy  in  1750  and  was  described  in  1771  by  Frapolli,  who  gave 
it  the  name  of  pellagra  (rough  skin).  By  the  eighteenth  century  it  had 
spread  over  northern  Italy  and  had  appeared  in  France  and  Eoumania.  It 
is  quite  probable  that  there  have  been  sporadic  cases  in  the  United  States  for 
the  last  fifty  years. 

Distribution. — The  disease  is  prevalent  in  parts  of  southern  Europe,  par- 
ticularly in  Italy  and  Eoumania.  There  are  probably  100,000  cases  in  Italy 
and  50,000  in  Roumania.  It  exists  in  Spain,  Portugal,  France,  Egypt  and 
the  United  States,  in  the  southern  part  of  which  country  the  disease  has 
spread  with  extraordinary  rapidity  in  the  last  few  j^ears.  Better  diagnosis  can 
hardly  explain  the  frequency,  as  the  disease  is  so  striking  in  its  manifestations 
that  many  cases  could  hardly  be  overlooked.  There  is  evidence  that  the  dis- 
ease is  to  some  extent  one  of  particular  localities,  as  beri-beri ;  it  is  also  a  disease 
of  the  country  more  than  of  the  cities.  This  applies  particularly  to  Europe, 
but  in  the  United  States  many  of  the  small  towns  and  villages  show  a  number 
of  cases.  As  regards  the  influence  of  place,  the  number  of  cases  in  the  asy- 
lums of  the  United  States  is  significant.  A  few  cases  have  occurred  in  Eng- 
land. 

Etiology. — There  are  two  main  views,  one  that  it  is  due  to  a  defect  in  the 
diet,  in  other  words,  a  deficiency  disease,  and  the  other  that  it  is  due  to 
infection  of  some  kind.  If  the  latter  be  the  case  the  infectious  agent  is  appar- 
ently not  conveyed  directly  from  person  to  person,  and  Sambon  suggested  that 
it  may  be  a  protozoal  disease,  carried  by  sand  flies  of  the  genus  Simulium. 
There  is  absence  of  proof  that  the  disease  is  communicated  from  one  person  to 
another.  In  the  Italian  institutions,  where  a  large  number  of  pellagrins  are 
treated,  no  attendant  has  contracted  the  disease.  If  due  to  food  intoxication, 
the  accused  article  is  corn  (maize),  comparable  to  the  part  thought  to  be 
played  by  rice  in  beri-beri.  The  experiments  of  Goldberger  and  Wheeler  sup- 
port the  dietetic  view.  Eleven  prisoners  were  kept  on  ordinary  diet  from 
February  4  to  April  19,  1915,  from'  which  date  until  October  31,  1915,  they 
received  a  restricted  diet  lacking  meat,  eggs,  milk,  beans,  peas  and  othei 
proteins.  The  food  was  chiefly  maize,  rice,  sweet  potatoes,  brown  gravy,  syrup, 
sugar  and  coffee — all  of  the  best  quality.  Within  five  months,  six  of  th«» 
eleven  volunteers  had  dermatitis  said  by  experts  to  be  pellagra. 

AGE. — The  disease  occurs  at  any  age,  but  the  majority  of  cases  are  be- 
tween twenty  and  forty  years.  As  regards  races,  the  negro  is  more  suscepti- 


412  THE  INTOXICATIONS 

ble  than  the  white,  and,  in  reference  to  sex,  women  are  apparently  slightly 
more  susceptible  than  men. 

OCCUPATION. — In  Europe  the  disease  is  almost  confined  to  laborers  of  the 
poorer  classes,  but  this  is  not  true  of  the  United  States. 

SEASON. — The  effect  of  this  is  very  striking  and  the  disease  occurs  par- 
ticularly in  the  spring  and  sometimes  in  the  autumn,  both  in  its  onset  and 
recurrences. 

Pathology. — There  is  nothing  characteristic  in  the  morbid  anatomy.  In 
the  acute  cases  there  may  be  atrophy  of  the  walls  of  the  intestines,  fatty  de- 
generation of  the  internal  organs  and  changes  in  the  nervous  system.  The 
alterations  in  the  cord  are  fairly  constant.  There  is  degeneration  of  the  lat- 
eral columns  in  the  dorsal  region  and  of  the  posterior  columns  in  the  cervical 
and  dorsal  regions.  In  the  brains  of  patients  with  mental  deterioration  atro- 
phy of  the  cerebrum  is  found.  As  regards  the  pathogenesis  there  are  two 
views,  one  that  it  is  a  chronic  disease  with  recurring  exacerbations,  the  other 
that  it  is  due  to  repeated  poisoning. 

Symptoms. — These  vary  markedly  in  severity,  usually  appearing  in  the 
spring  and  sometimes  in  the  autumn.  There  is  always  a  tendency  to  recur- 
rence, and  with  each  succeeding  attack  more  damage  is  done,  particularly  to 
the  nervous  system.  The  onset  is  usually  in  the  spring  with  indefinite  symp- 
toms, such  as  weakness,  headache,  and  depression. 

DIGESTIVE  TRACT. — Disturbance  of  the  alimentary  tract  is  usually  an  early 
symptom.  In  the  mouth  there  may  be  sensations  of  heat,  with  loss  of 
taste.  Stomatitis  is  common,  the  mucous  membrane  is  very  red,  ulcers  may 
appear  and  the  epithelium  is  stripped  off,  leaving  a  raw  surface  so  that  chew- 
ing is  painful.  Anorexia,  nausea,  vomiting  and  dyspeptic  symptoms  are  com- 
mon; there  is  also  diarrhoea,  often  severe  and  accompanied  by  pain,  the  stools 
being  serous  or  bloody.  It  may  alternate  with  constipation. 

SKIN — The  erythema  usually  begins  on  the  backs  of  the  hands  and  at 
first  resembles  an  ordinary  sunburn.  There  may  be  puffy  swelling.  The  af- 
fected areas  are  symmetrical  and  sharply  defined  as  a  rule,  extending  above 
the  wrist  and  down  to  the  last  finger  joint.  The,  face,  neck  and  feet  may  be 
affected  in  the  same  way.  The  process  may  not  advance  any  further,  the 
skin  becomes  darker  and  desquamates,  after  which  some  pigmentation  remains. 
In  other  cases  vesicles  and  bulls  form,  containing  serum  or  pus.  These  dry 
gradually,  with  the  production  of  fissures.  After  drying  and  desquamation 
the  skin  may  have  a  dry  appearance  and  a  deep  red  color.  With  repeated 
attacks  the  skin  may  become  indurated,  thickened  and  dark  in  color;  later 
atrophy  and  thinning  may  follow.  Exposure  to  the  sun  may  have  an  influence 
on  the  eruption,  but  is  not  the  cause.  The  erythema  occurs  sometimes  on  pro- 
tected parts. 

NERVOUS  SYSTEM. — Headache  and  vertigo  are  common.  Mental  features 
are  often  marked,  among  which  are  confusion,  dullness,  lassitude,  irritability, 
feelings  of  anxiety  and  depression,  change  in  the  disposition,  and  hallucina- 
tions of  sight  and  hearing.  These  may  progress  to  profound  depression  and 
ultimately  to  dementia.  Mania  occurs  sometimes  and  suicidal  tendencies  are 
not  uncommon.  The  symptoms  due  to  changes  in  the  cord  vary  with  the 
lesion.  A  spastic  condition,  disturbances  of  sensation,  paralysis  of  the  sphinc- 
ters, or  loss  of  the  reflexes  of  the  legs  may.  be  found. 


PELLAGRA  413 

The  blood  shows  no  special  features  beyond  those  of  a  secondary  anaemia. 
The  temperature  is  usually  normal  except  in  the.  acute  cases  in  which  fever 
occurs. 

Clinical  Forms. — The  disease  occurs  in  two  main  forms,  an  acute  and  a 
chronic  recurrent  form.  In  the  acute  form  there  are  fever,  marked  prostra- 
tion, severe  diarrhoea,  delirium  or  stupor  and  a  rapid  downward  course.  Death 
may  occur  in  a  few  weeks  from  the  onset.  These  cases  seem  to  be  more  fre- 
quent in  the  United  States  than  in  Europe.  In  the  chronic  form  the  mani- 
festations are  not  severe,  but  tend  to  recur  each  year,  and  each  attack  leaves 
the  patient  in  a  worse  condition.  There  is  always  the  tendency  to  mental  de- 
terioration which  occurs  in  fully  10  per  cent,  of  the  cases.  Death  occurs  from 
exhaustion  and  cachexia,  or  some  intercurrent  disease.  Fortunately,  succeed- 
ing attacks  are  not  necessarily  more  severe  than  the  preceding  ones.  There 
are  instances  of  this  form  persisting  for  twenty-five  years.  Cases  without 
the  skin  lesions — pellagra  sine  pellagra — have  been  described. 

Diagnosis. — A  typical  case  offers  no  difficulties,  but  in  the  absence  of  the 
skin  lesions  considerable  difficulty  may  be  experienced.  Scurvy  might  give  dif- 
ficulty, but  the  absence  of  the  other  features  of  pellagra  should  be  conclusive. 
Skin  lesions  of  the  nature  of  erythema  might  cause  confusion,  but  the  absence 
of  the  general  features  removes  doubt.  Sprue  may  be  difficult  to  separate; 
in  fact,  some  consider  it  a  form  of  pellagra.  The  psychical  features  might 
suggest  general  paresis,  but  the  skin  lesions  and  digestive  disturbance  should 
make  the  diagnosis  clear.  The  acute  cases  might  be  mistaken  for  various 
infections,  but  the  erythema  and  gastro-intestinal  features  should  prevent  this. 

Prognosis. — In  the  United  States  the  outlook  is  regarded  as  serious,  if  not 
as  regards  death,  certainly  as  regards  ultimate  recovery.  In  Europe,  where 
the  disease  has  existed  for  a  long  time,  the  prognosis  is  more  favorable,  and 
in  Italy  in  some  years  the  mortality  was  only  4  per  cent.  In  cases  with  acute 
features  or  fever  the  prognosis  is  grave  and  signs  of  severe  toxaamia  or  of 
mental  involvement  are  ominous.  Erythema  of  a  moist  character  is  regarded 
as  a  grave  sign.  Any  complications  should  be  regarded  seriously.  The  prog- 
nosis is  best  in  the  chronic  cases  without  mental  features.  The  outlook  is 
serious  in  asylum  cases. 

Prophylaxis. — "Peasant  life,  poverty,  and  polenta  (corn)"  have  been  given 
as  the  causal  factors.  Improvement  in  the  living  conditions  and  good  sani- 
tation are  important  points  in  the  prevention.  Too  much  corn  or  maize  should 
not  be  used,  particularly  in  institutions.  The  experiments  noted  above  sug- 
gest that  it  is  a  deficiency  disease  which  may  possibly  be  eradicated  by  a  proper 
protein  diet,  as  has  been  the  case  with  beri-beri. 

Treatment. — The  patient  should  be  placed  in  the  best  general  conditions 
and  a  change  of  diet  and  climate  is  advisable.  Eest  in  bed  is  necessary  while 
the  symptoms  are  acute.  The  diet  should  be  as  nutritious  as  possible  and  the 
diarrhoea  need  not  interfere  with  taking  sufficient  nourishment.  Salt  should 
be  given  freely.  There  is  no  proof  that  we  have  any  remedy  with  a  specific 
influence.  Arsenic  has  been  given  by  the  mouth  or  by  injection.  Atoxyl  and 
salvarsan  have  been  used  in  ordinary  dosage,  but  arsenic  by  mouth,  as  Fow- 
ler's solution,  is  apparently  more  useful  than  the  newer  preparations  given 
by  injection.  Transfusion  of  blood,  both  from  healthy  individuals  and  those 
who  have  recovered  from  the  disease,  has  been  done  apparently  with  good 


4U  THE   INTOXICATIONS 

results  in  some  cases.  Symptomatic  treatment,  on  the  whole,  seems  to  have 
been  as  successful  as  any  special  measure  and  should  be  carried  out  as  de- 
manded by  the  conditions  in  each  patient. 


VII.    BERI-BERI 

(Kakke,  Endemic  Multiple  Neuritis) 

Definition. — A  deficiency  disease  due  to  the  absence  of  certain  elements 
of  the  food,  the  so-called  vitamines,  and  characterized  clinically  by  multiple 
neuritis,  anasarca,  and  muscular  atrophy. 

History. — The  disease  is  believed  to  be  of  great  antiquity  in  China,  and 
is  possibly  mentioned  in  the  oldest  known  medical  treatise.  In  the  early 
years  of  the  nineteenth  century  it  attracted  much  attention  among  the  Anglo- 
Indian  surgeons,  and  we  may  date  the  modern  scientific  study  of  the  disease 
from  Malcolmson's  monograph,  published  at  Madras  in  1835.  The  opening 
of  Japan  gave  an  opportunity  to  the  European  physicians  holding  university 
positions,  particularly  Anderson,  Baelz,  Scheube,  and  more  recently  Grimm, 
to  investigate  the  disease.  The  studies  of  the  native  Japanese  physicians, 
particularly  Miura  and  Takagi,  and  of  the  Dutch  physicians  in  the  East, 
have  contributed  much  to  our  knowledge.  The  recent  studies  of  Schaumann, 
Fraser,  .Stanton,  and  others  and  the  dietetic  experiments  in  the  Philippines 
have  confirmed  the  older  views  that  it  is  a  disorder  depending  upon  an  im- 
perfect dietary. 

Distribution. — It  is  specially  prevalent  among  the  Malays,  Chinese  and 
Japanese,  and  during  the  Eussian  war  more  than  50,000  cases  occurred  in 
the  Japanese  army.  It  prevails  excessively  in  the  Philippines.  In  India  it 
is  less  common.  Localized  outbreaks  have  occurred  in  Australia.  It  prevails 
in  parts  of  South  America,  and  in  the  West  Indies.  It  is  met  with  among 
the  fishermen  of  Norway  and  of  the  Newfoundland  Banks.  It  occurs  also  in 
asylums,  in  which  there  have  been  severe  outbreaks  in  the  United  States,  and 
in  the  Eichmond  Asylum,  Dublin,  in  the  years  1894,  1896  and  1897  under 
conditions  of  over-crowding. 

Etiology. — Two  main  views  have  prevailed:  That  it  is  an  acute  infec- 
tion and  that  it  is  a  disorder  of  metabolism.  Numerous  bacteriological  studies 
have  not  determined  the  presence  of  any  definite  organism.  On  the  other 
hand,  the  work  of  the  past  few  years  has  confirmed  the  food  theory  widely  held 
in  Japan. 

Studies  in  the  Far  East  leave  no  doubt  that  the  disease  is  there  due  to  a 
diet  of  rice  from  which  the  pericarp  has  been  removed,  in  what  is  called  "pol- 
ishing" or  "milling."  This  is  an  old  story,  as  the  Dutch  knew  of  the  associa- 
tion of  the  disease  with  rice,  and  it  was  by  modifying  the  rice  diet  of  the 
sailors  that  Takagi  eradicated  beri-beri  from  the  Japanese  navy.  Braddon, 
too,  showed  the  importance  of  the  retention  of  the  pericarp  for  the  prevention 
of  the  disease. 

Schaumann's  experiments,  which  have  been  amply  confirmed  by  Fraser 
and  Stanton,  leave  no  question  that  beri-beri  is  associated  with  a  diet  freed 
from  the  materials  existing  in  the  pericarp.  Whether  these  are  the  phosphorus 


BERI-BERI  415 

compounds,  as  Sehaumann  believes,  or  unknown  substances,  the  so-called  vita- 
mines,  as  Fraser  and  Stanton  hold,  has  not  yet  been  settled. 

That  beri-beri  occurs  in  ships  and  in  institutions  may  be  explained  by  the 
fact  that  in  the  dietary,  though  it  may  not  be  of  rice,  similar  compounds  are 
lacking.  On  the  other  hand,  certain  French  workers  in  the  East  hold  that 
white  rice  alone  does  not  produce  the  disease,  and  that  there  must  be  some 
other  factor,  since  the  great  majority  of  rice-eaters  in  the  East  are  immune. 

Other  factors  are  overcrowding,  as  in  ships,  jails  and  asylums,  hot  and 
moist  seasons,  and  exposure  to  wet.  Males  are,  more  subject  to  the  disease 
than  females.  Under  good  hygienic  conditions  Europeans  rarely  contract  the 
disease. 

Symptoms. — The  incubation  period  is  unknown,  but  it  probably  extends 
over  several  months.  The  following  forms  of  the  disease  are  recognized  by 
Scheube : 

(a)  THE  INCOMPLETE  OR  RUDIMENTARY  FORM  which  often  sets  in  with 
catarrhal  symptoms,  followed  by  pains  and  weakness  in  the  limbs  and  a  lower- 
ing of  the  sensibility  in  the  legs,  with  the  occurrence  of  paraesthesia.  Slight 
oedema  sometimes  appears.  After  a  time  paraasthesia  is  felt  in  other  parts 
of  the  body,  and  the  patient  may  complain  of  palpitation  of  the  heart,  uneasy 
sensations  in  the  abdomen,  and  sometimes  shortness  of  breath.  There  may  be 
weakness  and  tenderness  of  the  muscles.  After  lasting  from  a  few  days  to 
many  months,  these  symptoms  all  disappear,  but  with  the  return  of  the  warm 
weather  there  may  be  a  recurrence.  One  of  Scheube's  patients  suffered  in  this 
way  for  twenty  years. 

(&)  THE  ATROPHIC  FORM  sets  in  with  much  the  same  symptoms,  but  the 
loss  of  power  in  the  limbs  progresses  more  rapidly,  and  very  soon  the  patient 
is  no  longer  able  to  walk  or  to  move  the  arms.  The  atrophy,  which  is  asso- 
ciated with  a  good  deal  of  pain,  may  extend  to  the  muscles  of  the  face.  The 
cedematous  symptoms  and  heart  troubles  play  a  minor  role  in  this  form,  which 
is  known  as  the  dry  or  paralytic  variety. 

(c)  THE  WET  OR  DROPSICAL  FORM. — Setting  in  as  in  the  rudimentary 
variety,  the  oedema  soon  becomes  the  most  marked  feature,  extending  over  the 
whole  subcutaneous  tissue,  and  associated  with  effusions  into  the  serous  sacs. 
The  atrophy  of  the  muscles  and  disturbance  of  sensation  are  not  such  promi- 
nent symptoms.    On  the  other  hand,  palpitation  and  rapid  action  of  the  heart 
and  dyspnoea  are  common.    The  wasting  may  not  be  apparent  until  the  dropsy 
disappears. 

(d)  THE  ACUTE,  PERNICIOUS,  OR  CARDIAC  FORM  is  characterized  by  threat- 
enings  of  an  acute  cardiac  failure,  coming  on  rapidly  after  the  existence  of 
slight  symptoms,  such  as  occur  in  the  rudimentary  form.     Death  may  follow 
within  twenty-four  hours;  more  commonly  the  symptoms  extend  over  several 
weeks.    Widespread  paralysis  with  anaesthesia  may  be  present. 

The  mortality  of  the  disease  varies  greatly,  from  2  or  3  per  cent,  to  40  or 
50  per  cent,  among  the  coolies  in  certain  of  the  settlements  of  the  Malay 
Archipelago. 

Morbid  Anatomy. — The  most  constant  and  striking  features  are  changes 
in  the  peripheral  nerves  and  degenerative  inflammation  involving  the  axis 
cylinder  and  medullary  sheaths.  In  the  acute  cases  this  is  found  not  only  in 
the  peripheral  nerves,  but  also  in  the  pneumogastric  and  in  the  phrenic.  The 


416  THE  INTOXICATIONS 

fibres  of  the  voluntary  muscles,  as  well  as  of  the  myocardium,  are  also  much 
degenerated. 

Diagnosis. — In  tropical  countries  there  is  rarely  any  difficulty  in  the 
diagnosis.  In  cases  of  peripheral  neuritis,  associated  with  oedema,  coming 
from  tropical  ports,  the  possibility  of  this  disease  should  be  remembered. 

The  peculiar  epidemic  dropsy  of  Calcutta  and  Bengal  is  probably  beri-beri. 
Greig  has  shown  it  to  be  a  nutritional  disorder  associated  with  the  use  of 
polished  rice. 

Prophylaxis. — Much  has  been  done  to  prevent  the  disease,  particularly  in 
Japan.  There  has  been  no  more  remarkable  triumph  of  modern  hygiene  than 
Takagi's  dietetic  reforms  in  the  Japanese  navy.  Everywhere  in  the  East  a 
change  in  the  diet  has  been  followed  by  the  disappearance  of  the  disease.  In 
the  Straits  Settlements  a  group  of  men  took  No.  1  polished  white  Siam  rice, 
and  developed  beri-beri  within  sixty  days.  A  group  that  took  unpolished  rice 
remained  free  from  the  disease.  By  exchange  of  clothing,  contact,  living  to- 
gether, the  disease  was  not  conveyed  from  one  group  to  the  other.  Then  the 
group  that  had  partaken  of  the  unpolished  rice  was  fed  with  polished  rice, 
and  within  two  months  developed  beri-beri. 

The  change  of  diet  in  the  Philippine  Scouts  instituted  on  September  30th, 
1909,  has  been  followed  by  remarkable  results.  Instead  of  20  ounces  of  highly 
milled  rice,  the  amount  was  limited  to  16  ounces  of  unpolished  rice.  The 
number  of  admissions  for  the  disease  in  1908  and  1909  in  a  strength  of  men 
of  5,000  was  619  and  558.  In  1910  there  were  50  cases,  and  in  the  first  five 
months  of  1911  only  one  case.  Chamberlain,  from  whose  report  I  quote, 
states  that  the  Philippine  experiments  bear  out  at  every  point  the  polished 
rice  theory  of  the  production  of  the  disease.  After  having  been  continuously 
present  for  five  years  at  the  Culion  Leper  Colony  in  the  Philippines,  beri-beri 
disappeared  entirely  in  nine  months  after  the  use  oi  unpolished  rice  was 
enforced  (Heiser). 

Treatment. — It  is  a  very  chronic  and  obstinate  malady.  A  nutritious  diet, 
without  much  rice,  rest  in  bed,  purgation  for  the  dropsy,  cardiac  stimulants, 
and  the  usual  measures  for  the  neuritis  are  the  important  factors  in  the  treat- 
ment. Salicylates  and  saline  laxatives  are  used  in  Japan.  When  the  oadema 
has  subsided  massage,  passive  movements,  and  electricity  may  be  used  for  the 
atrophic  muscles. 


SECTION    IV 
DISEASES    OF    METABOLISM 

I.     GOUT 

(Podagra) 

Definition. — A  disorder  of  metabolism  associated  with  retention  of  uric 
acid  and  of  other  purin  bodies  in  the  body,  characterized  clinically  by  attacks 
of  acute  arthritis,  the  deposition  of  sodium-biurate  in  and  about  the  joints, 
and  by  the  occurrence  of  irregular  constitutional  symptoms. 

Etiology. — The  purin  bodies,  adenin,  guanin,  hypoxanthin,  xanthin,  and 
uric  acid,  result  from  the  transformation  of  the  nucleo-proteins  of  the  food  and 
of  the  tissues  by  ferments  or  enzymes,  each  one  of  which  has  its  own  specific 
action.  Among  the  proteolytic  enzymes  nuclease  has  a  universal  distribution, 
and,  no  matter  what  the  source  of  the  nucleo-protein,  it  sets  free  adenin  and 
guanin.  Specific  enzymes  also  liberate  uric  acid  from  the  nucleo-proteins  of 
the  tissues  and  from  the  purins  of  the  food.  'Once  formed,  the  difficulty  is  to 
get  rid  of  uric  acid  from  the  system,  and  this  appears  to  be  one  essential  factor 
in  the  etiology  of  gout.  Birds  and  serpents,  unable  to  oxidize  it,  excrete  large 
quantities.  "All  mammals,  with  the  important  exception  of  man,  are  able  to 
destroy  uric  acid  rapidly  and  in  considerable  quantities.  This  destruction 
is  an  oxidation  accomplished  by  a  specific  enzyme  called  uricase,  and  the  reac- 
tion seems  to  consist  of  the  removal  of  one  of  the  carbon  atoms  from  the  uric 
acid,  thus  converting  it  into  the  more  readily  soluble  allantoin"  (Wells). 
These  transforming  enzymes  are  very  variously  distributed  in  the  body;  nu- 
clease is  present  in  all  cells,  adenase  and  the  xanthin  enzyme  are  not  so  widely 
distributed.  Uricase,  on  which  the  uricolytic  power  of  the  different  tissues 
depends,  is  present  chiefly  in  the  liver  and  kidneys  of  mammals,  and  to  a  less 
degree  in  the  muscles.  Man  alone  seems  to  have  a  difficulty  in  oxidizing  uric 
acid.  Even  on  a  purin-free  diet  he  excretes  daily  a  certain  amount,  and  purin- 
rich  food  is  at  once  followed  by  a  rise.  In  other  mammals  it  is  readily  oxy- 
dized  into  allantoin,  of  which  human  urine  never  contains  more  than  a  trace. 

Gout,  then,  cannot  be  regarded  as  loss  of  the  power  of  a  given  individual  to 
destroy  uric  acid,  since  this  does  not  appear  to  be  an  active  function  in  the 
human  body.  Loss  of  power  to  eliminate  favors  the  deposition  of  uric  acid, 
and  individuals  who  cannot  get  rid  easily  of  their  purins,  endogenous  or  ex- 
ogenous, may  be  said  to  be  gouty. 

There  is  a  form  of  gout  in  swine,  characterized  by  a  deposit  of  guanin  in 
the  muscles — the  chalky  flakes  which  are  so  often  seen  in  old  Virginia  and 
Westphalian  hams — and  it  has  been  found  that  the  pig's  liver  is  deficient  in 

417 


418  DISEASES    OF    METABOLISM 

the  enzyme  guanase,  which  in  other  animals  oxidizes  this  purin  body.  We 
cannot  say  yet  how  great  is  the  part  played  by  uric  acid  in  human  gout  and 
how  much  by  the  other  purin  bodies,  but  recent  work  favors  the  view  that 
imperfect  elimination  rather  than  imperfect  oxidation  of  the  purin  bodies 
is  the  chief  factor  in  the  disease. 

The  normal  daily  output  of  uric  acid  is  from  0.04  to  1.0  gm.,  and  it  is 
greater  by  day  than  by  night.  The  amount  from  the  intake  of  the  exogenous 
oxy-purins  varies  from  40  to  60  per  cent,  of  the  total  purin  content.  The 
more  active  the  functions  of  the  body  the  greater  the  discharge.  Severe 
exertion,  fever  and  exposure  to  cold  increase  the  output.  The  amount  is  greatly 
influenced  by  food,  particularly  when  rich  in  purin  bases.  For  example,  after 
.  a  meal  containing  sweetbread  the  amount  may  be  doubled.  In  gouty  persons 
the  output  is  low,  and  I  have  had  cases  of  tophaceous  gout  in  which,  in  the  in- 
tervals between  the  attacks,  the  excretion  was  nil  (Futcher).  With  the  onset 
of  an  attack  the  output  rises,  and  the  phosphoric  acid  is  also  greatly  increased, 
as  shown  in  Chart  XIV. 

PREDISPOSING  FACTORS. — Heredity  is  important.  In  from  50  per  cent,  to 
60  per  cent,  of  all  cases  the  disease  existed  in  the  parents  or  grandparents,  and 
the  transmission  is  more  marked  on  the  male  side.  Males  are  more  subject 
than  females.  It  is  rarely  seen  before  the  thirtieth  year,  though  cases  have 
occurred  before  puberty,  and  even  in  infants  at  the  breast. 

Alcohol  is  an  important  factor  in  the  etiology.  Fermented  liquors  are 
more  apt  to  cause  it  than  distilled  spirits,  and  the  disease  is  much  more  com- 
mon in  England  and  in  Germany,  the  countries  which  consume  the  largest 
amount  of  beer  per  capita.  The'  disease  is  common  in  the  United  States,  and 
is  perhaps  on  the  increase.  As  Futcher  pointed  out,  gout  is  only  one-third 
less  frequent  at  the  Johns  Hopkins  Hospital  than  at  St.  Bartholomew's  Hos- 
pital, London.  Among  18,000  patients  in  my  wards  there  were  59  cases  of 
gout;  all  but  three  in  whites,  and  all  in  males  but  two  (Futcher). 

Food  plays  a  role  of  importance  equal  to  alcohol.  Overeating  without 
active  exercise  is  a  special  predisposing  cause.  But  the  disease  is  by  no  means 
confined  to  the  well-to-do.  A  combination  of  poor  food,  defective  hygiene  and 
the  excessive  consumption  of  malt  liquors  makes  "poor  man's  gout"  not  in- 
frequent. 

Occupation  is  of  great  importance,  and  the  disease  is  much  more  common 
in  workers  in  breweries,  and  in  persons  who  deal  in  any  way  with  alcohol. 

It  is  not  uncommon  in  persons  of  great  mental  and  bodily  vigor.  Among 
distinguished  members  of  our  profession  who  have  been  terrible  sufferers  were 
the  elder  Scaliger,  Jerome  Cardan  and  Sydenham.  The  statement  of  the 
latter,  however,  that  "more  wise  men  than  fools  are  victims"  of  the  affection, 
does  not  hold  good  to-day.  •  The  celebrated  Pirckheimer  wrote  a  famous 
"Apology  for  Gout"  (1521),  and  there  is  much  truth  in  what  Podagra  says: 
"For  I  take  no  pleasure  in  those  hard,  rough,  rusticke,  agresticke  kind  of 
people,  who  never  are  at  rest,  but  always  exercise  their  bodies  with  hard 
labors,  are  ever  moyling  and  toyling,  do  seldom  or  never  give  themselves 
to  pleasure,  do  endure  hunger,  which  are  content  with  a  slender  diet."  (Eng- 
lish Edition,  1617.) 

Among  the  directly  EXCITING  CAUSES  of  an  attack  may  be  mentioned  a 
meal  with  large  quantities  of  rich  food  and  too  much  to  drink;  worry,  or  a 


GOUT 


419 


sudden  mental  shock,  and  in  sensitive  persons  a  slight  injury  or   accident 
may  be  followed  by  acute  arthritis. 

Morbid  Anatomy. — The  blood  contains  an  excess  of  uric  acid.  The  aver- 
age amount  in  156  non-gouty  patients  was  1.7  mgs.  per  100  gm.  of  blood  with 
variations  from  0.7  to  4.5  mgs.  (Adler  and  Ragle).  Pratt's  studies  in  16 


CHART  XIV. — URIC  ACID  AND  PHOSPHORIC  ACID  OUTPUT  IN  CASE  OF  ACUTE  GOUT. 


gouty  patients  showed  an  average  of  3.7  mgs.  per  100  gm.  of  blood.  The  high 
uric  acid  content  is  generally  constant  in  gout  and  the  amount  is  apparently 
greater  during  an  attack  than  in  the  intervals.  This  excess,  also,  is  not 
peculiar  to  gout,  but  occurs  in  leuka?mia  and  chlorosis.  The  red  cells  in  the 
"lead-gout"  cases  may  show  basophilic  granular  staining. 


420  DISEASES    OF    METABOLISM 

The  important  changes  are  in  the  articular  tissues.  The  first  joint  of  the 
great  toe  is  most  frequently  involved;  then  the  ankles,  knees,  and  the  small 
joints  of  the  hands  and  wrists.  The  deposits  may  be  in  all  the  joints  of  the 
lower  limbs  and  absent  from  those  of  the  upper  limbs  (Norman  Moore).  If 
death  takes  place  during  an  acute  paroxysm,  there  are  signs  of  inflammation, 
hypersemia,  swelling  of  the  ligamentous  tissues,  and  of  effusion  into  the  joint. 
The  primary  change,  according  to  Ebstein,  is  a  local  necrosis,  due  to  the 
presence  of  an  excess  of  urates  in  the  blood.  This  is  seen  in  the  cartilage 
and  other  articular  tissues  in  which  the  nutritional  currents  are  slow.  In 
these  areas  of  coagulation  necrosis  the  reaction  is  always  acid  and  the  neutral 
urates  are  deposited  in  crystalline  form,  as  insoluble  acid  urate.  The  articu- 
lar cartilages  are  first  involved.  The  gouty  deposit  may  be  uniform,  or  in 
small  areas.  Though  it  looks  superficial,  the  deposit  is  invariably  interstitial 
and  covered  by  a  thin  lamina  of  cartilage.  The  deposit  is  thickest  at  the  part 
most  distant  from  the  circulation.  The  ligaments  and  fibro-cartilage  ulti- 
mately become  involved  and  are  infiltrated  with  biurate  deposits,  the  so- 
called  chalk-stones,  or  tophi.  These  are  usually  covered  by  skin ;  but  in  some 
cases,  particularly  in  the  metacarpo-phalangeal  articulations,  this  ulcerates 
and  the  chalk-stones  appear  externally.  The  synovial  fluid  may  also  contain 
crystals.  In  very  long-standing  cases,  owing  to  an  excessive  deposit,  the  joint 
becomes  immobile.  The  marginal  outgrowths  in  gouty  arthritis  are  true 
exostoses  (Wynne).  The  cartilage  of  the  ear  may  contain  tophi,  which  are 
seen  as  whitish  nodules  at  the  margin  of  the  helix.  The  cartilages  of  the  nose, 
eyelids,  and  larynx  are  less  frequently  affected. 

Of  changes  in  the  internal  organs  those  in  the  renal  and  vascular  systems 
are  the  most  important.  The  kidney  changes  believed  to  be  characteristic 
of  gout  are:  (a)  A  deposit  of  urates  chiefly  in  the  region  of  the  papillae. 
This,  however,  is  less  common  than  is  usually  supposed.  Norman  Moore 
found  it  in  only  12  out  of  80  cases.  The  apices  of  the  pyramids  show  lines 
of  whitish  deposit.  Ebstein  has  described  ana  figured  areas  of  necrosis  in 
both  cortex  and  medulla,  in  the  interior  of  which  were  crystalline  deposits  of 
urate  of  soda.  (&)  An  interstitial  nephritis,  either  the  ordinary  "contracted 
kidney"  or  the  artek-io-sclerotic  form,  neither  of  which  is  in  any  way  dis- 
tinctive. 

The  metatarso-phalangeal  joint  of  the  big  toe  should  be  carefully  exam- 
ined, as  it  may  show  typical  lesions  of  gout  without  any  outward  token  of 
arthritis. 

Arterio-sclerosis  and  cardiac  hypertrophy  are  very  constant  lesions.  Con- 
cretions of  urate  of  soda  may  occur  on  the  valves.  Myocarditis  is  common. 

Changes  in  the  respiratory  system  are  rare.  Deposits  have  been  found  in 
the  vocal  cords,  and  uric-acid  crystals  have  been  found  in  the  sputum  of  a 
gouty  patient  (J.  W.  Moore). 

Symptoms. — Gout  is  usually  divided  into  acute,  chronic,  and  irregular 
forms. 

ACUTE  GOUT. — Premonitory  symptoms  are  common — twinges  of  pain  in 
the  small  joints  of  the  hands  or  feet,  nocturnal  restlessness,  irritability  of 
temper,  and  dyspepsia.  The  urine  is  acid,  scanty,  and  high-colored.  It  de- 
posits urates  on  cooling,  and  there  may  be.  transient  albuminuria.  There 
may  be  traces  of  sugar  (gouty  glycosuria).  Before  an  attack  the  output  of 


GOUT  421 

uric  acid  is  low  and  is  also  diminished  in  the  early  part  of  the  paroxysm.  The 
relation  of  uric  and  phosphoric  acids  to  the  acute  attacks  is  well  represented 
in  Chart  XIV,  prepared  by  Futcher.  Both  are  extremely  low  in  the  intervals, 
but  reach  normal  limits  shortly  after  the  onset  of  the  acute  symptoms.  The 
phosphoric  acid  and  uric  acid  show  almost  parallel  curves.  The  patient  was 
on  a  very  light  fixed  diet  at  the  time  the  determinations  were  made.  In  some 
instances  the  throat  is  sore,  and  there  may  be  asthmatic  symptoms.  The 
attack  sets  in  usually  in  the  early  morning  hours.  The  patient  is  aroused 
by  a  severe  pain  in  the  metatarso-phalangeal  articulation  of  the  big  toe,  and 
more  commonly  on  the  right  than  on  the  left  side.  The  pain  is  agonizing, 
and,  as  Sydenham  says,  "insinuates  itself  with  the  most  exquisite  cruelty 
among  the  numerous  small  bones  of  the  tarsus  and  metatarsus,  in  the  liga- 
ments of  which  it  is  lurking."  The  joint  swells  rapidly,  and  becomes  hot, 
tense,  and  shiny.  The  sensitiveness  is  extreme,  and  the  pain  makes  the 
patient  feel  as  if  the  joint  were  being  pressed  in  a  vice.  There  is  fever,  and 
the  temperature  may  rise  to  102°  to  103°  F.  Toward  morning  the  severity  of 
the  symptoms  subsides,  and,  although  the  joint  remains  swollen,  the  day  may 
be  passed  in  comparative  comfort.  The  symptoms  recur  the  next  night,  and 
the  fit,  as  it  is  called,  usually  lasts  for  from  five  to  eight  days,  the  severity  of 
the  symptoms  gradually  abating.  There  is  usually  a  moderate  leucocytosis 
during  the  acute  manifestations.  Occasionally  other  joints  are  involved, 
particularly  the  big  toe  of  the  opposite  foot.  The  inflammation,  however 
intense,  never  goes  on  to  suppuration.  With  the  subsidence  of  the  swelling 
the  skin  desquamates.  The  tarsus  alone  may  be  involved  and  so  obstinate  may 
be  the  inflammation  that  the  question  of  surgical  interference  may  be  raised 
in  the  belief  that  it  is  tuberculous  or  suppurative.  After  the  attack  the  gen- 
eral health  may  be  much  improved.  As  Aretaeus  remarks,  a  person  in  the 
interval  has  won  the  race  at  the  Olympian  games.  Recurrences  are  frequent. 
Some  patients  have  three  or  four  attacks  in  a  year;  others  suffer  at  longer 
intervals. 

The  term  retrocedent  or  suppressed  gout  is  applied  to  serious  internal 
symptoms,  coincident  with  a  rapid  disappearance  or  improvement  of  the  local 
signs.  Very  remarkable  manifestations  may  occur  under  these  circumstances. 
The  patient  may  have  severe  gastro-intestinal  symptoms — pain,  vomiting,  diar- 
rhoea, and  great  depression — and  death  may  occur  during  such  an  attack.  Or 
there  may  be  cardiac  manifestations — dyspnoea,  pain,  and  irregular  action 
of  the  heart.  In  some  instances,  in  which  the  gout  is  said  to  attack  the  heart, 
an  acute  pericarditis  proves  fatal.  So,  too,  there  may  be  marked  cerebral 
manifestations — delirium  or  coma,  and  even  apoplexy — but  in  a  majority  of 
these  instances  the  symptoms  are,  in  all  probability,  uramic. 

CHRONIC  GOUT. — With  increased  frequency  in  the  attacks,  the  articular 
symptoms  persist  for  a  longer  time,  and  gradually  many  joints  become  af- 
fected. Deposits  of  urates  take  place,  at  first  in  the  articular  cartilages  and 
then  in  the  ligaments  and  capsular  tissues;  so  that  in  the  course  of  years  the 
joints  become  swollen,  irregular,  and  deformed.  The  feet  are  usually  first 
affected,  then  the  hands.  In  severe  cases  there  may  be  extensive  concretions 
about  the  elbows  and  knees  and  along  the  tendons  and  in  the  bursse.  The  tophi 
appear  in  the  ears.  Finally,  a  unique  clinical  picture  is  produced  which  can 
not  be  mistaken  for  that  of  any  other  affection.  The  skin  over  the  tophi  may 


422  DISEASES    OF   METABOLISM 

rupture  or  ulcerate,  and  about  the  knuckles  the  chalk-stones  may  be  freely 
exposed.  Patients  with  chronic  gout  are  usually  dyspeptic,  often  of  a  sallow 
complexion,  and  show  signs  of  arterio-sclerosis.  The  pulse  tension  is  increased, 
the  vessels  are  stiff,  and  the  left  ventricle  is  hypertrophied.  The  urine  is 
increased  in  amount,  is  of  low  specific  gravity,  and  usually  contains  a  slight 
amount  of  albumin,  with  a  few  hyaline  casts.  Severe  cramps  involving  the 
calf,  abdominal,  and  thoracic  muscles  are  common.  Intercurrent  attacks  of 
acute  polyarthritis  may  occur,  in  which  the  joints  become  inflamed,  and  the 
temperature  ranges  from  101°  to  103°  F.  There  may  be  pain,  redness,  and 
swelling  of  several  joints  without  fever.  Uremia,  pleurisy,  pericarditis,  peri- 
tonitis, and  meningitis  are  common  terminal  affections. 

IRREGULAR  GOUT. — This  is  a  motley,  ill-defined  group  of  symptoms,  mani- 
festations of  a  condition  of  disordered  nutrition,  to  which  the  terms  gouty 
diathesis  or  lithcemic  state  have  been  given.  Cases  are  seen  in  members  of 
gouty  families,  who  may  never  themselves  have  suffered  from  the  acute  dis- 
ease, and  in  persons  who  have  lived  not  wisely  but  too  well,  who  have  eaten 
and  drunk  largely,  lived  sedentary  lives,  and  yet  have  been  fortunate  enough 
to  escape  an  acute  attack.  It  is  interesting  to  note  the  various  manifestations 
of  the  disease  in  a  family  with  marked  hereditary  disposition.  The  daughters 
often  escape,  while  one  son  may  have  gouty  attacks  of  great  severity,  even 
though  he  lives  a  temperate  life  and  tries  in  every  way  to  avoid  the  conditions 
favoring  the  disorder.  Another  son  has,  perhaps,  only  the  irregular  manifesta- 
tions and  never  the  acute  articular  affection.  While  the  irregular  features 
are  perhaps  more  often  met  with  in  the  hereditary  affection,  they  are  by  no 
means  infrequent  in  persons  who  appear  to  have  acquired  the  disease.  The 
tendency  in  some  families  is  to  call  every  affection  gouty.  Even  infantile 
complaints,  such  as  scald-head,  naso-pharyngeal  vegetations,  and  enuresis,  are 
often  regarded,  without  sufficient  grounds,  as  evidences  of  the  family  ailment. 
Among  the  commonest  manifestations  of  irregular  gout  are  the  following : 

(a)  Cutaneous  Eruptions. — Garrod  and  others  have  called  special  atten- 
tion to  the  frequent  association  of  eczema  with  the  gduty  habit. 

(6)  Gastro-intestinal  Disorders. — Attacks  of  what  is  termed  biliousness, 
in  which  the  tongue  is  furred,  the  breath  foul,  the  bowels  constipated,  and 
the  action  of  the  liver  torpid,  are  not  uncommon  in  gouty  persons.  A  gouty 
parotitis  is  described. 

(c)  Cardio-vascular  Symptoms. — With  gout  arterio-sclerosis  is  frequently 
associated.  The  blood  tension  is  persistently  high,  the  vessel  walls  become 
stiff,  and  cardiac  and  renal  changes  gradually  occur.  In  this  condition  the 
symptoms  may  be  renal,  as  when  the  albuminuria  becomes  more  marked,  or 
dropsical  symptoms  supervene.  The  manifestations  may  be  cardiac,  when 
the  hypertrophy  of  the  left  ventricle  fails  and  there  are  palpitation,  irregular 
action,  and  ultimately  a  condition  of  asystole.  Or,  finally,  the  manifestations 
may  be  vascular,  and  thrombosis  of  the  coronary  arteries  may  cause  sudden 
death,  or,  as  most  frequently  happens,  a  blood-vessel  gives  away  in  the  brain, 
and  the  patient  dies  of  apoplexy.  It  makes  but  little  difference  whether  we 
regard  this  condition  as  primarily  an  arterio-sclerosis  or  as  a  gouty  nephritis ; 
the  point  to  be  remembered  is  that  the  nutritional  disorder  with  which  an 
excess  of  uric  acid  is  associated  induces  in  time  increased  tension,  arterio-scle- 
rosis, chronic  interstitial  nephritis,  and  changes  in  the  myocardium,  Pericar- 


GOUT  423 

ditis  is  not  an  infrequent  terminal  complication  of  gout.  Phlebitis  is  a  trouble- 
some and  not  very  uncommon  complication.  It  may  arise  in  connection  with, 
varicose  veins  of  the  legs  or  it  may  occur  in  many  venous  districts  in  succes- 
sion or  simultaneously. 

(d)  Nervous  Manifestations. — Headache  and  migraine  attacks  are  not  in- 
frequent. Neuralgias,  sciatica,  and  parsesthesias  are  not  uncommon.  A  com- 
mon gouty  manifestation,  upon  which  Duckworth  has  laid  stress,  is  the  occur- 
rence of  hot  or  itching  feet  at  night.  Plutarch  mentions  that  Strabo  called 
this  symptom  "the  lisping  of  the  gout."  Cramps  in  the  legs  may  also  be  very 
troublesome.  Hutchinson  has  called  attention  to  hot  and  itching  eyeballs. 
Associated  or  alternating  with  this  symptom  there  may  be  attacks  of  episcleral 
congestion.  Apoplexy  is  a  common  termination  of  gout.  Meningitis  may 
occur,  usually  basilar. 

(e}  Urinary  Disorders. — The  urine  is  highly  acid  and  high-colored,  and 
may  deposit  on  standing  crystals  of  uric  acid.  Transient  .and  temporary 
increase  in  this  ingredient  cannot  be  regarded  as  serious.  In  many  cases  of 
chronic  gout  the  amount  may  be  diminished,  and  increased  only  at  certain 
periods,  forming  the  so-called  uric-acid  showers.  A  sediment  of  uric  acid 
in  a  urine  does  not  necessarily  mean  an  excess.  It  is  often  dependent  on  the 
inability  of  the  urine  to  hold  it  in  solution.  Sugar  is  found  intermittently 
in  the  urine  of  gouty  persons — gouty  glycosuria.  It  may  pass  into  true  dia- 
betes, but  is  usually  very  amenable  to  treatment.  Oxaluria  may  also  be  pres- 
ent. Gouty  persons  are  specially  prone  to  calculi,  Jerome  Cardan  to  the  con- 
trary, who  reckoned  freedom  from  stone  among  the  chief  of  the  dona  podagrce. 
Minute  quantities  of  albumin  are  very  common  in  persons  of  gouty  dyscrasia, 
and,  when  the  renal  changes  are  well  established,  tube-casts.  Urethritis,  with 
a  purulent  discharge,  may  arise,  so  it  is  stated,  usually  at  the  end  of  an  at- 
tack. It  may  occur  spontaneously,  or  follow  a  pure  connection. 

(/)  Pulmonary  Disorders. — There  are  no  characteristic  changes,  but 
chronic  bronchitis  occurs  with  great  frequency  in  persons  of  a  gouty  habit. 

(g)  Of  eye  affections,  iritis,  glaucoma,  hamorrhagic  retinitis,  and  sup- 
purative  panophthalmitis  have  been  described. 

Diagnosis. — Eecurring  attacks  of  arthritis,  limited  to  the  big  toe  or  to 
the  tarsus,  occurring  in  a  member  of  a  gouty  family,  or  in  a  man  who  has 
lived  too  well,  leave  no  question  as  to  the  nature  of  the  trouble.  There  are 
many  cases  of  gout,  however,  in  which  the  feet  do  not  suffer  most  severely. 
After  an  attack  or  two  in  one  toe,  other  joints  may  be  affected,  and  it  is  just 
in  such  cases  of  polyarthritis  that  the  difficulty  in  diagnosis  is  apt  to  arise.  I 
have  had  cases  admitted  for  the  third  or  fourth  time  with  involvement  of 
three  or  more  of  the  larger  joints.  The  presence  of  tophi  has  settled  the  nature 
of  a  trouble  which  in  the  previous  attacks  had  been  regarded  as  rheumatic. 
The  following  are  suggestive  points  in  such  cases:  (1)  The  patient's  habits 
and  occupation.  In  the  United  States  the  brewery  men  and  barkeepers  are 
often  affected.  (2)  The  presence  of  tophi.  The  ears  should  always  be  in- 
spected in  a  case  of  polyarthritis.  The  diagnosis  may  rest  with  a  small 
tophus.  The  student  should  learn  to  recognize,  on  the  ear  margin,  Woolner's 
tip,  fibroid  nodules,  and  small  sebaceous  tumors.  The  last  are  easily  recog- 
nized microscopically.  The  needle-shaped  sodium  biurate  crystals  are  dis- 
tinctive of  the  tophi.  (3)  The  condition  of  the  urine.  As  shown  in  Chart 


424 

XIV,  the  uric-acid  output  is  usually  very  low  during  the  intervals  of  the 
paroxysm.  At  the  height  of  the  attack  the  elimination,  as  a  rule,  is  greatly 
increased.  The  ratio  of  the  uric  acid  to  the  urea  excretion  is  disturbed  in 
gouty  cases,  and  may  fall  as  low  as  1  to  100  or  1  to  150.  (4)  The  gouty 
polyarthritis  may  be  afebrile.  A  patient  with  three  or  four  joints  red,  swol- 
len, and  painful  in  rheumatic  fever  has  pyrexia,  and,  while  it  may  be 
present  and  often  is  in  gout,  its  absence  is,  I  think,  a  valuable  diagnostic  sign. 
Many  cases  .go  a-begging  for  a  diagnosis.  A  careful  study  of  the  patient's 
habits  as  to  beer  drinking,  of  the  location  of  the  initial  arthritic  attacks,  and 
the  examination  for  tophi  in  the  ears  will  prevent  many  cases  being  mistaken 
for  rheumatic  fever  or  arthritis  deformans.  Lastly,  in  these  doubtful  forms 
of  arthritis  a  careful  study  of  the  purin  metabolism  will  give  important  in- 
formation. 

Prognosis. — "Once  gouty,  always  gouty"  is  usually  true,  but  by  care  the 
frequency  and  intensity  of  attacks  can  be  much  reduced.  As  regards  the  dura- 
tion of  life,  the  state  of  the  circulation  and  kidneys  is  the  most  important 
factor. 

Treatment. — HYGIENIC. — Individuals  who  have  inherited  a  tendency  to 
gout,  or  who  have  shown  any  manifestations  of  it,  should  live  temperately, 
abstain  from  alcohol,  and  eat  moderately.  An  open-air  life,  with  plenty  of 
exercise  and  regular  hours,  does  much  to  counteract  an  inborn  tendency  to 
the  disease.  The  skin  should  be  kept  active:  if  the  patient  is  robust,  by  the 
morning  cold  bath  with  friction  after  it;  but  if  he  is  weak  or  debilitated  thp 
evening  warm  bath  should  be  substituted.  An  occasional  Turkish  "bath  with 
active  shampooing  is  very  advantageous.  The  patient  should  dress  warmly, 
avoid  rapid  alterations  in  temperature,  and  be  careful  not  to  have  the  skin 
suddenly  chilled. 

DIETETIC. — With  'few  exceptions,  persons  over  forty  eat  too  much,  and 
the  first  injunction  to  a  gouty  person  is  to  keep  his  appetite  within  reasonable 
bounds,  to  eat  at  stated  hours,  and  to  take  plenty  of  time  at  his  meals.  In 
the  matter  of  food,  quantity  is  a  factor  of  more  importance  than  quality  with 
many  gouty  persons.  As  Sir  William  Eoberts  well  says,  "Nowhere  perhaps 
is  it  more  necessary  than  in  gout  to  consider  the  man  as  well  as  the  ailment, 
and  very  often  more  the  man  than  the  ailment." 

The  weight  of  opinion  leans  to  the  use  of  a  modified  nitrogenous  diet, 
without  excess  in  starchy  and  saccharine  articles  of  food.  Animal  foods  rich 
in  nuclear  material,  such  as  sweetbreads,  liver,  kidneys,  and  brain,  should  be 
avoided.  Beef  extracts  are  injurious,  owing  to  their  richness  in  extractives 
belonging  to  the  xanthin  group.  Milk  and  eggs  are  particularly  useful, 
owing  to  their  not  containing  any  nuclein.  Fresh  vegetables  and  fruits  may 
be  used  freely,  but  among  the  latter  strawberries  and  bananas  should  be 
avoided. 

Ebstein  urges  strongly  the  use  of  fat  in  the  form  of  good  fresh  butter, 
from  2y2  to  3l/2  ounces  in  the  day.  He  says  that  stout  gouty  subjects  not 
only  do  not  increase  in  weight  with  plenty  of  fat  in  the  food,  but  that  they 
acutally  become  thin  and  the  general  condition  improves  very  much.  Hot 
bread  of  all  sorts  and  the  various  articles  of  food  prepared  from  Indian  corn 
should,  as  a  rule,  be  avoided.  Roberts  advised  gouty  patients  to  restrict  as 
far  as  practicable  the  use  of  common  salt  with  their  meals,  since  the  sodium 


GOUT  425 

biurate  very  readily  crystallizes  out  in  tissues  with  a  high  percentage  of  so- 
dium salts, 

In  this  matter  of  diet  each  individual  case  must  receive  separate  con- 
sideration. 

There  are  very  few  conditions  in  the  gouty  in  which  stimulants  of  any 
sort  are  required.  Whenever  indicated,  whisky  will  be  found  perhaps  the 
most  serviceable.  While  all  are  injurious  to  these  patients,  some  are  much 
more  so  than  others,  particularly  malted  liquors,  champagne,  port,  and  a  very 
large  proportion  of  all  the  light  wines. 

MINERAL  WATERS. — All  forms  may  be  said  to  be  beneficial  in  gout,  as  the 
main  element  is  the  water,  and  the  ingredients  are  usually  indifferent.  Much 
of  the  humbuggery  in  the  profession  still  lingers  about  mineral  waters,  more 
particularly  about  the  so-called  lithia  waters. 

The  question  of  the  utility  of  alkalies  in  the  treatment  of  gout  is  closely 
connected  with  this  subject  of  mineral  waters.  This  deep-rooted  belief  in  the 
profession  was  rudely  shaken  a  few  years  ago  by  Sir  William  Eoberts,  who 
claimed  to  have  shown  conclusively  that  alkalescence  as  such  has  no  influence 
whatever  on  the  sodium  biurate.  The  sodium  salts  are  believed  by  this  author 
to  be  particularly  harmful,  but,  in  spite  of  all  the  theoretical  denunciation 
of  the  use  of  the  sodium  salts  in  gout,  the  gouty  from  all  parts  of  the  world 
flock  to  those  very  Continental  springs  in  which  these  salts  are  most  predomi- 
nant. 

Of  the  mineral  springs  best  suited  for  the  gouty  may  be  mentioned,  in  the 
United  States,  those  of  Saratoga,  Bedford,  and  the  White  Sulphur;  Buxton 
and  Bath,  in  England;  in  France,  Aix-les-Bains  and  Contrexeville ;  and 
in  Germany,  Carlsbad,  Wildbad,  Homburg,  and  Marienbad.  Excellent  re- 
sults are  claimed  for  these  mineral  waters  with  special  radio-active  proper- 
ties. 

The  efficacy  in  reality  is  in  the  water,  in  the  way  it  is  taken,  on  an  empty 
stomach,  and  in  large  quantities;  and,  as  every  one  knows,  the  important 
accessories  in  the  modified  diet,  proper  hours,  regular  exercises,  with  baths, 
douches,  etc.,  play  a  very  important  role  in  the  "cure." 

MEDICAL  TREATMENT. — In  an  acute  attack  the  limb  should  be  elevated 
and  the  affected  joint  wrapped  in  cotton-wool.  Warm  fomentations,  or 
Fuller's  lotion,  may  be  used.  The  local  hot-air  or  passive  hyperamia  treat- 
ment may  be  tried.  A  brisk  mercurial  purge  is  always  advantageous  at  the 
outset.  The  wine  or  tincture  of  colchicum,  in  doses  of  20  to  30  minims  (1.2 
to  2  c.  c.)  may  be  given  every  four  hours  in  combination  with  the  citrate  of 
potash  or  the  citrate  of  lithium.  The  action  of  the  colchicum  should  be  care- 
fully watched ;  its  effect  is  most  marked  when  free  purgation  follows.  It  has 
in  a  majority  of  the  cases  a  powerful  influence  over  the  symptoms — relieving 
the  pain,  and  reducing,  sometimes  with  great  rapidity,  the  swelling  and  red- 
ness. It  should  be  promptly  stopped  so  soon  as  it  has  relieved  the  pain.  In 
cases  in  which  the  pain  and  sleeplessness  are  distressing  and  do  not  yield  to 
colchicum  morphia  is  necessary.  The  patient  should  be  placed  on  a  diet 
chiefly  of  milk  and  barley-water,  but  if  there  is  any  debility,  strong  broths 
or  eggs  may  be  given.  It  is  occasionally  necessary  to  give  small  quantities 
of  stimulants.  During  convalescence  meats  and  fish  and  game  may  be  taken, 
and  gradually  the  patient  may  resume  the  diet  previously  laid  down. 
29 


426  DISEASES    OF   METABOLISM 

In  some  of  the  subacute  intercurrent  attacks  of  arthritis  sodium  salicylate 
or  aspirin  is  occasionally  useful. 

The  chronic  and  irregular  forms  of  gout  are  best  treated  by  the  dietetic 
and  hygienic  measures  already  referred  to.  Potassium  iodide  is  sometimes 
useful,  and  preparations  of  guaiacum,  quinine,  and  the  bitter  tonics  combined 
with  alkalies  are  undoubtedly  of  benefit. 

Piperazin  has  been  much  lauded  as  an  efficient  aid  in  the  solution  of  uric 
acid.  The  clinical  results,  however,  are  very  discordant.  It  may  be  employed 
in  doses  of  from  15  to  30  grains  in  the  day,  and  is  conveniently  given  in 
aerated  water  containing  5  grains  to  the  tumblerful.  Piperazin,  as  a  uric 
acid  solvent,  was  rapidly  followed  by  lysidin,  urotropin,  urea,  and  urol  aii^ong 
others — a  sure  indication  of  their  therapeutic  worthlessness. 

Albu  speaks  favorably  of  lemon-juice  as  a  remedy.  The  vegetable  acids 
are  converted  in  the  system  into  alkaline  carbonates,  thus  enabling  the  blood 
to  keep  the  uric  acid  compounds  in  solution,  and  consequently  facilitating 
their  elimination  by  the  kidneys. 

Where  the  arthritic  attacks  are  confined  to  one  joint,  such  as  the  great-toe 
joint,  surgical  interference  may  be  considered.  Eiedel  reports  two  successful 
cases  in  which  he  removed  the  entire  joint  capsule  of  the  big-toe  joint,  with 
permanent  relief. 

H.     DIABETES  MELLITUS 

(Disturbances  of  the  Carbohydrate  Metabolism) 

Definition. — A  syndrome  due  to  disturbance  in  the  carbohydrate  metabol- 
ism from  various  causes,  in  which  sugar  appears  in  the  urine,  either  as  a 
slight  and  transient  condition  (Glycosuria),  or  as  a  more  severe  form  asso- 
ciated with  thirst,  polyuria,  wasting  and  imperfect  oxidation  of  the  fats 
(Diabetes). 

History. — The  disease  was  known  to  Celsus.  Aretasus  first  used  the  term 
diabetes,  calling  it  a  wonderful  affection  "melting  down  the  flesh  and  limbs 
into  urine."  He  suggested  that  the  disease  got  its  name  from  the  Greek  word 
signifying  a  syphon.  Willis  in  the  seventeenth  century  gave  a  good  descrip- 
tion and  recognized  the  sweetness  of  the  urine  "as  if  there  has  been  sugar 
and  honey  in  it."  Dobson  in  1776  demonstrated  the  presence  of  sugar,  and 
Hollo  in  1797  wrote  an  admirable  account  and  recommended  the  use  of  a 
Sneat  diet.  The  modern  study  of  the  disease  dates  from  Claude  Bernard's 
demonstration  of  the  glycogenic  function  of  the  liver  in  1857. 

Etiology. — The  enzymes  of  the  intestinal  mucosa  convert  the  starches  and 
sugars  of  the  food  into  monosaccharides — dextrose,  galactose  and  levulose — 
which  pass  into  the  portal  circulation,  but  the  major  portion  remains  in  the 
liver,  where  it  is  converted  into  glycogen.  The  percentage  of  sugar  in  the 
systemic  blood  remains  constant — 0.05  to  0.15  per  cent.  Part  of  the  sugar 
passes  to  the  muscles,  where  it  is  stored  as  glycogen.  The  total  storage 
capacity  of  the  liver  is  estimated  at  about  one-tenth  of  its  weight,  i.  e.,  about 
150  gms.  for  an  ordinary  organ  weighing  1,500  gms.  Not  all  of  the  glycogen 
comes  from  the  carbohydrates,  a  small  part  in  health  is  derived  from  the 
proteins  and  fats.  This  treble  process  of  transformation,  storage  and  re- 
transformation  of  the  sugars  is  effected  by  special  enzymes,  which  are  fur- 


DIABETES    MELLITUS  427 

nished  by  internal  secretions,  chiefly  of  the  pancreas  and  hypophysis,  and  are 
directly  influenced  by  the  nervous  system.  According  to  Claude  Bernard  the 
sugar  is  simply  warehoused  on  demand  in  the  liver,  and  given  out  to  the 
muscles  which  need  it  in  their  work.  On  the  other  hand,  Pavy  maintained 
that  the  glycogen  was  not  converted  into  sugar,  but  into  fat,  and  also  helped 
to  build  up  the  proteins.  In  any  case,  the  sugar,  one  of  the  chief  fuels  of 
the  body,  is  burned  up,  supplying  energy  to  the  muscles,  and  is  eliminated  as 
CO,  and  water.  The  nature  of  the  intermediate  stages  of  the  transformation 
is  still  under  discussion. 

The  following  are  the  conditions  which  influence  the  appearance  of  sugar 
in  the  urine: 

(a)  EXCESS  OF  CARBOHYDRATE  INTAKE. — As  mentioned,  in  a  normal  state 
the  sugar  in  the  blood  is  never  above  0.15  per  cent.  Once  past  this  point,  the 
hyperglycaemia  is  immediately  manifested  by  the  appearance  of  sugar  in  the 
urine.  The  healthy  person  has  a  definite  limit  of  carbohydrate  assimilation; 
the  total  storage  capacity  for  glycogen  is  estimated  at  about  300  gms.  Fol- 
lowing the  ingestion  of  enormous  amounts  of  carbohydrates  the  liver  and 
the  muscles  may  not  be  equal  to  the  task  of  storing  it;  the  blood  content  of 
sugar  passes  beyond  the  0.15  or  0.2  per  cent,  limit  and  the  cells  of  the  renal 
epithelium  immediately  begin  to  get  rid  of  the  surplus.  Like  the  balance 
at  the  Mint,  which  is  sensitive  to  the  correct  weight  of  the  gold  coins  passing 
over  it,  they  only  react  at  a  certain  point  of  saturation.  Fortunately  excessive 
quantities  of  pure  sugar  itself  are  not  taken.  The  carbohydrates  are  chiefly 
in  the  form  of  starch,  the  digestion  and  absorption  of  which  take  place  slowly, 
so  that  this  so-called  alimentary  glycosuria  very  rarely  occurs,  though  enor- 
mous quantities  may  be  taken.  The  assimilation  limit  of  a  normal  fasting 
individual  for  sugar  itself  is  about  250  gms.  of  grape  sugar,  and  considerably 
less  of  cane  and  milk  sugar.  Clinically  one  meets  with  many  cases  in  which 
glycosuria  is  present  as  a  result  of  excessive  ingestion  of  carbohydrates,  par- 
ticularly in  stout  persons  and  heavy  feeders — so-called  lipogenic  diabetes — a 
form  very  readily  controlled. 

(&)  DISTURBANCES  IN  THE  NERVOUS  SYSTEM. — Bernard  shows  that  there 
was  a  centre  in  th,e  medulla — the  diabetic  centre — puncture  of  which  is  fol- 
lowed by  hyperglycaBmia  due  to  an  increased  outflow  of  sugar  from  the  liver 
warehouse.  He  demonstrated  that  the  efferent  path  of  this  influence  was 
through  the  splanchic  nerves  and  the  afferent  through  the  vagi.  The  exact 
location  of  this  centre  has  never  been  determined,  and  its  precise  role  in  the 
carbohydrate  metabolism  is  obscure.  Clinically,  however,  it  has  long  been 
known  that  many  lesions  of  the  nervous  system  cause  glycosuria — tumors, 
particularly  those  in  the  neighborhood  of  the  medulla,  injuries  both  to  the 
brain  and  to  the  upper  part  of  the  spinal  cord,  meningitis,  and  hemorrhage. 
Some  of  these  may  disturb  Claude  Bernard's  centre  in  the  medulla,  but,  as 
will  be  mentioned  later,  a  great  many  of  them  disturb  the  internal  secretion  of 
the  hypophysis.  Clinically,  glycosuria  arising  from  disturbances  in  the  nerv- 
ous system  is  not  a  very  important  variety. 

(c)  DISTURBANCES  OF  THE  INTERNAL  SECRETIONS.— The  part  played  in 
the  carbohydrate  metabolism  by  the  ductless  glands  is  of  the  first  importance. 
Though  not  yet'  fully  understood,  the  following  are  the  chief  points,  so  far 
as  they  bear  on  clinical  work: 


428  DISEASES    OF    METABOLISM 

(1)  Pancreatic  Secretion. — Extirpation  of  the  pancreas  in  a  dog  is  fol- 
lowed by  hyperglycsemia  and  prolonged  glycosuria,  which  is  not  relieved  by 
feeding  pancreas  to  the  animal,  but  which  is  checked  if  experimentally  a  por- 
tion of  healthy  organ  from  another  dog  is  inserted  into  the  portal  circulation. 
The  pancreas  contains  structures  known  as  "the   islands  of   Langerhans/' 
which,  from  the  work  of  Opie  and  others,  are  believed  to  furnish  an  internal 
secretion  necessary  to  normal  carbohydrate  metabolism.     A  portion  of  the 
organ  separated  from  the  rest,  and  its  duct  ligated,  atrophies,  but  a  tissue 
remains  composed  of  enlarged  islands  of  Langerhans.     If  the  remainder  of 
the  pancreas  be  removed,  this  atrophied  portion  is  able  to  ward  off  glycosuria; 
but   if  this   is   removed   glycosuria   appears  immediately    (W.    G.    MacCal- 
lum).    In  some  way  the  secretion  furnished  by  this  organ  is  essential  to  the 
proper  preparation  of  the  sugars.     Cohnheim  suggests  a  correlation  of  this 
internal  secretion  with  a  muscle  enzyme,  to  which  it  acts  as  an  ambocepter, 
and  that  it  is  by  the  combined  action  of  these  two  glycolytic  bodies  that  the 
sugars  are  normally  burned  up  in  the  muscles.    Many  diseases  of  the  pancreas 
are  associated  with  glycosuria,  some  with  permanent  diabetes.     HaBmorrhagic 
pancreatitis,  cancer,  calculus,  chronic  interstitial  pancreatitis,  catarrh  of  the 
ducts  may  all  be  associated  with  a  profound  disturbance  in  the  metabolism 
of  the  sugars.     In  fact,  there  is  no  one  organ  the  disease  of  which  is  more 
constantly  associated  with  glycosuria,  and  the  studies  of  Opie  warrant  the 
belief  that  the  essential  factor  is  a  disturbance  of  the  function  of  the  internal 
secretion  provided  by  the  islands  of  Langerhans. 

(2)  Hypophysis. — It  was  long  known  that  glycosuria  occurred  in  tumors 
of  the  region  of  the  hypophysis,  particularly  in  acromegaly,  and  it  follows 
fractures  of  the  base  of  the  skull.    Experimentally,  Gushing  and  his  students 
have  shown  that  the  posterior  lobe  of  the  pituitary  gland  has  an  important 
influence  in  carbohydrate  metabolism.     The  secretion  of  this  portion  of  the 
gland  is  discharged  into  the  third  ventricle,  and  any  operative  disturbance 
of  it,  or  of  the  infundibulum,  is  at  once  followed  by  glycosuria,  and  by  a  re- 
markable lowering  of  the  assimilation  limit  for  sugars.    On  the  other  hand,  a 
deficiency  of  this  secretion,  or  the  removal  of  this  portion  of  the  gland  alone, 
is  followed  by  a  remarkable  increased  tolerance  for  carbo-hydrates. 

Clinically,  this  sequence  is  not  infrequently  seen.  A  tumor  which  at  first 
irritates  the  gland,  as  in  the  early  stages  of  acromegaly,  may  cause  glycosuria, 
but  later,  as  the  posterior  lobe  of  the  gland  is  destroyed,  there  is  an  extraordi- 
narily high  assimilation  limit  for  sugars,  and  associated  with  it  a  great 
increase  in  the  deposition  of  fat  in  the  body,  a  syndrome  to  be  referred  to 
later.  Intravenous  or  subcutaneous  injection  of  the  extract  of  the  posterior 
lobe  promptly  lowers  this  high  assimilation  limit  for  carbohydrates. 

(3)  Adrenals  and  Thyroids. — We  have  less  positive  information  about 
the  relation  of  carbohydrate  metabolism  to  the  internal  secretions  of  these 
glands.     Glycosuria  does  not  necessarily  follow  lesions  of  the  adrenals,  but 
experimentally  it  has  been  shown  that  adrenalin  has  a  powerful  influence 
on  the  carbohydrate  metabolism,  and  glycosuria  may  be  readily  produced  in 
animals  by  subcutaneous  injection,  and  by  the  local  application  of  adrenalin 
to  the  pancreas.     Clinically,  we  know  practically  nothing  of  an  adrenal  gly- 
cosuria.    It  does  not  occur  in  Addison's  disease.     It  has  occasionally  been 
noticed  in  the  prolonged  therapeutic  use  of  adrenalin.    In  disturbances  of  the 


DIABETES    MELLITUS  429 

thyroid  gland  glycosuria  is  not  uncommon.  There  is  a  lowered  tolerance  for 
sugar  in  Graves'  disease  which  is  sometimes  associated  with  a  true  diabetes, 
and  in  the  remarkable  instances  of  acute  myxcedema  the  amount  of  sugar 
in  the  urine  may  be  large.  The  use  of  thyroid  extract  is  occasionally  fol- 
lowed by  glycosuria.  On  the  other  hand,  patients  may  take  the  extract  con- 
tinuously for  many  years  without  the  appearance  of  sugar  in  the  urine. 

Possibly  the  glycosuria  associated  with  pregnancy  is  due  to  a  disturbance 
in  the  internal  secretions  at  this  period.  It  is  a  transient  condition,  usually 
disappearing  with  parturition,  and  rarely  leads  to  diabetes.  I  have  known 
it  to  recur  in  successive  pregnancies. 

(d)  DISTURBANCES  IN  THE  FUNCTION  OF  THE  LIVER. — One  of  the  most 
remarkable  features  in  carbohydrate  metabolism  is  that  the  great  warehouse 
of  the  sugars  may  be  damaged  to  any  degree  without  causing  hyperglycasmia 
or  glycosuria.     Whether  or  not  there  is  a  type  of  disease  to  which  the  name 
of  "liver  diabetes"  may  be  given  is  doubtful.     There  are  cases  of  cirrhosis  of 
the  liver  and  of  gallstones — particularly  those  associated  with  enlargement  of 
the  organ — in  which  glycosuria  is  present,  but  they  are  probably  all  asso- 
ciated with  coincident  affections  of  the  pancreas.     In  the  "bronze  diabetes," 
which  is  accompanied  by  great  hypertrophy  of  the  liver,  the  glycosuria  is 
probably  pancreatic. 

(e)  DISTURBANCES  IN  THE  KIDNEY  FUNCTIONS. — Disease  of  the  kidneys 
is  rarely   associated  with  glycosuria.     Occasionally  one   finds  it  in  chronic 
Bright's  disease,  but  the  existence  of  a  true  diabetes  depending  upon  changes 
in  the  kidneys  has  not  been  proved.    There  is  a  remarkable  experimental  dia- 
betes of  great  interest  in  connection  with  carbohydrate  metabolism.     If  phlo- 
ridzin,  a  glucoside  prepared  from  the  bark  of  the  apple-tree,  is  given  by  mouth 
or  subcutaneously  to  man  or  animals  glycosuria  results,  and  even  continues 
on  a  nitrogenous  diet,  and  in  man  when  fasting.     The  amount  of  sugar 
excreted  may  be  large,  yet  there  is  no  hyperglycsemia.     It  seems  that  the 
sugar  is  directly  manufactured  by  the  kidney  epithelium,  and  largely  from 
the  proteins. 

(/)  MISCELLANEOUS  DISTURBANCES. — The  carbohydrate  metabolism  may 
be  upset  in  acute  fevers,  in  many  of  which  a  transient  glycosuria  is  present. 
It  is  not  uncommon  after  the  administration  of  ether,  less  so  after  chloro- 
form. Metabolic  disturbances  in  gout  are  not  infrequently  associated  with 
glycosuria,  and  cachexias  and  profound  anemias  may  be  accompanied  by 
transient  glycosuria.  A  mental  shock,  a  severe  nervous  strain  and  worry 
precede  many  cases.  Patients  suffocated  by  smoke,  or  poisoned  by  coal  gas, 
may  have  sugar  in  the  urine. 

INCIDENCE. — According  to  statistics  diabetes  appears  to  be  about  as  fre- 
quent in  the  United  States  as  in  European  countries.  In  England  and  Wales 
the  death-rate  from  diabetes  is  about  9  per  100,000  of  population.  The  dis- 
ease is  on  the  increase  in  the  United  States.  The  statistics  for  1870  gave  2.1 ; 
for  1880,  2.8;  for  1890,  3.8;  for  1900,  9.3;  and  for  1914,  16.2  deaths  to  the 
100,000  population.  This  apparent  increase  may  be  in  part  due  to  more 
accurate  vital  statistics  records.  Among  27,618  patients  admitted  to  the 
medical  wards  of  the  Johns  Hopkins  Hospital  in  twenty-two  years  there  were 
276  cases  of  diabetes,  or  one  per  cent. 

HEREDITARY  INFLUENCES  play  an  important  role  and  cases  are  on  record 


430  DISEASES    OF    METABOLISM 

of  its  occurrence  in  many  members  of  the  same  family.  Morton,  who  calls 
the  disease  hydrops  ad  matulam  (Phthisiologia,  1689),  records  a  remarkable 
family  in  which  four  children  were  affected,  one  of  which  recovered  on  a  milk 
diet  and  diascordium.  An  analysis  of  the  cases  in  my  series  gave  only  6  cases 
with  a  history  of  diabetes  in  relatives  (Pleasants).  Naunyn  obtained  a  fam- 
ily history  of  diabetes  in  35  out  of  201  private  cases,  but  in  only  7  of  157  hos- 
pital cases.  There  are  instances  of  the  coexistence  of  the  disease  in  man  and 
wife.  Among  516  married  pairs  collected  by  Senator,  in  which  either  hus- 
band or  wife  was  diabetic,  in  18  cases  the  second  partner  had  become  diabetic. 
It  is  not  easy  to  explain  this  conjugal  diabetes.  The  suggestion  of  contagion 
seems  scarcely  tenable. 

SEX. — Men  are  more  frequently  affected  than  women,  the  ratio  being 
about  three  to  two.  Of  the  276  cases  of  diabetes  above  referred  to  179  were 
in  males  and  97  in  females  (Futcher).  It  is  a  disease  of  adult  life;  a  majority 
of  the  cases  occur  from  the  third  to  the  sixth  decade.  Of  the  276  cases,  the 
largest  number — 70,  or  25  per  cent. — occurred  between  fifty  and  sixty  years  of 
age. 

DIABETES  IN  CHILDREN. — Stern  has  analyzed  117  cases  in  children.  They 
usually  occur  among  the  better  classes.  Six  were  under  one  year  of  age. 
Hereditary  influences  were  marked.  The  course  of  the  disease  is,  as  a  rule, 
much  more  rapid  than  in  adults.  The  shortest  duration  was  two  days,  and  in 
7  cases  it  did  not  last  a  month.  One  case  is  mentioned  of  a  child  apparently 
born  with  glycosuria,  who  recovered  in  eight  months. 

In  the  above  series  there  were  2  cases  in  the  first  hemi-decade,  5  in  the 
second,  and  24  in  the  second  decade. 

Persons  of  a  neurotic  temperament  are  often  affected.  It  is  a  disease  of 
the  higher  classes.  Van  ISToorden  states  that  the  statistics  for  London  and 
Berlin  show  that  the  number  of  cases  in  the  upper  ten  thousand  exceeds  that 
in  the  lower  hundred  thousand  inhabitants. 

RACE. — Hebrews  seem  especially  prone  to  it;  one-fourth  of  Frerichs'  pa- 
tients were  of  the  Semitic  race.  I  have  been  much  impressed  with  the  fre- 
quency of  the  disease  among  them.  Diabetes  is  comparatively  rare  in  the 
colored  race,  but  not  so  uncommon  as  was  formerly  supposed.  Of  the  series 
of  276  cases,  29,  or  10.6  per  cent.,  were  in  negroes. 

Metabolism  in  Diabetes. — Glycosuria,  neurotic,  dietetic  or  toxic,  may  be 
a  matter  of  simple  overflow,  but  the  essence  of  true  diabetes  is  a  waste  of  the 
carbohydrates,  which  hurry  through  the  body,  in  great  part  never  warehoused 
as  glycogen.  Why  this  should  be,  whether  the  liver  and  muscles  are  at  fault 
in  refusing  to  transform  the  carbohydrate,  or  whether  the  defect  is  the  en- 
zymes of  the  ductless  glands,  are  problems  awaiting  solution.  Naunyn  held 
that  hyperglycsemia  is  due  to  a  failure  of  the  liver  and  muscles  to  store  up 
glycogen  as  in  health.  On  the  other  hand,  Lepine,  Opie,  and  others  support 
the  view  that  the  glycolitic  ferments  are  lacking — the  former  may  depend  on 
the  latter.  In  either  case  the  result  is  a  failure  of  the  normal  oxidation  of 
the  carbohydrates.  Hyperglycaemia  is  responsible  for  the  thirst  and  the  polyu- 
ria,  and  there  is  a  very,  considerable  daily  loss  of  energy  in  warming  the 
liquids  taken  to  the  temperature  of  the  body,  according  to  Benedict  and  Joslin 
nearly  6  per  cent,  of  the  total  heat  of  the  day;  and  it  is  this  excess  of  sugar 
in  the  system  that  renders  the  body  so  favorable  a  culture  medium  for  pus 


DIABETES    MELLITUS  431 

organisms.  There  is  loss  of  energy  with  the  steady  waste  of  sugar  fuel; 
practically  every  gram  of  sugar  excreted  in  the  urine  results  in  a  loss  of  4.1 
calories,  consequently  a  diabetic  patient  excreting  100  grams  of  sugar  and  20 
grams  of  /3 -oxy  butyric  acid  loses  500  calories  in  this  way,  so  that  the  patients 
are  apt  to  be  underfed,  unless  this  loss  is  made  up  by  a  full  amount  of  other 
food  (Benedict  and  Joslin).  Studies  upon  the  respiratory  quotient — which  is 
the  ratio  between  the  C02  given  out  and  the  0  taken  in  by  a  healthy  individual 
on  a  mixed  diet  (expressed  by  the  fraction  0.9) — favor  the  view  that  there  is 
failure  in  the  proper  combustion  of  the  carbohydrates.  Benedict  and  Joslin 
conclude  that  a  respiratory  quotient  above  0.74  indicates  a  fairly  liberal  sup- 
ply of  glycogen  stored  in  the  body;  while  a  respiratory  quotient  of  0.70,  or 
below  that,  indicates  that  the  patient  has  no  available  carbohydrates,  and  has 
lost  in  a  measure  the  power  of  storing  them.  And  here  comes  the  special 
danger;  as  the  carbohydrates  pass  through  the  body  unburned,  the  energy 
must  be  provided  from  the  proteins  and  fats.  The  metabolism  of  the  former 
does  not  appear  to  be  seriously  disturbed,  and  the  carbohydrate  portion  of 
the  protein  molecule  is  well  tolerated  and  in  part  supplies  the  place  of  the  lost 
sugars.  The  danger  is  in  the  metabolism  of  the  fats.  The  carbohydrates  are 
not  used  as  fuel;  the  proteins  are  easily  utilized,  but  apparently  it  takes  so 
much  draught  to  burn  them  that  not  enough  is  left  to  consume  the  fats  com- 
pletely; and  the  products  of  incomplete  combustion  accumulate  in  the  system 
Lnd  suffocate  the  patient  as  effectually  as  does  the  CO  of  a  charcoal  stove. 
The  chief  product  of  this  incomplete  combustion  of  the  fats  is  the  /3-oxybuty- 
ric  acid,  which  itself  is  the  source  of  the  diacetic  acid  and  acetone,  and  the 
special  danger  of  the  disease  is  now  recognized  to  be  the  production  'of  an 
acidosis  in  consequence  of  this  imperfect  fat  metabolism.  One  of  the  most 
valuable  advances  in  our  knowledge  of  the  metabolism  of  the  disease  has  been 
the 'work  of  Beddard,  Pembrey  and  Spriggs  and  more  recently  of  Poulton, 
who  have  shown  that  the  amount  of  C02  in  the  alveolar  air  may  be  taken  as  a 
measure  of  the  acidosis.  The  acetone  bodies  in  the  urine  indicate  a  large 
production  in  the  body  but  this  may  have  been  completely  compensated.  The 
blood  examination  is  more  important  to  determine  the  degree  of  accumulation 
and  with  even  slight  degrees  there  are  changes  in  the  alveolar  air. 

Morbid  Anatomy. — The  nervous  system  shows  no  constant  lesions.  In  a 
few  instances  there  have  been  tumors  or  sclerosis  in  the  medulla,  or  a  cysti- 
cercus  has  pressed  on  the  floor.  A  secondary  multiple  neuritis  is  not  rare,  and 
to  it  the  so-called  diabetic  tabes  is  probably  due,  and  changes  occur  in  the 
posterior  columns  of  the  cord  similar  to  those  which  have  been  found  in  per- 
nicious anaemia.  In  the  sympathetic  system  the  ganglia  have  been  enlarged 
and  in  some  instances  sclerosed.  The  heart  is  hypertrophied  in  some  cases. 
Endocarditis  is  very  rare.  Arterio-sclerosis  is  common.  The  lungs  show 
important  changes.  Acute  broncho-pneumonia  or  croupous  pneumonia  (either 
of  which  may  terminate  in  gangrene)  and  tuberculosis  are  -common.  The  so- 
called  diabetic  phthisis  is  always  tuberculous  and  results  from  a  caseating 
broncho-pneumonia.  In  rare  cases  there  is  a  chronic  interstitial  pneumonia, 
non-tuberculous.  Fat  embolism  of  the  pulmonary  vessels  may  occur  in  con- 
nection with  diabetic  coma. 

The  liver  is  usually  enlarged;  fatty  degeneration  is  common.  In  the  so- 
called  diabetic  cirrhosis — the  cirrhosis  pigmentaire — the  liver  is  enlarged  and 


432  DISEASES    OF    METABOLISM 

sclerotic,  and  cacliexia  develops  with  melanoderma.  Dilatation  of  the  stomach 
with  enlargement  of  the  duodenum  and  colonic  stasis  are  common, 

Pancreas. — Of  15  autopsies  in  27  fatal  cases,  in  9  the  pancreas  was  found 
atrophic.  In  one  of  these  fat  necroses  were  present,  in  another  calculi. 
Hyaline  degeneration  of  the  islands  of  Langerhans  has  been  described  by  Opie 
and  is  a  special  feature  in  certain  cases.  Chronic  interstitial  pancreatitis  is 
common. 

The  kidneys  show  a  diffuse  nephritis  with  fatty  degeneration.  Hyaline 
change  is  often  found  in  the  tubal  epithelium,  particularly  of  the  descending 
limb  of  the  loop  of  Henle,  and  in  the  Malphigian  tufts. 

Symptoms.- — Acute  and  chronic  forms  are  recognized,  but  there  is  no 
essential  difference  between  them,  except  that  in  the  former  the  patients  are 
younger,  the  course  is  more  rapid,  and  the  emaciation  more  marked.  I  have 
twice  seen  acute  diabetes  in  the  aged. 

The  onset  of  the  disease  is  gradual,  and  either  frequent  micturition  or 
inordinate  thirst  first  attracts  attention.  Very  rarely  it  sets  in  rapidly,  after 
a  sudden  emotion,  an  injury,  or  after  a  severe  chill.  When  fully  established 
the  disease  is  characterized  by  great  thirst,  the  passage  of  large  quantities  of 
saccharine  urine,  a  voracious  appetite,  and,  as  a  rule,  progressive  emaciation. 

Among  the  GENERAL  SYMPTOMS  of  the  disease  thirst  is  one  of  the  most 
distressing.  Large  quantities  of  water  are  required  to  keep  the  sugar  in 
solution  and  for  its  excretion  in  the  urine.  The  amount  of  fluid  consumed 
will  be  found  to  bear  a  definite  ratio  to  the  quantity  excreted.  Instances, 
however,  are  not  uncommon  of  pronounced  diabetes  in  which  the  thirst  is 
not  excessive;  but  in  such  cases  the  amount  of  urine  passed  is  never  large. 
The  thirst  is  most  intense  an  hour  or  two  after  meals.  As  a  rule,  the  diges- 
tion is  good  and  the  appetite  inordinate.  The  condition  is  sometimes  termed 
bulimia  or  polyphagia.  Lumbar  pain  is  common. 

The  tongue  is  usually  dry,  red,  and  glazed,  and  the  saliva  scanty.  The 
gums  may  become  swollen,  and  in  the  later  stages  aphthous  stomatitis  is 
common.  Constipation  is  the  rule.  , 

In  spite  of  the  enormous  amount  of  food  consumed  a  patient  may  be- 
come rapidly  emaciated.  This  loss  of  flesh  bears  some  ratio  to  the  polyuria, 
and  when,  under  suitable  diet,  the  sugar  is  reduced,  the  patient  may  quickly 
gain  in  flesh.  The  skin  is  dry  and  harsh,  and  sweating  rarely  occurs,  except 
when  phthisis  coexists.  Drenching  sweats  have  been  known  to  alternate  with 
excessive  polyuria.  General  pruritus  or  pruritus  pudendi  may  be  very  dis- 
tressing, and  occasionally  is  one  of  the  earliest  symptoms.  The  temperature 
is  often  subnormal;  the  pulse  is  usually  frequent,  and  the  tension  increased. 
Many  diabetics  do  not  show  marked  emaciation.  Patients  past  the  middle 
period  of  life  may  have  the  disease  for  years  without  much  disturbance  of  the 
health,  and  may  remain  well  nourished.  These  are  the  cases  of  the  diabete 
gras  in  contradistinction  to  diabete  maigre. 

THE  URINE. — The  amount  varies  from  3  to  4  litres  in  mild  cases  to  15 
10  20  litres  in  very  severe  cases.  In  rare  instances  the  quantity  of  urine  is 
not  much  increased.  Under  strict  diet  the  amount  is  much  lessened,  and 
in  intercurrent  febrile  affections  it  may  be  reduced  to  normal.  The  specific 
gravity  is  high,  ranging  from  1.025  to  1.045;  but'in  exceptional  cases  it  may 
be  low,  1.013  to  1.020.  The  highest  specific  gravity  recorded,  so  far  as  I 


DIABETES    MELLITUS  433 

know,  is  by  Trousseau— 1.074.  Very  high  specific  gravities— 1.070  -\ sug- 
gest fraud.  The  urine  is  pale  in  color,  almost  like  water,  and  has  a  sweetish 
odor  and  a  distinctly  sweetish  taste.  The  reaction  is  acid.  Sugar  is  present 
in  varying  amounts.  In  mild  cases  it  does  not  exceed  ll/2  or  2  per  cent.,  but 
it  may  reach  from  5  to  10  per  cent.  The  total  amount  excreted  in  the  twenty- 
four  hours  may  range  from  10  to  20  ounces  (320  to  640  grams)  and  in 
exceptional  cases  from  1  to  2  pounds. 

Ketonuria. — The  ketone  bodies,  acetone,  diacetic  acid  and  yS-oxybutyric 
acid  are  present,  sometimes  in  small  amounts  in  mild  cases  but  increasing  with 
the  severity  of  the  disease ;  and  are  indications  of  acidosis.  In  coma  the  excre- 
tion of  /?-oxybutyric  acid  may  be  as  much  as  100  gm.  or  more  a  day. 

Glycogcn  has  also  been  found  in  the  urine,  and  in  rare  instances  sugars 
other  than  glucose  occur,  lactose,  levulose,  and  pentose,  and  to  these  conditions 
the  term  melUuria  is  sometimes  applied.  Albumin  is  not  infrequent. 

Pneumaturia,  gas  in  the  urine,  due  to  fermentation  in  the  bladder,  is 
occasionally  met  with.  Cammidge's  reaction  may  be  present.  Fat  may  be 
passed  in  the  urine  in  the  form  of  a  fine  emulsion  (lipuria). 

BLOOD  IN  DIABETES. — The  water  content  is  lower  than  normal.  Poly- 
cythaemia  may  be  present  to  6  or  8  millions  of  red  cells  per  cmm.  Towards 
the  end  and  with  complications  there  may  be  a  leucocytosis  and  the  leucocytes 
may  contain  glycogen.  Hyperglycsemia  is  present  to  0.3  or  even  0.8  per  cent., 
instead  of  the  normal  0.1  to  0.15  per  cent.  The  increase  in  the  blood  sugar 
may  persist  after  glycosuria  has  disappeared.  Eecent  studies  have  shown  the 
great  importance  of  estimating  the  sugar  content  of  the  blood. 

The  alkalinity  is  lessened  and  the  specific  gravity  reduced.  Lipsemia  is 
present  in  many  cases  and  may  be  readily  recognized  by  the  presence  of  dancing 
particles  among  the  red  cells  in  a  slide  of  fresh  blood.  In  a  centrifugalized 
specimen  the  serum  is  creamy.  Normally  the  blood  contains  about  1  per  cent, 
of  lipoid  substances;  in  severe  acidosis  the  content  may  rise  to  15  per  cent. 
Serous  exudates  may  be  turbid  with  fat.  Lipagmia  may  be  present  without 
acidosis  and  is  sometimes  due  to  surcharging  of  the  blood  stream  with  the 
products  of  fatty  digestion  as  in  the  normal  lipajmia  of  sucklings. 

Complications. — (a)  COMA. — There  are  three  groups  of  cases: 

(1)  Typical  dyspnceic  coma,  the  air-hunger  of  Kussmaul,  in  which  with 
loud  and  deep  in-  and  expirations,  the  pulse  grows  weak,  and  the  patient 
gradually  fails  and  dies,  sometimes  within  twenty-four  hours.  The  breath 
very  often  has  the  fruity  odor  of  acetone.  It  may  come  on  without  any  pre- 
monition and  the  patient  may  waken  out  of  sleep  in  dyspnoea.  An  acyanotic 
dyspnoea  is  one  of  the  best  indications  of  acidosis.  (2)  Cases  in  which,  with- 
out any  previous  dyspnoea  or  distress,  the  patient  is  attacked  with  headache, 
a  feeling  of  intoxication,  thick  speech  and  a  staggering  gait,  and  gradually 
falls  into  deep  coma.  (3)  Cases  in  which,  particularly  after  exertion,  the 
patient  is  attacked  suddenly  with  weakness,  giddiness  and  fainting;  the  hands 
and  feet  are  cold  and  livid,  the  pulse  small,  respiration  rapid;  the  patient 
becomes  drowsy,  and  death  occurs  within  a  few  hours.  Dyspepsia,  constipa- 
tion, abdominal  pain,  marked  irritability  and  restlessness  may  precede  the 
onset  of  coma  and  should  suggest  its  possibility. 

(?>)  CUTANEOUS. — Boils  and  carbuncles  are  extremely  common.  Painful 
onychia  may  occur.  Eczema  is  also  met  with,  and  at  times  an  intolerable 


434  DISEASES    OF    METABOLISM 

itching.  In  women  the  irritation  of  the  urine  may  cause  the  most  intense 
pruritus  pudendi,  and  in  men  a  balanitis.  Rarer  affections  are  xanthoma  and 
purpura.  Gangrene  is  not  uncommon,  and  is  associated  usually  with  arterio- 
sclerosis. Perforating  ulcer  of  the  foot  occurred  in  7  of  276  cases.  Bronzing 
of  the  skin  (diabete  bronze)  occurs  in  certain  cases  in  which  the  diabetes  arises 
as  a  late  event  in  the  disease  known  as  hsemochromatosis,  which  is  further 
characterized  by  pigmentary  cirrhosis  of  the  liver  and  pancreas.  With  the 
onset  of  severe  complications  the  tolerance  of  the  carbohydrates  is  much  in- 
creased. Profuse  sweats  may  occur. 

(c)  PULMONARY. — The  patients  are  not  infrequently  carried  off  by  acute 
pneumonia,  which  may  be  lobar  or  lobular.     Gangrene  is  very  apt  to  super- 
vene, but  the  breath  does  not  necessarily  have  the  foul  odor  of  ordinary  gan- 
grene.    Abscess  following  lobar  pneumonia  occurred  in  one  of  my  cases. 
Tuberculous  broncho-pneumonia  is  very  common  and  may  run  a  very  rapid 
course. 

(d)  RENAL. — Albuminuria  is   a   tolerably   frequent   complication.      The 
amount  varies  greatly,  and,  when  slight,  does  not  seem  to  be  of  much  moment. 
(Edema  of  the  feet  and  ankles  is  not  an  infrequent  symptom.     General  ana- 
sarca  is  rare,  however,  owing  to  the  marked  polyuria.     It  is  sometimes  asso- 
ciated with  arterio-sclerosis.     It  occasionally  precedes  the  occurrence  of  the 
diabetic  coma.    Occasionally  cystitis  is  a  troublesome  symptom. 

(e)  NERVOUS  SYSTEM. — Peripheral  Neuritis. — Neuralgia,  numbness  and 
tingling,  uncommon  symptoms  in  diabetes,  are  probably  minor  neuritic  mani- 
festations.   The  involvement  may  be  general  of  the  upper  and  lower  extremi- 
ties.    Sometimes  it  is  unilateral,  or  the  neuritis  may  be  in  a  single  nerve — 
the  sciatic  or  the  third  nerve.     Herpes  zoster  may  occur. 

Diabetic  Tabes  (so-called). — This  is  a  peripheral  neuritis,  characterized  by 
lightning  pains  in  the  legs,  loss  of  knee-jerk — which  may  occur  without  the 
other  symptoms — and  a  loss  of  power  in  the  extensors  of  the  feet.  The  gait 
is  the  characteristic  steppage,  as  in  arsenical,  alcoholic,  and  other  forms  of 
neuritic  paralysis.  Charcot  states  that  there  may  fye  atrophy  of  the  optic 
nerves.  Changes  in  the  posterior  columns  of  the  cord  have  been  found  by 
Williamson  and  others. 

Diabetic  Paraplegia. — This  is  also  in  all  probability  due  to  neuritis.  There 
are  cases  in  which  power  has  been  lost  in  both  arms  and  legs. 

Mental  Symptoms. — The  patients  are  often  morose,  and  there  is  a 
strong  tendency  to  become  hypochondriacal.  General  paralysis  has  been 
met  with.  Some  patients  display  an  extraordinary  degree  of  restlessness  and 
anxiety. 

(/)  SPECIAL  SENSES. — Cataract  is  liable  to  occur,  and  with  rapidity  in 
young  persons.  Diabetic  retinitis  closely  resembles  the  albuminuric  form. 
Hasmorrhages  are  common.  Sudden  amaurosis,  similar  to  that  which  occurs 
in  urasmia,  may  occur.  Paralysis  of  the  muscles  of  accommodation  may  be 
present;  and,  lastly,  atrophy  of  the  optic  nerves.  Aural  symptoms  may  come 
on  with  great  rapidity,  either  an  otitis  media,  or  in  some  instances  inflamma- 
tion of  the  mastoid  cells.  Ocular  tension  may  be  lowered  in  coma. 

(g)  SEXUAL  FUNCTION. — Impotence  is  common,  and  may  be  an  early 
symptom.  Conception  is  rare;  if  it  occurs,  abortion  is  apt  to  follow.  A  dia- 
betic mother  may  bear  a  healthy  child;  there  is  no  known  instance  of  a  dia- 


DIABETES    MELLITUS  435 

betic  mother  bearing  a  diabetic  cbild.  The  course  of  the  disease  is  usually 
aggravated  after  delivery. 

Diagnosis. — There  is  no  difficulty  in  determining  the  presence  of  sugar 
in  the  urine  if  the  proper  tests  are  applied.  Alcapton  may  prove  very  decep- 
tive, and  in  one  case  of  ochronosis  which  I  reported  a  diagnosis  of  diabetes 
was  made  by  four  or  five  of  the  leading  physicians  in  Europe,  one  of  whom 
was  an  authority  on  diabetes.  Deception  may  be  practiced.  A  young  girl 
under  my  care  had  urine  with  a  specific  gravity  of  1.065,  but  the  reactions 
were  for  cane  sugar;  and  there  is  a  case  in  the  literature  in  which,  when  the 
cane  sugar  fraud  was  detected,  the  woman  bought  grape  sugar  and  put  it 
into  her  bladder. 

To  determine  whether  the  case  is  one  of  simple  glycosuria  or  of  true  dia- 
betes is  not  always  easy,  as  the  one  readily  merges  into  the  other.  The  younger 
the  individual  the  greater  the  probability  that  the  case  is  one  of  true  diabetes. 
It  is  well  always  to  test  the  assimilation  limit;  100  grams  of  glucose  given 
in  solution  two  hours  after  a  breakfast  of  a  roll  and  butter  with  coffee  should 
not  give  glycosuria.  To  do  so  indicates  a  deficiency  in  the  capacity  to  store 
carbohydrates  and  a  possibility  that  true  diabetes  may  follow.  Transient  gly- 
cosuria occurs  in  a  great  many  conditions  already  mentioned.  For  practical 
purposes  the  common  form  is  that  met  with  in  persons  above  50  years  of  age, 
who  eat  and  drink  too  much  and  tend  to  grow  stout.  The  detection  of  a  little 
sugar  in  the  urine  may  have  the  great  advantage  of  frightening  the  patient 
into  a  more  rational  mode  of  life.  The  forms  following  anesthesia,  accidents, 
business  worries,  fright  and  that  which  occurs  in  pregnancy  are,  as  a  rule, 
readily  controlled. 

Prognosis. — The  younger  the  patient  the  less  likely  is  recovery.  In  chil- 
dren the  disease  may  run  a  very  rapid  course,  and  death  may  occur  within  a 
few  weeks,  or,  indeed,  a  child  may  die  in  coma  before  the  condition  has  been 
recognized.  The  case  referred  to  by  Morton,  in  which  one  recovered  of  four 
children  in  a  family  affected,  is  one  of  the  few  instances  on  record.  Person- 
ally I  have  not  known  an  instance  of  recovery  in  a  child.  On  the  other  hand, 
in  persons  over  fifty  sugar  may  be  present  in  the  urine  for  years  without  any 
impairment  of  strength  or  health.  The  outlook  is  good  in  the  fat,  bad  in  the 
lean.  It  is  particularly  good  in  the  stout,  active,  business  man,  whose  glyco- 
suria has  come  on  as  a  result  of  worry,  work,  and  excess  in  food  and  drink. 

The  following  steps  should  be  taken  to  estimate  the  gravity  of  a  case. 
The  carbohydrate  tolerance  should  be  estimated  in  exact  figures  and  the  pres- 
ence of  acetone  and  diacetic  acid  determined,  as  they  usually  indicate  a  serious 
disturbance  in  the  metabolism  of  the  fats.  It  is  well  to  remember,  however, 
that  the  acetone  bodies  may  be  only  temporarily  present,  and  it  is  not  neces- 
sary to  sign  the  patient's  death  warrant  so  soon  as  they  appear.  A  patient 
may  live  for  many  years  with  traces,  and  they  may  disappear  after  having 
been  present  for  months. 

Treatment. — In  families  with  a  marked  predisposition  to  the  disease  the 
use  of  starchy  and  saccharine  articles  of  diet  should  be  restricted. 

The  personal  hygiene  of  a  diabetic  patient  is  •  of  the  first  importance. 
Sources  of  worry  should  be  avoided,  and  he  should  lead  an  even,  quiet  life, 
if  possible  in  an  equable  climate.  The  heat  waste  should  be  prevented  by  wear- 
ing warm  clothes  and  avoiding  cold.  A  warm,  or,  if  tolerably  robust,  a  cold. 


436  DISEASES    OF    METABOLISM 

bath  should  be  taken  every  day.  An  occasional  Turkish  bath  is  useful.  System- 
atic, moderate  exercise  should  be  taken.  When  this  is  not  feasible,  massage 
should  be  given.  It  is  well  to  study  accurately  the  dietetic  capabilities  of  each 
patient,  for  no  two  can  be  treated  alike.  The  weight  should  be  recorded  weekly. 
A  patient  who  is  glycosuric  and  losing  weight  on  a  non-carbohydrate  diet  must 
be  regarded  as  doing  badly,  but  as  a  result  of  the  fasting  treatment  we  have 
learned  that  some  patients  are  better  after  a  moderate  loss  of  weight. 

DIET.— Keep  the  patient  for  three  or  four  days  on  an  ordinary  diet,  con- 
taining moderate  amounts  of  carbohydrates — to  ascertain  the  amount  of  sugar 
excretion.  For  two  days  more  the  starches  are  gradually  cut  off.  Then  place 
him  on  the  following  non-carbohydrate  diet,  modified  according  to  the  patient's 
age  and  weight,  and  arranged  from  a  list  recommended  by  von  Xoorden : 

Breakfast:  7:30,  200  c.  c.  (5  vi)  of  tea  or  coffee:  150  grams  (5  iv)  of 
beefsteak,  mutton-chops  without  bone,  or  boiled  ham ;  one  or  two  eggs. 

Lunch:  12:30,  200  grams  (5  vi)  cold  roast  beef;  60  grams  (5  ij)  celery, 
fresh  cucumbers  or  tomatoes  with  vinegar,  olive  oil,  pepper  and  salt  to  taste; 
20  c.  c.  (3  v)  whisky  with  400  c.  c.  (3  xiij)  water;  60  c.  c.  (5  ij)  coffee,  with- 
out milk  or  sugar. 

Dinner:  6  P.  M.,  200  c.  c.  clear  bouillon;  250  grams  (5  viiss)  roast  beef; 
10  grams  (5  iiss)  butter;  80  grams  (5  ij)  green  salad,  with  10  grams  (5  iiss) 
vinegar  and  20  grams  (3  v)  olive  oil,  or  three  tablespoonfuls  of  some  well- 
cooked  green  vegetable,  three  sardines  a  1'huile;  20  c.  c.  (3  v)  whisky,  with 
400  c.  c.  (5  xiij)  water. 

Supper:  9  P.  M.,  two  eggs  (raw  or  cooked) ;  400  c.  c.  (5  xiij)  water. 

This  diet  contains  about  200  grams  of  albumin  and  about  135  grams  of 
fat.  The  effect  of  the  diet  on  the  sugar  excretion  is  remarkable.  In  many 
cases  there  is  an  entire  disappearance  of  the  sugar  from  the  urine  in  three  or 
four  days.  In  cases  in  which  the  urine  becomes  free  from,  sugar  gradually 
increasing  quantities  of  starch  up  to  20,  50,  and  100  grams  are  added  daily. 
White  bread  contains  fifty-five  per  cent,  of  starch.  The  effect  of  the  non-carbo- 
hydrate diet  is  to  improve  the  metabolic  functions /so  that  the  system  can 
warehouse  considerable  quantities  of  carbohydrates  without  sugar  appearing 
in  the  urine. 

In  cases  in  which  a  standard  diet  is  not  ordered  it  is  well  to  begin  cutting 
off  article  by  article  until  the  sugar  disappears  from  the  urine.  Within  a 
month  or  two  the  patient  may  be  allowed  a  more  liberal  diet,  testing  the  dif- 
ferent kinds  of  food. 

The  oatmeal  diet,  introduced  by  von  Noorden,  is  most  excellent,  particu- 
larly in  the  severer  forms.  Two  hundred  and  fifty  grams  of  oatmeal,  the  same 
amount  of  butter  and  the  whites  of  six  or  eight  eggs  constitute  the  day's  food. 
The  oatmeal  is  cooked  for  two  hours,  and  the  butter  and  albumin  stirred  in. 
It  may  be  taken  in  four  portions  during  the  day.  Coffee,  tea,  or  whisky  and 
water  may  be  taken  with  it. 

Fasting  Treatment. — From  Naunyn  to  Nellis  Foster  authors  have  recog- 
nized the  value  of  fasting  days,  but,  based  on  careful  and  elaborate  experiments, 
F.  M.  Allen  has  introduced  prolonged  fasting  followed  by  a  low  diet,  as  a  sys- 
tematic treatment.  Control  and  education  of  the  patient  are  essential  factors. 
So  far  the  reports  are  favorable:  of  42  patients  treated  by  Allen,  all  severe 
forms  and  many  young,  7  died ;  of  55  cases  treated  by  Joslin,  6  died.  Great  en- 


DIABETES   MELLITUS  437 

thusiasm  is  expressed.  "At  one  stroke  the  patient  is  delivered  from  medicines, 
patent  and  otherwise,  sham  kinds  of  treatment,  gluten  breads,  and  in  99  cases 
out  of  100  of  alkalis",  (Joslin).  As  a  rule  the  patients  stand  the  fasting  well. 
The  patient  is  put  to  bed,  the  treatment  explained,  a  note-book  and  a  diet- 
card  given,  and  he  is  taught  to  test  the  urine.  The  following  are  the  steps 
in  the  treatment,  which  I  take  from  the  papers  of  Allen  and  of  Joslin. 

(1)  Determine  the  glycosuria  and  ketonuria  on  an  ordinary  diet  for  two 
days. 

(2)  Fasting,  the  patient  should  be  in  bed  in  charge  of  an  intelligent  nurse; 
no  food  is  given  until  the  urine  is  sugar-free  and  acid-free.     The  time  ranges 
from  two  to  five  days.     Water  is  given  freely,  and  tea  and  coffee.     Alcohol  in 
small  doses  may  be  taken  every  three  hours.     If  after  two  days  fasting  the 
sugar  persists  give  300  c.c.  of  clear  meat  broth  in  divided  doses.     Once  the 
urine  is  sugar-free  and  acid-free  the  second  part  of  the  treatment  is  begun, 
to  determine  the  lowest  grade  of  nutrition  at  which  the  patient  can  live  in 
comfort  without  glycosuria  and  ketonuria.   •  Here  the  intelligent  co-operation 
of  the  patient  is  essential. 

(3)  Carbohydrate  tolerance.     When  a  24-hour  specimen  of  the  urine  is 
free,  give  150  grams  of  the  5  per  cent,  vegetables  (see  annexed  list)  and  con^ 
tinue  to  add  5  grams  of  carbohydrate  daily  up  to  20  grams ;  and  then  5  grams 
every  other  day,  passing  through  the  5,  10  and  15  per  cent,  vegetables,  and 
5,  10  and  15  per  cent,  fruits  (see  list).     Of  the  more  starchy  foods,  potatoes, 
or  oatmeal  may  be  used,  and  then  bread,  if  sugar  does  not  reappear. 

(4)  Protein  tolerance.     When  the  urine  is  sugar-free  for  two  days  add 
20  grams  of  protein — 3  eggs — and  then  five  grams  of  meat  daily  until  the 
patient  is  getting  1  gram  of  protein  per  kilogram  of  body  weight.     It  may  even 
be  raised  to  1.5  gram  per  kilo  of  weight. 

(5)  Fat  tolerance.    A  small  amount  of  fat  is  in  the  meat  and  eggs.    Later 
add  25  grams  daily  until  the  patient  ceases  to  lose  weight.     Bacon,  butter 
and  oil  may  be  used. 

(6)  Ee-appearance  of  sugar  calls  for  a  fasting  day  and  a  return  to  the  low 
diet. 

(7)  Days  of  Reduced  Diet.     In  every  case  it  is  well  to  restrict  the  diet  on 
one  day  a  week.     When  the  tolerance  is  less  than  20  grams  of  carbohydrates 
daily  the  patient  should  fast  one  day  in  seven.     In  mild  cases  the  carbohydrate 
should  be  reduced  to  one-half  or  one-third  of  the  usual  amount.     A  day  when 
only  eggs  and  5  per  cent,  vegetables  are  taken  is  an  advantage,  or  a  day  on 
which  nothing  but  broth  is  allowed.     The  lower  the  carbohydrate  tolerance 
the  greater  the  importance  of  a  fast  day. 

Each  case  must  be  dealt  with  separate^,  and  the  number  of  calories  given 
is  to  be  gauged  by  the  absence  of  glycosuria  and  ketonuria,  not  by  the'  state 
of  the  nutrition  which  has  often  to  be  kept  permanently  low.  Alkalis  may  be 
given  for  the  first  few  days  of  the  fast,  particularly  if  coma  seems  imminent, 
but  under  the  fasting  treatment  there  is  not  the  same  necessity  for  their 
administration.  The  patient  is  encouraged  to  feel  that  the  treatment  is  largely 
in  his  own  hands. 

MEDICINAL  TREATMENT. — Opium  alone  stands  the  test  of  experience  as 
a  remedy  capable  of  limiting  the  progress  of  the  disease.  Codeia  is  less  con- 
stipating than  morphia.  A  patient  may  begin  with  half  a  grain  three  times 


438 


DISEASES    OF    METABOLISM 


QUANTITY  OF  FOOD  Required  by  a  Severe  Diabetic  Patient  Weighing  60  kilograms. 

(Joslin.) 


FOOD 
Carbohydrate. 

Protein 

Fat 

Alcohol 


QUANTITY  GRAMS 

10 

75 

150 

15 


CALORIES  PSR  GRAM 
4 
4 
9 
7 


TOTAL  CALORIES 

40  ' 
300 
1,350 
105 

1,795 


STRICT  DIET.      (Foods  without  sugar.)     Meats,  Poultry,  Game,  Fish,  Clear  Soups, 
Gelatine,  Eggs,  Butter,  Olive  Oil,  Coffee,  Tea  and  Cracked  Cocoa. 


FOODS  ARRANGED  APPROXIMATELY  ACCORDING  TO  CONTENT  OF  CARBOHYDRATES 


5% 

+ 

10%    + 

15%    + 

20%    + 

Lettuce 

Cauliflower 

Onions 

Green  Peas 

Potatoes 

.A     Spinach 
1     Sauerkraut 
j     String  Beans 
CD     Celery 
<     Asparagus 

Tomatoes 
Rhubarb 
Egg  Plant 
Leeks 
Beet  Greens 

Squash 
Turnip 
Carrots 
Okra 
•    Mushrooms 

Artichakes 
Parsnips 
Canned  Lima 
Beans 

Shell  Beans 
Baked  Beans 
Green  Corn 
Boiled  Rice 
Boiled  Macaroni 

H     Cucumbers 

Water  Cress 

Beets 

U     Brussels  Sprouts 

Cabbage 

O     Sorrel 

Radishes 

U     Endive 

Pumpkin 

>     Dandelion  Greens 

Kohl-Rabi 

Swiss  Chard 

Sea  Kale 

Vegetable  Marrow 

Ripe  Olives  (20  per  cent,  fat) 
Grape  Fruit 

Lemons                         Apples 
Oranges                       Pears 

Plums 
Bananas 

(0 

Cranberries 

Apricots 

h 

Strawberries 

Blueberries 

Blackberries 

Cherries 

£ 

Gooseberries 

Currants 

Peaches 

Raspberries 

Pineapples 

Huckleberries 

Watermelon 

0j     Butternuts 

Brazil  Nuts 

Tllar-L-   \V<ilmit-a 

Almonds 

Walnnta    f~f?Y*tT  \ 

Peanuts 

L       rignolitlS 

3 

XjldGK     TV  nlllUlja 

Hickory 

amULS    \lilig.} 

Beechnuts 

40% 

Pecans 

Pistachios 

Filberts 

Pine  Nuts 

Chestnuts 

:J  a    Unsweetened  and  Unspiced  Pickle 

0    Clams 

Oysters 

g  J   Scallops 

Liver 

5  3   Fish  Roe 

30  grams  (1  oz.) 


PROTEIN 


FAT      CARBOHYDRATES       CALORIES 


CONTAIN    APPROXIMATELY 

GRAMS 

Oatmeal  

5 

2 

20 

110 

Meat  (uncooked)  

6 

2 

0 

40 

(cooked)  

8 

3 

o 

60 

Potato  

1 

0 

6 

25 

Bacon  

5 

15 

0 

155 

Cream,  40%  

1 

12 

1 

120 

20%  

1 

6 

1 

60 

Milk  

1 

1 

2 

20 

Bread  

3 

0 

18 

90 

Rice  

3 

0 

24 

110 

Butter  

0 

25 

0 

240 

Egg  (one)  

6 

5 

o 

75 

Biazil  Nuts  

5 

2D 

2 

210 

Oiange  (one)  
Grape  Fruit  (one)  
Vegetables  from  5-6%  groups.  .  .  . 

0 
0 
0.5 

0 
0 
0 

10 
10 
1 

40 

40 
6 

1  gram  protein  contains  4  calories. 

carbohydrate  contains  4  calories. 

fat  contains  9  calories. 
1      '        alcohol  contains  7  calories. 


1  kilogram  —  2.2  pounds. 
6.25  grams  protein  contain  1  gram  nitrogen. 
A  patient  "at  rest"  requires  30  calories   per  kilogram 
body  weight. 


CHART  XV.— DIABETIC  Foob  TABLES.     (JOSLIN.) 


DIABETES    IXSIPIDUS  439 

a  day,  which  may  be  gradually  increased  to  6  or  8  grains  in  the  twenty-four 
hours.  Xot  much  effect  is  noticed  unless  the  patient  is  on  a  rigid  diet.  When 
the  sugar  is  reduced  to  a  minimum,  or  is  absent,  the  opium  should  be  gradu- 
ally withdrawn.  The  patients  not  only  bear  well  these  large  doses  of  the  drug, 
but  they  stand  its  gradual  reduction. 

Glycerine  extracts  of  the  pancreas  and  glycolytic  ferments  have  been  used 
but  without  satisfactory  results.  The  worst  vagaries  of  hormonic  therapy  have 
of  late  been  in  connection  with  the  treatment  of  diabetes. 

Of  the  complications,  the  pruritus  and  eczema  are  best  treated  by  cooling 
lotions  of  boric  acid  or  hyposulphite  of  soda  (1  ounce;  water,  1  quart),  or 
the  use  of  ichthyol  and  lanolin  ointment. 

The  bowels  should  be  kept  open  and  the  urine  tested  at  short  intervals  for 
acetone  and  diacetic  acid — the  derivatives  of  /?-oxybutyric  acid. 

Coma. — The  presence  of  acetone  and  diacetic  acid  is  a  sign  for  reduction 
in  the  diet,  especially  carbohydrates  and  fats.  If  sugar  is  present  fasting  is 
usually  indicated.  If  signs  of  coma  are  present  fasting  should  be  begun  at 
once,  as  outlined  above.  The  use  of  bicarbonate  of  soda  in  very  large  doses 
is  recommended  to  neutralize  the  acid  intoxication.  It  may  be  used  intra- 
venously; as  much  as  80  grams  have  been  injected.  The  solution  used  for 
intravenous  injection  is  a  1  to  2  per  cent,  solution  of  sodium  bicarbonate  in 
normal  salt  solution,  made  from  freshly  distilled  water.  A  litre  may  be 
injected  slowly  into  a  vein  every  six  hours  in  desperate  cases.  In  the  less 
serious  cases  administration  should  be  by  mouth,  or  mouth  and  rectum.  The 
sodium  bicarbonate  should  be  pushed  until  the  urine  is  alkaline,  and  as  much 
as  100  grams  given  daily.  All  diabetics  with  a  marked  diacetic  acid  reaction 
in  the  urine  should  be  placed  on  sodium  bicarbonate.  By  the  "Murphy  drip" 
method  large  amounts  of  alkali  and  fluid  may  be  introduced.  The  bowels 
of  a  diabetic  patient  should  be  kept  acting  freely,  as  constipation  is  believed 
to  predispose  to  the  development  of  coma. 

HI.     DIABETES  INSIPIDUS 

Definition. — A  chronic  affection  characterized  by  the  passage  of  large 
quantities  of  normal  urine  of  low  specific  gravity. 

The  condition  is  to  be  distinguished  from  diuresis  or  polyuria,  which  is 
a  frequent  symptom  in  hysteria,  in  Bright's  disease,  and  occasionally  in  cere- 
bral or  other  affections.  Willis  in  1674  first  recognized  the  distinction  be- 
tween a  saccharine  and  non-saccharine  form  of  diabetes. 

Etiology.  — The  disease  is  most  common  in  young  persons.  Of  the  85  cases 
collected  by  Strauss,  9  were  under  five  years;  12  between  five  and  ten  years; 
36  between  ten  and  twenty-five  years.  Males  are  more  frequently  attacked 
than  females.  The  affection  may  be  congenital.  A  hereditary  tendency  has 
been  noted  in  many  instances,  the  most  extraordinary  of  which  has  been 
reported  by  Weil.  Of  91  members  in  four  generations,  23  had  persistent 
polyuria  without  any  deterioration  in  health. 

Clinical  Classification. — There  are  two  forms:  primary  or  idiopathic,  in 
which  there  is  no  evident  organic  basis,  and  secondary  or  symptomatic,  in 
which  there  is  evidence  of  disease  in  the  brain  or  elsewhere.  Of  9  cases  re- 
ported from  my  clinic  by  Futcher,  4  belonged  to  the  former  and  5  to  the 


440  DISEASES    OP   METABOLISM 

latter  group.  Trousseau  stated  that  the  parents  of  children  with  diabetes 
insipidus  frequently  have  glycosuria  or  albuminuria.  The  disease  has  fol- 
lowed rapidly  the  copious  drinking  of  cold  water,  or  a  drinking  bout,  or  has 
set  in  during  the  convalescence  from  an  acute  disease. 

The  secondary  or  symptomatic  form  is  almost  always  associated  with 
injury  or  disease  of  the  nervous  system,  traumatism  to  the  head  or,  in  some 
cases,  to  the  trunk.  It  occurs  in  30  per  cent,  of  the  cases,  according  to  Stoer- 
mer.  Tumors  of  the  brain,  lesions  of  the  medulla  and  of  the  hypophysis  (with 
dystrophia  adiposo-genitalis)  and  haemorrhage  are  found,  but  above  all  syphilis, 
present  in  5  of  9  cases  in  my  clinic.  The  lesion  is  usually  at  the  base,  and 
meningitic.  Hemianopsia  is  present  in  a  number  of  these  cases;  it  occurred 
in  2  of  Futcher's  series.  It  is  not  necessary  that  the  lesions  should  involve 
the  medulla.  It  has  been  met  with  in  spinal  cord  lesions.  In  tumors  and 
aneurisms  in  the  abdomen,  in  tuberculous  peritonitis,  and  in  carcinoma  there 
may  be  excessive  polyuria.  The  condition  of  the  pituitary  gland  should  be 
studied  in  the  so-called  idiopathic  cases. 

The  most  reasonable  view  of  the  production  of  the  polyuria  is  that  it 
results  from  a  vasomotor  disturbance  of  the  renal  vessels,  due  either  to  local 
irritation,  as  in  a  case  of  abdominal  tumor,  to  central  disturbance  in  cases 
of  brain-lesion,  or  to  functional  irritation  of  the  centre  in  the  medulla,  giving 
rise  to  continuous  renal  congestion.  In  some  cases  the  functional  capacity  of 
the  kidney  to  eliminate  salt  and  urea  is  diminished. 

Morbid  Anatomy. — There  are  no  constant  anatomical  lesions.  The  kid- 
neys have  been  found  enlarged  and  congested.  The  bladder  has  been  found 
hypertrophied.  Dilatation  of  the  ureters  and  of  the  pelves  of  the  kidneys  has 
been  present.  Death  has  not  infrequently  resulted  from  chronic  pulmonary 
disease.  Very  varied  lesions  have  been  met  with  in  the  nervous  system. 

Symptoms. — The  disease  may  come  on  rapidly,  as  after  a  fright  or  an 
injury;  more  commonly  it  is  gradual.  A  copious  secretion  of  urine,  with 
increased  thirst,  is  the  prominent  feature  of  the  disease.  The  amount  of 
urine  in  the  twenty-four  hours  may  range  from  20  to  40  pints,  or  even  more. 
Trousseau  speaks  of  a  patient  who  consumed  50  pints  of  fluid  daily  and 
passed  about  56  pints  of  urine  in  the  twenty-four  hours.  In  two  of  our 
cases  the  amount  passed  was  greater  than  that  ingested  in  liquids  and  solids. 
The  specific  gravity  is  low,  1.001  to  1.005;  the  color  is  extremely  pale  and 
watery.  The  total  solid  constituents  may  not  be  reduced.  The  amount  of 
urea  has  sometimes  been  found  in  excess.  Abnormal  ingredients  are  rare. 
Muscle-sugar,  inosite,  has  been  occasionally  found.  Albumin  is  rare.  Traces 
of  sugar  have  been  met  with.  Naturally,  with  the  passage  of  such  enormous 
quantities  of  urine,  there  is  a  proportionate  thirst,  and  the  only  inconvenience 
of  the  disease  is  the  necessity  for  frequent  micturition  and  frequent  drinking. 
The  appetite  is  usually  good,  rarely  excessive  as  in  diabetes  mellitus;  but 
Trousseau  tells  of  the  terror  inspired  by  one  of  his  patients  in  the  keepers  of 
those  eating-houses  where  bread  was  allowed  without  extra  charge  to  the 
extent  of  each  customer's  wishes,  and  says  that  the  man  was  paid  to  stay 
away.  The  patients  may  be  well  nourished  and  healthy-looking.  The  disease 
in  many  instances  does  not  appear  to  interfere  in  any  way  with  the  general 
health.  The  perspiration  is  naturally  slight  and  the  skin  is  harsh.  The 
amount  of  saliva  is  small  and  the  mouth  usually  dry.  The  tolerance  of  al- 


EICKETS  441 

eohol  is  remarkable,  and  patients  have  been  known  to  take  a  couple  of  pints 
of  brandy,  or  a  dozen  or  more  bottles  of  wine,  in  the  day. 

Course. — The  course  depends  entirely  upon  the  nature  of  the  primary 
trouble.  Sometimes,  with  organic  disease,  either  cerebral  or  abdominal,  the 
general  health  is  much  impaired;  the  patient  becomes  thin,  and  rapidly  loses 
strength.  In  the  essential  or  idiopathic  cases  good  health  may  be  maintained 
for  an  indefinite  period,  and  the  affection  has  been  known  to  persist  for  fifty 
years.  Death  usually  results  from  some  intercurrent  affection.  Spontaneous 
cure  may  take  place. 

Diagnosis. — A  low  specific  gravity  and  the  absence  of  sugar  in  the  urine 
distinguish  the  disease  from  diabetes  mellitus.  Hysterical  polyuria  may 
sometimes  simulate  it  very  closely.  The  amount  of  urine  excreted  may  be 
enormous,  and  only  the  development  of  other  hysterical  manifestations  may 
enable  the  diagnosis  to  be  made.  This  condition  is,  however,  always  transi- 
tory. 

In  certain  cases  of  chronic  Bright's  disease  a  very  large  amount  of  urine 
of  low  specific  gravity  may  be  passed,  but  the  presence  of  albumin  and  of 
hyaline  casts  and  the  existence  of  heightened  arterial  tension,  stiff  vessels, 
and  hypertrophied  left  ventricle  make  the  diagnosis  easy. 

Treatment. — The  treatment  is  not  satisfactory.  No  attempt  should  be 
made  to  reduce  the  amount  of  liquid.  In  some  cases  gradual  reduction  of  the 
protein  and  salt  intake  is  useful.  This  should  be  done  gradually.  Opium 
is  highly  recommended,  but  is  of  doubtful  service.  The  preparations  of  valer- 
ian may  be  tried;  either  the  powdered  root,  beginning  with  5  grains  (0.3  gm.) 
three  times  a  day,  and  increasing  until  2  drachms  (8  gm.)  are  taken  in  the  day, 
or  the  valerianate  of  zinc,  in  15-grain  (1  gm.)  doses,  gradually  increased  to 
30  grains  (2  gm.),  three  times  a  day.  Theocin  is  sometimes  useful  in  doses  of 
5  grains  (0.3  gm.)  three  times  a  day.  Antisyphilitic  treatment  should  be 
thoroughly  tried  in  patients  with  a  suspicious  history  or  a  positive  Wassermann 
reaction.  Electricity  may  be  used. 

IV.    RICKETS  (RHACHITIS) 

Definition. — A  disease  of  infants,  characterized  by  impaired  nutrition  of 
the  entire  body  and  alterations  in  the  growing  bones. 

Glisson,  the  anatomist  of  the  liver,  accurately  described  the  disease  in 
1650. "  The  name  is  derived  from  the  old  English  word  wricTcken,  to  twist, 
Glisson  suggested  to  change  the  name  to  rhachitis,  from  the  Greek,  />«£*£, 
the  spine,  as  it  was  one  of  the  first  parts  affected,  and  also  from  the  sim- 
ilarity in  the  sound  to  rickets. 

Etiology. — Eickets  exists  in  all  parts  of  the  world,  but  is  particularly 
marked  among  the  poor  of  the  larger  cities,  who  are  badly  housed  and  ill  fed. 
It  is  much  more  common  in  Europe  than  in  America.  In  Vienna  and  London 
from  50  to  80  per  cent,  of  all  the  children  at  the  clinics  present  signs  of 
rickets.  It  is  a  comparatively  rare  disease  in  Canada.  In  the  cities  of  the 
United  States  it  is  very  prevalent,  particularly  among  the  children  of  the 
negro  and  of  the  Italian  races.  Want  of  sunlight,  impure  air,  confinement, 
and  lack  of  exercise  are  important  factors.  Prolonged  lactation  and  suckling 
the  child  during  pregnancy  are  accessory  influences  in  some  cases. 
30 


442  DISEASES    OF   METABOLISM 

There  is  no  evidence  that  the  disease  is  hereditary. 

Rickets  affects  male  and  female  children  equally.  It  is  a  disease  of  the 
first  and  second  years  of  life,  rarely  beginning  before  the  sixth  month.  Jermer 
has  described  a  late  rickets,  in  which  form  the  disease  may  not  appear  until 
the  ninth  or  even  until  the  twelfth  year,  or  later  (the  osteomalacia  of  puberty). 
A  faulty  diet  is  a  factor  in  the  production  of  the  disease.  Like  scurvy,  rickets 
may  be  found  in  the  families  of  the  wealthy  under  perfect  hygienic  conditions. 
It  is  most  common  in  children  fed  on  condensed  milk,  the  various  proprietary 
foods,  cow's  milk,  and  food  rich  in  starches.  "An  analysis  of  the  foods  on 
which  rickets  is  most  frequently  and  certainly  produced  shows  invariably  a 
deficiency  in  two  of  the  chief  elements  so  plentiful  in  the  standard  food  of 
young  animals — namely,  animal  fat  and  proteid"  (Cheadle).  Bland  Button's 
interesting  experiment  with  the  lion's  cubs  at  the  "Zoo"  illustrates  this  point. 
When  milk,  pounded  bones,  and  cod-liver  oil  were  added  to  the  meat  diet  the 
rickets  disappeared,  and  for  the  first  time  in  the  history  of  the  society  the 
cubs  were  reared.  Associated  with  the  defect  in  food  is  a  lack  of  proper 
assimilation  of  the  lime  salts. 

Morbid  Anatomy. — Glisson's  original  description  of  the  external  appear- 
ances of  the  body  of  a  rickety  child  is  remarkably  complete;  indeed,  the  entire 
monograph  is  an  enduring  monument  to  the  skill  and  powers  of  observation 
of  this  great  physician.  "(1)  An  irregular  or  unusual  proportion  of  its 
parts.  The  head  is  evidently  larger  than  normal,  and  the  face  fatter  in  respect 
to  the  other  parts.  .  .  .  (2)  The  external  members  and  muscles  of  the 
whole  body  are  seen  to  be  delicate  and  emaciated,  as  though  consumed  by 
atrophy  or  tabes,  and  this  (so  far  as  we  know)  is  always  observed  in  those 
dead  of  this  affection.  (3)  The  whole  skin,  both  the  true  and  the  fleshy  and 
fatty  layers,  is  flaccid  and  rather  pendulous,  like  a  loose  glove,  so  that  you 
think  it  could  hold  much  more  flesh.  (4)  About  the  joints,  especially  in  the 
wrists  and  ankles,  there  are  certain  protuberances  which,  if  opened,  are  seen 
to  arise,  not  in  the  fleshy  or  membranous  parts,  but  in  the  ends  of  the  bones 
themselves,  especially  in  their  epiphyses.  (5)  The  joints,  limbs,  and  habitus 
of  all  these  external  parts  are  less  firm  and  rigid,  less  inflexible  than  in  other 
dead  bodies,  and  the  neck  scarcely  becomes  rigid,  a  frig  ore,  post  mortem,  or 
to  a  less  extent  than  in  other  cadavers.  (6)  The  chest  externally  is  thin  and 
much  narrowed,  especially  beneath  the  scapulae,  as  though  compressed  from 
the  sides,  and  the  sternum  accuminated  like  the  keel  of  a  ship  or  the  breast  of 
a  fowl.  (7)  The  ends  of  the  ribs  which  join  with  the  cartilages  of  the  sternum 
are  nodular,  like  the  ends  of  the  wrists  and  ankles." 

He  also  describes  the  prominent  abdomen,  the  enlarged  liver,  and  the 
changes  in  the  mesenteric  glands. 

The  bones  show  the  most  important  changes,  particularly  the  ends  of  the 
long  bones  and  the  ribs.  Between  the  shaft  and  epiphyses  a  slight  bulging 
is  apparent,  and  on  section  the  zone  of  proliferation,  which  normally  is 
represented  by  two  narrow  bands,  is  greatly  thickened,  bluish  in  color,  more 
irregular  in  outline,  and  very  much  softer.  The  width  of  this  cushion  of 
cartilage  varies  from  5  to  15  mm.  The  line  of  ossification  is  also  irregular 
and  more  spongy  and  vascular  than  normal.  The  periosteum  strips  off  very 
readily  from  the  shaft,  and  beneath  it  there  may 'be  a  spongy  tissue  not  unlike 
decalcified  bone.  The  practical  outcome  of  these  changes  is  an  imperfect 


RICKETS  443 

ossification,  so  that  the  bone  has  neither  the  natural  rate  of  growth  nor  the 
normal  firmness.  In  the  cranium  there  may  be  large  areas,  particularly  in 
the  parieto-occipital  region,  in  which  the  ossification  is  delayed,  producing 
the  so-called  cranio-tabes,  so  that  the  bone  yields  readily  to  pressure  with 
the  finger.  There  are  localized  depressed  spots  of  atrophy,  which,  on  pressure, 
give  the  so-called  "parchment  crackling."  Flat  hyperostoses  arise  on  the  outer 
table,  particularly  on  the  frontal  and  parietal  bones,  producing  the  character- 
istic broad  forehead  with  prominent  frontal  eminences,  a  condition  sometimes 
mistaken  for  hydrocephalus. 

Kassowitz,  the  leading  authority  on  the  anatomy  of  rickets,  regards  the 
hyperasmia  of  the  periosteum,  the  marrow,  the  cartilage,  and  of  the  bone  itself 
as  the  primary  lesion,  out  of  which  all  the  others  arise.  It  is  interesting  to 
note  that  Glisson  attributed  rickets  to  disturbed  nutrition  by  arterial  blood, 
and  believed  the  changes  in  the  long  bones  to  be  due  to  excessive  vascularity. 

The  chemical  analysis  of  rickety  bones  shows  a  marked  diminution  in  the 
calcareous  salts,  which  may  be  as  low  as  25  or  35  per  cent. 

The  liver  and  spleen  are  usually  enlarged,  and  sometimes  the  mesenteric 
glands.  As  Gee  suggested,  these  conditions  probably  result  from  the  general 
state  of  the  health  associated  with  rickets.  Beneke  has  described  a  relative 
increase  in  the  size  of  the  arteries  in  rickets. 

Symptoms. — The  disease  conies  on  insidiously  about  the  period  of  denti- 
tion, before  the  child  begins  to  walk.  Mild  grades  of  it  are  often  overlooked. 
In  many  cases  digestive  disturbances  precede  the  appearance  of  the  charac- 
teristic lesions,  and  the  nutrition  of  the  child  is  markedly  impaired.  There  is 
usually  slight  fever,  the  child  is  irritable  and  restless,  and  sleeps  badly.  If  he 
has  already  walked,  he  now  shows  a  marked  disinclination  to  do  so,  and  seems 
feeble  and  unsteady  in  his  gait.  Sir  William  Jenner  called  attention  to  three 
general  symptoms  of  great  importance:  First,  a  diffuse  soreness  of  the  body, 
so  that  the  child  cries  when  an  attempt  is  made  to  move  it,  and  prefers  to  keep 
perfectly  still.  Secondly,  slight  fever  (100°  to  101.5°  F.),  with  nocturnal 
restlessness,  and  a  tendency  to  throw  off  the  bedclothes.  This  may  be  partly 
due  to  the  fact  that  the  general  sensitiveness  is  such  that  even  their  weight 
may  be  distressing.  And,  thirdly,  profuse  sweating,  particularly  about  the 
head  and  neck,  so  that  in  the  morning  the  pillow  is  found  soaked  with  per- 
spiration. 

The  tissues  become  soft  and  flabby;  the  skin  is  pale;  and  from  a  healthy, 
plump  condition  the  child  becomes  puny  and  feeble.  The  muscular  weakness 
may  be  marked,  particularly  in  the  legs,  and  paralysis  may  be  suspected.  This 
so-called  pseudo-paresis  of  rickets  results  in  part  from  the  flabby,  weak  con- 
dition of  the  legs  and  in  part  from  the  pain  associated  with  the  movements. 
Coincident  with,  or  following  closely  upon,  the  general  symptoms  the  charac- 
teristic skeletal  lesions  are  observed.  Among  the  first  of  these  to  appear  are 
the  changes  in  the  ribs,  at  the  junction  of  the  bone  with  the  cartilage,  forming 
the  so-called  rickety  rosary.  When  the  child  is  thin  these  nodules  may  be 
distinctly  seen,  and  in  any  case  can  be  easily  made  out  by  touch.  They  very 
rarely  appear  before  the  third  month.  They  may  increase  in  size  up  to  the 
second  year,  and  are  rarely  seen  after  the  fifth  year.  The  thorax  undergoes 
important  changes.  Just  outside  the  junction  of  the  cartilages  with  the  ribs 
there  is  an  oblique,  shallow  depression  extending  downward  and  outward. 


444  DISEASES    OF    METABOLISM 

A  transverse  curve,  sometimes  called  Harrison's  groove,  passes  outward  from 
the  level  of  the  ensiform  cartilage  toward  the  axilla,  and  may  be  deepened  at 
each  inspiration.  It  is  rendered  more  prominent  by  the  eversion  and  promi- 
nence of  the  costal  border.  The  sternum  projects,  particularly  in  its  lower 
half,  forming  the  so-called  pigeon  or  chicken  breast.  These  changes  in  the 
thorax  are  not  peculiar,  however,  to  rickets,  and  are  much  more  commonly 
associated  with  hypertrophy  of  the  tonsils,  or  any  trouble  which  interferes 
witli  the  free  entrance  of  air  into  the  lungs.  The  spine  is  often  curved  pos- 
teriorly, the  processes  are  prominent;  lateral  curvature  is  not  so  common. 

The  head  of  a  rickety  child  usually  looks  large  in  proportion  both  to  the 
body  and  the  face,  and  the  fontanelles  remain  open  for  a  long  time.  There  are 
areas,  particularly  in  the  parieto-occipital  regions,  in  which  ossification  is 
imperfect;  and  the  bone  may  yield  to  the  pressure  of  the  finger,  a  condition 
to  which  the  term  cranio-tabes  has  been  given.  Coincidently  with  this,  hyper- 
plasia  proceeds  in  the  frontal  and  parietal  eminences,  so  that  these  portions  of 
the  skull  increase  in  thickness,  and  may  form  irregular  bosses.  In  one  type 
the  skull  may  be  large  and  elongated,  with  the  top  considerably  flattened.  In 
another,  and  perhaps  more  common,  case  the  shape  of  the  skull,  when  seen 
from  above,  is  rectangular — the  caput  quadratum.  The  skull  looks  large  in 
proportion  to  the  face.  The  forehead  is  broad  and  square,  and  the  frontal 
eminences  marked.  The  anterior  fontanelle  is  late  in  closing,  and  may  remain 
open  until  the  third  or  fourth  year.  The  skin  is  thin,  the  veins  are  full  and 
prominent,  and  the  hair  is  often  rubbed  from  the  back  of  the  skull. 

On  placing  the  ear  over  the  anterior  fontanelle,  or  in  the  temporal  region, 
a  systolic  murmur  may  frequently  be  heard.  This  condition,,  first  described 
by  John  D.  Fisher,  of  Boston,  in  1833,  is  heard  with  the  greatest  frequency 
in  rickets,  but  its  presence  and  persistence  in  perfectly  healthy  infants  have 
been  amply  demonstrated.  The  murmur  is  rarely  present  after  the  fifth  year. 
A  knowledge  of  the  existence  of  this  systolic  brain  murmur  may  prevent  errors. 
A  case  has  been  reported  as  an  instance  of  tumor  of  the  brain. 

Changes  occur  in  the  bones  of  the  face,  chiefly  'in  the  maxilla?,  which  are 
reduced  in  size.  The  normal  process  of  dentition  is  much  disturbed;  indeed, 
late  teething  is  one  of  the  marked  features  in  rickets.  The  teeth  which  appear 
may  be  small  and  badly  formed. 

In  the  upper  limbs  changes  in  the  scapulae  are  not  common.  The  clavicle 
may  be  thickened  at  the  sternal  end,  and  there  may  be  thickening  near  the 
attachment  of  the  sterno-cleido  muscle.  The  most  noticeable  changes  are 
at  the  lower  ends  of  the  radius  and  ulna.  The  enlargement  is  at  the  junction- 
area  of  the  shaft  and  epiphysis.  Less  evident  enlargements  may  occur  at  the 
lower  end  of  the  humerus.  In  severe  cases  the  natural  shape  of  the  bones 
of  the  arm  may  be  much  altered,  since  they  have  had  to  support  the  weight  of 
the  child  in  crawling  on  the  floor,  The  changes  in  the  pelvis  are  of  special 
importance,  particularly  in  female  children,  as  in  extreme  cases  they  lead  to 
great  deformity,  with  narrowing.  In  the  legs,  the  lower  end  of  the  tibia  first 
becomes  enlarged;  and  in  slight  cases  it  may  alone  be  affected.  In  the  severe 
forms  the  upper  end  of  the  bone,  the  corresponding  parts  of  the  fibula,  and 
the  lower  end  of  the  femur  become  greatly  thickened.  If  the  child  walks, 
slight  bowing  of  the  tibia?  inevitably  results.  In  more  advanced  cases  the 
tibiae,  and  even  the  femora,  may  be  arched  forward.  In  other  instances  the 


RICKETS  445 

condition  of  knock-knee  occurs.  Unquestionably  the  chief  cause  of  these 
deformities  is  the  weight  of  the  body  in  walking,  but  muscular  action  takes 
part  in  it.  The  green-stick  fracture  is  not  uncommon  in  the  soft  bones  of 
rickets. 

These  changes  in  the  skeleton  proceed  slowly,  and  the  general  symptoms 
vary  a  good  deal  with  their  progress.  The  child  becomes  more  or  less  ema- 
ciated, though  "fat  rickets"  is  by  no  means  uncommon,  and  a  child  may  be 
well  nourished  but  "pasty"  and  flabby.  Fever  is  not  constant,  but  in  actively 
progressing  changes  in  the  bone  there  is  usually  a  slight  pyrexia.  The  abdo- 
men is  large,  "pot-bellied,"  due  partly  to  flatulent  distention,  partly  to  en- 
largement of  the  liver,  and  in  severe  cases  to  diminution  of  the  volume  of 
the  thorax.  The  spleen  is  often  enlarged  and  readily  palpable.  The  urine  is 
stated  to  contain  an  excess  of  lime  salts.  There  is  usually  slight  anaemia,  the 
hemoglobin  is  absolutely  and  relatively  decreased;  a  leucocytosis  may  or  may 
not  be  present;  it  is  more  common  with  enlargement  of  the  spleen  (Morse). 
Many  rickety  children  show  marked  nervous  symptoms;  irritability,  peevish- 
ness, and  sleeplessness  are  constantly  present.  Jenner  called  attention  to  the 
close  relationship  which  existed  between  rickets  and  infantile  convulsions, 
particularly  to  the  fits  which-  occur  after  the  sixth  month.  Tetany  is  by  no 
means  uncommon.  It  involves  most  frequently  the  arms  and  hands;  oc- 
casionally the  legs  as  well.  Laryngismus  stridulus  is  a  common  complication, 
and  though  not,  as  some  state,  invariably  associated,  yet  it  is  certainly  much 
more  frequent  in  rickety  than  in  other  children.  Severe  rickets  interferes 
seriously  with  the  growth  of  a  child.  Extreme  examples  of  rickety  dwarfs 
are  not  uncommon.  Acute  rickets,  so-called,  is  in  reality  a  manifestation  of 
scurvy  and  will  be  described  with  that  disease.  '  . 

Prognosis. — The  disease  is  never  in  itself  fatal,  but  the  condition  of  the 
child  is  such  that  it  is  readily  carried  off  by  intercurrent  affections,  particu- 
larly those  of  the  respiratory  organs.  Spasm  of  the  larynx  and  convulsions 
occasionally  cause  death.  In  females  the  deformity  of  the  pelvis  is  serious, 
as  it  may  lead  to  difficulties  in  parturition. 

Treatment. — The  better  the  condition  of  the  mother  during  pregnancy  the 
less  likelihood  is  there  of  the  development  of  rickets  in  the  child.  Rapidly 
repeated  pregnancies  and  suckling  of  a  child  during  pregnancy  seem  impor- 
tant factors  in  the  production  of  the  disease.  Of  the  general  treatment,  at- 
tention to  the  feeding  of  the  child  is  the  first  consideration.  If  the  mother 
is  unhealthy,  or  cannot  from  any  cause  nurse  the  child,  a  suitable  wet-nurse 
should  be  provided,  or  the  child  must  be  artificially  fed,  in  which  case  cow's 
milk,  diluted  according  to  the  age  of  the  child,  should  constitute  the  chief  food. 
Care  should  be  taken  to  examine  the  condition  of.  the  stools,  and  if  curds  are 
present  the  child  is  taking  too  much,  or  it  is  not  sufficiently  diluted.  Barley- 
water  and  carefully  strained  and  well-boiled  oatmeal  gruel  form  excellent  addi- 
tions to  the  milk. 

The  child  should  be  warmly  clad  and  should  be  in  the  fresh  air  and  sun- 
shine the  greater  part  of  the  day.  The  child  should  be  bathed  daily  in  warm 
water.  Careful  friction  with  sweet  oil  is  very  advantageous,  and,  if  properly 
performed,  allays  rather  than  aggravates  the  sensitiveness.  .  Special  care  should 
be  taken  to  prevent  deformity.  The  child  should  not  be  allowed  to  walk,  and 
for  this  purpose  splints  applied  so  as  to  extend  beyond  the  feet  are  very  ef- 


446  DISEASES    OF   METABOLISM 

fective.  Of  medicines,  phosphorus  has  been  warmly  recommended  by  Kasso- 
witz,  and  its  use  is  also  advised  by  Jacobi.  The  child  may  be  given  gr.  1/120 
two  or  three  times  a  day,  dissolved  in  olive  oil.  The  best  preparation  in  such 
cases  is  the  elixir  phosphori,  six  to  ten  or  twelve  minims  three  times  a  day 
(Jacobi).  Cod-liver  oil,  in  doses  of  from  a  half  to  one  teaspoonful,  is  very 
advantageous.  The  syrup  of  the  iodide  of  iron  may  be  given  with  the  oil.  The 
digestive  disturbances,  together  with  the  respiratory  and  nervous  complica- 
tions, should  receive  appropriate  treatment. 


V.    SCURVY 

(Scorbutus) 

Definition. — A  disorder  of  metabolism  of  unknown  origin,  characterized  by 
great  debility,  with  anemia,  a  spongy  condition  of  the  gums,  and  a  tendency 
to  hemorrhages. 

Etiology. — The  disease  has  been  known  from  the  earliest  times',  and  has 
prevailed  particularly  in  armies  in  the  field  anfl  among  sailors  on  long  voy- 
ages. It  has  been  well  called  "the  calamity  of  sailors." 

From  the  early  part  of  the  last  century,  owing  largely  to  the  efforts  of 
Liud  and  to  a  knowledge  of  the  conditions  upon  which  the  disease  depends, 
scurvy  has  gradually  disappeared  from  the  naval  service.  In  the  mercantile 
marine  cases  still  occasionally  occur,  owing  to  the  lack  of  proper  and  suitable 
food. 

In  parts  of  Eussia  scurvy  is  endemic.  In  the  United  States  scurvy  is  not  a 
very  rare  disease.  To  the  hospitals  in  the  seaport  towns  sailors  are  now  and 
then  admitted  with  it.  In  large  almshouses  outbreaks  occasionally  occur.  A 
very  great  increase  of  foreign  population  of  a  low  grade  has  in  certain  districts 
made  the  disease  not  at  all  uncommon.  In  the  mining  districts  of  Pennsyl- 
vania the  Hungarian,  Bohemian,  and  Italian  settlers  are  not  infrequently 
attacked.  McGrew  has  reported  42  cases  in  Chicago,  limited  entirely  to  Poles. 
He  ascertained  that  in  a  large  proportion  of  the  cases  the  diet  was  composed 
of  bread,  strong  coffee,  and  meat.  Occasionally  one  meets  with  scurvy  among 
quite  well-to-do  people.  Some  years  ago  scurvy  was  not  infrequent  in  the 
large  lumbering  camps  in  the  Ottawa  Valley.  In  Great  Britain  and  Ireland 
it  has  become  very  rare;  only  302  cases  were  admitted  to  the  Seaman's  Hos- 
pital in  the  twenty-two  years  ending  1896  (Johnson  Smith).  It  is  not  un- 
common in  the  South  African  natives. 

The  cause  is  unknown;  there  are  three  theories  of  the  disease: 

(a)  That  it  is  the  result  of  an  absence  of  those  ingredients  in  the  food 
which  are  supplied  by  fresh  vegetables.  What  these  constituents  are  has  not 
yet  been  definitely  determined,  whether  the  potassium  salts  or  the  absence  of 
the  organic  salts  present  in  fruits  and  vegetables.  Wright  has  brought  forward 
evidence  which  suggests  that  it  may  be  an  acid  intoxication.  That  it  is  not 
due  to  an  absence  of  fresh  vegetables  or  the  salts  of  fruits  and  vegetables  seems 
to  have  been  settled  by  Nansen  and  his  comrades,  who,  living  for  months  under 
the  most  unfavorable  hygienic  surroundings,  but  eating  fresh  bear's  meat  and 
bear's  blood,  escaped  scurvy. 


SCUEVY  447 

(•&)  That  it  is  due  to  toxic  materials  in  the  food — some  unknown  organic 
poison  the  product  of  decomposition.  Hoist  and  Frb'lich  oppose  this  toxic  view, 
and  maintain  that  the  disease  is  due  to  the  lack  in  the  food  of  nutrient  con- 
stituents which  so  far  have  not  been  identified. 

(c)  In  opposition  to  these  chemical  views  it  is  urged  that  the  disease 
depends  upon  a  specific  (as  yet  unknown)  micro-organism. 

Other  factors  play  an  important  part,  particularly  physical  and  moral 
influences — overcrowding,  dwelling  in  cold,  damp  quarters,  and  prolonged 
fatigue  under  depressing  influences,  as  during  the  retreat  of  an  army.  Among 
prisoners,  mental  depression  plays  an  important  role.  It  is  stated  that  epi- 
demics of  the  disease  have  broken  out  in  the  French  convict  ships  en  route 
to  New  Caledonia  even  when  the  diet  was  amply  sufficient.  Nostalgia  is  some- 
times an  important  element.  It  is  an  interesting  fact  that  prolonged  starva- 
tion in  itself  does  not  necessarily  cause  scurvy.  Not  one  of  the  professional 
fasters  of  late  years  has  displayed  any  scorbutic  symptom.  The  disease  attacks 
all  ages,  but  the  old  are  more  susceptible  to  it.  Sex  has  no  special  influence, 
but  during  the  siege  of  Paris  it  was  noted  that  the  males  attacked  were  greatly 
in  excess  of  the  females. 

Morbid  Anatomy. — The  anatomical  changes  are  marked,  though  by  no 
means  specific,  and  are  chiefly  those  associated  with  hemorrhage.  The  blood 
is  dark  and  fluid.  The  microscopic  alterations  are  those  of  a  severe  anaemia, 
without  leucocytosis.  The  skin  shows  the  ecchymoses  evident  during  life. 
There  are  haemorrhages  into  the  muscles,  and  occasionally  about  or  even  into 
the  joints.  Haemorrhages  occur  in  the  internal  organs,  particularly  on  the 
serous  membranes  and  in  the  kidneys  and  bladder.  The  gums  are  swollen 
and  sometimes  ulcerated,  so  that  in  advanced  cases  the  teeth  are  loose  and 
have  even  fallen  out.  Ulcers  are  occasionally  met  with  in  the  ileum  and  colon. 
Haemorrhages  into  the  mucous  membranes  are  extremely  common.  The  spleen 
is  enlarged  and  soft.  Parenchymatous  changes  are  constant  in  the  liver,  kid- 
neys, and  heart. 

Symptoms. — The  disease  is  insidious  in  its  onset.  Early  symptoms  are 
loss  in  weight,  progressive  weakness,  and  pallor.  Very  soon  the  gums  are 
noticed  to  be  swollen  and  spongy,  to  bleed  easily,  and  in  extreme  cases  to  pre- 
sent a  fungous  appearance.  These  changes,  regarded  as  characteristic,  are 
sometimes  absent.  The  teeth  may  become  loose  and  even  fall  out.  Actual 
necrosis  of  the  jaw  is  not  common.  The  breath  is  excessively  foul.  The 
tongue  is  swollen,  but  may  be  red  and  not  much  furred.  The  salivary  glands 
are  occasionally  enlarged.  Haemorrhages  beneath  the  mucous  membranes  of 
the  mouth  are  common.  The  skin  becomes  dry  and  rough,  and  ecchymoses 
soon  appear,  first  on  the  legs  and  then  on  the  arms  and  trunk,  and  particularly 
into  and  about  the  hair-follicles.  They  are  petechial,  but  may  become  larger, 
and  when  subcutaneous  may  cause  distinct  swellings.  In  severe  cases,  par- 
ticularly in  the  legs,  there  may  be  effusion  between  the  periosteum  and  the 
bone,  forming  irregular  nodes,  which  may  break  down  and  form  foul-looking 
sores.  The  slightest  bruise  or  injury  causes  haemorrhages  into  the  injured 
part.  (Edema  about  the  ankles  is  common.  The  "scurvy  sclerosis,"  seen 
oftenest  in  the  legs,  is  a  remarkable  infiltration  of  the  subcutaneous  tissues  and 
muscles,  forming  a  brawny  induration,  the  skin  over  which  may  be  blood- 
stained. Haemorrhages  from  the  mucous  membranes  are  less  constant  symp- 


448  DISEASES    OF    METABOLISM 

toms;  epistaxis  is,  however,  frequent.  Haemoptysis  and  haamatemesis  are 
uncommon.  Hsematuria  and  bleeding  from  the  bowels  may  be  present  in 
very  severe  cases. 

Palpitation  of  the  heart  and  feebleness  and  irregularity  of  the  impulse 
are  prominent  symptoms.  A  haemic  murmur  can  usually  be  heard  at  the 
base.  Hsemorrhagic  infarction  of  the  lungs  and  spleen  has  been  described. 
Respiratory  symptoms  are  not  common.  The  appetite  is  impaired,  and  owing 
to  the  soreness  of  the  gums  the  patient  is  unable  to  chew  the  food.  Constipa- 
tion is  more  frequent  than  diarrhoea.  The  urine  is  often  albuminous.  The 
changes  in  its  composition  are  not  constant;  the  specific  gravity  is  high;  the 
color  is  deeper.  The  statements  with  reference  to  the  inorganic  constituents 
are  contradictory.  Some  authorities  have  found  the  phosphates  and  potassium 
salts  to  be  deficient;  others  hold  that  they  are  increased. 

There  are  mental  depression,  indifference,  in  some  cases  headache,  and 
in  the  later  stages  delirium.  Cases  of  convulsions,  or  hemiplegia,  and  of  men- 
ingeal  haemorrhage  have  been  described.  Eemarkable  ocular  symptoms  are 
occasionally  met  with,  such  as  night-blindness  or  day-blindness. 

In  advanced  cases  necrosis  df  the  bones  may  occur,  and  in  young  persons 
even  separation  of  the  epiphyses.  There  are  instances  in  which  the  cartilages 
have  separated  from  the  sternum.  The  callus  of  a  recently  repaired  fracture 
has  been  known  to  undergo  destruction.  Fever  is  not  present,  except  in  the 
later  stages,  or  when  secondary  inflammations  in  the  internal  organs  appear. 
The  temperature  may,  indeed,  be  sometimes  below  normal.  Acute  arthritis 
is  an  occasional  complication. 

Diagnosis. — No  difficulty  is  met  in  the  recognition  of  scurvy  when  a  num- 
ber of  persons  are  affected  together.  In  isolated  cases,  however,  the  disease 
is  distinguished  with  difficulty  from  certain  forms  of  purpura.  The  associa- 
tion with  manifest  insufficiency  in  diet,  and  the  rapid  amelioration  with  suit- 
able food,  are  points  by  which  the  diagnosis  can  be  readily  settled. 

Prognosis. — The  outlook  is  good,  unless  the  disease  is  far  advanced  and  the 
conditions  persist  which  lead  to  its  occurrence.  Th'e  mortality  now  is  rarely 
great.  Death  results  from  gradual  heart-failure,  occasionally  from  sudden 
syncope.  Meningeal  hemorrhage,  extravasation  into  the  serous  cavities,  en- 
tero-colitis,  and  other  intercurrent  affections  may  prove  fatal. 

Prophylaxis. — The  regulations  of  the  Board  of  Trade  require  that  a  suffi- 
cient supply  of  antiscorbutic  articles  of  diet  be  taken  on  each  ship;  so  that 
now,  except  as  the  result  of  accident,  the  occurrence  of  scurvy  is  rare  in 
sailors. 

Treatment. — The  juice  of  two  or  three  lemons  daily  and  a  diet  of  plenty 
of  meat  and  fresh  vegetables  suffice  to  cure  all  cases  of  scurvy,  unless  far 
advanced.  When  the  stomach  is  much  disordered,  small  quantities  of  scraped 
meat  and  milk  should  be  given  at  short  intervals,  and  the  lemon-juice  in  grad- 
ually increasing  quantities.  As  the  patient  gains  in  strength  the  diet  may 
be  more  liberal,  and  he  may  eat  freely  of  potatoes,  cabbage,  water-cresses,  and 
lettuce.  The  stomatitis  is  the  symptom  which  causes  the  greatest  distress. 
A  permanganate  of  potash  or  dilute  carbolic  acid  solution  forms  the  best 
mouth-wash.  Penciling  the  swollen  gums  with  a  tolerably  strong  solution 
of  nitrate  of  silver  is  very  useful.  The  solution  is  better  than  the  solid  stick, 
as  it  reaches  to  the  crevices  between  the  granulations.  The  constipation  which 


SCUEVY  440 

is  so  common  is  best  treated  with  large  enemata.    For  other  conditions,  such 
as  haemorrhages  and  ulcerations,  suitable  measures  must  be  employed. 

INFANTILE    SCUEVY 
(Barlow's  Disease) 

A  special  form  of  scurvy  occurs  in  children  in  consequence  of  imperfect 
food  supply. 

W.  B.  Cheadle  and  Gee,  in  London,  described  in  very  young  children 
a  cachexia  associated  with  hemorrhage.  Cheadle  regarded  the  cases  as  scurvy 
ingrafted  on  a  rickety  stock.  Gee  called  his  cases  periosteal  cachexia.  Cases 
had  previously  been  regarded  as  acute  rickets. 

A  few  years  later  Barlow  made  an  exhaustive  study  of  the  condition  with 
careful  anatomical  observations.  The  affection  is  now  recognized  as  infantile 
scurvy,  and  is  called  Barlow's  disease.  The  American  Pasdiatric  Society  col- 
lected 379  cases  in  1898  in  the  United  States.  Of  these,  the  hygienic  sur- 
roundings were  good  in  303.  A  majority  of  the  patients  were  under  twelve 
months.  The  proprietary  foods,  particularly  malted  milk  and  condensed  milk, 
seem  to  be  the  most  important  factors  in  producing  the  disease.  There  are 
instances  in  which  it  has  developed  in  breast-fed  infants,  and  in  others  fed 
on  the  carefully  prepared  milk  of  the  Walker-Gordon  laboratories. 

The  following  clinical  summary  is  taken  from  Barlow's  description: 

"So  long  as  it  is  left  alone  the  child  is  tolerably  quiet;  the  lower  limbs 
are  kept  drawn  up  and  still;  but  when  placed  in  its  bath  or  otherwise  moved 
there  is  continuous  crying,  and  it  soon  becomes  clear  that  the  pain  is  con- 
nected with  the  lower  limbs.  At  this  period  the  upper  limbs  may  be  touched 
with  impunity,  but  any  attempt  to  move  the  legs  or  thighs  gives  rise  to 
screams.  Next,  some  obscure  swelling  may  be  detected,  first  on  one  lower 
limb,  then  on  the  other,  though  it  is  not  absolutely  symmetrical.  .  .  .  The 
swelling  is  ill-defined,  but  is  suggestive  of  thickening  round  the  shafts  of  the 
bones,  beginning  above  the  epiphyseal  junctions.  Gradually  the  bulk  of  the 
limbs  affected  becomes  visibly  increased.  .  .  .  The  position  of  the  limbs  be- 
comes somewhat  different  from  what  it  was  at  the  outset.  Instead  of  being 
flexed  they  lie  everted  and  immobile,  in  'a  state  of  pseudo-paralysis.  .  .  . 
About  this  time,  if  not  before,  great  weakness  of  the  back  becomes  manifest. 
A  little  swelling  of  one  or  both  scapula?  may  appear,  and  the  upper  limbs 
may  show  changes.  These  are  rarely  so  considerable  as  the  alterations  in 
the  lower  limbs.  There  may  be  swelling  above  the  wrists,  extending  for  a  short 
distance  up  the  forearm,  and  some  swelling  in  the  neighborhood  of  the  epi- 
physes  of  the  humerus.  There  is  symmetry  of  lesions,  but  it  is  not  absolute; 
and  the  limb  affection  is  generally  consecutive,  though  the  involvement  of  one 
limb  follows  very  close  upon  another.  The  joints  are  free.  In  severe  cases 
another  symptom  may  now  be  found — namely,  crepitus  in  the  regions  adjacent 
to. the  junctions  of  the  shafts  with  the  epiphyses.  The  upper  and  lower  ex- 
tremities of  the  femur,  and  the  upper  extremity  of  the  tibia,  are  the  common 
sites  of  such  fractures;  but  the  upper  end  of  the  humerus  may  also  be  so 
affected.  ...  A  very  startling  appearance  may  be  observed  at  this  period 
in  the  front  of  the  chest.  The  sternum,  with  the  adjacent  costal  cartilages 


450  DISEASES    OF    METABOLISM 

and  a  small  portion  of  the  contiguous  ribs,  seems  to  have  sunk  bodily  back, 
en  bloc,  as  though  it  had  been  subjected  to  some  violence  which  had  fractured 
several  ribs  in  the  front  and  driven  them  back.  Occasionally  thickenings  of 
varying  extent  may  be  found  on  the  exterior  of  the  vault  of  the  skull,  or 
even  on  some  of  the  bones  of  the  face.  .  .  .  Here  also  must  be  mentioned  a 
remarkable  eye  phenomenon.  There  develops  a  rather  sudden  proptosis  of  one 
eyeball,  with  puffiness  and  very  slight  staining  of  the  upper  lid.  Within  a 
day  or  two  the  other  eye  presents  similar  appearances,  though  they  may  be  of 
less  severity.  The  ocular  conjunctiva  may  show  a  little  ecchymosis,  or  may 
be  quite  free.  With  respect  to  the  constitutional  symptoms  accompanying  the 
above  series  of  events  the  most  important  feature  is  the  profound  anaemia 
which  is  developed.  .  .  .  The  anaemia  is  proportional  to  the  amount  of 
limb  involvement.  As  the  case  proceeds  there  is  a  certain  earthy-colored  or 
sallow  tint,  which  is  noteworthy  in  severe  cases,  and  when  once  this  is  estab- 
lished bruise-like  ecchymoses  may  appear,  and  more  rarely  small  purpura. 
Emaciation  is  not  a  marked  feature,  but  asthenia  is  extreme  and  suggestive  of 
muscular  failure.  The  temperature  is  very  erratic ;  it  is  often  raised  for  a  day 
or  two,  when  successive  limbs  are  involved,  especially  during  the  tense  stage, 
but  is  rarely  above  101°  or  102°  F.  At  other  times  it  may  be  normal  or  sub- 
normal." If  the  teeth  have  appeared  the  gums  may  be  spongy. 

In  young  children  with  difficulty  in  moving  the  lower  limbs,  or  in  whom 
paralysis  is  suspected,  the  condition  should  always  be  looked  for.  What  is 
known  sometimes  as  Parrot's  disease,  or  syphilitic  pseudo-paralysis,  may  be 
confounded  with  it.  In  it  the  loss  of  motion  is  more  or  less  sudden  in  the 
upper  or  lower  limbs,  or  in  both,  due  to  a  solution  of  continuity  and  separa- 
tion of  the  cartilage  at  the  end  of  the  diaphysis.  There  are  usually  crepita- 
tion and  much  pain  on  movement. 

The  essential  lesion  is  a  subperiosteal  blood  extravasation,  which  causes  the 
thickening  and  tenderness  in  the  shafts  of  the  bones.  In  some  instances  there 
is  haemorrhage  in  the  intramuscular  tissue. 

The  prophylaxis  is  most  important.  The  various  proprietary  forms  of  con- 
densed milk  and  preserved  foods  for  infants  should  not  be  used.  The  fresh 
cow's  milk  should  be  substituted,  and  a  teaspoonful  of  meat-juice  or  gravy 
may  be  given  with  a  little  mashed  potato.  Orange-juice  or  lemon-juice  should 
be  given  three  or  four  times  a  day.'  Recovery  is  usually  prompt  and  satis- 
factory. 

VI.     OBESITY 

Definition. — A  disorder  of  metabolism  characterized  by  excessive  deposit 
of  fat  in  the  body. 

Etiology. — Corpulence,  an  overgrowth  of  the  bodily  fat,  an  "oily  dropsy," 
as  Byron  termed  it,  is  a  common  condition  which  may  be  a  source  of  great 
bodily  and  mental  distress.  Primarily  it  results  from  inadequate  oxidation 
of  the  food  stuffs,  associated  either  with  excessive  absorption  of  the  materials 
which  produce  fat,  or  with  incomplete  combustion.  Both  factois  probably 
take  part.  It  is  not  always  due  to  excessive  intake  of  food;  many  stout  per- 
sons are  light  eaters.  On  the  other  hand,  there  are  cases  in  which  the  increase 
in  weight  is  directly  due  to  an  excessive  consumption  of  food.  There  is  a 


OBESITY  451 

marked  hereditary  tendency.  Certain  races  are  prone  to  obesity,  and  women 
are  more  often  affected  than  men. 

Fat  metabolism  is  as  yet  imperfectly  understood;  it  is  under  the  control 
of  the  internal  secretions.  We  see  the  deposition  of  fat  in  connection  with 
many  processes  with  which  the  internal  secretions  are  concerned.  At  puberty 
there  is  a  great  increase  in  the  fat  deposits,  particularly  of  the  skin.  Follow- 
ing castration  there  is  an  increase  in  the  amount  of  subcutaneous  fat.  Eunuchs 
as  a  rule  are  very  stout.  At  the  menopause  increase  in  weight  is  common, 
and  during  both  pregnancy  and  lactation  the  subcutaneous  fat  may  be  greatly 
increased. 

In  only  one  point  have  we  positive  knowledge  as  to  the  internal  secretions 
controlling  fat  metabolism.  It  has  been  known  that  tumors  of  the  pituitary 
gland  or  in  its  neighborhood  may  be  associated  with  general  adiposity  and 
sexual  infantilism  (Frolich's  syndrome).  The  studies  of  Gushing  and  his 
students  have  shown  that  the  pituitary  body  controls  carbohydrate  metabolism, 
and  that  with  the  removal  of  the  posterior  lobe  there  is  a  great  increase  in  the 
body  weight.  There  seems  to  be  a  definite  hypophysial  syndrome  of  increased 
tolerance  for  carbohydrates  with  adiposity.  It  is  not  unlikely  that  many  of  the 
cases  of  extreme  obesity  in  young  persons  are  due  to  hypopituitarism.  The 
remarkable  acute  obesity,  in  which  as  much  as  70  pounds  in  weight  may  be 
gained  in  six  months,  probably  depends  upon  perversions  of  some  internal 
secretions. 

Symptoms. — Inconvenience  caused  by  the  bulk,  and  loss  of  good  looks 
in  women,  are  the  features  for  which  we  are  usually  consulted.  While  fat  is 
no  sign  of  health,  the  great  bulk  may  be  consistent  with  remarkable  vigor  and 
activity.  Shortness  of  breath,  embarrassed  cardiac  action,  difficulty  in  walk- 
ing are  the  most  common  complaints.  In  children  obesity  is  very  often  asso- 
ciated with  careless  habits  in  eating  and  lack  of  proper  control  on  the  part 
of  parents.  The  condition  is  increasing,  particularly  in  the  United  States, 
where  one  sees  an  extraordinary  number  of  very  stout  children.  A  remarkable 
phenomenon  associated  with  excessive  fat  in  young  persons  is  an  uncontrolla- 
ble tendency  to  sleep — like  the  fat  boy  in  Pickwick.  It  is  quite  possible  that 
this  narcolepsy  is  also  a  manifestation  of  disturbed  internal  secretions. 

Treatment. — In  women  obesity  is  a  very  distressing  state,  accompanied 
with  all  sorts  of  inconveniences  and  discomforts.  With  a  marked  hereditary 
tendency  not  much  can  be  expected.  The  famous  George  Cheyne,  who  was 
a  man  of  enormous  bulk,  reduced  himself  by  dieting  from  thirty-two  stones 
(448  pounds)  to  proper  dimensions.  One  of  his  aphorisms  says:  "Every 
wise  man  after  Fifty  ought  to  begin  and  lessen  at  least  the  quantity  of  his 
Aliment,  and  if  he  would  continue  free  from  great  and  dangerous  Distempers 
and  preserve  his  Senses  and  Faculties  clear  to  the  last,  he  ought  every  seven 
years  to  go  on  abating  gradually  and  sensibly,  and  at  last  descend  out  of  life 
as  he  ascended  into  it,  even  into  a  Child's  Diet."  Put  in  other  words,  it  reads 
—We  eat  too  much  after  forty  years  of  age. 

In  the  case  of  children  very  much  may  be  done  by  regulating  the  diet, 
reducing  the  starches  and  fats  in  the  food,  not  allowing  them  to  eat  sweets, 
and  encouraging  systematic  exercises.  In  the  case  of  women  who  tend  to  grow 
stout  after  child-bearing  or  at  the  climacteric,  in  addition  to  systematic  exer- 
cises;  they  should  be  told  to  avoid  taking  too  much  food,  and  particularly  to 


452  DISEASES    OF    METABOLISM 

reduce  the  starches  and  sugars.  There  are  a  number  of  methods  or  systems 
in  vogue  at  present.  In  the  celebrated  one  of  Banting  the  carbohydrates  and 
fats  were  excluded  and  the  amount  of  food  was  greatly  reduced. 

Oertel's  method  is  given  under  the  treatment  of  fatty  heart.  He  reduces 
the  amount  of  liquid  taken,  and  this  is  practically,  too,  the  so-called  Schwen- 
inger  cure,  in  which  liquids  are  allowed  only  two  hours  after  the  food. 

Von  Noorden's  dietary  is  as  follows:  Eight  o'clock,  80  grams  of  lean, 
cold  meat,  25  grams  of  bread,  one  cup  of  tea,  with  a  spoonful  of  milk,  no 
sugar.  Ten  o'clock,  one  egg.  Twelve  o'clock,  a  cup  of  strong  meat  broth. 
One  o'clock,  a  small  plate  of  meat  soup  flavored  with  vegetables,  150  grams 
of  lean  meat  of  one  or  two  sorts,  partly  fish,  partly  flesh,  100  grams  of  potatoes 
with  salad,  100  grams  of  fresh  fruit,  or  compote  without  sugar.  Three  o'clock, 
a  cup  of  black  coffee.  Four  o'clock,  200  grams  of  fresh  fruit.  Six  o'clock,  a 
quarter  of  a  litre  of  milk,  if  desired,  with  tea.  Eight  o'clock,  125  grams  of 
cold  meat,  or  180  grams  of  meat  weighed  raw  and  grilled,  and  eaten  with 
pickles  or  radishes  and  salad,  30  grams  of  Graham  bread,  and  two  or  three 
spoonfuls  of  cooked  fruit  without  sugar.  He  believes  it  more  satisfactory 
to  give  in  addition  to  the  three  meals  smaller  quantities  of  food  at  shorter 
intervals,  so  as  to  obviate  the  tendency  to  weakness  which  these  patients  often 
experience.  In  addition  he  allows  twice  in  the  day  a  glass  of  wine.  The  use 
of  mineral  water,  weak  tea,  or  lemonade 'is  not  limited  at  the  meal  times  or 
in  the  intervals.  An  occasional  "hunger-day"  is  given. 

In  the  treatment  of  extreme  obesity  it  is  very  much  better  that  the  patient 
should  be  in  hospital,  or  under  the  care  of  a  nurse,  who  will  undertake  the 
proper  weighing  and  administration  of  the  food.  The  amount  of  fluid  in- 
gested should  not  be  reduced  below  one  litre  a  day.  Many  of  these  patients 
are  anemic,  even  with  a  florid  appearance,  and  for  them  iron  in  full  doses  is 
advisable. 

The  thyroid  extract  should  be  used  only  in  a  systematic  "cure."  Five 
grains  three  times  a  day  is  a  sufficient  dose.  In  conjunction  with  the  diet  and 
exercises  it  is  useful,  but  it  should  not  be  ordered  indiscriminately  to  fat 
persons.  Pituitary  gland  extracts  have  also  been  used. 


VII.    THE   LIPOMATOSES 

Various  forms  of  localized  deposits  of  fat  may  be  considered  here,  and  I 
follow  the  division  in  Lyon's  thorough  study  of  these  conditions  (Archives  of 
Internal  Medicine,  VI,  1). 

I.  Adiposis  Dolorosa  (Dercum's  Disease). — In  the  words  of  the  original 
description  this  is  a  disorder  characterized  by  irregular  symmetrical  deposits 
of  fatty  masses  in  various  portions  of  the  body,  preceded  or  attended  by  pain, 
and  associated  sometimes  with  asthenia  and  psychical  changes. 

The  lipomatous  masses  are  diffuse  and  symmetrical,  involving  the  abdo- 
men, chest,  arms  or  legs ;  or  localized  on  the  limbs  or  trunk.  The  hands,  face 
and  feet  are  usually  spared.  The  pain  is  sometimes  spontaneous  and  is  easily 
excited  by  pressure.  Asthenia,  not  always  present,  may  be  a  marked  feature. 
The  patients  are  often  irritable,  and  the  French  writers  have  described  cases 
with  mental  changes.  Sometimes  the  skin  over  the  areas  of  infiltration  is 


H^MOCHROMATOSIS  453 

markedly  hypersesthetic.  The  affection  is  more  common  in  females.  Nine 
or  ten  autopsies  have  been  made,  none  of  which  threw  clear  light  on  the 
pathology.  Quite  possibly  it  is  a  disturbance  of  the  internal  secretions. 

II.  Nodular  Circumscribed  Lipomatosis. — The    cases    are    common.     The 
lipomata  are   distributed  in  various  localities  and  vary  in  size  from  small 
encapsulated   nodules   to   large   circumscribed  tumors,   solitary   or   multiple, 
sometimes  symmetrically  placed.    They  may  be  painful,  and  Lyon  calls  atten- 
tion to  the  fact  that  the  accessory  features  of  asthenia  and  psychical  changes 
may  also  be  present. 

III.  Diffuse  Symmetrical  Lipomatosis  of  the  Neck. — This   remarkable   af- 
fection, also  called  adeno-lipomatosis,  is  characterized  by  symmetrical  fatty 
infiltrations,  either  simple  or  lobulated,  of  the  subcutaneous  tissues,  forming 
a  huge  collar  about  the  neck.    It  may  occur  in  this  part  alone,  or  other  limited 
lipomata  are  found  elsewhere.    Males  are  much  more  frequently  attacked  than 
females.    The  tumors  interfere  but  little  with  health,  but  as  they  increase  the 
condition  becomes  very  disfiguring.    There  are  sometimes  constitutional  symp- 
toms.    The    name    "adeno-lipomatosis"    has    been    given    because    scattered 
throughout  the  diffuse  fatty  masses  there  are  small  firm  nodules  of  lymphatic 
tissue — sometimes  hagmo-lymph  glands. 

IV.  Cerebral  Adiposity  (Dystrophia  Adiposo-Genitalis,  Frolich}. — As  al- 
ready mentioned,  a  condition  of  obesity  may  occur  in  connection  with  tumors 
of  the  hypophysis,  or  adjacent  parts,  associated  with  a  hypoplasia  of  the  geni- 
tal organs  and  a  condition  of  infantilism.     The  condition  will  be  further  dis- 
cussed in  the  section  on  internal  secretions,  as  it  would  appear  from  the 
researches  of  Gushing  to  be  associated  with  the  perversion  of  the  function  of 
the  pituitary  gland. 

V.  Pseudo-Lipoma. — Sydenham  made  the  keen  observation  that  in  hys- 
terical patients,  there  were  sometimes  swellings,  which  neither  yielded  to  the 
impress  of  the  finger  nor  left  a  mark.     Charcot  described  the  condition  as 
"hysterical  oedema,"  of  which  there  is  both  a  blue  and  a  white  variety. 

Many  of  these  subcutaneous  infiltrations,  just  as  in  the  soft,  supraclavicu- 
lar  pad,  so  common  in  stout  women,  are  due  to  fat,  and  French  writers  de- 
scribe all  grades  of  transition  from  a  pseudo-oedema  to  a  true  lipoma. 

Treatment. — This  is  not  satisfactory.  A  trial  of  thyroid  extract  in  small 
doses  is  advisable,  but  it  is  well  to  suspend  its  use  for  a  week  in  every  month. 
Extracts  of  other  glands  may  also  be  tried.  In  patients  with  signs  of  tumor 
of  the  hypophysis  surgical  measures  should  be  considered. 


VIII.    EUEMOCHROMATOSIS 

Definition. — A  disorder  of  metabolism  characterized  by  a  deposition  of  an 
iron  containing  pigment  in  the  glandular  organs,  and  by  an  increase  in  the 
normal  pigmentation  with  which  is  associated  a  progressive  sclerosis  of  various 
organs,  and,  in  a  large  proportion  of  the  cases,  diabetes.  The  disease  was 
first  described  by  von  Eecklinghausen. 

Etiology. — There  are  about  60  cases  on  record  (1911),  all,  with  the  excep- 
tion of  about  a  dozen,  with  diabetes.  Only  one  occurred  in  a  woman.  In  the 
majority  of  the  patients,  middle-aged  men,  there  seemed  to  be  no  marked 


454  DISEASES   OF   METABOLISM 

predisposing  causes,  though  Blumer  in  a  recent  study  maintains  that  alcohol 
plays  an  important  part. 

'Pathology. — On  autopsy  the  ochre  or  bronze  color  of  the  organs  is  the 
striking  feature.  The  liver  is  large  and  sclerotic;  the  spleen  also  enlarged, 
and  the  pancreas  either  small  and  atrophic  or  fatty  and  fibroid.  The  lymph 
nodes  are  also  pigmented.  The  pigment  is  hamosiderin  or  iron-reacting.  It 
is  chiefly  in  the  cells  of  the  glands,  in  the  muscle  cells  of  the  heart,  and  in  the 
lymph  nodes.  The  amount  in  the  various  organs  is  enormous,  a  hundred  times 
the  normal  in  the  liver,  for  example.  The  haemofuscin,  the  non-iron-reacting 
pigment,  varies  in  different  amounts,  and  it  has  a  yellow  tint,  and  is  found 
chiefly  in  the  connective  tissue  cells.  The  blood  shows  no  special  changes. 

The  pathogenesis  of  the  disease  is  obscure,  and  Sprunt,  whose  recent  study 
(Archives  of  Internal  Medicine,  July,  1911)  contains  an  admirable  summary 
of  our  knowledge,  concludes  that  there  is  no  evidence  of  abnormal  blood  de- 
struction, and  that  it  is  a  primary  disorder  of  metabolism,  "implicating  many 
of  the  body  tissues,  and  manifested  by  a  change  in  the  chromogenic  groups 
of  the  proteid  molecule  with  the  deposition  of  pigments." 

Clinical  Features. — There  are  two  groups  of  cases,  the  larger  one  in  which 
diabetes  is  present,  and  the  smaller  in  which  there  is  no  sugar  in  the  urine. 
The  former  group  is  spoken  of  by  the  French  as  diabete  bronze.,  which  has  the 
features  of  a  severe  diabetes  with  weakness,  progressive  pigmentation  of  the 
skin,  and  an  enlarged  liver.  The  pigmentation  of  the  skin  which  is  the  fea- 
ture that  attracts  attention  varies  in  color  from  a  dark  brown  to  a  leaden  or 
bluish  black.  Dr.  Maude  Abbott's  case  was  known  as  Blue  Mary.  The  liver 
is  in  a  state  of  hypertrophic  cirrhosis,  a  smooth  and  uniform  enlargement. 
The  spleen  may  be  enlarged  secondarily.  It  was  vecy  large  in  two  of  my  cases. 
The  diabetes  is  usually  severe,  and  runs  a  rapid  course.  Prior  to  the  onset  of 
diabetes  the  disease  may  last  for  years. 

There  is  no  special  treatment  beyond  measures  for  the  general  health ;  in 
the  patients  with  diabetes  the  usual  treatment  for  th#t  disease  should  be  car- 
ried out. 

IX.     OCHRONOSIS 

Definition. — A  rare  disorder  of  metabolism  associated  with  blackening  of 
the  cartilages  and  fibrous  tissues  and  pigmentation  of  the  skin,  and  the  pres- 
ence of  dark  urine  due  to  alcapton  or  to  derivatives  of  carbolic  acid. 

Etiology. — There  are  two  groups  of  cases: 

(a)  There  is  a  congenital  life-long  chemical  malformation,  sometimes  a 
family  affection,  in  which  there  is  a  failure  to  complete  the  catabolism  of  cer- 
tain aromatic  compounds,  with  the  result  that  peculiar  bodies,  homogenistic 
acid  and  uroleucic  acid  are  excreted  in  the  urine,  which  blackens  on  exposure 
to  air — alcaptonuria.  The  anomaly  may  be  present  in  three  generations. 

(&)  In  the  other  group  the  dark  urine  and  the  blackening  of  the  tissues 
are  due  to  the  prolonged  use  of  carbolic  acid,  usually  the  application  of  strong 
solutions  externally  to  ulcers.  There  may  possibly  be  other  causes. 

Symptoms. — When  well  developed,  ochronosis  presents  a  very  striking  pic- 
ture. The  discoloration  of  the  fibrous  tissues  is  best  seen  about  the  knuckles, 
and  in  thin  persons  the  tendons  of  the  hands  and  feet  show  a  bluish-gray  ap- 


OCHRONOSIS  455 

pearance.  The  cartilage  of  the  ear  has  a  bluish  tint,  and  there  may  be  sym- 
metrical black  patches  on  the  sclerotics.  Widespread  pigmentation  of  the 
skin  has  been  observed.  In  one  of  my  patients  there  was  a  coal-black  dis- 
coloration of  the  skin  over  the  nose  and  cheeks,  and  the  same  was  beginning 
in  the  hands.  This  may  occur  also  in  the  carboluria  group,  as  well  shown 
in  the  colored  illustration  of  Dr.  Pope's  patient.  Several  of  the  reported  cases 
had  arthritis,  and  the  two  brothers  in  the  Maryland  family  had  a  curious 
anterior  inclination  of  the  trunk,  and  a  peculiar  waddling  gait.  There  are 
few  symptoms  directly  due  to  the  chemical  malformation.  The  patients  enjoy 
good  health,  but  the  disfigurement  may  be  very  great.  Post  mortem,  the 
appearance  is  remarkable,  as  pictured  in  Virchow's  original  case;  the  carti- 
lages, ligaments  and  fibrous  structures  are  everywhere  of  a  brown-black  color. 


SECTION   V 

DISEASES  OF  THE  DIGESTIVE  SYSTEM 

A.   DISEASES  OF  THE  MOUTH 
STOMATITIS 

Acute  Stomatitis. — Simple  or  erythematous  stomatitis,  the  commonest 
form,  results  from  the  action  of  irritants  of  various  sorts.  Frequent  at  all 
ages,  in  children  it  is  usually  associated  with  dentition  and  with  gastro-intes- 
tinal  disturbance,  particularly  in  ill-nourished,  unhealthy  subjects;  in  adults 
it  may  follow  the  abuse  of  tobacco,  or  the  use  of  too  hot  or  too  highly  seasoned 
food;  it  is  a  concomitant  of  indigestion,  or  of  the  specific  fevers. 

The  affection  may  be  limited  to  the  gums  and  lips  or  may  extend  over  the 
whole  surface  of  the  mouth  and  include  the  tongue.  There  are  at  first  super- 
ficial redness  and  dryness  of  the  membrane,  followed  by  increased  secretion 
and  swelling  of  the  tongue,  which  is  furred,  and  indented  by  the  teeth.  There 
is  rarely  any  constitutional  disturbance,  but  in  children  there  may  be  slight 
elevation  of  temperature.  The  condition  causes  considerable  discomfort,  some- 
times amounting  to  actual  distress  and  pain,  particularly  in  mastication. 

In  infants  the  mouth  should  be  carefully  sponged  after  each  feeding.  A 
mouth-wash  of  borax  or  glycerin  and  borax  may  be  used,  and  in  severe 
cases,  which  tend  to  become  chronic,  a  dilute  solution  of  nitrate  of  silver  (3 
or  4  grains  to  the  ounce)  may  be  applied. 

Aphthous  Stomatitis. — This  form,  also  known  as  follicular  or  vesicular 
stomatitis,  is  characterized  by  the  presence  of  small,  slightly  raised  spots, 
from  2  to  4  mm.  in  diameter,  surrounded  by  reddened  areolse.  The  spots 
appear  first  as  vesicles,  which  rupture,  leaving  small  ulcers  with  grayish  bases 
and  bright-red  margins.  They  are  seen  most  frequently  on  the  inner  surfaces 
of  the  lips,  the  edges  of  the  tongue,  and  the  cheeks.  They  are  seldom  present 
on  the  mucous  membrane  of  the  pharynx.  This  form  is  met  with  most  often 
in  children  under  three  years,  either  as  an  independent  affection  or  in  asso- 
ciation with  one  of  the  febrile  diseases  of  childhood  or  with  an  attack  of  indi- 
gestion. The  vesicles  come  out  with  great  rapidity  and  the  little  ulcers  may 
be  fully  formed  within  twenty-four  hours.  The  child  complains  of  soreness 
of  the  mouth  and  takes  food  with  reluctance.  The  buccal  secretions  are  in- 
creased and  the  breath  is  heavy,  but  not  foul.  The  constitutional  symptoms 
are  usually  those  of  the  disease  with  which  the  aphthae  are  associated.  The 
disease  must  not  be  confounded  with  thrush.  No  special  parasite  has  been 
found  in  connection  with  it.  It  is  not  a  serious  condition,  and  heals  rapidly 
456 


STOMATITIS  457 

with  the  improvement  of  the  constitutional  state.  In  severe  cases  it  may 
extend  to  the  pillars  of  the  fauces  and  to  the  pharynx,  and  produce  ulcers  which 
are  irritating  and  difficult  to  heal. 

Each  ulcer  should  be  touched  with  nitrate  of  silver  and  the  mouth  should 
be  thoroughly  cleansed  after  taking  food.  A  wash  of  chlorate  of  potassium, 
or  of  borax  and  glycerin,  may  be  used.  The  constitutional  symptoms  should 
receive  careful  attention. 

A  curious  affection  occurs  in  southern  Italy  sometimes  in  epidemic  form, 
characterized  by  a  pearly-colored  membrane  with  induration,  immediately 
beneath  the  tongue  on  the  fraenum  (Eiga's  disease).  There  may  be  much  in- 
duration and  ultimately  ulceration.  It  occurs  in  both  healthy  and  cachectic 
children,  usually  about  the  time  of  the  eruption  of  the  first  teeth. 

TJlcerative  Stomatitis. — This  form,  which  is  also  known  by  the  names 
of  fetid  stomatitis,  or  putrid  sore  mouth,  occurs  particularly  in  children  after 
the  first  dentition.  It  may  prevail  as  a  widespread  epidemic  in  institutions 
in  which  the  sanitary  conditions  are  defective.  It  has  been  met  with  in  jails 
and  camps.  Insufficient  and  unwholesome  food,  improper  ventilation,  and 
prolonged  damp,  cold  weather  seem  to  be  special  predisposing  causes.  Lack 
of  cleanliness  of  the  mouth,  the  presence  of  carious  teeth,  and  the  collection 
of  tartar  around  them  favor  the  occurrence  of  the  disease.  The  affection 
spreads  like  a  specific  disease,  but -the  microbe  has  not  yet  been  isolated.  It 
has  been  held  that  the  disease  is  the  same  as  the  foot-and-mouth  disease  of 
cattle,  and  that  it  is  conveyed  by  the  milk,  but  there  is  no  positive  evidence 
on  these  points. 

The  morbid  process  begins  at  the  margin  of  the  gums,  which  become 
swollen  and  red,  and  bleed  readily.  Ulcers  form,  the  bases  of  which  are 
covered  with  a  grayish-white,  firmly  adherent  membrane.  In  severe  cases  the 
teeth  may  become  loosened  and  necrosis  of  the  alveolar  process  may  occur. 
The  ulcers  extend  along  the  gum-line  of  the  upper  and  lower  jaws ;  the  tongue, 
lips,  and  mucosa  of  the  cheeks  are  usually  swollen,  but  rarely  ulcerated.  There 
is  salivation,  the  breath  is  foul,  and  mastication  is  painful.  The  submaxillary 
lymph-glands  are  enlarged.  An  exanthem  may  appear  and  be  mistaken  for 
measles.  The  constitutional  symptoms  are  often  severe,  and  in  debilitated 
children  death  sometimes  occurs. 

In  the  treatment  of  this  form  of  stomatitis  chlorate  of  potassium  has  been 
found  to  be  almost  specific.  It  should  be  given  in  doses  of  10  grains  (0.6 
gm.),  three  times  a  day,  to  a  child,  and  to  an  adult  double  that  amount.  Lo- 
cally it  may  be  used  as  a  mouth-wash,  or  the  powdered  salt  may  be  applied 
directly  to  the  ulcerated  surfaces.  When  there  is  much  fetor,  a  solution  of 
potassium  permanganate  may  be  used  as  a  wash,  and  an  application  of  nitrate 
of  silver  made  to  the  ulcers. 

A  variety  of  ulcerative  sore  mouth,  which  differs  entirely  from  this  form, 
is  common  in  nursing  women,  and  is  usually  seen  on  the  mucous  mem- 
brane of  the  lips  and  cheeks.  The  ulcers  arise  from  the  mucous  follicles,  and 
are  from  3  to  5  mm.  in  diameter.  They  may  cause  little  or  no  inconveni- 
ence; but  in  some  instances  they  are  very  painful  and  interfere  seriously 
with  the  taking  of  food  and  its  masticatidh.  As  a  rule  they  heal  readily 
after  the  application  of  nitrate  of  silver,  and  the  condition  is  an  indication 
for  tonics,  fresh  air,  and  a  better  diet. 
31 


458  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

Kecurring  outbreaks  of  an  Jierpetic,  even  pemphigoid,  stomatitis  are  seen 
in  neurotic  individuals  (stomatitis  neurotica  chronica,  Jacobi).  It  may  pre- 
cede or  accompany  the  fatal  form  of  pemphigus  vegetans. 

Parrot  describes  the  occasional  appearance  in  new-born,  debilitated  chil- 
dren of  small  ulcers  symmetrically  placed  on  the  hard  palate  on  either  side 
of  the  middle  line.  They  rarely  heal,  but  tend  to  increase  in  size,  and  may 
involve  the  bone. 

Bednar's  aphthae  consist  of  small  patches  and  ulcers  on  the  hard  palate, 
caused  as  a  rule  in  young  infants  by  the  artificial  nipple  or  the  nurse's 
finger. 

Parasitic  Stomatitis  (Thrush;  Soor;  Muguet). — This  affection,  most 
commonly  seen  in  children,  is  dependent  upon  a  fungus,  Saccharomyces 
albicans,  called  by  Eobin  O'idium  albicans.  It  belongs  to  the  order  of  yeast 
fungi,  and  consists  of  branching  filaments,  from  the  ends  of  which  ovoid 
torula  cells  develop.  The  disease  does  not  arise  apparently  in  a  normal 
mucosa.  The  use  of  an  improper  diet,  uncleanliness  of  the  mouth,  the  acid 
fermentation  of  remnants  of  food,  or  the  occurrence,  from  any  cause,  of  ca- 
tarrhal  stomatitis  predispose  to  the  growth.  In  institutions  it  is  frequently 
transmitted  by  unclean  feeding-bottles,  spoons,  etc.  It  is  not  confined  to 
children,  but  is  met  with  in  adults  in  the  final  stages  of  fever,  in  chronic 
tuberculosis,  diabetes,  and  in  cachectic  states.  The  parasite  grows  in  the 
upper  layers  of  the  mucosa,  and  the  filaments  form  a  dense  felt-work  among 
the  epithelial  cells.  The  disease  begins  on  the  tongue  and  is  seen  in  the  form 
of  slightly  raised,  pearly-white  spots,  which  increase  in  size  and  gradually 
coalesce.  The  membrane  thus  formed  can  be  readily  scraped  off,  leaving  an 
intact  mucosa,  or,  if  the  process  extends  deeply,  a  bleeding,  slightly  ulcerated 
surface.  The  disease  spreads  to  the  cheeks,  lips,  and  hard  palate,  and  may 
involve  the  tonsils  and  pharynx.  In  very  severe  cases  the  entire  buccal  mucosa 
is  covered  by  the  grayish-white  membrane.  It  may  even  extend  into  the 
oesophagus  and  to  the  stomach  and  cascum.  It  is  occasionally  met  with  on 
the  vocal  cords.  Robust,  well-nourished  children  are 'sometimes  affected;  but 
it  is  usually  met  with  in  enfeebled,  emaciated  infants  with  digestive  or  intes- 
tinal troubles.  In  such  cases  the  disease  may  persist  for  months. 

The  affection  is  readily  recognized,  and  must  not  be  confounded  with 
aphthous  stomatitis,  in  which  the  ulcers,  preceded  by  the  formation  of  vesi- 
cles, are  perfectly  distinctive.  In  thrush  the  microscopic  examination  shows 
the  presence  of  the  characteristic  fungus  throughout  the  membrane.  In  this 
condition,  too,  the  mouth  is  usually  dry — a  striking  contrast  to  the  salivation 
accompanying  aphthae. 

Thrush  is  more  readily  prevented  than  removed.  The  child's  mouth 
should  be  kept  scrupulously  clean,  and,  if  artificially  fed,  the  bottles  should 
be  thoroughly  sterilized.  Lime-water  or  any  other  alkaline  fluid,  such  as  the 
bicarbonate  of  soda  (a  drachm  to  a  tumbler  of  water),  may  be  employed. 
When  the  patches  are  present  these  alkaline  mouth-washes  may  be  continued 
after  each  feeding.  A  spray  of  borax  or  of  sulphite  of  soda  (a  drachm  to  the 
ounce)  or  the  black  wash  with  glycerine  may  be  employed.  The  perman- 
ganate of  potassium  is  also  useful.  The  constitutional  treatment  is  of  equal 
importance,  and  it  will  often  be  found  that  the  thrush  persists,  in  spite  of  all 
local  measures,  until  the  general  health  of  the  infant  is  improved  by  change 


STOMATITIS  459 

of  air  or  the  relief  of  the  diarrhoea,  or,  in  obstinate  cases,  the  substitution  of 
a  natural  for  the  artificial  diet. 

Gangrenous  Stomatitis  (Cancrum  Oris;  Noma). — An  affection  character- 
ized by  a  rapidly  progressing  gangrene,  starting  on  the  gums  or  cheeks,  and 
leading  to  extensive  sloughing  and  destruction.  This  terrible,  but  fortunately 
rare,  disease  is  seen  only  in  children  under  very  insanitary  conditions  or  dur- 
ing convalescence  from  the  acute  fevers.  It  is  more  common  in  girls  than  in 
boys.  It  is  met  with  between  the  ages  of  two  and  five  years.  In  at  least  one- 
half  of  the  cases  the  disease  has  occurred  during  convalescence  from  measles. 
Cases  have  been  seen  also  after  scarlet  fever  and  typhoid.  The  mucous  mem- 
brane is  first  affected,  usually  of  the  gums  or  of  one  cheek.  The  process 
begins  insidiously,  and  when  first  seen  there  is  a  sloughing  ulcer  of  the  mucous 
membrane,  which  spreads  rapidly  and  leads  to  brawny  induration  of  the  skin 
and  adjacent  parts.  The  sloughing  extends,  and  in  severe  cases  the  cheek  is 
perforated.  The  disease  may  spread  to  the  tongue  and  chin;  it  may  invade 
the  bones  of  the  jaws  and  even  involve  the  eyelids  and  ears.  In  mild  cases  an 
ulcer  forms  on  the  inner  surface  of  the  cheek,  which  heals  or  may  perforate 
and  leave  a  fistulous  opening.  Naturally  in  such  a  severe  affection  the  con- 
stitutional disturbance  is  very  great,  the  pulse  is  rapid,  the  prostration  ex- 
treme, and  death  usually  takes  place  within  a  week  or  ten  days.  The  tem- 
perature may  reach  103°  or  104°  F.  Diarrhoea  is  usually  present,  and  aspira- 
tion pneumonia  is  a  common  complication.  No  specific  organism  has  been 
found. 

In  many  cases  the  onset  is  so  insidious  that  there  is  an  extensive  sloughing 
sore  when  the  case  first  comes  under  observation.  Destruction  of  the  sore  by 
the  Paquelin  cautery  or  fuming  nitric  acid  is  the  most  effectual.  Antiseptic 
applications  should  be  made  to  destroy  the  fetor.  The  child  should  be  care- 
fully nourished  and  stimulants  given  freely. 

Mercurial  Stomatitis  (Ptyalism). — It  occurs  in  persons  with  a  special 
susceptibility,  rarely  now  as  a  result  of  the  excessive  use  of  the  drug,  and 
also  in  those  whose  occupation  necessitates  the  constant  handling  of  mercury. 
It  may  follow  the  administration  of  repeated  small  doses.  Thus,  a  patient 
with  heart-disease  who  was  ordered  an  eighth  of  a  grain  of  calomel  every  three 
hours  for  diuretic  purposes  had,  after  taking  eight  or  ten  doses,  a  severe 
stomatitis,  which  persisted  for  several  weeks.  I  have  known  it  to  follow  the 
administration  of  small  doses  of  gray  powder.  The  patient  complains  first 
of  a  metallic  taste  in  the  mouth,  the  gums  become  swollen,  red,  and  sore, 
mastication  is  difficult,  the  salivary  glands  become  enlarged  and  painful,  and 
there  is  a  great  increase  in  their  secretion.  The  tongue  is  swollen,  the  breath 
has  a  foul  odor,  and,  if  the  affection  progresses,  there  may  be  ulceration  of  the 
mucosa,  and,  in  rare  instances,  necrosis  of  the  jaw.  Although  troublesome 
and  distressing,  the  disease  is  rarely  serious,  and  recovery  usually  takes  place 
in  a  couple  of  weeks.  Instances  in  which  the  teeth  become  loosened  or  de- 
tached or  in  which  the  inflammation  extends  to  the  pharynx  and  Eustachian 
tubes  are  rarely  seen  now. 

The  administration  of  mercury  should  be  suspended  so  soon  as  the  gums 
are  "touched."  Mild  cases  of  the  affection  subside  within  a  few  days  and 
require  only  a  simple  mouth-wash.  In  severer  cases  the  chlorate  of  potassium 
may  be  given  internally,  and  used  io  rinse  the  mouth.  The  bowels  should  be 


460  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

freely  opened;  the  patient  should  take  a  hot  bath  every  evening  and  should 
drink  plentifully  of  alkaline  mineral  waters.  Atropine  is  sometimes  service- 
able, and  may  be  given  in  doses  of  1/100  of  a  grain  twice  a  day.  Iodine  is 
also  recommended.  When  the  salivation  is  severe  and  protracted  the  patient 
becomes  much  debilitated  and  anasmic,  so  that  a  supporting  treatment  is  indi- 
cated. The  diet  is  necessarily  liquid,  for  the  patient  finds  the  chief  difficulty 
in  taking  food.  If  the  pain  is  severe  Dover's  powder  may  be  given  at  night. 

Here  may  be  appropriately  mentioned  the  influence  of  stomatitis,  particu- 
larly the  mercurial  form,  upon  the  developing  teeth  of  children.  The  con- 
dition known  as  erosion,  in  which  the  teeth  are  honeycombed  or  pitted  owing 
to  defective  formation  of  enamel,  is  indicative,  as  a  rule,  of  infantile  stoma- 
titis. Such  teeth  must  be  distinguished  carefully  from  those  of  congenital 
syphilis,  which  may,  of  course,  coexist,  but  the  two  conditions  are  distinct. 
The  honeycombing  is  frequently  seen  on  the  incisors;  but,  according  to  Jona- 
than Hutchinson,  the  test  teeth  of  infantile  stomatitis  are  the  first  permanent 
molars,  then  the  incisors,  "which  are  almost  as  constantly  pitted,  eroded,  and 
of  bad  color,  often  showing  the  transverse  furrow  which  crosses  all  the  teeth 
at  the  same  level."  Magitot  regards  these  transverse  furrows  as  the  result 
of  infantile  convulsions  or  of  severe  illness  during  early  life.  He  thinks  they 
are  analogous  to  the  furrows  on  the  nails  which  so  often  follow  a  serious 
disease. 

Geographical  Tongue  (Eczema  of  the  Tongue). — A  remarkable  desqua- 
mation  of  the  superficial  epithelium  of  the  tongue  in  circinate  patches,  which 
spread  while  the  central  portions  heal.  Fusion  of  patches  leads  to  areas  with 
sinuous  outlines.  When  extensive  the  tongue  may  be  covered  with  these  areas, 
like  a  geographical  map.  The  affection  causes  a  good  deal  of  itching  and 
heat,  and  it  may  be  a  source  of  much  mental  worry  to  the  patients,  who  often 
dread  lest  it  may  be  a  commencing  cancer. 

The  etiology  of  the  disease  is  unknown.  It  occurs  in  infants  and  chil- 
dren, and  it  is  not  very  infrequent  in  adults.  It  has  been  regarded  as  a  gouty 
manifestation,  and  transient  attacks  may  accompany  indigestion.  It  is  very 
liable  to  relapse.  In  adults  it  may  prove  very  obstinate,  and  I  know  of  one 
instance  in  which  the  disease  persisted  in  spite  of  all  treatment  for  more  than 
two  years.  Solutions  of  nitrate  of  silver  give  the  most  satisfactory  results  in 
relieving  the  intense  burning. 

There  is  a  superficial  glossitis,  limited  usually  to  the  border  and  point  of 
the  tongue,  which  presents  irregular  reddish  spots,  looking  as  if  the  epithelium 
was  removed,  and  the  papilla?  are  reddened  and  swollen.  The  condition  is 
sometimes  known  as  Holler's  glossitis.  Local  treatment  with  nitrate  of  silver 
as  a  rule  gives  relief. 

Leukoplakia  Buccalis. — Samuel  Plumbe  described  the  condition  as  icthyo- 
sis  lingualis.  It  has  also  been  called  buccal  psoriasis  and  leuco-keratosis 
imicoscB  oris.  The  following  forms  occur:  (a)  Small  white  spots  upon  the 
tongue,  slightly  raised,  even  papillomatous — lingual  corns.  (&)  Diffuse  thick- 
ening of  the  epithelial  coating  of  the  tongue,  either  a  thin,  bluish-white  color 
or  opaque  white,  depending  upon  the  thickness.  It  is  patchy,  and  more  often 
upon  the  dorsum  and  sides,  (c)  Diffuse  oral  leukoplakia,  a  remarkable  con- 
dition in  which  the  roof  of  the  mouth,  the  gums,  lips,  and  cheeks  are  covered 
with  an  opaque  white,  sometimes  smooth,  sometimes  fissured,  rugose  layer. 


STOMATITIS  461 

In  this  widespread  form  the  tongue  may  be  spared.  The  visible  mucosa  of 
the  lips  may  be  involved,  and  occasionally  the  genital  mucosa. 

While  appearing  spontaneously,  the  condition  is  most  common  in  heavy 
smokers,  and  has  been  called  smoker's  tongue.  Epithelioma  occasionally 
starts  from  the  localized  patches.  A  majority  of  the  patients  have  had  syphi- 
lis, but  the  condition  does  not  yield,  as  a  rule,  to  specific  treatment. 

Leukoplakia  is  a  very  obstinate  affection.  All  irritants,  such  as  smoke  and 
very  hot  food,  should  be  avoided.  Local  treatment  with  one-half-per-cent. 
corrosive  sublimate  or  a  one-per-cent.  chromic-acid  solution  has  been  recom- 
mended. The  propriety  of  active  local  treatment  is  doubtful.  Papillomatous 
outgrowths  should  be  cut  off.  The  X-rays  may  be  tried.  The  most  extensive 
form  may  disappear  spontaneously. 

The  glossy  flat  atrophy  of  the  posterior  part  of  the  tongue,  described  by 
Virchow,  is  in  a  majority  of  instances  of  syphilitic  origin.  Scars  may  give  an 
irregular  appearance  to  the  surface.  Symmers  found  this  smooth  atrophy  in 
55  of  75  post  mortems  in  syphilitic  subjects. 

Fetor  Oris. — The  practitioner  is  frequently  consulted  for  foul  breath,  and 
is  daily  made  aware  of  its  widespread  prevalence.  All  unconscious,  he  is  him- 
self too  often  subject  of  the  condition,  to  the  disgust  of  his  patients,  with 
whom  he  has  to  come  into  such  close  contact.  It  is  impossible  to  give  even  a 
list  of  all  the  causes  mentioned.  The  following  are  a  few  of  the  more  im- 
portant: (a)  In  connection  with  indigestion  and  the  associated  catarrhal 
disturbances  in  the  mouth,  pharynx,  and  stomach.  The  breath  is  "heavy," 
as  the  mothers  say.  A  simple  mouth-wash  and  a  mercurial  purge  suffice  to 
remove  it.  In  a  more  serious  disease  of  the  stomach  the  breath  may  be  foul, 
and  occasionally,  in  sloughing  cancer,  horribly  stinking.  (6)  Local  condi- 
tions in  the  mouth:  (1)  All  the  forms  of  stomatitis.  Smokers  should  remem- 
ber that,  apart  altogether  from  the  smell  of  tobacco,  their  breath  in  the  morn- 
ing is  usually,  to  say  the  least,  "heavy."  (2)  Pyorrhoea  alveolaris.  This  is 
the  most  common  cause  of  foul  breath  in  adults,  and  is  almost  constantly 
present  after  middle  life,  causing  a  perfectly  distinctive  odor  only  too  well 
known  to  all  of  us.  To  test  for  the  presence  draw  a  bit  of  stout  thread  or  the 
edge  of  a  sheet  of  paper  high  up  between  the  teeth  and  the  gums  and  then 
smell  it.  Scrupulous  treatment  of  the  gums  by  a  dentist  is  needed,  and  daily 
scouring,  etc.  (c)  The  tonsillar  diseases.  In  the  crypts  of  the  tonsils  the 
epithelial  debris  accumulates,  and,  invaded  by  micro-organisms,  gradually 
forms  the  little  round  or  triangular  bodies  which  can  be  squeezed  out  of  the 
lacunae,  and  when  pressed  between  the  fingers  smell  like  Limburger  cheese. 
The  fetor  oris  from  this  cause  is  quite  distinctive.  To  test  the  presence  in 
child  or  adult,  smell  the  finger  after  it  has  been  rubbed  firmly  upon  the  tonsil. 
Local  treatment  is  needed,  (d)  Decayed  teeth,  the  foul  odor  of  which  is 
quite  distinct  from  that  of  pyorrhoea  or  chronic  tonsillitis,  (e)  Kespiratory. 
Many  diseases  of  the  nose,  larynx,  bronchi,  and  lungs  are  associated  with  foul 
breath.  (/)  Hsemic.  The  halitus — the  expired  air  from  the  lung — may  be 
impregnated  with  odors  from  the  blood.  Of  this  there  are  many  well-known 
instances. 

For  practical  purposes  it  is  to  be  remembered  that  pyorrhoea  alveolaris 
and  what  is  called  chronic  lacunar  tonsillitis  are  the  two  most  common  causes 
of  foul  breath. 


462  DISEASES    OF   THE   DIGESTIVE    SYSTEM 

Oral  Sepsis. — To  William  Hunter,  of  Charing  Cross  Hospital,  is  due  the 
credit  of  insisting  upon  the  importance  of  the  mouth  as  the  chief  channel  of 
entrance  of  the  pyogenic  organisms,  and  as  itself  the  seat  of  septic  processes. 
Necrosed  teeth,  pyorrhoea  alveolaris,  gingivitis,  alveolar  abscess,  etc.,  are  pres- 
ent in  a  great  many  people.  A  systemic  infection  may  follow  or  the  general 
health  may  be  lowered  by  the  continuous  production  of  pus.  In  extensive 
pyorrhoea  alveolaris  the  daily  amount  of  pus  must  be  considerable,  and  there 
can  be  no  question  that  it  has  a  debilitating  influence  on  the  general  health 
and  is  sometimes  associated  with  a  moderate  anaemia  and  with  a  pasty  com- 
plexion. Hunter  describes  septic  gastritis  and  septic  enteritis  as  common 
sequences ;  indeed,  he  regards  appendicular,  pleuritic,  gall-bladder  and  pyelitic 
inflammations  as  forms  of  "medical  sepsis"  due  largely  to  infection  from 
the  mouth.  One  form  of  pernicious  anaemia — infective  haemolytic  anaemia — 
he  believes  to  be  due  to  oral  sepsis,  or  an  infective  glossitis.  Certain  types  of 
nephritis  and  forms  of  arthritis  are  believed  to  be  due  to  oral  infection. 

There  is  no  question  of  the  importance  of  the  subject,  and  we  should  insist 
upon  scrupulous  cleanliness  of  the  mouth  and  teeth,  particularly  clearing 
away  the  tartar  and  the  pockets  of  pus.  An  adult  should  have  his  teeth 
cleansed  in  this  way  by  a  dentist  once  a  month.  We  should,  too,  have  less 
delicacy  in  telling  our  friends  in  whom  the  odor  of  the  breath  reveals  the 
presence  of  pyorrhoea.  It  is  a  very  difficult  condition  to  cure.  Locally  much 
may  be  done  to  keep  it  under  control.  Vaccines  have  been  used  extensively, 
sometimes,  but  not  always,  with  success.  If  possible,  the  patient  should  be 
referred  to  a  dentist  who  is  specially  competent  to  deal  with  it.  The  tartar 
should  be  removed  from  the  teeth  and  antiseptic  mouth  washes,  such  as  car- 
bolic acid  (1  per  cent),  used  frequently.  Hydrogen  peroxide  may  be  applied 
locally. 

Affections  of  the  mucous  glands  are  not  very  common.  In  catarrhal 
troubles  in  children  and  in  measles  they  may  be  swollen.  They  are  enlarged 
and  very  prominent  in  Mikulicz's  disease,  with  chronic  symmetrical  enlarge- 
ment of  the  salivary  and  lachrymal  glands.  There  is  a  singular  affection  of 
the  mucous  glands  of  the  lips,  chiefly  of  the  lower,  with  much  swelling  and 
infiltration.  It  was  described  by  Volkmann,  and  has  been  called  Balz's  dis- 
ease. The  mucous  glands  are  enlarged,  the  ducts  much  dilated,  and  on  pres- 
sure a  mucoid  or  muco-purulent  secretion  may  exude.  The  skin  over  the  lips 
may  be  reddened  and  swollen. 


B.    DISEASES   OF    THE    SALIVARY   GLANDS 

Supersecretion  (Ftyalism). — The  normal  amount  of  saliva  varies  from 
2  to  3  pints  in  the  twenty-four  hours.  The  secretion  is  increased  during  the 
taking  of  food  and  in  the  physiological  processes  of  dentition.  A  great  in- 
crease, to  which  the  term  ptyalism  is  applied,  is  met  with  (1)  occasionally  in 
mental  and  nervous  affections  and  in  rabies;  (2)  occasionally  in  the  acute 
fevers,  particularly  in  small-pox;  (3)  sometimes  with  disease  of  the  pancreas; 
(4)  during  gestation,  usually  early,  though  it  may  persist  through  the  entire 
course;  (5)  occasionally  at  each  menstrual  period ;  and,  lastly,  it  is  a  com/- 


DISEASES    OF    THE    SALIVARY    GLANDS  4G3 

mon  effect  of  certain  drugs — mercury,  gold,  copper,  the  iodine  compounds, 
and  (among  vegetable  remedies)  jaborandi,  muscarin,  and  tobacco  excite 
the  salivary  secretion.  Of  these  we  most  frequently  see  the  effect  of  mercury 
in  producing  ptyalism.  The  salivation  may  be  present  without  any  inflamma- 
tion of  the  mouth.  For  treatment  atropine  or  the  bromides  may  be  given  in 
small  doses  at  first  and  the  effect  watched  until  the  most  efficient  dosage  is 
found. 

Xerostomia  (Arrest  of  the  Salivary  and  Buccal  Secretions;  Dry  Mouth). — 
In  this  condition,  first  described  by  Jonathan  Hutchinson,  the  secretions  of 
the  mouth  and  salivary  glands  are  suppressed.  The  tongue  is  red,  sometimes 
cracked,  and  quite  dry ;  the  mucous  membrane  of  the  cheeks  and  of  the  palate 
is  smooth,  shining,  and  dry ;  and  mastication,  deglutition,  and  articulation  are 
very  difficult.  A  majority  of  the  cases  are  in  women,  and  in  several  instances 
have  been  associated  with  nervous  phenomena.  The  general  health,  as  a  rule, 
is  unimpaired.  It  may  be  due  to  involvement  of  some  centre  which  controls 
the  secretion  of  the  salivary  and  buccal  glands.  The  free  use  of  glycerin 
locally  is  sometimes  of  value  and  jaborandi  or  pilocarpine  can  be  given 
cautiously. 

Inflammation  of  the  Salivary  Glands. 

(a)   Specific  Parotitis.    (See  Mumps.) 

(6)   Symptomatic  parotitis  or  parotid  bubo  occurs: 

(1)  In  the  course  of  the  infectious  fevers — typhus,  typhoid,  pneumonia, 
pyasmia,  etc.     In   ordinary  practice  it  occurs  of tenest,  perhaps,  in  typhoid 
fever.     It  is  the  result  either  of  septic  infection  through  the  blood,  or  the 
inflammation,  in  many  cases,  passes  up  the  salivary  duet,  and  so  reaches  the 
gland.     The  process  is  usually  very  intense  and  leads  rapidly  to  suppuration. 
It  is,  as  a  rule,  an  unfavorable  indication  in  the  course  of  a  fever.     Parotitis 
may  occur  in  secondary  syphilis. 

(2)  In  connection  with  injury  or  disease  of  the  abdomen  or  pelvis,  a 
condition  to  which  Stephen  Paget  has  called  special  attention.     Of  101  cases 
of  this  kind,  "10  followed  injury  or  disease  of  the  urinary  tract,  18  were  due 
to  injury  or  disease  of  the  alimentary  canal,  and  23  were  due  to  injury  or 
disease  of  the  abdominal  wall,  the  peritoneum,  or  the  pelvic  cellular  tissue. 
The  remaining  50  were  due  to  injury,  disease,  or  temporary  derangement  of 
the  genital  organs."    By  temporary  derangement  is  meant  slight  injuries  or 
natural  processes — a  slight  blow  on  the  testis,  the  introduction  of  a  pessary, 
menstruation,  or  pregnancy.     Bucknell  has  brought  forward  strong  evidence 
to  show  that  in  all  these  cases  infection  takes  place  through  the  duct. 

(3)  In  association  with  facial  paralysis,  as  in  a  case  of  fatal  peripheral 
neuritis  described  by  Gowers;  in  diabetes  and  chronic  metallic  poisoning. 

In  the  infectious  diseases  rigid  cleanliness  is  an  important  preventive 
measure.  In  the  treatment  of  parotitis  the  application  of  half  a  dozen  leeches 
will  sometimes  reduce  the  inflammation  and  promote  resolution.  An  ice  bag 
often  aids,  or  hot  fomentations  may  be  applied.  A  free  incision  should  be 
made  early  if  there  are  signs  of  suppuration. 

(c)  Chronic  parotitis,  a  condition  in  which  the  glands  are  enlarged,  rarely 
painful,  may  follow  inflammation  of  the  throat  or  mumps.  Salivation  may 
be  present.  It  may  be  due  to  lead,  mercury,  or  potassium  iodide.  It  occurs 
also  in  chronic  Bright's  disease  and  in  secondary  syphilis.  Symmetrical  en- 


464  DISEASES   OF   THE   DIGESTIVE    SYSTEM 

largement  of  the  parotids  of  moderate  extent  is  not  very  uncommon  among 
hospital  patients.  The  cases  at  the  Johns  Hopkins  clinic  have  been  reported 
by  C.  P.  Howard  (Internat.  Clinics.,  xix,  1).  It  may  be  associated  with 
xerostomia.  The  parotid  and  submaxillary  glands  are  affected  with  equal 
frequency.  In  one  case  the  swelling  recurred  over  a  period  of  20  years  (Greig) . 

(d)  MiTculicz's  Disease. — In  this  remarkable  affection,  described  in  1888 
the  salivary  and  lachrymal  glands  are  enlarged  simultaneously.     The  condi- 
tion is  painless  and  chronic,  lasting  sometimes  for  several  years,  and  of  un- 
known etiology.    The  gland  substance  itself  may  not  be  disturbed,  but  there 
is  a  great  infiltration  of  the  interstitial  connective  tissue.     In  my  case  the 
lachrymal  glands  were  replaced  by  fibrous  tissue.     The  cases  so  far  reported 
in  America  have  been  in  negroes.     The  enlargement  may  subside  after  an 
acute  fever.    Good  results  have  followed  the.  use  of  arsenic. 

(e)  Gaseous  Tumors  of  Sieno's  Duct  and  of  the  Parotid  Gland. — In  glass- 
blowers  and  musicians  Steno's  duct  may  become  inflated  with  air  and  form 
a  tumor  the  size  of  a  nut  or  of  an  egg.     Some  have  contained  a  mixture  of 
air,  saliva,  and  pus.     In  rare  cases  there  are  gaseous  tumors  of  the  glands, 
which  give  a  sensation  of  crepitation  on  palpation. 


C.    DISEASES   OF   THE   PHARYNX 

Circulatory  Disturbances. — (a)  Hypercemia  is  common  in  acute  and 
chronic  affections  of  the  throat,  and  is  frequently  seen  as  a  result  of  the  irri- 
tation of  tobacco  smoke,  and  from  the  constant  use  of  the  voice.  Venous 
stasis  is  seen  in  valvular  disease  of  the  heart,  and  in  mechanical  obstruction 
of  the  superior  vena  cava  by  tumor  or  aneurism.  In  aortic  insufficiency  the 
capillary  pulse  may  sometimes  be  seen,  and  the  intense  throbbing  of  the  in- 
ternal carotid  may  be  mistaken  for  aneurism.  / 

(&)  Hemorrhage  is  found  in  association  with  bleeding  from  other  mucous 
surfaces,  or  it  is  due  to  local  causes — granulations,  varicosities,  or  vegetations. 
It  may  be  mistaken  for  haemorrhage  from  the  lungs  or  stomach.  Sometimes 
the  patient  finds  the  pillow  stained  in  the  morning  with  bloody  secretion.  The 
condition  is  rarely  serious,  and  requires  only  suitable  local  treatment.  Occa- 
sionally a  haemorrhage  takes  place  into  the  mucosa,  producing  a  pharyngeal 
haematoma.  I  have  thrice  seen  a  condition  of  the  uvula  resembling  haemor- 
rhagic  infarction.  One  was  in  a  patient  with  rheumatic  fever,  to  whom  large 
doses  of  salicylic  acid  had  been  given ;  the  other  two  were  instances  of  peliosis 
rheumatica,  in  both  of  which  partial  sloughing  of  the  uvula  took  place. 

(c)  (Edema. — An  infiltrated  cedematous  condition  of  the  uvula  and  adja- 
cent parts  is  not  very  uncommon  in  conditions  of  debility,  in  profound  anaemia, 
and  in  Bright's  disease.  The  uvula  is  sometimes  enormously  enlarged  from 
this  cause,  whence  may  arise  difficulty  in  swallowing  or  in  breathing. 

Acute  Pharyngitis  (Sore  Throat;  Angina  Simplex). — The  entire  pharyn- 
geal structures,  often  with  the  tonsils,  are  involved.  The  condition  may  fol- 
low cold  or  exposure.  In  other  instances  it  is  associated  with  constitutional 
states,  such  as  gout,  or  with  digestive  disorders.  The  patient  complains  of 
uneasiness  and  soreness  in  swallowing,  of  a  feeling  of  tickling  and  drynes/3 


DISEASES    OF    THE    PHARYNX  465 

in  the  throat,  together  with  a  constant  desire  to  hawk  and  cough.  Frequently 
the  inflammation  extends  into  the  larynx  and  produces  hoarseness.  Not  un- 
commonly it.  is  only  part  of  a  general  naso-pharyngeal  catarrh.  The  process 
may  pass  into  the  Eustachian  tubes  and  cause  slight  deafness.  There  is  stiff- 
ness of  the  neck,  the  lymph-glands  of  which  may  be  enlarged  and  painful. 
The  constitutional  symptoms  are  rarely  severe.  The  disease  sets  in  with  a 
chilly  feeling  and  slight  fever;  the  pulse  is  increased  in  frequency.  Occasion- 
ally the  f ebrHe  symptoms  are  more  severe,  particularly  if  the  tonsils  are 
specially  involved.  The  examination  of  the  throat  shows  general  congestion, 
of  the  mucous  membrane,  which  is  dry  and  glistening,  and  in  places  covered 
with  sticky  secretion.  The  uvula  may  be  much  swollen. 

Acute  pharyngitis  lasts  only  a  few  days  and  requires  mild  measures.  Cold 
compresses  or  an  ice  bag  may  be  applied  to  the  neck.  If  the  tonsils  are  in- 
volved and  the  fever  is  high,  aconite  or  sodium  salicylate  may  be  given. 
Guaiacum  also  is  beneficial;  but  in  a  majority  of  the  cases  a  calomel  purge 
or  a  saline  aperient  and  simple  inhalations  meet  the  indications. 

Chronic  Pharyngitis. — This  may  follow  repeated  acute  attacks.  It  is  very 
common  in  persons  who  smoke  or  drink  to  excess,  and  in  those  who  use 
the  voice  very  much,  such  as  clergymen,  hucksters,  and  others.  It  is  fre- 
quently associated  with  chronic  nasal  catarrh.  The  naso-pharynx  and  the 
posterior  wall  are  the  parts  most  frequently  affected.  The  mucous  membrane 
is  relaxed,  the  venules  are  dilated,  and  roundish  bodies,  from  2  to  4  mm. 
in  diameter,  reddish  in  color,  project  to  a  variable  distance  beyond  the  mucous 
membrane.  These  represent  the  proliferations  of  lymph  tissue  about  the 
mucous  glands.  They  may  be  very  abundant,  forming  elongated  rows  in  the 
lateral  walls  of  the  pharynx.  With  this  there  may  be  a  dry  glistening  state 
of  the  pharyngeal  mucosa,  sometimes  known  as  pharyngitis  sicca.  The  pillars 
of  the  fauces  and  the  uvula  are  often  much  relaxed.  The  secretion  forms 
at  the  back  of  the  pharynx  and  the  patient  may  feel  it  drop  down  from  the 
vault,  or  it  is  tenacious  and  adherent,  and  is  only  removed  by  repeated  efforts 
at  hawking. 

In  the  treatment  special  attention  must  be  paid  to  the  general  health.  If 
possible,  the  cause  should  be  ascertained.  The  condition  is  almost  constant 
in  smokers,  and  cannot  be  cured  without  stopping  the  use  of  tobacco.  The 
use  of  food  either  too  hot  or  too  much  spiced  should  be  forbidden.  When  it 
depends  upon  excessive  exercise  of  the  voice,  rest  should  be  enjoined.  In 
many  of  these  cases  change  of  air  and  tonics  help  very  much.  In  the  local 
treatment  of  the  throat,  gargles,  washes,  and  pastilles  of  various  sorts  give 
temporary  relief,  but  when  the  hypertrophic  condition  is  marked  the  spots 
should  be  thoroughly  destroyed  by  the  galvano-cautery.  In  many  instances 
this  affords  great  and  permanent  relief,  but  in  others  the  condition  persists, 
and,  as  it  is  not  unbearable,  the  patient  gives  up  all  hope  of  permanent  relief. 

TJlceration  of  the  Pharynx. —  (a)  Follicular. — The  ulcers  are  usually 
small,  superficial,  and  generally  associated  with  chronic  catarrh. 

(6)  Syphilitic. — Most  frequently  painless  and  situated  on  the  posterior 
wall  of  the  pharynx,  they  occur  in  the  secondary  stage  as  small,  shallow  ex- 
cavations with  the  mucous  patches.  In  the  tertiary  stage  they  are  due  to 
erosion  of  gummata,  and  in  healing  they  leave  whitish  cicatrices. 

(c)   Tuberculous. — Not  very  uncommon  in  advanced  cases  of  phthisis,  if 


466  •  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

extensive,  they  form  one  of  the  most  distressing  features  of  the  disease.  The 
ulcers  are  irregular,  with  ill-defined  edges  and  grayish-yellow  bases.  The  pos- 
terior wall  of  the  pharynx  may  have  an  eroded,  worm-eaten  appearance.  These 
ulcers  are,  as  a  rule,  intensely  painful.  Occasionally  the  primary  disease  is 
about  the  tonsils  and  the  pillars  of  the  fauces. 

(d)  Ulcers  occur  in  connection  with  pseudo-membranous  inflammation^ 
particularly  the  diphtheritic.    In  cancer  and  in  lupus  ulcers  are  also  present. 

(e)  Ulcers  are  met  with  in  certain  of  the  fevers,  particularly  in  typhoid. 
In  many  instances  the  diagnosis  of  the  nature  of  pharyngeal  ulcers  is  very 

difficult.  The  tuberculous  and  cancerous  varieties  are  readily  recognized,  but 
it  happens  not  infrequently  that  a  doubt  arises  as  to  the  syphilitic  character 
of  an  ulcer.  In  many  instances  the  local  conditions  may  be  uncertain.  Then 
other  evidences  of  syphilis  should  be  sought  for,  and  the  patient  should  be 
placed  on  mercury  and  iodide  of  potassium,  under  which  remedies  specific 
ulcers  usually  heal  with  great  rapidity. 

Acute  Infectious  Phlegmon  of  the  Pharynx. — Under  this  term  Senator 
has  described  cases  in  which,  along  with  difficulty  in  swallowing,  soreness  of 
the  throat,  and  sometimes  hoarseness,  the  neck  enlarges,  the  pharyngeal 
mucosa  becomes  swollen  and  injected,  the  fever  is  high,  the  constitutional 
symptoms  are  severe,  and  the  inflammation  passes  on  rapidly  to  suppuration. 
The  symptoms  are  very  intense.  The  swelling  of  the  pharyngeal  tissues  early 
reaches  such  a  grade  as  to  impede  respiration.  Similar  symptoms  may  be 
produced  by  foreign  bodies  in  the  pharynx. 

Betro-pharyngeal  abscess  occurs:  (a)  In  healthy  children  between  six 
months  and  two  years  of  age.  The  child  becomes  restless,  the  voice  changes; 
it  becomes  nasal  or  metallic  in  tone,  and  there  are  pain  and  difficulty  in  swal- 
lowing. Inspection  of  the  pharynx  reveals  a  projecting  tumor  in  the  middle 
line,  or,  if  it  be  not  visible,  it  is  readily  felt,  on  palpation,  projecting  from  the 
posterior  wall.  (&)  As  a  not  infrequent  sequel  of  the  fevers,  particularly  of 
scarlet  fever  and  diphtheria,  (c)  In  caries  of  the  bodies  of  the  cervical 
vertebrae. 

The  diagnosis  is  readily  made,  as  the  projecting  tumor  can  be  seen,  or 
felt  with  the  finger  on  the  posterior  wall  of  the  pharynx. 

Angina  Ludovici  (Ludwig's  Angina;  Cellulitis  of  the  Neck). — In  medical 
practice  this  is  seen  as  a  secondary  inflammation  in  the  specific  fevers,  par- 
ticularly diphtheria  and  scarlet  fever.  It  may,  however,  occur  idiopathically 
or  result  from  trauma.  It  is  probably  always  a  streptococcus  infection  which 
spreads  rapidly  from  the  glands.  The  swelling  at  first  is  most  marked  in  the 
submaxillary  region  of  one  side.  The  symptoms  are,  as  a  rule,  intense,  and, 
unless  early  and  thorough  surgical  measures  are  employed,  there  is  great  risk 
of  systemic  infection.  The  various  acute  septic  inflammations  of  the  throat 
— acute  oadema  of  the  larynx,  phlegmon  of  the  pharynx  and  larynx,  and  angina 
Ludovici — "represent  degrees  varying  in  virulence  of  one  and  the  same  proc- 
ess"  (Semon).  Treatment  is  surgical,  and  free  incisions  should  be  made. 


SUPPUKATIVE    TONSILLITIS  46? 


D.    DISEASES   OF    THE    TONSILS 


I.    SUPPURATIVE   TONSILLITIS 

Etiology. — Acute  suppuration  of  the  tonsillar  tissues  is  met  with  most 
frequently  in  young  persons,  with  chronic  enlargement  of  the  glands,  some- 
times as  a  sequence  of  the  acute  follicular  form  already  described  among 
the  infectious  diseases,  sometimes  as  a  result  of  exposure  to  cold  or  wet. 

Symptoms. — The  constitutional  disturbance  is  very  great.  The  tempera- 
ture rises  to  104°  or  105°  F.,  and  the  pulse  ranges  from  110  to  130.  Nocturnal 
delirium  is  not  uncommon.  The  prostration  may  be  extreme.  There  is  no 
local  disease  of  similar  extent  which  so  rapidly  exhausts  the  strength  of  a 
patient.  Soreness  and  dryness  of  the  throat,  with  pain  in  swallowing,  are 
the  symptoms  of  which  the  patient  first  complains.  One  or  both  tonsils  may 
be  involved.  They  are  enlarged,  firm  to  the  touch,  dusky  red  and  cedematous, 
and  the  contiguous  parts  are  also  much  swollen.  The  swelling  of  the  glands 
may  be  so  great  that  they  meet  in  the  middle  line,  or  one  tonsil  may  even 
push  the  uvula  aside  and  almost  touch  the  other1  gland.  The  salivary  and 
buccal  secretions  are  increased.  The  glands  of  the  neck  enlarge,  the  lower  jaw 
is  fixed,  and  the  patient  is  unable  to  open  his  mouth.  In  from  two  to  four 
days  the  enlarged  gland  becomes  softer,  and  fluctuation  can  be  distinctly  felt 
by  placing  one  finger  on  the  tonsil  and  the  other  at  the  angle  of  the  jaw.  The 
abscess  points  usually  toward  the  mouth,  but  in  some  cases  toward  the  pharynx. 
It  may  burst  spontaneously,  affording  instant  and  great  relief.  Suffocation 
has  followed  the  rupture  of  a  large  abscess  and  the  entrance  of  the  pus  into 
the  larynx.  When  the  suppuration  is  peritonsillar  and  extensive,  the  internal 
carotid  artery  may  be  opened;  but  these  are,  fortunately,  very  rare  accidents. 

Occasionally  a  small  focus  of  deep-seated  suppuration  is  the  cause  of  a 
fever  lasting  for  weeks  or  months. 

Treatment. — Hot  applications  in  the  form  of  poultices  and  fomentations 
are  more  comfortable  and  better  than  the  ice-bag.  The  gland  should  be  felt 
— it  cannot  always  be  seen — from  time  to  time,  and  should  be  opened  when 
fluctuation  is  distinct.  The  progress  of  the  disease  may  be  shortened  and  the 
patient  spared  several  days  of  great  suffering  if  an  incision  is  made  early. 
The  curved  bistoury,  guarded  nearly  to  the  point  with  plaster  or  cotton,  is  the 
most  satisfactory  instrument.  The  incision  should  be  made  from  above  down- 
ward, parallel  with  the  anterior  pillar.  There  are  cases  in  which,  before  sup- 
puration takes  place,  the  parenchymatous  swelling  is  so  great  that  the  patient 
is  threatened  with  suffocation.  In  such  instances  either  the  tonsil  must  be 
excised  or  tracheotomy  performed.  Delavan  refers  to  two  cases  in  which  he 
states  that  tracheotomy  would,  under  these  circumstances,  have  saved  life. 
Patients  with  this  affection  require  a  nourishing  liquid  diet,  and  during  con- 
valescence iron  in  full  doses. 

Early  removal  of  the  tonsils  should  be  practiced  when  a  child  suffers  with 
recurring  attacks,  and  thorough  local  treatment  should  be  given  to  the  naso- 
pharynx. Particular  care  should  be  taken  of  the  child's  mouth  and  throat. 


4G8  DISEASES    OF    THE    DIGESTIVE    SYSTEM 


IL    CHRONIC   TONSILLITIS 

(Chronic  Naso-pharyngeal  Obstruction;  Adenoids;  Mouth-breathing; 

Aprosexia) 

Under  this  heading  will  be  considered  also  hypertrophy  of  the  adenoid 
tissue  in  the'  vault  of  the  pharynx,  sometimes  known  as  the  pharyngeal  tonsil, 
as  the  affection  usually  involves  both  the  tonsils  proper  and  this  tissue,  and 
the  symptoms  are  not  to  be  differentiated. 

Chronic  enlargement  of  the  tissues  of  the  tonsillar  ring  is  an  affection  of 
great  importance,  and  may  influence  in  an  extraordinary  way  the  mental  and 
bodily  development  of  children. 

Etiology. — "Adenoids"  have  become  recognized  as  one  of  the  most  com- 
mon and  important  affections  of  childhood,  occurring  most  frequently  be- 
tween the  fifth  and  tenth  years.  The  introduction  of  the  systematic  inspec- 
tion of  school  children  has  done  more  than  anything  else  to  force  upon  the 
profession  and  the  public  the  recognition  of  the  condition  as  one  influencing 
seriously  the  bodily  and  mental  growth,  disturbing  hearing  and  furnishing  a 
focus  for  the  development  of  pathogenic  organisms.  Few  children  escape 
altogether.  In  many  it  is  a  trifling  affair,  easily  remedied;  in  others  it  is  a 
serious  and  obstinate  trouble,  taxing  the  skill  and  judgment  of  the  specialist. 
It  is  not  easy  to  say  why  the  disease  has  become  so  prevalent.  In  the  United 
States  it  is  attributed  to  the  dry,  hot  air  of  the  houses,  in  England  to  the  cold, 
damp  climate.  In  winter  nearly  all  the  school  children  in  England  have  the 
"snuffles,"  and  a  considerable  proportion  of  them  adenoids.  Interested  in  the 
subject  ever  since  reading  Meyer's  original  paper,  I  thought  American  children 
especially  prone,  but  the  disease  seems  to  be  even  more  prevalent  in  England. 

Adenoids  may  be  associated  with  slight  enlargement  of  the  lymph-glands, 
thymus  and  spleen  in  the  condition  of  lymphatism. 

Morbid  Anatomy. — The  tonsils  are  enlarged,  due  to  multiplication  of  all 
the  constituents  of  the  glands.  The  lymphoid  elements  may  be  chiefly  in- 
volved without  much  development  of  the  stroma.  In  other  instances  the 
fibrous  matrix  is  increased,  and  the  organ  is  then  harder,  smaller,  firmer,  and 
is  cut  with  much  greater  difficulty. 

The  adenoids,  which  spring  from  the  vault  of  the  pharynx,  form  masses 
varying  in  size  from  a  small  pea  to  an  almond.  They  may  be  sessile,  with 
broad  bases,  or  pedunculated.  They  are  reddish  in  color,  of  moderate  firm- 
ness, and  contain  numerous  blood-vessels.  "Abundant,  as  a  rule,  over  the 
vault,  on  a  line  with  the  fossa  of  the  Eustachian  tube,  the  growths  may  lie 
posterior  to  the  fossa — namely,  in  the  depression  known  as  the  fossa  of  Rosen- 
miiller,  or  upon  the  parts  which  are  parallel  to  the  posterior  wall  of  the 
pharynx.  The  growths  appear  to  spring  in  the  main  from  the  mucous  mem- 
brane covering  the  localities  where  the  connective  tissue  fills  in  the  inequalities 
of  the  base  of  the  skull"  (Harrison  Allen).  The  growths  are  most  frequently 
papillomatous  with  a  lymphoid  parenchyma.  Hypertrophy  of  the  pharyngeal 
adenoid  tissue  may  be  present  without  great  enlargement  of  the  tonsils  proper. 
Chronic  catarrh  of  the  nose  usually  coexists. 

Symptoms. — The  direct  effect  of  adenoids  is  the  establishment  of  mouth- 


CHRONIC    TONSILLITIS  469 

breathing.  The  indirect  effects  are  deformation  of  the  thorax,  changes  in  the 
facial  expression,  sometimes  marked  alteration  in  the  mental  condition,  in 
certain  cases  stunting  of  the  growth,  and  in  a  great  many  subjects  deafness. 
Woods  Hutch inson  has  suggested  that  the  embryological  relation  of  these 
structures  and  the  pituitary  body  may  account  for  the  interference  with  de- 
velopment. The  establishment  of  mouth-breathing  is  the  symptom  which 
first  attracts  the  attention.  It  is  not  so  noticeable  by  day,  although  the  child 
may  present  the  vacant  expression  characteristic  of  this  condition.  At  night 
the  child's  sleep  is  greatly  disturbed;  the  respirations  are  loud  and  snorting, 
and  there  are  sometimes  prolonged  pauses,  followed  by  deep,  noisy  inspira- 
tions. The  pulse  may  vary  strangely  during  these  attacks,  and  in  the  pro- 
longed intervals  may  be  slow,  to  increase  greatly  with  the  forced  inspira- 
tions. The  alas  nasi  should  be  observed  during  the  sleep  of  the  child,  as  they 
are  sometimes  much  retracted  during  inspiration,  due  to  a  laxity  of  the  walls, 
a  condition  readily  remedied  by  the  use  of  a  soft  wire  dilator.  Night  terrors 
are  common.  The  child  may  wake  up  in  a  paroxysm  of  shortness  of  breath. 
Sometimes  these  attacks  are  of  great  severity  and  the  dyspnoea,  or  rather 
orthopnoea,  may  suggest  pressure  of  enlarged  glands  on  the  trachea.  Some- 
times there  is  a  nocturnal  paroxysmal  cough  of  a  very  troublesome  character 
(Balne's  cough),  usually  excited  by  lying  down.  The  attacks  may  occur 
through  the  day. 

When  the  mouth-breathing  has  persisted  for  a  long  time  definite  changes 
are  brought  about  in  the  face,  mouth,  and  chest.  The  facies  is  so  peculiar 
and  distinctive  that  the  condition  may  be  evident  at  a  glance.  The  expression 
is  dull,  heavy,  and  apathetic,  due  in  part  to  the  fact  that  the  mouth  is  habitu- 
ally left  open.  In  long-standing  cases  the  child  is  very  stupid-looking,  re- 
sponds slowly  to  questions,  and  may  be  sullen  and  cross.  The  lips  are  thick, 
the  nasal  orifices  small  and  pinched-in-looking,  the  superior  dental  arch  is 
narrowed  and  the  roof  of  the  mouth  considerably  raised. 

The  remarkable  alterations  in  the  shape  of  the  chest  in  connection  with 
enlarged  tonsils  were  first  carefully  studied  by  Dupuytren  (1828),  who  evi- 
dently fully  appreciated  the  great  importance  of  the  condition.  He  noted 
"a  lateral  depression  of  the  parietes  of  the  chest  consisting  of  a  depression, 
more  or  less  great,  of  the  ribs  on  each  side,  and  a  proportionate  protrusion 
of  the  sternum  in  front."  J.  Mason  Warren  (Medical  Examiner,' 1839)  gave 
an  admirable  description  of  the  constitutional  symptoms  and  the  thoracic  de- 
formities induced  by  enlarged  tonsils.  These,  with  the  memoir  of  Lambron 
(1861),  constitute  the  most  important  contributions  to  our  knowledge  on  the 
subject.  Three  types  of  deformity  may  be  recognized : 

(a)  THE  PIGEON  OR  CHICKEN  BREAST,  by  far  the  most  common  form,  in 
which  the  sternum  is  prominent  and  there  is  a  circular  depression  in  the  lat- 
eral zone  (Harrison's  groove),  corresponding  to  the  attachment  of  the  dia- 
phragm. The  ribs  are  prominent  anteriorly  and  the  sternum  is  angulated 
forward  at  the  manubrio-gladiolar  junction.  As  a  mouth-breather  is  watched 
during  sleep  one  can  see  the  lower  and  lateral  thoracic  regions  retracted  dur- 
ing inspiration  by  the  action  of  the  diaphragm. 

(5)  BARREL  CHEST. — Some  children,  the  subject  of  chronic  naso-pharyn- 
geal  obstruction,  have  recurring  attacks  of  asthma,  and  the  chest  may  be 
gradually  deformed,  becoming  rounded  and  barrel-shaped,  the  neck  short,  and 


470  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

the  shoulders  and  back  bowed.  A  child  of  ten  or  eleven  may  have  the  thoracic 
conformation  of  an  old  man  with  emphysema. 

(c)  THE  FUNNEL  BREAST  (Trichterbrust) . — This  remarkable  deformity, 
in  which  there  is  a  deep  depression  at  the  lower  sternum,  has  excited  much 
controversy  as  to  its  mode  of  origin.  In  some  instances,  at  least,  it  is  due  to 
the  obstructed  breathing  in  connection  with  adenoid  vegetations.  I  have  seen 
two  cases  in  children,  in  which  the  condition  was  in  process  of  formation. 
During  inspiration  the  lower  sternum  was  forcibly  retracted,  so  much  so  that 
at  the  height  the  depression  corresponded  to  that  of  a  well-marked  "Trichter- 
brust." While  in  repose,  the  lower  sternal  region  was  distinctly  excavated. 

The  voice  is  altered  and  acquires  a  nasal  quality.  The  pronunciation  of 
certain  letters  is  changed,  and  there  is  inability  to  pronounce  the  nasal  con- 
sonants n  and  m.  Bloch  lays  great  stress  upon  the  association  of  mouth- 
breathing  with  stuttering. 

The  hearing  is  impaired,  usually  owing  to  the  extension  of  inflammation 
along  the  Eustachian  tubes  and  the  obstruction  with  mucus  or  the  narrowing 
of  their  orifices  by  pressure  of  the  adenoid  vegetations.  In  some  instances  it 
may  be  due  to  retraction  of  the  drums,  as  the  upper  pharynx  is  insufficiently 
supplied  with  air.  Naturally  the  senses  of  taste  and  smell  are  much  impaired. 
With  these  symptoms  there  may  be  little  or  no  nasal  catarrh  or  discharge, 
but  the  pharyngeal  secretion  of  mucus  is  always  increased.  Children,  however, 
do  not  notice  this,  as  the  mucus  is  usually  swallowed,  but  older  persons 
expectorate  it  with  difficulty. 

Among  other  symptoms  may  be  mentioned  headache,  which  is  by  no  means 
uncommon,  general  listlessness,  and  an  indisposition  for  physical  or  mental 
exertion.  Habit-spasm  of  the  face  has  been  described  in  connection  with  it. 
I  have  known  several  instances-  in  which  permanent  relief  has  been  afforded 
by  the  removal  of  the  adenoid  vegetations.  Enuresis  is  occasionally  an  asso- 
ciated symptom.  The  influence  upon  the  mental  development  is  striking. 
Mouth-breathers  are  usually  dull,  stupid,  and  backward.  It  is  impossible  for 
them  to  fix  the  attention  for  long  at  a  time,  and  to  this  impairment  of  the 
mental  function  Guye,  of  Amsterdam,  has  given  the  name  aprosexia.  Head- 
aches, forgetfulness,  inability  to  study  without  discomfort  are  frequent  symp- 
toms of  this  condition  in  students.  There  is  more  than  a  grain  of  truth  in 
the  aphorism  shut  your  mouth  and  save  your  life,  which  is  found  on  the  title- 
page  of  Captain  Catlin's  celebrated  pamphlet  on  mouth-breathing  (1861),  to 
which  cause  he  attributed  all  the  ills  of  civilization. 

A  symptom  specially  associated  with  enlarged  tonsils  is  fetor  of  the  breath. 
In  the  tonsillar  crypts  the  inspissated  secretion  undergoes  decomposition  and 
an  odor  not  unlike  that  of  Limburger  cheese  is  produced.  The  little  cheesy 
masses  may  sometimes  be  squeezed  from  the  crypts  of  the  tonsils.  Though 
the  odor  may  not  apparently  be  very  strong,  yet  if  the  mass  be  squeezed  be- 
tween the  fingers  its  intensity  will  at  once  be  appreciated.  In  some  cases  of 
chronic  enlargement  the  cheesy  masses  may  be  deep  in  the  tonsillar  crypts; 
and  if  they  remain  for  a  prolonged  period  lime  salts  are  deposited  and  a  ton- 
sillar calculus  is  in  this  way  produced. 

Children  with  adenoids  are  especially  prone  to  take  cold  and  to  recurring 
attacks  of  follicular  disease.  They  are  also  more  liable  to  diphtheria,  and  in. 
them  the  anginal  features  in  scarlet  fever  are  always  more  serious.  The  ulti- 


CHRONIC   TONSILLITIS  471 

mate  results  of  untreated  adenoid  hypertrophy  are  important.  In  some  cases 
the  vegetations  disappear,  leaving  an  atrophic  condition  of  the  vault  of  the 
pharynx.  Neglect  may  also  lead  to  the  so-called  Thornwaldt's  disease,  in 
which  there  is  a  cystic  condition  of  the  pharyngeal  tonsil  and  constant  secre- 
tion of  muco-pus. 

Diagnosis. — The  facial  aspect  is  usually  distinctive.  Enlarged  tonsils  are 
readily  seen  on  inspection  of  the  pharynx.  There  may  be  no  great  enlargement 
of  the  tonsils  and  nothing  apparent  at  the  back  of  the  throat  even  when  the 
naso-pharynx  is  completely  blocked  with  adenoid  vegetations.  In  children  the 
rhinoscopic  examination  is  rarely  practicable.  Digital  examination  is  the  most 
satisfactory.  The  growths  can  then  be  felt  either  as  small,  flat  bodies  or,  if 
extensive,  as  velvety,  grape-like  papillomata. 

Treatment. — If  the  tonsils  are  large  and  the  general  state  is  evidently 
influenced  by  them  they  should  be  at  once  removed.  Applications  of  iodine 
and  iron,  or  penciling  the  crypts  with  nitrate  of  silver,  are  of  service  in  the 
milder  grades,  but  it  is  waste  of  time  to  apply  them  to  very  enlarged  glands. 
There  is  a  condition  in  which  the  tonsils  are  not  much  enlarged,  but  the  crypts 
are  constantly  filled  with  cheesy  secretions  and  cause  a  very  bad  odor  in  the 
breath.  In  such  instances  the  removal  of  the  secretion  and  thorough  pencil- 
ing of  the  crypts  with  chromic  acid  may  be  practiced.  The  galvano-cautery 
is  of  great  service  in  many  cases  of  enlarged  tonsils  when  there  is  any  objec- 
tion to  the  more  radical  surgical  procedure. 

The  treatment  of  the  adenoid  growths  in  the  pharynx  is  of  the  greatest 
importance,  and  should  be  thoroughly  carried  out.  Parents  should  be  frankly 
told  that  the  affection  is  serious,  one  which  impairs  the  mental  not  less  than 
the  bodily  development  of  the  child.  In  spite  of  the  thorough  ventilation  of 
this  subject  by  specialists,  practitioners  do  not  appear  to  have  grasped  as  yet 
the  full  importance  of  this  disease.  They  are  far  too  apt  to  temporize  and 
unnecessarily  to  postpone  radical  measures.  The  child  must  be  anesthetized. 
Severe  haemorrhage  has  followed  in  a  few  cases.  Special  examination  should 
be  made  of  the  thymus  and  lymph  glands,  as  if  they  are  enlarged  the  operation 
should  be  postponed.  In  this  state  of  lymphatism  death  during  anesthesia 
lias  occurred.  The  good  effects  of  the  operation  are  often  apparent  within  a 
few  days,  and  the  child  begins  to  breathe  through  the  nose.  In  some  instances 
the  habit  of  mouth-breathing  persists.  As  soon  as  the  child  goes  to  sleep  the 
lower  jaw  drops  and  the  air  is  drawn  into  the  mouth.  In  these  cases  a  chin 
strap  can  be  readily  adjusted,  which  the  child  may  wear  at  night.  In  severe 
cases  it  may  take  months  of  careful  training  before  the  child  can  speak  prop- 
erly. An  all-important  point  in  the  treatment  of  lesions  of  the  naso-pharynx 
(and,  indeed,  in  the  prevention  of  this  unfortunate  condition)  is  to  increase 
the  breathing  capacity  of  the  chest  by  making  the  child  perform  systematic 
exercises,  which  cause  the  air  to  be  driven  freely  and  forcibly  in  and  out 
through  the  naso-pharynx.  I  cannot  too  strongly  commend  this  suggestion  of 
Mr.  Arbuthnot  Lane. 

Throughout  the  entire  treatment  attention  should  be  paid  to  hygiene  and 
diet,  and  cod-liver  oil  and  the  iodide  of  iron  may  be  administered  with  benefit. 


DISEASES    OP   THE    DIGESTIVE    SYSTEM 


E.    DISEASES   OF    THE   (ESOPHAGUS 


I    ACUTE    CESOPHAGITIS 

Etiology. — Acute  inflammation  occurs  (a)  in  the  catarrhal  processes  of 
the  specific  fevers;  more  rarely  as  an  extension  from  catarrh  of  the  pharynx. 
(6)  As  a  result  of  intense  mechanical  or  chemical  irritation,  produced  by 
foreign  bodies,  by  very  hot  liquids,  or  by  strong  corrosives,  (c)  In  the  form 
of  pseudo-membranous  inflammation  in  diphtheria,  and  occasionally  in  pneu- 
monia, typhoid  fever,  and  pyaemia,  (d)  As  a  pustular  inflammation  in  small- 
pox, and,  according  to  Laennec,  as  a  result  of  a  prolonged  administration  of 
tartar  emetic,  (e)  In  connection  with  local  disease,  particularly  cancer  either 
of  the  tube  itself  or  extension  to  it  from  without.  And,  lastly,  acute  cesopha- 
gitis,  occasionally  with  ulceration,  may  occur  spontaneously  in  sucklings. 

Morbid  Anatomy. — It  is  extremely  rare  to  see  redness  of  the  mucosa, 
except  when  chemical  irritants  have  been  swallowed.  More  commonly  the 
epithelium  is  thickened  and  has  desquamated,  so  that  the  surface  is  covered 
with  a  fine  granular  substance.  The  mucous  follicles  are  swollen  and  occa- 
sionally there  may  be  seen  small  erosions.  In  the  pseudo-membranous  inflam- 
mation there  is  a  grayish  croupous  exudate,  usually  limited  in  extent,  at  the 
upper  portion  of  the  gullet.  The  pustular  disease  is  very  rare  in  small-pox. 
In  the  phlegmonous  inflammation  the  mucous  membrane  is  greatly  swollen, 
and  there  is  purulent  infiltration  in  the  submucosa.  It  may  even  extend 
throughout  a  large  part  of  the  gullet.  Gangrene  occasionally  supervenes. 
There  is  a  remarkable  fibrinous  or  membranous  cesophagitis,  most  frequently 
met  with  in  the  fevers,  sometimes  also  in  hysteria,  in  which  long  casts  of  the 
tube  may  be  vomited. 

Symptoms. — Pain  in  deglutition  is  always  present  in  severe  inflammation 
of  the  oesophagus.  A  dull  pain  beneath  the  sternum  is  also  present.  In  the 
milder  forms  of  catarrhal  inflammation  there  are  usually  no  symptoms.  The 
presence  of  a  foreign  body  is  indicated  by  dysphagia  and  spasm  with  the 
regurgitation  of  portions  of  the  food.  Later,  blood  and  pus  may  be  ejected. 
It  is  surprising  how  extensive  the  disease  may  be  in  the  oesophagus  without 
producing  much  pain  or  great  discomfort,  except  in  swallowing.  The  intense 
inflammation  which  follows  the  swallowing  of  corrosives,  when  not  fatal, 
gradually  subsides,  and  often  leads  to  cicatricial  contraction  and  stricture. 
In  the  cases  in  which  there  is  danger  of  contraction  cesophageal  bougies  should 
be  passed  before  this  is  marked.  The  patient  should  swallow  some  oil  before 
the  passage  of  the  bougie,  the  size  of  which  should  be  gradually  increased. 
Dilatation  should  be  done  every  few  days  at  first. 

Treatment. — The  treatment  of  acute  inflammation  of  the  oesophagus  is 
extremely  unsatisfactory,  particularly  in  the  severer  forms.  The  slight  ca- 
tarrhal cases  require  no  special  treatment.  When  the  dysphagia  is  intense 
it  is  best  not  to  give  food  by  the  mouth,  but  to  feed  entirely  by  enemata. 
Fragments  of  ice  may  be  given,  and  as  the  pain  and  distress  subside,  demul- 
cent drinks.  External  applications  of  cold  often  give  relief. 


SPASM   OF   THE    (ESOPHAGUS  473 

A  chronic  form  of  cesophagitis  is  described,  but  this  results  usually  from 
the  prolonged  action  of  the  causes  which  produce  the  acute  form. 

Catarrhal  Ulceration. — Follicular  ulcers  are  not  uncommon.  Tuberculous 
and  syphilitic  ulcers  are  rare.  Very  prominent  varicose  veins  and  small  ero- 
sions are  not  uncommon.  The  other  forms  are  the  carcinomatous,  the  erosion 
due  to  aneurism,  and  the  ulcerative  action  of  corrosive  substances.  There  are 
two  other  important  varieties — the  ulcers  in  acute  infectious  diseases,  diphthe- 
ria, scarlet  fever,  and  pneumonia ;  and  the  peptic  ulcer,  first  described  by  Albers 
in  1839.  Tileston  has  collected  forty  cases  of  peptic  ulcer  in  the  oesophagus. 
The  pain,  dysphagia,  vomiting,  and  haemorrhage  have  been  the  most  important 
symptoms.  Perforation  occurred  in  six  cases,  in  one  instance  into  the  aorta. 
Treatment  is  difficult;  in  severe  cases  gastrostomy  should  be  done. 

(Esophageal  Varices. — Associated  with  chronic  heart-disease  and  more  fre- 
quently with  the  senile  and  the  cirrhotic  liver,  the  cesophageal  veins  may  be- 
come distended  and  varicose.  The  mucous  membrane  is  in  a  state  of  chronic 
catarrh,  and  the  patient  has  frequent  eructations  of  mucus.  Eupture  of  these 
varices  is  one  of  the  commonest  causes  of  haamatemesis  in  cirrhosis  of  the 
liver  and  in  enlarged  spleen.  The  blood  may  pass  per  rectum  alone. 


II.    SPASM   OF   THE  (ESOPHAGUS 

(CEsopTiagismus) 

This  so-called  spasmodic  stricture  of  the  gullet  is  met  with  in  hysterical 
patients  and  hypochrondriacs,  also  in  chorea,  epilepsy,  and  especially  hydro- 
phobia. It  is  sometimes  associated  also  with  the  lodgment  of  foreign  bodies, 
or  with  cases  in  which  a  patient  has  swallowed  a  foreign  body  and  thinks  it  has 
stuck.  For  weeks  there  may  be  spasm,  due  perhaps  to  autosuggestion,  though 
the  bougie  passes  freely.  The  idiopathic  form  is  found  in  females  of  a  marked 
neurotic  habit,  but  may  also  occur  in  elderly  men.  It  may  be  present  only 
during  pregnancy.  The  patient  complains  of  inability  to  swallow  solid  food, 
and  in  extreme  instances  even  liquids  are  rejected.  The  attack  may  come  on 
abruptly,  and  be  associated  with  emotional  disturbances  and  with  substernal 
pain.  The  bougie,  when  passed,  may  be  arrested  temporarily  at  the  seat  of 
the  spasm,  which  gradually  yields,  or  it  may  slip  through  without  the  slightest 
effort.  The  condition  is  rarely  serious,  though  it  may  persist  for  years. 
Spasm  of  the  lower  end  of  the  gullet,  associated  with  cardio-spasm,  may  be 
the  cause  of  a  remarkable  fusiform  dilatation  of  the  oesophagus. 

The  diagnosis  is  not  difficult,  particularly  in  young  persons  with  marked 
nervous  manifestations.  In  elderly  persons  cesophagismus  is  almost  always 
connected  with  hypochondriasis,  but  great  care  must  be  taken  to  exclude 
cancer. 

In  some  cases  a  cure  is  at  once  effected  by  the  passage  of  a  bougie.  The 
general  neurotic  condition  also  requires  special  attention. 

Paralysis  of  the  oesophagus  scarcely  demands  separate  consideration.     It 
is  a  very  rare  condition,  due  most  often  to  central  disease,  particularly  bulbar 
paralysis.    It  may  be  peripheral  in  origin,  as  in  diphtheritic  paralysis.    Occa- 
sionally it  occurs  also  in  hysteria.    The  essential  symptom  is  dysphagia. 
81 


474  DISEASES    OF   THE    DIGESTIVE    SYSTEM 


in.    STRICTURE   OF   THE    (ESOPHAGUS 

This  results  from:  (a)  Congenital  stenosis  of  the  oesophagus. — There  are 
two  groups  of  cases,  one  in  which  there  is  complete  occlusion,  and  the  middle 
of  the  tube  is  converted  into  a  fibrous  cord;  the  other,  the  more  common,  in 
which  the  lower  part  opens  into  the  trachea  or  one  of  the  bronchi.  There  are 
gome  19  cases  on  record  (William  Thomas).  (&)  The  cicatricial  contraction 
of  healed  ulcers,  usually  due  to  corrosive  poisons,  occasionally  to  syphilis,  and 
in  rare  instances  after  the  fevers,  (c)  The  growth  of  tumors  in  the  walls, 
as  in  the  so-called  cancerous  stricture.  Eighty-five  per  cent,  of  the  cases  are 
of  this  nature,  (d)  External  pressure  by  aneurism,  enlarged  lymph-glands, 
enlarged  thyroid,  other  tumors,  and  sometimes  by  pericardial  effusion. 

The  cicatricial  stricture  may  occur  anywhere  in  the  gullet,  and  in  extreme 
cases  may,  indeed,  involve  the  whole  tube,  but  in  a  majority  of  instances' it  is 
found  either  high  up  near  the  pharynx  or  low  down  toward  the  stomach.  The 
narrowing  may  be  extreme,  so  that  only  small  quantities  of  food  can  trickle 
through,  or  the  obstruction  may  be  quite  slight.  When  the  stricture  is  low 
down  the  oesophagus  is  dilated  and  the  walls  are  usually  much  hypertrophied. 
When  the  obstruction  is  high  in  the  gullet,  the  food  is  usually  rejected  at  once, 
whereas,  if  it  is  low,  it  may  be  retained  and  a  considerable  quantity  collects 
before  it  is  regurgitated.  Any  doubt  as  to  its  having  reached  the  stomach  is 
removed  by  the  alkalinity  of  the  material  ejected  and  the  absence  of  the  char- 
acteristic gastric  odor.  Auscultation  of  the  oesophagus  may  be  practiced  and 
is  sometimes  of  service.  The  patient  takes  a  mouthful  of  water  and  the  auscul- 
tator  listens  along  the  left  of  the  spine.  The  normal  cesophageal  bruit  may  be 
heard  later  than  seven  seconds,  the  normal  time,  or  there  may  be  heard  a  loud 
splashing,  gurgling  sound.  The  secondary  murmur,  heard  as  the  fluid  enters 
the  stomach,  may  be  absent.  The  bismuth  meal  and  the  fluoroscope  now  make 
the  diagnosis  very  easy.  The  passage  of  the  cesophageal  bougie  will  determine 
accurately  the  locality.  Conical  bougies  attached  to  a  flexible  whalebone  stem 
are  the  most  satisfactory,  but  the  gum-elastic  stomach  tube  may  be  used;  a 
large  one  should  be  tried  first.  The  patient  should  be  placed  on  a  low  chair 
with  the  head  well  thrown  back.  The  index  finger  of  the  left  hand  is  passed 
far  into  the  pharynx,  and  in  some  instances  this  procedure  alone  may  deter- 
mine the  presence  of  a  new  growth.  The  bougie  is  passed  beside  the  finger 
until  it  touches  the  posterior  wall  of  the  pharynx,  then  along  it,  more  to  one 
side  than  in  the  middle  line,  and  so  gradually  pushed  into  the  gullet.  It  is 
to  be  borne  in  mind  that  in  passing  the  cricoid  cartilage  there  is  often  a  slight 
obstruction.  Great  gentleness  should  be  used,  as  it  has  happened  more  than 
once  that  the  bougie  has  been  passed  through  a  cancerous  ulcer  into  the  me- 
diastinum or  through  a  diverticulum.  It  is  well  always,  as  a  precautionary 
measure  before  passing  the  bougie,  to  examine  carefully  for  aneurism,  which 
may  produce  all  the  symptoms  of  organic  stricture.  In  cases  in  which  the 
narrowing  is  extreme  there  is  always  emaciation.  For  treatment,  surgical 
works  must  be  consulted. 


CANCER  OF  THE  (ESOPHAGUS  475 


IV.  CANCER  OF  THE  (ESOPHAGUS 

This  is  usually  epithelioma.  It  is  not  a  common  disease;  there  were  only 
38  cases  in  the  medical  wards  of  the  Johns  Hopkins  Hospital  in  twenty-three 
years.  It  may  occur  in  quite  young  persons,  and  is  more  frequent  in  males 
than  in  females.  The  middle  and  lower  thirds  are  most  often  affected.  At 
first  confined  to  the  mucous  membrane,  the  cancer  gradually  increases  and  soon 
ulcerates.  The  lumen  of  the  tube  is  narrowed,  but  when  ulceration  is  exten- 
sive in  the  later  stages  the  stricture  may  be  less  marked.  Dilatation  of  the 
tube  and  hypertrophy  of  the  walls  usually  take  place  above  the  cancer.  The 
ulcer  may  perforate  the  trachea  or  a  bronchus,  the  lung,  the  pleura,  the  me- 
diastinum, the  aorta  or  one  of  its  larger  branches,  the  pericardium,  or  it  may 
erode  the  vertebral  column.  The  recurrent  laryngeal  nerves  are  not  infre- 
quently implicated.  Perforation  of  the  lung  produces,  as  a  rule,  local  gan- 
grene. 

Symptoms. — The  earliest  symptom  is  dysphagia,  which  is  progressive  and 
may  become  extreme,  so  that  the  patient  emaciates  rapidly.  Regurgitation 
may  take  place  at  once;  or,  if  the  cancer  is  situated  near  the  stomach,  it  may 
be  deferred  for  ten  or  fifteen  minutes,  or  even  longer  if  the  tube  is  much 
dilated.  The  rejected  materials  may  be  mixed  with  blood  and  may  contain 
cancerous  fragments.  In  persons  over  fifty  years  of  age  persistent  difficulty 
in  swallowing  accompanied  by  rapid  emaciation  usually  indicates  cesophageal 
cancer.  The  cervical  lymph-glands  are  frequently  enlarged  and  may  give 
early  indication  of  the  nature  of  the  trouble.  Pain  may  be  persistent  or  be 
present  only  when  food  is  taken.  In  certain  instances  the  pain  is  very  great. 
The  latent  cases  are  very  rare.  Bronchitis  and  broncho-pneumonia  are  com- 
mon terminal  events. 

Diagnosis. — The  bismuth  meal  and  the  Rontgen-ray  picture  give  informa- 
tion as  to  the  position  of  the  stricture,  and  a  very  dense  growth  may  throw  a 
shadow.  In  the  diagnosis  of  the  condition  it  is  important,  in  the  first  place, 
to  exclude  pressure  from  without,  as  by  aneurism  or  other  tumor.  The  history 
enables  us  to  exclude  cicatricial  stricture  and  foreign  bodies.  The  sound  may 
be  passed  and  the  presence  of  the  stricture  determined.  As  mentioned  above, 
great  care  should  be  exercised.  Fragments  of  carcinomatous  tissue  may  in 
some  instances  be  removed  with  the  tube.  On  auscultation  along  the  left  side 
of  the  spine  the  primary  fesophageal  murmur  may  be  much  altered  in  quality. 

Treatment. — In  most  cases  milk  and  liquids  can  be  swallowed,  but  supple- 
mentary nourishment  should  be  given  by  the  rectum.  It  may  be  advisable  in 
some  instances  to  pass  a  tube  into  the  stomach  and  introduce  food  in  this 
way.  When  there  is  difficulty  in  feeding  the  patient  it  is  very  much  better 
to  have  gastrostomy  performed  at  once,  as  it  gives  the  greatest  comfort  and 
ease,  and  prolongs  the  patient's  life. 

V.  RUPTURE    OF   THE   (ESOPHAGUS 

(a)  Rupture  may  occur  in  a  healthy  organ  as  a  result  of  prolonged  vomit- 
ing after  a  full  meal,  or  when  intoxicated.     Eight  cases  are  on  record  (Vir- 


476  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

chow's  Archiv,  vol.  162).  Boerhaave  described  the  first  case  in  Baron  Wassen- 
nar,  who  "broke  asunder  the  tube  of  the  oesophagus  near  the  diaphragm,  so 
that,  after  the  most  excruciating  pain,  the  elements  which  he  swallowed  passed, 
together  with  the  air,  into  the  cavity  of  the  thorax,  and  he  expired  in  twenty- 
four  hours." 

(6)  In  a  few  cases  the  rupture  has  occurred  in  a  diseased  and  weakened 
tube,  near  the  scar  of  an  ulcer,  for  example. 

(c)  Post  mortem  softening — oesophago-malacia — a  not  very  uncommon 
condition,  must  not  be  mistaken  for  it.  In  spontaneous  rupture  the  rent  is 
clean-cut  and  circumferential;  in  malacia  it  is  rounded  and  often  cribriform, 
and  the  margins  are  softened.  The  contents  of  the  stomach  may  be  in  the  left 
pleura. 

VI.    DILATATIONS  AND   DIVERTICULA 

Stenosis  of  the  gullet  is  followed  by  secondary  dilatation  of  the  tube  above 
the  constriction  and  great  hypertrophy  of  the  walls.  Primary  dilatation, 
which  is  extremely  rare,  appears  to  be  associated  with  spasm  of  the  lower 
end  of  the  gullet  and  of  the  cardiac  orifice.  The  tube  may  attain  extraordinary 
dimensions,  as  in  the  specimen  presented  in  1904  to  the  Association  of  Ameri- 
can Physicians  by  Kinnicutt.  Eegurgitation  of  food  is  the  most  common 
symptom.  There  may  also  be  difficulty  in  breathing  from  pressure. 

Diverticula  are  of  two  forms:  (a)  Pressure  diverticula,  which  are  most 
common  at  the  junction  of  the  pharynx  and  gullet,  on  the  posterior  wall. 
Owing  to  weakness  of  the  muscles  at  this  spot,  local  bulging  occurs,  which  is 
gradually  increased  by  the  pressure  of  food,  and  finally  forms  a  saccular  pouch. 
(&)  The  traction  diverticula  situated  on  the  anterior  wall  near  the  bifurcation 
of  the  trachea  result,  as  a  rule,  from  the  extension  of  inflammation  from  the 
lymph-glands  with  adhesion  and  subsequent  cicatricial  contraction,  by  which 
the  wall  of  the  gullet  is  drawn  out.  The  diagnosis  of  these  forms  is  now 
readily  made  with  the  bismuth  meal  and  X-rays.  Biverticula  have  been  suc- 
cessfully extirpated. 

A  rare  and  remarkable  condition,  of  which  a  case  has  been  recorded  by 
MacLachlan,  and  of  which  a  second  was  in  attendance  at  my  clinic,  is  the 
oesophago-pleuro-cutaneous  fistula.  In  my  patient  fluids  were  discharged  at 
intervals  through  a  fistula  in  the  right  infra-clavicular  region,  which  com- 
municated with  a  cavity  in  the  upper  part  of  the  pleura  or  lung.  The  condi- 
tion had  persisted  for  more  than  twenty-five  years. 


F.    DISEASES   OF    THE    STOMACH 

I.    ACUTE   GASTRITIS 

(Simple  Gastritis;  Acute  Gastric  Catarrh;  Acute  Dyspepsia) 

Etiology. — Acute  gastric  catarrh,  one  of  the  most  common  of  complaints, 
occurs  at  all  ages,  and  is  usually  traceable  to  errors  in  diet.     It  may  follow 


ACUTE    GASTRITIS  477 

the  ingestion  of  more  food  than  the  stomach  can  digest,  or  it  may  result  from 
taking  unsuitable  articles,  which  either  themselves  irritate  the  mucosa  or, 
remaining  undigested,  decompose,  and  so  excite  an  acute  dyspepsia.  A  fre- 
quent cause  is  the  taking  of  food  which  has  begun  to  decompose,  particularly 
in  hot  weather.  In  children  these  fermentative  processes  are  very  apt  to 
excite  acute  catarrh  of  the  bowels  as  well.  Another  very  common  cause  is  the 
abuse  of  alcohol,  and  the  acute  gastritis  which  follows  a  drinking-bout  is 
one  of  the  most  typical  forms  of  the  disease.  The  tendency  to  acute  indiges- 
tion varies  very  much  in  different  individuals,  and,  indeed,  in  families.  We 
recognize  this  in  using  the  expressions  a  "delicate  stomach"  and  a  "strong 
stomach."  Gouty  persons  are  generally  thought  to  be  more  disposed  to  acute 
dyspepsia  than  others.  Acute  catarrh  of  the  stomach  occurs  at  the  outset  of 
many  of  the  infectious  fevers. 

Morbid  Anatomy. — Beaumont's  study  of  St.  Martin's  stomach  showed 
that  in  acute  catarrh  the  mucous  membrane  is  reddened  and  swollen,  less 
gastric  juice  is  secreted,  and  mucus  covers  the  surface.  Slight  hemorrhages 
may  occur  or  even  small  erosions.  The  submucosa  may  be  somewhat  cedema- 
tous.  Microscopically  the  changes  are  chiefly  noticeable  in  the  mucous  and 
peptic  cells,  which  are  swollen  and  more  granular,  and  there  is  an  infiltration 
of  the  intertubular  tissue  with  leucocytes. 

Symptoms. — In  mild  cases  the  symptoms  are  those  of  slight  "indigestion" 
— an  uncomfortable  feeling  in  the  abdomen,  headache,  depression,  nausea, 
eructations,  and  vomiting,  which  usually  gives  relief.  The  tongue  is  heavily 
coated  and  the  saliva  is  increased.  In  children  there  are  intestinal  symptoms 
— diarrhoea  and  colicky  pains  and  often  slight  fever.  The  duration  is  rarely 
more  than  twenty-four  hours.  In  the  severer  forms  the  attack  may  set  in  with 
a  chill  and  febrile  reaction,  in  which  the  temperature  rises  to  102°  or  103°  F. 
The  tongue  is  furred,  the  breath  heavy,  and  vomiting  is  frequent.  The, 
ejected  substances,  at  first  mixed  with  food,  subsequently  contain  much  mucus 
and  bile-stained  fluids.  There  may  be  constipation,  but  very  often  there  is 
diarrhoea.  The  urine  presents  the  usual  febrile  characteristics,  and  there  is 
a  heavy  deposit  of  urates.  The  abdomen  may  be  somewhat  distended  and 
slightly  tender  in  the  epigastric  region.  Herpes  may  appear  on  the  lips.  The 
attack  may  last  from  one  to  three  days,  and  occasionally  longer.  The  exam- 
ination of  the  vomitus  shows,  as  a  rule,  absence  of  hydrochloric  acid,  the  pres- 
ence of  lactic  and  fatty  acids,  and  marked  increase  in  the  mucus. 

Diagnosis. — The  ordinary  afebrile  gastric  catarrh  is  readily  recognized. 
The  acute  febrile  form  is  so  similar  to  the  initial  symptoms  of  many  of  the 
infectious  diseases  that  it  is  impossible  for  a  day  or  two  to  make  a  diagnosis, 
particularly  in  the  cases  which  have  come  on,  so  to  speak,  spontaneously  and 
independently  of  an  error  in  diet.  Some  of  these  resemble  closely  an  acute 
infection;  the  symptoms  may  be  very  intense,  and  if,  as  sometimes  happens, 
the  attack  sets  in  with  severe  headache  and  delirium,  the  case  may  be  mistaken 
for  meningitis.  When  the  abdominal  pains  are  intense  the  attack  may  be 
confounded  with  gallstone  colic.  It  is  a  very  common  error  to  class  under 
"gastric  fever"  the  mild  forms  of  the  various  infectious  disorders.  The  gas- 
tric crises  in  locomotor  ataxia  have  in  many  instances  been  confounded  with 
a  simple  acute  gastritis,  and  it  is  always  wise  in  adults  to  test  the  knee-jerks 
and  pupillary  reactions. 


478  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

Treatment. — Mild  cases  recover  spontaneously  in  twenty-four  hours,  and 
require  no  treatment  other  than  a  dose  of  castor  oil  in  children  or  of  blue 
mass  in  adults.  In  the  severer  forms,  if  there  is  much  distress  in  the  region 
of  the  stomach,  the  vomiting  should  be  promoted  by  warm  water,  or  the 
stomach  tube  may  be  employed  for  some  patients.  A  dose  of  calomel,  2  to  3 
grains  (0.13  to  0.2  gm.),  should  be  given,  and  followed,  after  some  hours,  by  a 
saline  cathartic.  If  there  is  eructation  of  acid  fluid,  bicarbonate  of  soda  and 
bismuth  may  be  given.  The  stomach  should  have,  if  possible,  absolute  rest, 
and  it  is  a  good  plan  in  the  case  of  strong  persons,  particularly  in  those  ad- 
dicted to  alcohol,  to  cut  off  all  food  for  a  day  or  two.  The  patient  may  be 
allowed  soda  water  and  ice  freely.  It  is  well  not  to  attempt  to  check  the 
vomiting  unless  it  is  excessive  and  protracted.  Recovery  is  usually  complete, 
though  repeated  attacks  may  lead  to  subacute  gastritis  or  to  the  establishment 
of  chronic  dyspepsia. 

Phlegmonous  Gastritis;  Acute  Suppurative  Gastritis.— The  disease  is  due 
to  infection  of  the  submucosa,  probably  through  a  minute  abrasion.  Males 
are  more  frequently  affected  than  females,  and  most  of  the  cases  are  in  com- 
paratively young  people.  In  a  majority  of  the  instances  in  which  the  examina- 
tion has  been  made  streptococci  have  been  present,  but  the  pneumococcus  has 
been  found  in  a  few  cases.  The  disease  is  rare;  Leith  was  able  to  collect  only 
85  cases.  There  is  a  widespread  suppurative  infiltration  of  the  submucosa, 
with  great  thickening  of  the  walls.  Sometimes  there  is  a  localized  abscess 
formation,  with  tumor,  which  may  burst  into  the  stomach,  or  into  the  peri- 
toneum. I  have  seen  three  instances  of  this  condition,  all  in  connection  with 
cancer  of  the  stomach. 

The  important  symptoms  are  pain,  high  fever,  vomiting,  dry  tongue,  all 
the  features  of  a  severe  infection,  and  sometimes  jaundice.  A  diagnosis  is 
rarely  made;  occasionally  there  is  a  large  tumor  mass  to  be  felt.  The  cases 
are  uniformly  fatal  unless  one  counts  the  one  reported  by  Bovee,  in  which  he 
cut  down  and  opened  an  acute  abscess,  the  size  of  a  man's  fist,  in  the  anterior 
wall  of  the  pyloric  region. 

Toxic  Gastritis. — This  most  intense  form  of  inflammation  of  the  stomach 
is  excited  by  the  swallowing  of  concentrated  mineral  acids  or  strong  alkalies, 
or  by  such  poisons  as  phosphorus,  corrosive  sublimate,  ammonia,  arsenic,  etc. 
In  the  non-corrosive  poisons,  such  as  phosphorus,  arsenic,  and  antimony,  the 
process  consists  of  an  acute  degeneration  of  the  glandular  elements,  and  haem- 
orrhage. With  the  powerful  concentrated  poisons  the  mucous  membrane  is 
extensively  destroyed,  and  may  be  converted  into  a  brownish-black  eschar.  In 
the  less  severe  grades  there  may  be  areas  of  necrosis  surrounded  by  inflamma- 
tory reaction,  while  the  submucosa  is  haemorrhagic  and  infiltrated.  The  process 
is  of  course  more  intense  at  the  fundus,  but  the  active  peristalsis  may  drive 
the  poison  through  the  pylorus  into  the  intestine. 

SYMPTOMS. — The  symptoms  are  intense  pain  in  the  mouth,  throat,  and 
stomach,  salivation,  great  difficulty  in  swallowing,  and  constant  vomiting,  the 
vomited  materials  being  bloody  and  sometimes  containing  portions  of  the 
mucous  membrane.  The  abdomen  is  tender,  distended,  and  painful  on  pres- 
sure. In  the  most  acute  cases  symptoms  of  collapse  supervene;  the  pulse  is 
weak,  the  skin  pale  and  covered  with  sweat;  there  is  restlessness,  and  some- 
times convulsions.  There  may  be  albumin  or  blood  in  the  urine,  and  petechiaB 


CHRONIC    GASTRITIS  479 

may  occur  on  the  skin.  When  the  poison  is  less  intense,  the  sloughs  may 
separate,  leaving  ulcers,  which  too  often  lead,  in  the  oesophagus  to  stricture,  in 
the  stomach  to  chronic  atrophy,  and  finally  to  death  from  exhaustion. 

DIAGNOSIS. — The  diagnosis  of  toxic  gastritis  is  usually  easy,  as  inspection 
of  the  mouth  and  pharynx  shows,  in  many  instances,  corrosive  effects,  while 
the  examination  of  the  vomit  may  indicate  the  nature  of  the  poison. 

In  poisoning  by  acids,  magnesia  should  be  administered  in  milk  or  with 
egg  albumen.  When  strong  alkalies  have  been  taken,  the  dilute  acids  should 
be  administered.  If  the  case  is  seen  early,  lavage  should  be  used.  For  the 
severe  inflammation  which  follows  the  swallowing  of  the  stronger  poisons 
palliative  treatment  is  alone  available,  and  morphia  may  be  freely  employed 
to  allay  the  pain. 

Diphtheritic  or  Membranous  Gastritis. — This  condition  is  met  with  occa- 
sionally in  diphtheria,  but  more  commonly  as  a  secondary  process  in  typhus 
or  typhoid  fever,  pneumonia,  pyasmia,  small-pox,  and  occasionally  in  debili- 
tated children.  The  exudation  may  be  extensive  and  uniform  or  in  patches. 
The  condition  is  not  recognizable  during  life,  unless  the  membranes  are 
vomited. 

Mycotic  and  Parasitic  Gastritis. — It  occasionally  happens  that  fungi 
grow  in  the  stomach  and  excite  inflammation.  One  of  the  most  remarkable 
cases  of  the  kind  is  that  reported  by  Kundrat,  in  which  the  favus  fungus 
occurred  in  the  stomach  and  intestine. 

In  cancer  and  in  dilatation  of  the  stomach  the  sarcina3  and  yeast  fungi 
probably  aid  in  maintaining  the  chronic  gastritis.  As  a  rule,  the  gastric 
juice  is  capable  of  killing  the  ordinary  bacteria.  Orth  states  that  the  anthrax 
bacilli,  in  certain  cases,  produce  swelling  of  the  mucosa  and  ulceration.  Eug. 
Fraenkel  has  reported  a  case  of  acute  emphysematous  gastritis  probably  of 
mycotic  origin.  The  larvae  of  certain  insects  may  excite  gastritis,  as  in  the 
cases  reported  by  Gerhardt,  Meschede,  and  others. 


H.     CHRONIC    GASTRITIS 

(Chronic  Catarrh  of  the  Stomach;  Chronic  Dyspepsia) 

Definition. — A  condition  of  disturbed  digestion  associated  with  increased 
mucous  formation,  qualitative  or  quantitative  changes  in  the  gastric  juice, 
enfeeblement  of  the  muscular  coats>  so  that  the  food  is  retained  for  an  ab- 
normal time  in  the  stomach ;  and,  finally,  with  alterations  in  the  structure  of 
the  mucosa. 

Etiology. — The  causes  of  chronic  gastritis  may  be  classified  as  follows: 
(a)  Dietetic.  Unsuitable  or  improperly  prepared  food,  and  the  persistent 
use  of  certain  articles  of  diet,  such  as  very  fat  substances  or  foods  containing 
too  much  of  the  carbohydrates.  The  use  in  excessive  quantity  of  hot  bread, 
hot  cakes,  and  pie  is  a  fruitful  cause,  particularly  in  the  United  States.  The 
use  in  excess  of  tea  or  coffee,  and,  above  all,  of  alcohol  in  its  various  forms. 
Under  this  heading,  too,  may  be  mentioned  the  habits  of  eating  at  irregular 
hours  or  too  rapidly  and  imperfectly  chewing  the  food.  Excess  in  eating 
does  more  damage  than  excess  in  drinking.  The  platter  kills  more  than  the 


480  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

sword.  A  common  cause  of  chronic  catarrh  is  drinking  too  freely  of  ice-water 
during  meals,  a  practice  which  plays  no  small  part  in  the  prevalence  of  dys- 
pepsia in  America.  Another  frequent  cause  is  the  abuse  of  tobacco,  particu- 
larly chewing.  (6)  Constitutional  causes.  Anaemia,  chlorosis,  chronic  tuber- 
culosis, gout,  diabetes,  and  Bright's  disease  are  often  associated  with  chronic 
gastric  catarrh,  (c)  Local  conditions:  (I)  of  the  stomach,  as  in  cancer, 
ulcer,  and  dilatation,  which  are  invariably  accompanied  by  catarrh;  (2)  con- 
ditions of  the  portal  circulation,  causing  chronic  engorgement  of  the  mucous 
membrane,  as  in  cirrhosis,  chronic  heart-disease,  and  certain  chronic  lung 
affections. 

Morbid  Anatomy. — In  simple  chronic  gastritis  the  organ  is  usually  en- 
larged, the  mucous  membrane  pale  gray  in  color,  and  covered  with  closely 
adherent,  tenacious  mucus.  The  veins  are  large,  patches  of  ecchymosis  are 
not  infrequently  seen,  and  in  the  chronic  catarrh  of  portal  obstruction  and 
of  chronic  heart-disease  small  hsemorrhagic  erosions.  Toward  the  pylorus 
the  mucosa  is  not  infrequently  irregularly  pigmented,  and  presents  a  rough, 
wrinkled,  mammilated  surface,  the  etat  mamelone  of  the  French,  a  condition 
which  may  sometimes  be  so  prominent  that  writers  have  described  it  as  gas- 
tritis polyposa.  The  membrane  may  be  thinner  than  normal,  and  much 
firmer,  tearing  less  readily  with  the  finger-nail.  The  minute  anatomy  shows 
the  picture  of  a  parenchymatous  and  an  interstitial  inflammation.  The  mu- 
cous membrane  may  undergo  complete  atrophy  and  be  represented  by  a  smooth 
cuticular  membrane  resembling  that  of  the  cardiac  portion  of  the  horse's 
stomach.  This  was  the  condition  in  a  case  of  profound  ansmia  reported  by 
F.  P.  Henry  and  myself.  The  mucularis  mucosa  was  hypertrophied,  but  with 
no  great  general  thickening  of  the  stomach  walls. 

Symptoms. — The  affection  persists  for  an  indefinite  period,  and,  as  is  the 
case  with  most  chronic  diseases,  changes  from  time  to  time.  The  appetite 
is  variable,  sometimes  greatly  impaired,  at  others  very  good.  Among  early 
symptoms  are  feelings  of  distress  or  oppression  after  eating,  which  may  be- 
come aggravated  and  amount  to  actual  pain.  When  the  stomach  is  empty 
there  may  also  be  a  painful  feeling.  The  pain  differs  in  different  cases,  and 
'may  be  trifling  or  of  extreme  severity.  When  localized  and  felt  beneath  the 
sternum  or  in  the  prascordial  region  it  is  known  as  heart-burn  or  sometimes 
cardialgia.  There  is  pain  on  pressure  over  the  stomach,  usually  diffuse  and 
not  severe.  The  tongue  is  coated,  and  the  patient  complains  of  a  bad  taste  in 
the  mouth.  The  tip  and  margin  of  the  tongue  are  very  often  red.  Associated 
with  this  catarrhal  stomatitis  there  may  be  an  increase  in  the  salivary  and 
pharyngeal  secretions.  Nausea  is  an  early  symptom,  and  is  particularly  apt 
to  occur  in  the  morning  hours.  It  is  not,  however,  nearly  so  constant  a  symp- 
tom in  chronic  gastritis  as  in  cancer  of  the  stomach,  and  in  mild  grades  of  the 
affection  it  may  not  occur  at  all.  Eructation  of  gas,  which  may  continue  for 
some  hours  after  taking  food,  is  a  very  prominent  feature  in  cases  of  so-called 
flatulent  dyspepsia,  and  there  may  be  marked  distention  of  the  intestines. 
With  the  gas,  bitter  fluids  may  be  brought  up.  Vomiting,  which  is  not  very 
frequent,  occurs  either  immediately  after  eating  or  an  hour  or  two  later. 
In  the  chronic  catarrh  of  old  topers  a  bout  of  morning  vomiting  is  common, 
in  which  a  slimy  mucus  is  brought  up.  The  vomitus  consists  of  food  in 
various  stages  of  digestion  and  slimy  mucus,  and  the  chemical  examination 


CHRONIC    GASTRITIS  481 

shows  the  presence  of  abnormal  acids,  such  as  butyric,  or  even  acetic,  in  addi- 
tion to  lactic  acid,  while  the  hydrochloric  acid,  if  present,  is  much  reduced 
in  quantity.  The  digestion  may  be  much  delayed,  and,  on  washing  out  the 
stomach  as  late  as  seven  hours  after  eating,  portions  of  food  are  still  present. 
The  prolonged  retention  favors  decomposition,  the  stomach  becomes  dis- 
tended with  gas,  and  this,  with  the  chronic  catarrh,  may  induce  gradually  an 
atony  of  the  muscular  walls,  but  the  motor  function  of  the  stomach  is  not  usu- 
ally much  impaired.  The  absorption  is  slow,  and  iodide  of  potassium,  given 
in  capsules,  which  should  normally  reach  the  saliva  within  fifteen  minutes, 
may  not  be  evident  for  more  than,  half  an  hour. 

Constipation  is  usually  present,  but  in  some  instances  there  is  diarrhoea, 
and  undigested  food  passes  rapidly  through  the  bowels.  The  urine  is  often 
scanty,  high-colored,  and  deposits  a  heavy  sediment  of  urates. 

Of  other  symptoms  headache  is  common,  and  the  patient,  feels  constantly 
out  of  sorts,  indisposed  for  exertion,  and  low-spirited.  In  aggravated  cases 
melancholia  may  occur.  Trousseau  called  attention  to  the  occurrence  of  ver- 
tigo, a  marked  feature  in  certain  cases.  The  pulse  is  small,  sometimes  slow, 
and  there  may  be  palpitation  of  the  heart.  Fever  does  not  occur.  Cough  is 
sometimes  present,  but  the  so-called  stomach  cough  of  chronic  dyspeptics  is  in 
all  probability  dependent  upon  pharyngeal  irritation.  J.  T.  Pilcher  has  called 
attention  to  the  frequency  with  which  absence  of  free  hydrochloric  acid  is 
found  with  the  presence  of  occult  blood  in  chronic  gastritis.  In  very  many  of 
these  the  stomach  condition  appears  to  be  secondary  to  local  disease  elsewhere 
in  the  abdomen,  particularly  the  appendix,  gall-bladder  or  the  pancreas.  The 
bleeding  comes  from  small  erosions,  and  is  always  of  the  so-called  occult 
variety.  Many  varieties  of  pathogenic  organisms  are  almost  constantly  found, 
of  which  the  streptococci  are  the  most  important. 

The  Gastric  Contents. — The  fasting  stomach  may  be  empty  or  it  may 
contain  much  mucus — gastritis  mucipara,  of  Boas.  In  the  test  breakfast, 
withdrawn  in  an  hour,  the  HC1  is  usually  diminished,  though  it  may  be  nor- 
mal— gastritis  acida.  In  other  cases  the  free  HC1  may  be  absent— #as iritis 
anacida.  While  in  the  advanced  forms  of  atrophy  of  the  mucosa  there  may 
be  neither  acids  nor  ferments — gastritis  atrophicans. 

The  symptoms  of  atrophy  of  the  mucous  membrane  of  the  stomach,  with- 
out contraction  of  the  organ,  are  very  complex,  and  cannot  be  said  to  present 
a  uniform  picture.  The  majority  of  the  cases  present  the  symptoms  of  an 
aggravated  chronic  dyspepsia,  often  of  such  severity  that  cancer  is  suspected. 
In  one  of  the  cases  which  I  examined  the  persistent  distress  after  eating,  the 
vomiting,  and  the  gradual  loss  of  flesh  and  strength  very  naturally  led  to  this 
diagnosis,  but  the  duration  of  the  disease  far  exceeded  that  of  ordinary  carci- 
noma. The  clinical  picture  may  be  that  of  a  severe  anaemia.  As  early  as 
1860  Flint  called  attention  to  this  connection  between  atrophy  of  the  gastric 
tubules  and  anaemia,  an  observation  which  Fenwick  and  others  have  amply 
confirmed. 

Diagnosis. — Ewald  distinguishes  three  forms  of  chronic  gastritis:  (1) 
Simple  gastritis;  (2)  mucous  (schleimige)  gastritis;  (3)  atrophic  gastritis. 

In  (1)  the  fasting  stomach  contains  only  a  small  quantity  of  a  slimy 
fluid,  while  after  the  test  breakfast  the  HC1  is  diminished  in  quantity  or  may 
be  absent.  Lactic  acid  and  the  fatty  acids  may  be  present.  After  Boas's 


482  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

more  rigid  test  meal  the  organic  acids  are  rarely  found.  The  pepsin  and 
renjiin  are  always  present. 

In  (2)  the  acidity  is  always  slight  and  the  condition  is  distinguished  from 
(1)  chiefly  by  the  large  amount  of  mucus  present. 

In  (3)  the  fasting  stomach  is  generally  empty,  while  after  the  test  break- 
fast HC1,  pepsin,  and  rennin  are  wholly  wanting. 

The  diagnosis  of  cancer  of  the  stomach  from  chronic  gastritis  may  be  very 
difficult  when  a  tumor  is  not  present.  The  cases  require  most  careful  study, 
and  it  is  important  to  decide  whether  the  stomach  is  primarily  at  fault,  or 
whether  the  chronic  gastritis  is  associated  with  disease  of  the  other  organs — 
liver,  gall-bladder,  appendix  or  pancreas. 

Treatment. — When  possible  the  cause  in  each  case  should  be  ascertained 
and  an  attempt  made  to  determine  the  special  form  of  indigestion.  Usually 
there  is  no  difficulty  in  differentiating  the  ordinary  catarrhal  and  the  nervous 
varieties.  A  careful  study  of  the  phenomena  of  digestion,  though  not  essential 
in  every  instance,  should  certainly  be  carried  out  in  the  more  obstinate  and 
obscure  forms.  Two  important  questions  should  be  asked  of  every  dyspeptic 
— first,  as  to  the  time  taken  at  his  meals;  and,  second,  as  to  the  quantity  he 
eats.  Practically  a  large  majority  of  all  cases  of  disturbed  digestion  come 
from  hasty  and  imperfect  mastication  of  the  food  and  from  overeating. 
Especial  stress  should  be  laid  upon  the  former  point.  In  some  instances  it 
will  alone  suffice  to  cure  dyspepsia  if  the  patient  will  count  a  certain  number 
before  swallowing  each  mouthful.  The  second  point  is  of  even  greater  im- 
portance. People  habitually  eat  too  much,  and  it  is  probably  true  that  a 
greater  number  of  maladies  arise  from  excess  in  eating  than  from  excess  in 
drinking.  Chittenden's  researches  have  shown  that  we  require  much  less 
nitrogenous  food  to  maintain  a  standard  of  perfect  health — a  lesson  that  the 
Hindoos  and  Japanese  have  also  taught  us.  George  Cheyne's  thirteenth 
aphorism,  already  quoted  under  the  section  on  Obesity,  contains  a  volume  of 
dietetic  wisdbm. 

(a)  GENERAL  AND  DIETETIC. — A  careful  and  systematically  arranged  diet- 
ary is  the  first,  sometimes  the  only,  essential  in  the  treatment  of  a  case  of 
chronic  dyspepsia.  It  is  impossible  to  lay  down  rules  applicable  to  all  cases. 
Individuals  differ  extraordinarily  in  their  capability  of  digesting  different 
articles  of  food,  and  there  is  much  truth  in  the  old  adage,  "One  man's  food 
is  another  man's  poison."  The  individual  preferences  for  different  articles 
of  food  should  be  permitted  in  the  milder  forms.  Physicians  have  probably 
been  too  arbitrary  in  this  direction,  and  have  not  yielded  sufficiently  to  the 
intimations  given  by  the  appetite  and  desires  of  the  patient. 

A  rigid  milk  diet  may  be  tried.  "Milk  and  sweet  sound  Blood  differ  in 
nothing  but  in  Color:  Milk  is  Blood"  (George  Cheyne).  In  the  forms  asso- 
ciated with  Bright's  disease  and  chronic  portal  congestion,  as  well  as  in  many 
instances  in  which  the  dyspepsia  is  part  of  a  neurasthenic  or  hysterical  trou- 
ble, this  plan  in  conjunction  with  rest  is  most  efficacious.  If  milk  is  not 
digested  well  it  may  be  diluted  one-third  with  soda  water  or  Vichy,  or  5  to  10 
grains  of  carbonate  of  soda,  or  a  pinch  of  salt  may  be  added  to  each  tumbler- 
ful. In  many  cases  the  milk  from  which  the  cream  has  been  taken  is  better 
borne.  Buttermilk  is  particularly  suitable,  but  can  rarely  be  taken  for  so  long 
a  time  alone,  as  patients  tire  of  it  much  more  readily  thai*  £it5>  3r  of  ordinary 


CHRONIC    GASTRITIS  483 

milk.  Not  only  can  the  general  nutrition  be  maintained  on  this  diet,  but 
patients  sometimes  increase  in  weight,  and  the  unpleasant  gastric  symptoms 
disappear  entirely.  It  should  be  given  at  fixed  hours  and  in  definite  quantities. 
A  patient  may  take  6  or  8  ounces  every  three  hours.  The  amount  necessary 
varies  a  good  deal,  but  at  least  3  to  5  pints  should  be  given  in  the  twenty-four 
hours.  This  form  of  diet  is  not,  as  a  rule,  well  borne  when  there  is  a  ten- 
dency to  dilatation  of  the  stomach.  The  milk  may  be  previously  peptonized, 
but  it  is  impossible  to  feed  a  chronic  dyspeptic  in  this  way.  The  stools  should 
be  carefully  watched,  and  if  more  milk  is  taken  than  can  be  digested  it  is  well 
to  supplement  the  diet  with  eggs  and  dry  toast  or  biscuits. 

In  a  large  proportion  of  the  cases  of  chronic  indigestion  it  is  not  necessary 
to  annoy  the  patient  with  such  strict  dietaries.  It  may  be  quite  sufficient  to 
cut  off  certain  articles  of  food.  Thus,  if  there  are  acid  eructations  or  flatu- 
lency the  farinaceous  foods  should  be  restricted,  particularly  potatoes  and  the 
coarser  vegetables.  A  fruitful  source  of  indigestion  is  the  hot  bread  which, 
in  different  forms,  is  regarded  as  an  essential  part  of  an  American  break- 
fast. This,  as  well  as  the  various  forms  of  pancakes,  pies  and  tarts,  with 
heavy  pastry,  and  fried  articles  of  all  sorts,  should  be  strictly  forbidden.  As  a 
rule,  white  bread,  toasted,  is  more  readily  digested  than  bread  made  from  the 
whole  meal.  Persons,  however,  differ  very  much  in  this  respect,  and  the  Gra- 
ham or  brown  bread  is  most  digestible  for  many  people.-  Sugar  and  very  sweet 
articles  of  food  should  be  taken  in  great  moderation  or  avoided  altogether  by 
persons  with  chronic  dyspepsia.  Many  instances  of  aggravated  indigestion 
have  come  to  my  notice  due  to  the  prevalent  practice  of  eating  largely  of  ice- 
cream. One  of  the  most  powerful  enemies  of  the  American  stomach  in  the 
present  day  is  the  soda-water  fountain,  which  has  usurped  so  important  a 
place  in  the  apothecary  shop. 

Fats,  with  the  exception  of  a  moderate  amount  of  good  butter,  very  fat 
meats,  and  thick,  greasy  soups  should  be  avoided.  Ripe  fruit  in  moderation 
is  often  advantageous,  particularly  when  cooked.  Bananas  are  not,  as  a  rule, 
well  borne.  Strawberries  are  to  many  persons  a  cause  of  an  annual  attack  of 
indigestion  and  sore  throat. 

As  stated,  in  the  matter  of  special  articles  of  food  it  is  impossible  to  lay 
down  rigid  rules,  and  it  is  the  common  experience  that  one  patient  with  indi- 
gestion will  take  with  impunity  the  very  articles  which  cause  the  greatest 
distress  to  another. 

Another  detail  of  importance  which  may  be  mentioned  in  this  connection 
is  the  general  hygienic  management  of  dyspeptics.  These  patients  are  often 
introspective,  dwelling  in  a  morbid  manner  on  their  symptoms,  and  much  in- 
clined to  take  a  despondent  view  of  their  condition.  Very  little  progress  can 
be  made  unless  the  physician  gains  their  confidence  from  the  outset.  Their 
fears  and  whims  should  not  be  made  too  light  of  or  ridiculed.  Systematic 
exercise,  carefully  regulated,  particularly  when,  as  at  watering  places,  it  is 
combined  with  a  restricted  diet,  is  of  special  service.  Change  of  air  and 
occupation,  a  prolonged  sea  voyage,  or  a  summer  in  the  mountains  will  some- 
times cure  the  most  obstinate  dyspepsia. 

(&)  MEDICINAL. — The  special  therapeutic  measures  may  be  divided  into 
those  which  attempt  to  replace  in  the  digestive  juices  important  elements 
which  are  lacking  and  those  which  stimulate  the  weakened  action  of  the  organ. 


484  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

In  the  first  group  come  the  hydrochloric  acid  and  ferments,  which  are  so 
freely  employed  in  dyspepsia.  The  former  is  the  most  important.  It  is  the 
ingredient  in  the  gastric  juice  most  commonly  deficient.  It  is  not  only  neces- 
sary for  its  own  important  actions,  but  its  presence  is  intimately  associated 
with  that  of  the  pepsin,  as  it  is  only  in  the  presence  of  a  sufficient  quantity 
that  the  pepsinogen  is  converted  into  the  active  digestive  ferment.  It  is  best 
given  as  the  dilute  acid  taken  in  somewhat  larger  quantities  than  are  usually 
advised.  Ewald  recommends  large  doses— of  from  90  to  100  drops— at  in- 
tervals of  fifteen  minutes  after  the  meals.  Leube  and  Eiegel  advise  smaller 
doses.  Probably  from  15  to  20  drops  is  sufficient.  The  prolonged  use  of  it 
does  not  appear  to  be  in  any  way  hurtful.  The  use,  however,  should  be  re- 
stricted to  cases  of  neurosis  and  atrophy  of  the  mucous  membrane.  In  actual 
gastritis  its  value  is  doubtful. 

Nitrate  of  silver  is  a  good  remedy  in  some  cases,  used  in  solution  in  the 
lavage  (1  to  1,500  or  1  to  2,000),  or  in  pill  form,  one-eighth  to  one-fourth 
of  a  grain  three  times  a  day.  For  many  years  Pepper  advocated  the  more 
extended  use  of  this  drug  in  chronic  gastritis.  I  have  seen  an  instance  of 
argyria  after  its  protracted  use. 

The  digestive  ferments  are  extensively  employed  to  strengthen  the  weak- 
ened gastric  and  intestinal  secretions.  The  use  of  pepsin,  according  to  Ewald, 
may  be  limited  to  the  cases  of  advanced  mucous  catarrh  and  the  instances  of 
atrophy  of  the  stomach,  in  which  it  should  be  given,  in  doses  of  from  10  to  15 
grains,  with  dilute  hydrochloric  acid  a  quarter  of  an  hour  after  meals.  Pan- 
creatin  is  of  equal  or  even  greater  value  than  pepsin,  but  pains  should  be 
taken  to  use  a  good  article.  It  should  be  given  in  doses  of  from  15  to  20 
grains,  in  combination  with  bicarbonate  of  soda.  It  is  conveniently  admin- 
istered in  tablets,  each  of  which  contains  5  grains  of  the  pancreatin  and  the 
soda,  and  of  these  two  or  three  may  be  taken  fifteen  or  twenty  minutes  after 
each  meal.  Ptyalin  and  diatase  are  particularly  indicated  when  the  acid  is 
excessive.  The  action  of  the  former  continues  in  the  stomach  during  normal 
digestion.  The  malt  diastase  is  often  very  serviceable  given  with  alkalies. 

Of  measures  which  stimulate  the  glandular  activity  in  chronic  dyspepsia 
lavage  is  by  far  the  most  important,  particularly  in  the  forms  characterized 
by  the  secretion  of  a  large  quantity  of  mucus.  Lukewarm  water  should  be 
used,  or,  if  there  is  much  mucus,  a  1-per-cent.  salt  solution,  or  a  3-  to  5-per- 
cent, solution  of  bicarbonate  of  soda.  If  there  is  much  fermentation  the 
3-per-cent.  solution  of  boric  acid  may  be  used.  It  is  best  employed  in  the 
morning  on  an  empty  stomach,  or  in  the  evening  some  hours  after  the  last 
meal  in  those  cases  in  which  there  is  much  nocturnal  distress  and  flatulency. 
Once  a  day  is,  as  a  rule,  sufficient,  or,  in  the  case  of  delicate  persons,  every 
second  day.  The  irrigation  may  be  continued  until  the  water  which  comes 
away  is  quite  clear.  It  is  not  necessary  to  remove  all  the  fluid  after  the  irriga- 
tion. While  perhaps  in  some  hands  this  measure  has  been  carried  to  extremes, 
it  is  one  of  such  extraordinary  value  in  certain  cases  that  it  should  be  more 
widely  employed.  When  there  is  an  insuperable  objection  to  lavage  a  substi- 
tute may  be  used  in  the  form  of  warm  alkaline  drinks,  taken  slowly  in  the 
early  morning  or  the  last  thing  at  night. 

Of  medicines  which  stimulate  the  gastric  secretion  the  most  important  are 
the  bitter  tonics,  such  as  nux  vomica,  quassia,  gentian,  calumba,  and  carda- 


CHRONIC    GASTRITIS  485 

mom.  These  are  probably  of  more  value  in  chronic  gastritis  than  the  hydro- 
chloric acid.  Of  these  nux  vomica  is  the  most  powerful,  though  none  of  them 
have  probably  any  very  great  stimulating  action  on  the  secretion,  and  influ- 
ence rather  the  appetite  than  the  digestion.  Of  stomachics  which  are  believed 
to  favorably  influence  digestion  the  most  important  are  alcohol  and  common 
salt.  The  former  would  appear  to  act  in  moderate  quantities  by  increasing 
the  acid  in  the  gastric  juice,  and  with  it  probably  the  pepsin  formation. 
Others  hold  that  it  is  not  so  much  the  secretory  as  the  motor  function  of  the 
stomach  which  the  alcohol  stimulates.  In  moderate  quantities  it  has  certainly 
no  directly  injurious  influence  on  the  digestive  processes.  Special  care  should 
be  taken,  however,  in  ordering  alcohol  to  dyspeptics.  If  a  patient  has  been 
in  the  habit  of  taking  beer  or  light  wines  or  stimulants  with  his  meals,  the 
practice  may  be  continued  if  moderate  quantities  are  taken.  Beer,  as  a  rule, 
is  not  well  borne.  A  dry  sherry  or  a  glass  of  claret  is  preferable.  In  the  case 
of  women  with  any  form  of  dyspepsia  stimulants  should  be  employed  with  the 
greatest  caution,  and  the  practitioner  should  know  his  patient  well  before 
ordering  alcohol. 

The  importance  of  salt  in  gastric  digestion  rests  upon  the  fact  that  its 
presence  is  essential  in  the  formation  of  the  hydrochloric  acid.  An  increase 
in  its  use  may  be  advised  in  all  cases  of  chronic  dyspepsia  in  which  the  acid 
is  defective. 

(c)  TREATMENT  OF  SPECIAL  CONDITIONS. — Fermentation  and  Flatulency. 
— When  the  digestion  is  slow  or  imperfect,  fermentation  goes  on  in  the  con- 
tents, with  the  formation  of  gas  and  the  production  of  lactic,  butyric,  and 
acetic  acids.  For  the  treatment  of  this  condition  careful  dieting  may  suffice, 
particularly  forbidding  such  articles  as  tea,  pastry,  and  the  coarser  vegetables. 
It  is  usually  combined  with  pyrosis,  in  which  the  acid  fluids  are  brought  into 
the  mouth.  Bismuth  and  carbonate  of  soda  sometimes  suffice  to  relieve  the 
condition.  Thymol,  creasote,  and  carbolic  acid  may  be  employed.  For  acid 
dyspepsia  Sir  William  Roberts  recommended  the  bismuth  lozenge  of  the  British 
Pharmacopoeia,  the  antacid  properties  of  which  depend  on  chalk  and  bicar- 
bonate of  soda.  It  should  be  taken  an  hour  or  two  after  meals,  and  only  when 
the  pain  and  uneasiness  are  present.  The  burnt  magnesia  is  also  a  good 
remedy.  Glycerin  in  from  20-  to  60-minim  doses,  the  essential  oils,  animal 
charcoal  alone  or  in  combination  with  compound  cinnamon  powder  may  be 
tried.  If  there  is  much  pain,  chloroform  in  20-minim  doses  or  a  teaspoonful 
of  Hoffman's  anodyne  may  be  used.  In  obstinate  cases  lavage  is  indicated  and 
is  sometimes  striking  in  its  effects.  Alkaline  solutions  may  be  used. 

Vomiting  is  not  a  feature  which  often  calls  for  treatment  in  chronic  dys- 
pepsia; sometimes  in  children  it  is  a  persistent  symptom.  Creasote  and  car- 
bolic acid  in  drop  doses,  a  few  drops  of  chloroform  or  of  dilute  hydrocyanic 
acid,  cocaine,  bismuth,  and  oxalate  of  cerium  may  be  used.  If  obstinate,  the 
stomach  should  be  washed  out  daily. 

Constipation  is  a  frequent  and  troublesome  feature  of  most  forms  of  indi- 
gestion. Occasionally  small  doses  of  mercury,  podophyllin,  the  laxative  min- 
eral waters,  sulphur,  and  cascara  may  be  employed.  Glycerin  suppositories 
and  the  injection  of  from  half  a  teaspoonful  to  a  teaspoonful  of  glycerin  are 
very  efficacious. 

Many  cases  of  chronic  dyspepsia  are  greatly  benefited  by  the  use  of  mineral 


486  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

waters,  particularly  a  residence  at  the  springs  with  a  careful  supervision  of 
the  diet  and  systematic  exercise. 

m.    CIRRHOSIS   VENTRICULI 

(Plastic  Linitis) 

Brinton  described  under  the  term  linitis  plastica  a  condition  of  diffuse 
sclerosis  of  the  stomach  with  thickening  of  the  walls  and  reduction  of  the 
lumen. 

It  may  be  localized,  but  more  commonly  involves  the  whole  organ,  and 
a  similar  condition  has  been  found  in  the  colon,  small  bowel,  and  rectum. 
In  the  first  case  I  saw,  a  patient  of  Dr.  Drake's,  Montreal,  the  stomach  was 
no  bigger  than  a  cucumber,  and  the  cascum  and  part  of  the  ascending  colon 
showed  the  same  thickening.  The  special  lesion  is  an  enormous  hypertrophy 
of  the  submucosa,  with  atrophy  of  the  gland  elements  and  hypertrophy  of 
the  muscular  layers,  so  that  the  wall  is  six  to  eight  times  the  normal  thick- 
ness; but,  as  Brinton  remarks,  the  layers  remain  distinct.  There  are  two 
forms,  benign  and  malignant,  which  are  not  easy  to  separate  without  the  most 
careful  microscopic  examination.  Lyle  has  collected  118  cases  from  the  litera- 
ture, more  than  half  of  which  were  the  true  plastic  linitis  of  Brinton. 

The  symptoms  are  at  first  indefinite,  but  when  well  established  vomiting 
becomes  marked  and  there  is  inability  to  retain  even  small  amounts  of  food. 
The  presence  of  a  sausage-shaped  tumor  in  the  epigastrium  is  important. 
Haemorrhage  may  be  present.  The  X-ray  picture  should  be  of  great  help. 
In  the  only  case  in  which  I  made  a  diagnosis  the  protracted  history,  the  re- 
striction in  capacity  of  the  stomach,  and  the  tumor  seemed  characteristic. 
Nothing  could  be  done  at  operation ;  and  in  a  more  recent  case  the  walls  were 
so  hard  and  the  stomach  so  small  that  it  was  impossible  to  make  a  gastro- 
enterostomy,  of  which  Lyle  has  reported  a  successful, case.  Total  gastrectomy 
has  been  performed  in  three  cases. 


IV.    DILATATION   OF   THE    STOMACH 

(Gastrectasis) 

Etiology. — ACUTE  DILATATION  is  a  very  serious  condition,  described  by 
Hilton  Fagge,  characterized  by  sudden  onset,  vomiting  of  enormous  quantities 
of  fluid,  and  symptoms  of  collapse.  Of  102  cases  collected  by  Lewis  A.  Con- 
ner 42  followed  operation  with  general  anesthesia.  The  next  largest  group 
occurs  in  the  course  of  severe  diseases,  or  during  convalescence.  Cases  have 
followed  injuries,  particularly  of  the  head  and  spine.  In  9  cases  the  symp- 
toms came  on  after  a  single  large  meal;  6  cases  were  associated  with  spinal 
disease,  in  3  while  the  patients  were  in  a  plaster  of  Paris  jacket,  and  in  a 
few  cases  it  has  come  on  in  persons  in  good  health.  There  were  74  deaths.  In 
69  autopsies  the  duodenum  was  found  dilated  in  38  cases.  In  a  majority  of 
cases  it  is  due  to  a  constriction  of  the  lower  end  of  the  duodenum  by  traction 
on  the  mesenteric  root,  which  is  particularly  apt  to  occur  when  there  is  a 


DILATATION    OF    THE    STOMACH  487 

long  mesentery  and  when  the  coil  of  small  bowel  is  empty  and  falls  into  the 
true  pelvis.  The  diagnosis  is  usually  easy — repeated  vomiting  of  large  quan- 
tities of  bilious  non-faecal  fluid,  with  subnormal  temperature,  pain,  collapse 
symptoms,  and  distended  abdomen  are  the  common  features.  The  treatment 
consists  in  repeated  emptying  of  the  stomach  with  the  tube;  change  in  pos- 
ture from  the  dorsal  to  the  belly  position  or  the  knee-elbow  position  has  been 
followed  by  prompt  relief.  Operation  has  not  proved  very  satisfactory. 

CHRONIC  DILATATION  results  from:  (a)  Pyloric  obstruction  due  to  nar- 
rowing of  the  orifice  or  of  the  duodenum  by  the  cicatrization  of  an  ulcer, 
hypertrophic  stenosis  of  the  pylorus  (whether  cancerous  or  simple)  congeni- 
tal stricture,  or  occasionally  by  pressure  from  without  of  a  tumor  or  of  a 
floating  kidney.  The  pylorus  may  be  tilted  up  by  adhesions  to  the  liver  or 
gall-bladder,  or  the  stomach  may  be  so  dilated  that  the  pylorus  is  dragged 
down  and  kinked.  Adhesions  about  the  gall-bladder  may  extend  along  the 
adjacent  parts  of  the  stomach  and  hitch  up  the  pylorus  into  the  hilus  of  the 
liver,  forming  a  very  acute  kink.  (&)  Relative  or  absolute  insufficiency  of  the 
muscular  power  of  the  stomach,  due  on  the  one  hand  to  repeated  overfilling  of 
the  organ  with  food  and  drink,  and  on  the  other  to  atony  of  the  coats  induced 
by  chronic  inflammation  or  the  degeneration  of  impaired  nutrition,  the  result 
of  constitutional  affections. 

The  most  extreme  forms  are  met  with  as  a  sequence  of  the  cicatricial  con- 
traction of  an  ulcer.  There  may  be  considerable  stenosis  without  much  dila- 
tation, the  obstruction  being  compensated  by  hypertrophy  of  the  muscular 
coats. 

In  the  second  group,  due  to  atony  of  the  muscular  coats,  we  must  distin- 
guish between  instances  in  which  the  stomach  is  simply  enlarged  and  those 
with  actual  dilatation,  conditions  characterized  by  Ewald  as  megalogastria 
and  gastrectasis  respectively.  The  size  of  the  stomach  varies  greatly  in  differ- 
ent individuals,  and  the  maximum  capacity  of  a  normal  organ  Ewald  places 
at  about  1,600  c.  c.  Measurements  above  this  point  indicate  absolute  dilata- 
tion. 

Atonic  dilatation  of  the  stomach  may  result  from  weakness  of  the  coats, 
due  to  repeated  overdistention  or  to  chronic  catarrh  of  the  mucous  membrane, 
or  to  the  general  muscular  debility  which  is  associated  with  chronic  wasting 
disorders  of  all  sorts.  The  combination  of  chronic  gastric  catarrh  with  over- 
feeding and  excessive  drinking  is  one  of  the  most  fruitful  sources  of  atonic 
dilatation,  as  pointed  out  by  Naunyn.  The  condition  is  frequently  seen  in 
diabetics,  in  the  insane,  and  in  beer-drinkers.  In  Germany  this  form  is  very 
common  in  men  employed  in  the  breweries.  Possibly  muscular  weakness  of 
the  coats  may  result  in  some  cases  from  disturbed  innervation.  Dilatation 
of  the  stomach  is  most  frequent  in  middle-aged  or  elderly  persons,  but  the 
condition  is  not  uncommon  in  children,  especially  in  association  with  rickets. 

Symptoms. — In  atonic  dilatation  there  may  be  no  symptoms  whatever, 
even  with  a  very  greatly  enlarged  organ ;  more  frequently  there  are  the  asso- 
ciated features  of  neurasthenia,  enteroptosis,  and  nervous  dyspepsia ;  while  in 
a  third  group  there  may  be  all  the  symptoms  of  pyloric  obstruction — vomiting 
of  enormous  quantities,  etc.  There  is  no  limit  to  the  capacity  of  the  organ 
in  this  condition.  Gould  and  Pyle  mention  an  instance  in  which  the  stomach 
held  70  pints ! 


488  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

The  features  of  pyloric  obstruction,  from  whatever  cause,  are  usually  very 
evident.  Dyspepsia  is  present  in  nearly  all  cases,  and  there  are  feelings  of 
distress  and  uneasiness  in  the  region  of  the  stomach.  The  patient  may  com- 
plain much  of  hunger  and  thirst  and  eat  and  drink  freely.  The  most  charac- 
teristic symptom  is  the  vomiting  at  intervals  of  enormous  quantities  of  liquid 
and  of  food,  amounting  sometimes  to  four  or  more  litres.  The  material  is 
often  of  a  dark-grayish  color,  with  a  characteristic  sour  odor  due  to  the 
organic  acids  present,  and  contains  mucus  and  remnants  of  food.  On  stand- 
ing it  separates  into  three  layers,  the  lowest  consisting  of  food,  the  middle 
of  a  turbid,  dark-gray  fluid,  and  the  uppermost  of  a  brownish  froth.  The 
microscopic  examination  shows  a  large  variety  of  bacteria,  yeast  fungi,  and 
the  sarcina  ventriculi.  There  may  also  be  cherry  stones,  plum  stones,  and 
grape  seeds. 

The  hydrochloric  acid  may  be  absent,  diminished,  normal,  or  in  excess, 
depending  upon  the  cause  of  the  dilatation.  The  fermentation  produces  lac- 
tic, butyric,  and,  possibly,  acetic  acid  and  various  gases. 

In  consequence  of  the  small  amount  of  fluid  which  passes  from  the  stom- 
ach or  is  absorbed  there  are  constipation,  scanty  urine,  and  extreme  dryness 
of  the  skin.  The  general  nutrition  of  the  patient  suffers  greatly ;  there  is  loss 
of  flesh  and  strength,  and  in  some  cases  the  most  extreme  emaciation.  The 
gastric  tetany  will  be  considered  in  the  section  on  that  disease. 

PHYSICAL  SIGNS. — Inspection. — The  abdomen  may  be  large  and  promi- 
nent, the  greatest  projection  occurring  below  the  navel  in  the  standing  posture. 
In  some  instances  the  outline  of  the  distended  stomach  can  be  plainly  seen, 
the  small  curvature  a  couple  of  inches  below  the  ensiform  cartilage,  and  the 
greater  curvature  passing  obliquely  from  the  tip  of  the  tenth  rib  on  the  left 
side,  toward  the  pubes,  and  then  curving  upward  to  the  right  costal  margin. 
Too  much  stress  can  not  be  laid  on  the  importance  of  inspection.  Very  often 
the  diagnosis  may  be  made  de  visu.  Active  peristalsis  may  be  seen  in  the 
dilated  organ,  the  waves  passing  from  left  to  right.  Occasionally  anti-peri- 
stalsis may  be  seen.  In  cases  of  stricture,  particularly  of  hypertrophic  steno- 
sis, as  the  peristaltic  wave  reaches  the  pylorus,  the  tumor-like  thickening  can 
sometimes  be  distinctly  seen  through  the  thin  abdominal  wall.  To  stimulate 
the  peristalsis  the  abdomen  may  be  flipped  with  a  wet  towel.  Inflation  may 
be  practiced  with  carbonic-acid  gas.  A  small  tearspoonful  of  tartaric  acid 
dissolved  in  an  ounce  of  water  is  first  given,  then  a  rather  larger  quantity  oC 
bicarbonate  of  soda.  In  many  cases,  particularly  in  thin  persons,  the  outline 
of  the  dilated  stomach  stands  out  with  great  distinctness,  and  waves  of  peri- 
stalsis are  seen  in  it. 

Palpation. — The  peristalsis  may  be  felt,  and  usually  in  stenosis  a  tumor 
is  evident  at  the  pylorus.  The  resistance  of  a  dilated  stomach  is  peculiar, 
and  has  been  aptly  compared  to  that  of  an  air  cushion.  Bimanual  palpation 
elicits  a  splashing  sound — clapotage — which  is,  of  course,  not  distinctive,  as 
it  can  be  obtained  whenever  there  is  much  liquid  and  air  in  the  organ.  The 
splashing  may  be  very  loud,  and  the  patient  may  produce  it  himself  by  sud- 
denly depressing  the  diaphragm,  or  it  may  be  readily  obtained  by  shaking 
him.  The  gurgling  of  gas  through  the  pylorus  may  be  felt. 

Percussion. — The  note  is  tympanitic  over  the  greater  portion  of  a  dilated 
stomach ;  in  the  dependent  part  the  note  is  flat.  In  the  upright  position  the 


489 

percussion  should  be  made  from  above  downward,  in  the  left  parasternal  line, 
until  a  change  in  resonance  is  reached.  The  line  of  this  should  be  marked, 
and  the  patient  examined  in  the  recumbent  position,  when  it  will  be  found 
to  have  altered  its  level.  When  this  is  on  a  line  with  the  navel  or  below  it, 
dilatation  of  the  stomach  may  generally  be  assumed  to  exist.  The  fluid  may 
be  withdrawn  from  the  stomach  with  a  tube,  and  the  dulness  so  made  to 
disappear,  or  it  may  be  increased  by  pouring  in  more  fluid.  In  cases  of  doubt 
the  organ  should  be  artificially  distended  with  carbonic-acid  gas  in  the  manner 
described  above,  or  the  stomach  is  inflated  through  a  stomach-tube  with  a 
Davidson's  syringe. 

Auscultation. — The  clapotage  or  succussion  can  be  obtained  readily.  Fre- 
quently a  curious  sizzling  sound  is  present,  not  unlike  that  heard  when 
the  ear  is  placed  over  a  soda-water  bottle  when  first  opened.  It  can  be  heard 
naturally,  and  is  usually  evident  when  the  artificial  gas  is  being  generated. 
The  heart  sounds  may  sometimes  be  transmitted  with  great  clearness  and 
with  a  metallic  quality. 

Mensuration  may  be  used  by  passing  a  hard  sound  into  the  stomach  until 
the  greater  curvature  is  reached.  Normally  it  rarely  passes  more  than  60 
cm.,  measured  from  the  teeth,  but  in  cases  of  dilatation  it  may  pass  as  much 
as  70  cm. 

Diagnosis. — This  can  usually  be  made  without  much  difficulty.  I  would 
like  to  emphasize  again  the  great  value  of  inspection,  particularly  in  com- 
bination with  inflation  of  the  stomach.  Curious  errors,  however,  are  on  rec- 
ord, one  of  the  most  remarkable  of  which  was  the  confounding  of  dilated 
stomach  with  an  ovarian  cyst ;  even  after  tapping  and  the  removal  of  portions 
of  food  and  fruit  seeds,  abdominal  section  was  performed  and  the  dilated 
stomach  opened.  The  diagnosis  of  ascites  has  been  made  and  the  abdomen 
opened.  The  prognosis  depends  upon  the  cause;  it  is  good  in  simple  atony, 
bad  in  cancerous  stricture,  fairly  good  in  simple  stricture,  from,  whatever 
cause. 

Treatment. — In  the  cases  due  to  atony  careful  regulation  of  the  diet  and 
proper  treatment  of  the  associated  catarrh  will  suffice  to  effect  a  cure.  Strych- 
nine, ergot,  and  iron  are  recommended.  Washing  out  the  stomach  is  of  great 
service,  though  we  do  not  see  such  striking  and  immediate  results  in  this 
form.  In  cases  of  mechanical  obstruction  the  stomach  should  be  emptied  and 
thoroughly  washed,  either  with  warm  water  or  with  an  antiseptic  solution. 
We  accomplish  in  this  way  three  important  things:  We  remove  the  weight, 
which  helps  to  distend  the  organ;  we  remove  the  mucus  and  the  stagnating 
and  fermenting  material  which  irritates  and  inflames  the  stomach  and  im- 
pedes digestion;  and  we  cleanse  the  inner  surface  of  the  organ  by  the  appli- 
cation of  water  and  medicinal  substances.  The  patient  can  usually  be  taught 
to  wash  out  his  own  stomach,  and  in  a  case  of  dilatation  from  simple  stric- 
ture I  have  known  the  practice  to  be  followed  daily  for  three  years  with 
great  benefit.  The  rapid  reduction  in  the  size  of  the  stomach  is  often  remark- 
able, the  vomiting  ceases,  food  is  taken  readily,  and  in  many  cases  the  general 
nutrition  improves  rapidly.  As  a  rule,  once  a  day  is  sufficient,  and  it  may 
be  practiced  either  the  first  thing  in  the  morning  or  before  going  to  bed.  So 
soon  as  the  fermentative  processes  have  been  checked  lukewarm  water  alone 
should  be  used. 
33 


490  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

The  food  should  be  taken  in  small  quantities  at  frequent  intervals,  and 
should  consist  of  scraped  beef,  Leube's  beef  solution,  and  tender  meats  of  all 
sorts.  Fatty  and  starchy  articles  of  diet  are  to  be  avoided.  Liquids  should 
be  taken  sparingly. 

Surgery  should  be  resorted  to  early  in  cases  of  organic  stricture ;  in  atonic 
dilatation  after  all  other  measures  have  been  given  a  thorough  trial,  gastro- 
enterostomy  may  be  practiced. 


V.    THE   PEPTIC   ULCER,    GASTRIC   AND   DUODENAL 

The  round,  perforating,  simple  or  peptic  ulcer  is  usually  single,  and 
occurs  in  the  stomach  and  in  the  duodenum  as  far  as  the  papilla.  Post 
mortem  statistics  show  a  great  preponderance  of  the  gastric  ulcer,  but  the 
enormous  experience  of  surgeons  has  taught  us  that  in  more  than  fifty  per 
cent,  of  the  clinical  cases  the  ulcer  is  outside  the  pyloric  ring. 

Erosions. — Small  abrasions  of  the  mucosa — 2  to  4  mm. — usually  multiple, 
are  common,  extending  half  way  or  quite  through  the  layer.  They  are  often 
called  hagmorrhagic  erosions  from  their  blood-stained  appearance.  They  are 
met  with  in  the  new-born,  in  cachectic  states  in  children,  in  chronic  heart  and 
arterial  disease,  in  cirrhosis  of  the  liver,  etc.  Of  no  clinical  importance,  as  a 
rule,  occasionally  an  acute  haemorrhagic  erosion  of  quite  small  size  opens  a 
large  artery,  and  the  patient  bleeds  to  death.  There  is  no  difference  between 
this  condition  and  the  acute  form  of  the  gastric  ulcer. 

In  many  cases  of  chronic  dyspepsia  small  fragments  of  the  mucosa  are 
washed  out  by  the  stomach  tube,  and  Einhorn  thinks  that  this  may  be  a  special 
form  characterized  by  pains,  dyspepsia,  and  weakness. 

In  certain  acute  infections  with  the  pneumococcus  (Dieulafoy)  and  septic 
organisms  there  may  be  haemorrhagic  erosions,  which  occasionally  prove  fatal 
by  haematemesis. 

And,  lastly,  it  is  probable  that  the  post-operative'  haematemesis,  slight  or 
grave,  may  be  due  to  these  erosions.  The  French  have  described  them  as  if 
peculiar  to  operations  for  appendicitis  (vomito-negro  appendiculaire) ,  but 
cases  occur  after  all  sorts  of  abdominal  operations.  It  is  probable  that  the 
slight  gastric  haemorrhages  which  occur  in  connection  with  the  throbbing 
aorta  in  neurotic  women  are  due  to  these  erosions. 

Etiology  of  Peptic  Ulcer. — INCIDENCE. — The  disease  is  much  more  com- 
mon than  medical  and  pathological  statistics  indicate.  The  surgical  work 
of  the  Mayo  clinic  and  of  Moynihan  of  Leeds  has  taught  us  that  the  peptic 
ulcer  exists  in  many  cases  which  we  had  regarded  as  simple  hyperchlorhydria. 
In  two  points  surgical  experience  has  completely  changed  our  medical  stand- 
point, viz. :  the  incidence  of  ulcer  in  the  male  is  greater  than  in  the  female, 
and  the  duodenal  is  much  more  common  than  the  gastric  ulcer.  Perhaps 
nothing  illustrates  more  forcibly  the  frequency  of  duodenal  ulcer  than  the  fact 
that  in  the  month  of  July,  1910,  17  cases  were  operated  upon  at  the  Mayo 
clinic,  5  of  which  had  perforated,  and  in  the  same  period  only  three  cases  of 
ulcer  of  the  stomach  came  to  operation.  The  surgical  statistics,  now  amount- 
ing to  many  hundreds  of  cases,  have  sent  our  medical  statistics  to  the  scrap 
heap.  The  incidence  of  the  disease  appears  to  vary  in  different  localities,  and 


THE    PEPTIC    ULCER,    GASTRIC   AND   DUODENAL        491 

post  mortem  figures  from  the  United  States  and  Canada  show  a  much  lower 
percentage  of  cases  (1.32)  than  on  the  continent  of  Europe  (5  per  cent.),  and 
in  London,  4.2  per  cent.  (C.  P.  Howard). 

SEX. — Of  1,699  cases  collected  from  hospital  statistics  by  W.  H.  Welch 
and  examined  post  mortem,  40  per  cent,  were  in  males  and  60  per  cent,  were 
in  females.  In  82  cases  (J.  H.  H.)  there  were  48  males  and  28  females — in 
striking  contrast  to  the  Massachusetts  General  Hospital  figures,  5  females  to 
1  male.  Recent  surgical  statistics  show  an  enormous  preponderance  of  males. 

AGE. — In  females  the  largest  number  of  cases  occurred  between  fifteen  and 
twenty-five;  in  males  between  forty  and  fifty,  in  our  series.  It  may  occur  in 
old  people.  E.  G.  Cutler  has  studied  a  series  of  29  cases  in  children.  In  6 
the  symptoms  came  on  immediately  after  birth.  There  were  8  cases  under 
seven  years  of  age,  and  9  between  eight  and  thirteen. 

HEREDITY  appears  to  play  a  part  in  some  cases  (Dreschfeld). 

OCCUPATION. — It  was  impossible  in  our  series  to  say  that  occupation  had 
any  influence.  Among  women,  chlorotic,  dyspeptic  servant  girls  seem  very 
prone.  Shoemakers  are  thought  to  be  specially  liable.  It  appears  relatively 
more  common  in  the  hospital  classes. 

TRAUMA. — Ulcers  have  been  known  to  follow  a  blow  in  the  region  of  the 
stomach.  There  was  a  history  of  injury  in  7  cases  in  our  series. 

ASSOCIATED  DISEASES. — Anaemia  and  chlorosis  predispose  strongly  to  gas- 
tric ulcer,  particularly  in  women  and  in  association  with  menstrual  disorders. 
A  very  considerable  number  of  all  cases  of  gastric  ulcer  occur  in  chlorotic 
girls.  It  has  been  found  also  in  connection  with  disease  of  the  heart,  arterio- 
sclerosis, and  disease  of  the  liver.  The  tuberculous  and  syphilitic  ulcers  of  the 
stomach  have  already  been  considered. 

BURNS. — The  duodenal  ulcer  may  follow  large  superficial  burns.  Perry 
and  Shaw  found  it  in  five  of  one  hundred  and  forty-nine  autopsies  in  cases  of 
burns  of  the  skin. 

Morbid  Anatomy  and  Pathology. — Ninety  per  cent,  of  gastric  ulcers  are 
to  be  found  at  the  pyloric  end;  nearly  all  duodenal  ulcers  are  in  the  first  or 
ascending  portion,  and  more  than  one-half  extend  up  to  or  within  three- 
fourths  of  an  inch  of  the  pylorus,  while  twenty  per  cent,  involve  the  margin 
of  the  pyloric  ring  (Mayo).  It  may  not  be  easy  on  the  operating  table  to 
distinguish  between  an  ulcer  of  the  duodenum  and  that  of  the  stomach,  but 
Mayo  says  that  the  position  of  the  pyloric  vein  gives  the  exact  location.  Mul- 
tiple ulcers  may  occur,  8.2  per  cent,  in  Mayo's  series.  From  5  to  34  have 
been  found.  In  the  stomach,  post  mortem  statistics  (Welch)  give,  in  793 
cases,  288  on  the  lesser  curvature,  235  on  the  posterior  wall,  69  on  the  ante- 
rior wall,  95  at  the  pylorus,  50  at  the  cardia,  29  at  the  fundus,  and  27  on 
the  greater  curvature. 

The  acute  ulcer  is  usually  small,  punched  out,  the  edges  clean-cut,  the  floor 
smooth,  and  the  peritoneal  surface  not  thickened.  The  chronic  ulcer  is  of 
larger  size,  the  margins  are  no  longer  sharp,  the  edges  are  indurated,  and  the 
border  is  sinuous.  It  may  reach  ah  enormous  size,  as  in  the  one  reported  by 
Peabody,  which  measured  19  by  10  cm.  and  involved  all  of  the  lesser  curva- 
ture and  spread  over  a  large  part  of  the  anterior  and  posterior- walls.  The 
sides  are  often  terraced.  The  floor  is  formed  either  by  the  submucosa,  by  the 
muscular  layers,  or,  not  infrequently,  by  the  neighboring  organs,  to  which  the 


492  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

stomach  has  become  attached.  In  the  healing  of  the  ulcer,  if  the  mucosa  is 
alone  involved,  the  granulation  tissue  grows  from  the  edges  and  the  floor  and 
the  newly  formed  tissue  gradually  contracts  and  unites  the  margins,  leaving 
a  smooth  scar.  In  larger  ulcers  which  have  become  deep  and  involved  the 
muscular  coat  the  cicatricial  contraction  may  cause  serious  changes,  the  most 
important  of  which  is  narrowing  of  the  pyloric  orifice  and  consequent  dila- 
tation of  the  stomach.  In  the  case  of  a  girdle  ulcer  hour-glass  contraction 
of  the  stomach  may  be  produced.  Large  ulcers  persist  for  years  without  any 
attempt  at  healing. 

Among  the  more  serious  changes  which  may  proceed  in  an  ulcer  are  the 
following : 

PERFORATION. — This  occurred  in  28.1  per  cent,  of  1,871  cases  collected  by 
Musser.  In  some  series  (Mayo's)  duodenal  perforation  is  the  more  common. 
Of  272  cases  of  duodenal  ulcer  in  Mayo's  series  (to  June  1,  1908),  perforation 
was  found  sixty-six  times,  16  acute,  13  subacute  with  abscess,  and  37  chronic 
and  protected.  Perforation  of  the  anterior  wall  of  the  stomach  usually  excites 
an  acute  peritonitis.  On  the  posterior  wall  the  ulcer  penetrates  directly  into 
the  lesser  peritoneal  cavity,  in  which  case  it  may  produce  an  air-containing 
abscess  with  the  symptoms  of  the  condition  known  as  subphrenic  pyopneumo- 
thorax.  In  rare  instances  adhesions  and  a  gastrocutaneous  fistula  form,  usu- 
ally in  the  umbilical  region.  Fistulous  communication  with  the  colon  may 
also  occur,  or  a  gastroduodenal  fistula.  The  pericardium  may  be  perforated, 
and  even  the  left  ventricle.  Perforation  into  the  pleura  may  also  occur.  It 
is  to  be  noted  that  general  emphysema  of  the  subcutaneous  tissues  occasion- 
ally follows  perforation  of  a  gastric  ulcer. 

EROSION  OF  BLOOD-VESSELS. — In  both  forms  of  ulcer  hemorrhage  occurs, 
in  8.1  per  cent,  of  Musser's  series  of  1,871  cases.  In  Moynihan's  114  cases  of 
duodenal  ulcer,  hemorrhage  occurred  in  41.  It  is  more  common  in  the 
chronic  form.  Ulcers  on  the  posterior  wall  may  erode  the  splenic  artery,  but 
perhaps  more  frequently  the  bleeding  proceeds  from  the  artery  of  the  lesser 
curvature.  In  the  case  of  duodenal  ulcer  the  pancreaticoduodenal  artery  may 
be  eroded,  or  (as  in  one  of  my  cases)  fatal  hemorrhage  may  result  from  the 
opening  of  the  hepatic  artery,  or  more  rarely  the  portal  vein.  Interesting 
changes  occur  in  the  vessels.  Embolism  of  the  artery  supplying  the  ulcerated 
region  has  been  met  with  in  several  cases;  in  others  diffuse  endarteritis. 
Small  aneurisms  have  been  found  in  the  floor  of  the  ulcers  by  Douglas  Pow- 
ell, Welch,  and  others.  A  rare  event  is  emphysema  of  the  sub-peritoneal  tis- 
sue, which  may  be  very  extensive  and  even  pass  on  to  the  posterior  mediasti- 
num. Jurgensen  ascribes  it  to  entrance  of  air  into  the  veins,  but  Welch  thinks 
it  represents  an  invasion  with  the  gas  bacillus. 

CICATRIZATION. — Superficial  ulcers  often  heal  without  leaving  any  serious 
damage.  Stenosis  of  the  pyloric  orifice  not  infrequently  follows  the  healing 
of  an  ulcer  in  its  neighborhood.  In  other  instances  the  large  annular  ulcer 
may  cause  in  its  cicatrization  an  hour-glass  contraction  of  the  stomach.  The 
adhesion  of  the  ulcer  to  neighboring  parts  may  subsequently  be  the  cause 
of  much  pain.  The  parts  of  the  mucosa  in  the  neighborhood  of  the  ulcer 
frequently  show  signs  of  chronic  gastritis. 

PERIGASTRIC  ADHESIONS. — The  condition  is  common,  as  high  as  5  per 
cent,  of  post  mortem  records.  It  follows  ulcer,  lesions  of  the  gall-bladder, 


493 

pancreatic  disease,  syphilitic  disease  of  the  liver,  and  chronic  tuberculosis. 
In  some  instances  the  lesions  are  quite  extensive,  and  the  condition  has  been 
called  plastic  perigastritis.  It  may  be  associated,  too,  with  hypertrophic  thick- 
ening of  the  coats  cf  the  stomach  and  with  chronic  plastic  peritonitis.  In 
some  instances  the  pylorus  may  be  narrowed  as  a  result  of  the  adhesions,  or 
a  sort  of  hour-glass  stomach  may  be  produced,  or  the  motility  of  the  organ 
is  interfered  with.  Pain  is  the  most  constant  feature,  and  may  simulate  that 
of  gastric  ulcer  or  of  hyperacidity,  and  may  be  present  constantly  or  at.  in- 
tervals. It  is  much  influenced  by  posture  and  usually  relieved  by  pressure. 
Local  tenderness  is  present  in  a  majority  of  instances.  The  cases  are  chronic, 
the  gen  ?ral  health  is  but  slightly  interfered  with,  and  there  are  not,  as  a  rule, 
signs  of  gastric  dilatation.  A  definite  tumor  may  be  present  about  the  region 
of  the  pylorus. 

CARCINOMA  AND  ULCER. — The  observations  at  the  Mayo  clinic  by  Wilson 
and  MacCarty  show  a  much  closer  relationship  between  these  conditions  than 
we  had  previously  supposed.  The  latter  author,  who  has  made  a  study  of 
21G  resections  of  the  stomach  for  ulcer  or  cancer,  concludes  that  71  per  cent, 
of  the  resected  specimens  of  cancer  were  associated  with  ulcer,  and  that  68 
per  cent,  of  the  resected  gastric  ulcers  were  associated  with  cancer. 

MODE  OF  ORIGIN. — The  mode  of  origin  is  unknown.  The  anatomical  basis 
is  an  interference  with  the  blood  supply  in  a  limited  area  of  the  mucosa, 
attributed  to  embolism,  thrombosis,  or  spasm  of  the  arteries.  As  they  are  not 
end  vessels,  simple  obstruction  can  not  account  for  it.  Trophic  influences, 
bacterial  necrosis  of  the  mucosa,  spasm  of  the  muscular  coat  in  limited  areas, 
etc.,  are  among  the  hypotheses  which  have  been  advanced.  The  erosion  is 
effected  by  the  gastric  juice,  and  the  healing  is  probably  retarded  by  its  high 
grade  of  acidity. 

A  few  cases  of  acute  duodenal  ulcer  have  a  curious  relation  with  super- 
ficial burns.  Bardeen's  researches  upon  the  necroses  in  the  viscera  following 
extensive  burns  throw  an  important  light  upon  these  cases,  showing  especially 
how  the  gastro-intestinal  mucous  membrane  is  implicated  in  the  toxic  effects. 

JEJUNAL  PEPTIC  ULCER. — This  may  occur  after  gastrojejunostomy,  but 
in  many  cases  the  ulcer  involves  both  stomach  and  jejunum.  The  condition 
is  rare,  as  after  1,141  gastrojejunostomies  at  the  Mayo  clinic  not  one  developed 
an  ulcer. 

Symptoms.— The  condition  may  be  latent  and  only  met  with  accidentally, 
post  mortem.  The  first  symptoms  may  be  those  of  perforation.  In  other 
cases  again,  for  months  and  years,  the  patient  has  had  dyspepsia,  and  the 
ulcer  may  not  have  been  suspected  until  the  occurrence  of  a  sudden  haemor- 
rhage. 

DYSPEPSIA  may  be  slight  and  trifling  or  of  a  most  aggravated  character. 
In  a  considerable  proportion  of  all  cases  nausea  and  vomiting  occur,  the 
latter  not  for  two  or  more  hours  after  eating.  The  vomitus  usually  contains 
a  large  amount  of  hydrochloric  acid. 

HEMORRHAGE  is  present  in  at  least  one-third  of  all  cases.  It  may  be 
latent  (occult).  A  patient  may  feel  faint  and  turn  pale  and  sweat;  the  next 
day  the  stools  may  be  tarry  from  the  blood  that  has  passed  into  the  small 
bowel.  These  concealed  hemorrhages  are  more  often  small,  and  the  blood 
is  not  readily  seen  in  the  vomitus  or  stools.  Weber's  test  may  be  tried;  the 


494  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

fluid  to  be  examined  is  mixed  with  2  or  3  c.  c.  of  glacial  acetic  acid,  and  then 
shaken  with  sulphuric  ether.  If  blood  be  present  the  ethereal  extract  has  a 
Tokay  wine-like  color.  M-eat  should  not  be  eaten  for  a  few  days  before  the 
test  is  made.  These  small,  latent  haemorrhages  may  cause  a  slowly  progres- 
sive anaemia.  More  commonly  the  bleeding  is  profuse,  and  the  blood  may  be 
in  such  quantities  and  brought  up  so  quickly  that  it  is  fluid,  bright  red  in 
color,  and  quite  unaltered.  When  it  remains  for  some  time  in  the  stomach 
and-  is  mixed  with  food  it  may  be  greatly  changed,  but  the  vomiting  of  a 
large  quantity  of  unaltered  blood  is  very  characteristic  of  ulcer.  As  a  rule, 
there  are  only  one  or  two  attacks;  in  our  series  7  cases  had  one  hemorrhage,  7 
two,  11  three,  1  four,  and  15  many  (Howard).  Profuse  bleedings  may  occur 
at  intervals  for  many  years.  Death  may  follow  directly.  From  16  to  18  per 
cent,  of  the  fatal  cases  are  due  to  it  (S.  and  W.  Fenwick). 

The  immediate  effect  of  the  haemorrhage  is  a  severe  anaemia,  from  which 
it  may  take  months  to  rally;  slight  fever  is  common.  Eare  and  untoward 
effects  are  convulsions,  sometimes  only  the  usual  convulsions  of  extreme  cere- 
bral anaemia  from  which  recovery  takes  place,  or  they  may  precede  a  hemi- 
plegia,  due  probably  to  thrombosis. 

Amaurosis  may  follow  the  haemorrhage,  and  unfortunately  may  be  perma- 
nent, due  to  degeneration  of  the  retinal  ganglion  cells,  or  to  a  throm- 
bosis of  the  cerebral  arteries  or  veins. 

PAIN  is  perhaps  the  most  constant  and  distinctive  feature  of  ulcer.  It 
varies  greatly  in  character;  it  may  be  only  a  gnawing  or  burning  sensation, 
which  is  particularly  felt  when  the  stomach  is  empty,  and  is  relieved  by  taking 
food,  but  the  more  characteristic  form  comes  on  in  paroxysms,  in  which  the 
pain  is  not  only  felt  in  the  epigastrium,  but  radiates  to  the  back  and  to  the 
sides.  In  many  cases  the  two  points  of  epigastric  pain  and  dorsal  pain,  about 
the  level  of  the  tenth  dorsal  vertebra,  are  very  well  marked.  These  attacks 
are  most  frequently  induced  by  taking  food,  and  they  may  recur  at  a  variable 
period  after  eating,  sometimes  within  fifteen  or  twenty  minutes,  at  others  as 
late  as  two  or  three  hours.  It  is  usually  stated  that  when  the  ulcer  is  near 
the  cardia  the  pain  is  apt  to  set  in  earlier,  but  there  is  no  certainty  on  this 
point.  In  some  cases  it  comes  on  in  the  early  morning  hours.  The  attacks 
may  occur  at  intervals  with  great  intensity  for  weeks  or  months  at  a  time,  so 
that  the  patient  constantly  requires  morphia,  then  again  they  may  disappear 
entirely  for  a  prolonged  period.  In  the  attack  the  patient  is  usually  bent  for- 
ward, and  finds  relief  from  pressure  over  the  epigastric  region;  one  patient 
during  the  attack  would  lean  over  the  back  of  a  chair ;  another  would  lie  flat 
on  the  floor,  with  a  hard  pillow  under  the  abdomen.  Pressure  is,  as  a  rule, 
grateful.  It  has  been  thought  that  the  posture  assumed  during  the  attack 
would  indicate  the  site  of  the  ulcer,  but  this  is  very  doubtful. 

TENDERNESS  on  pressure  is  a  common  symptom  in  ulcer,  and  patients 
wear  the  waist-band  very  low.  Pressure  should  be  made  with  great  care,  as 
rupture  of  an  ulcer  is  said  to  have  been  induced  by  careless  manipulation. 

In  old  ulcers  with  thickened  bases  an  indurated  mass  may  be  felt  in  the 
neighborhood  of  the  pylorus. 

Of  general  symptoms,  loss  of  weight  results  from  the  prolonged  dyspepsia, 
but  it  rarely,  except  in  association  with  cicatricial  stenosis  of  the  pylorus, 
reaches  the  high  grade  met  with  in  cancer.  The  anaemia  may  be  extreme,  and 


THE    PEPTIC    ULCER,    GASTRIC    AND    DUODENAL        495 

in  one  case  of  duodenal  ulcer,  which  I  examined,  the  blood-count  was  as  low 
as  700,000  per  c.  mm.  Of  44  cases  in  my  wards  in  which  blood-counts  were 
made,  the  lowest  was  1,902,000  per  c.  mm.  There  are  instances,  such  as  the 
one  reported  by  Pepper  and  Griffith,  in  which  the  extreme  anaemia  can  not 
be  explained  by  the  occurrence  of  haemorrhage.  In  a  few  instances  polycythae- 
mia  is  present,  even  after  a  haemorrhage,  due  to  concentration  of  the  blood 
and  possibly  associated  dilatation  of  the  stomach.  In  a  few  cases  parotitis 
occurs,  with  the  perforation  sometimes,  or  after  a  haemorrhage.  In  one  of 
my  cases  there  was  a  remarkable  pigmentation  of  the  face  and  of  the  axillary 
folds. 

PERFORATION. — This  occurred  in  28.1  per  cent,  of  Musser's  series.  The 
acute,  perforating  form  is  much  more  common  in  women  than  in  men.  The 
symptoms  are  those  of  perforative  peritonitis.  Particular  attention  must  be 
given  to  this  accident,  since  it  has  come  so  succesfully  within  the  sphere  of 
the  surgeon.  As  already  mentioned,  perforation  may  take  place  either  into  the 
lesser  peritoneum  or  into  the  general  peritoneal  cavity,  in  both  of  which  cases 
operation  is  indicated;  in  rare  instances  the  ulcer  may  perforate  the  peri- 
cardium. This  was  the  case  in  10  of  28  cases  in  which  the  diaphragm  was 
perforated  (Pick). 

Localized,  more  frequently  subphreriic,  abscess  may  follow  perforation. 

URINE. — Albumin  is  occasionally  present;  in  14  of  our  series  with  dilata- 
tion of  the  stomach.  Indican  may  be  present.  Acetone  and  diacetic  acid 
(with  syncopal  attacks)  have  been  described  by  Dreschfeld. 

HOUR-GLASS  STOMACH  most  frequently  results  from  the  cicatrization  of 
an  ulcer.  In  a  few  cases  it  is  congenital.  The  symptoms,  fairly  character- 
istic, are  thus  given  by  Moynihan: 

(a)  In  washing  out  the  stomach  part  of  the  fluid  is  lost.  (6)  If  the  stom- 
ach is  washed  clean,  a  sudden  reappearance  of  stomach  contents  may  take 
place,  (c)  "Paradoxical  dilatation";  when  the  stomach  has  apparently  been 
emptied,  a  splashing  sound  may  be  elicited  by  palpation  of  the  pyloric  seg- 
ment, (d)  After  distending  the  stomach,  a  change  in  the  position  of  the 
distention  tumor  may  be  seen  in  some  cases,  (e)  Gushing,  bubbling,  or 
sizzling  sounds  are  heard  on  dilatation  with  carbon  dioxide  at  a  point  distinct 
from  the  pylorus.  (/)  In  some  cases,  when  both  parts  are  dilated,  two  tumors 
with  a  notch  or  sulcus  between  are  apparent  to  sight  or  touch.  To  these  may 
now  be  added  (g)  a  most  characteristic  X-ray  picture. 

Prognosis. — In  all  statistics  the  acute  and  chronic  ulcer  have  been  consid- 
ered together.  The  former  is  more  amenable  to  medical  treatment,  but  grave 
complications  may  occur  even  before  the  digestive  symptoms  have  been  very 
pronounced.  The  chronic  ulcer  may  last  for  years — twelve,  eighteen,  or  even 
twenty — with  intervals  of  good  health.  The  all-important  point  in  the  prog- 
nosis relates  to  the  question  of  medical  or  surgical  treatment — which  gives 
the  best  results  ?  So  far  as  figures  count,  the  exhaustive  study  of  Musser  fa- 
vors the  former,  12.4  per  cent,  mortality  against  20  per  cent,  for  the  latter. 
This  for  simple  cases  including  complications.  In  private  practice  many 
series  of  cases  have  not  a  mortality  above  6  per  cent.  The  mortality  of  the 
chronic  peptic  ulcer  in  the  hands  of  such  experts  as  the  Mayos  and  Moyni- 
han is  very  low.  In  311  gastrojejunostomies  for  ulcer  of  the  stomach  and 
duodenum  the  mortality  was  less  than  1  per  cent.,  and  only  three  patients  re- 


496  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

quired  a  secondary  operation  (Mayo's) .  In  Moynihan's  cases  of  duodenal  ulcer, 
114  in  number  (exclusive  of  perforation),  there  were  only  two  deaths.  The 
end  results  of  gastro-enterostomy  for  the  chronic  ulcer  appear  to  be  excel- 
lent. 

Diagnosis. — The  acute  non-indurated  ulcer  may  cause  very  few  symptoms 
— nothing  beyond  ordinary  dyspepsia  with  pain.  Examination  of  the  stomach 
contents  shows  an  increase  in  the  free  HC1.  Haematemesis  may  be  the  first 
symptom  of  moment.  This  group  of  cases  is  seen  chiefly  in  young  girls,  and 
appears  to  be  much  more  common  in  England  than  in  the  United  States.  A 
condition  which  may  be  confounded  with  it  is  gastrostaxis,  described  by  Hale 
White.  The  stomach  symptoms  are  marked,  the  bleeding  may  be  profuse,  but 
post  mortem  or  at  operation  no  ulcer  is  found.  Of  course  very  careful  inspec- 
tion must  be  made,  as  fatal  bleeding  may  come  from  a  very  small  erosion. 
The  symptoms  of  non-indurated  mucous  ulcer  yield  to  a  few  months'  medical 
treatment. 

In  the  chronic  cases  the  nutrition  at  first  may  remain  good,  and  the  pa- 
tient looks  well.  The  whole  complaint  is  of  the  stomach,  of  pain  and  distress, 
with  belching  and  nausea  or  vomiting  from  two  to  four  hours  after  meals. 
This  special  feature  of  the  recurrence  of  the  pain  some  hours  after  taking 
food,  its  extraordinary  regularity,  persisting  day  by  day  for  months  or  even 
years,  and  the  relief  afforded  by  taking  food  clearly  separate  the  dyspeptic 
features  of  ulcer  from  other  types. 

Einhorn  has  introduced  an  ingenious  thread  test.  A  perforated  olive  with 
a  long  white  thread  attached  is  swallowed  and  remains  in  the  stomach  for 
10  or  12  hours.  If  an  ulcer,  gastric  or  duodenal,  is  present,  there  is  a  stain 
corresponding  to  the  part  of  the  thread  that  has  lain  in  contact  with  the  ul- 
cer, and  the  position  on  the  thread  gives  an  idea  of  the  distance  of  the  ulcer 
from  the  cardia. 

Treatment.  — Post  mortem  observations  show  that  a  very  large  number  of 
ulcers  heal  completely,  but  the  process  is  slow  and  tedious,  often  requiring 
months,  or,  in  severe  cases,  years.  The  following  are  the  important  points 
in  treatment : 

(a)  Absolute  rest  in  bed. 

(&)  A  carefully  and  systematically  regulated  diet.  While  theoretically 
it  is  better  to  give  the  stomach  complete  rest  by  rectal  feeding,  yet  in  prac- 
tice this  strict  limitation  is  not  found  satisfactory.  The  food  should  be 
bland,  easily  digested,  and  given  at  stated  intervals.  The  following  dietary 
will  be  found  useful :  At  8  a.  m.  give  200  c.  c.  of  Leube's  beef  solution ;  at 
12  m.,  300  c.  c.  of  milk  gruel  or  peptonized  milk.  The  gruel  should  be  made 
with  ordinary  flour  or  arrowroot,  and  is  mixed  with  an  equal  quantity  of 
milk.  If  necessary  it  may  be  peptonized.  Buttermilk  is  very  well  borne 
by  these  patients.  At  4  p.  m.  the  beef  solution  again,  and  at  8  p.  m.  the  milk 
gruel  or  buttermilk.  Feeding  by  the  duodenal  tube  is  often  successful. 

The  stomach  in  some  cases  is  so  irritable  that  the  smallest  amount  of 
food  is  not  well  borne.  In  such  cases  lavage  may  be  practiced,  if  necessary, 
every  morning,  with  mildly  alkaline  water,  after  which  the  beef  solution  is 
given  and  the  feeding  supplemented  by  the  rectal  injections.  Ill  effects  rarely 
follow  the  careful  use  of  the  stomach  tube  in  gastric  ulcer.  There  are  some 
patients  who  do  well  from  the  outset  on  a  milk  diet,  given  at  regular  intervals, 


THE    PEPTIC    ULCER,    GASTRIC    AND   DUODENAL        49? 

3  or  4  ounces  every  two  hours.  When  milk  is  not  well  borne  egg  albumen 
may  be  substituted,  or  the  whites  of  eight  eggs  may  be  alternated  with  Leube's 
beef  solution.  At  the  end  of  a  month,  if  the  condition  has  improved,  the 
patient  may  be  allowed  scraped  beef  or  young  chicken,  perfectly  fresh  sweet- 
bread, and  farinaceous  puddings  made  with  milk  and  eggs.  Local  applica- 
tions, such  as  warm  fomentations,  over  the  abdomen  are  very  useful.  The 
patient  should  be  told  that  the  treatment  will  take  at  least  three  months,  and 
for  the  greater  portion  of  the  time  he  should  be  in  bed. 

(c)  Medicinal  measures  are  of  very  little  value  in  gastric  ulcer,  and  the 
remedies  employed  probably  do  not  benefit  the  ulcer,  but  the  gastric  catarrh. 
The  Carlsbad  salts  are  warmly  recommended  by  von  Ziemssen.  The  artificial 
preparation  (sulphate  of  sodium,  50  parts;  bicarbonate  of  sodium,  6;  chloride 
of  sodium,  3)  may  be  substituted,  of  which  a  teaspoonful  is  taken  every  morn- 
ing. Bismuth,  in  doses  of  30  to  60  grains  (2  to  4  gm.)  three  times  a  day, 
and  nitrate  of  silver  may  be  given,  but  they  influence  the  associated  condi- 
tions rather  than  the  ulcer. 

The  pain,  if  severe,  requires  opium.  Unless  the  gastralgia  is  intense  mor- 
phia should  not  be  given  hypodermically,  as  there  is  a  very  serious  danger 
in  these  cases  of  establishing  the  morphia  habit.  Doses  of  an  eighth  of  a 
grain,  with  the  bicarbonate  of  soda  and  bismuth,  will  allay  the  mild  attacks, 
but  the  very  severe  ones  require  the  hypodermic  injection  of  a  quarter  or  often 
half  a  grain.  Antipyrin  and  antifebrin  may  be  tried,  but,  as  a  rule,  are  quite 
ineffectual.  In  the  milder  attacks  Hoffman's  anodyne,  or  20  or  30  drops  of 
spirit  of  chloroform,  or  the  spirits  of  camphor,  will  give  relief.  Counter- 
irritation  over  the  stomach  with  mustard  or  cantharides  is  often  useful. 

When  the  stomach  is  irritable,  the  patient  should  be  fed  per  rectum. 
He  will  sometimes  retain  food  which  is  passed  into  the  stomach  through  the 
tube,  and  Leube's  beef  solution  or  milk  may  be  given  in  this  way.  Cracked 
ice,  chloroform,  oxalate  of  cerium,  and  bismuth  may  be  tried.  When  haemor- 
rhage occurs  the  patient  should  be  put  under  the  influence  of  opium  as  rar> 
idly  as  possible.  No  attempt  should  be  made  to  check  the  haemorrhage  b) 
administering  medicines  by  the  mouth;  as  the  profuse  bleeding  is  always 
from  an  eroded  artery,  frequently  from  one  of  considerable  size,  it  is  doubtful 
if  acetate  of  lead,  tannic  and  gallic  acids,  and  the  usual  remedies  have  the 
slightest  influence.  The  essential  point  is  to  give  rest,  which  is  best  ob- 
tained by  opium.  Nothing  should  be  given  by  the  mouth  except  small  quan- 
tities of  ice.  In  profuse  bleeding  the  extremities  may  be  tightly  bandaged. 
Not  infrequently  the  loss  of  blood  is  so  great  that  the  patient  faints.  A 
fatal  result  is  not,  however,  very  common  from  haemorrhage.  Transfusion, 
direct  from  artery  to  vein  by  Crile's  method,  or  the  subcutaneous  infusion  of 
saline  solution,  may  be  necessary. 

The  patients  usually  recover  rapidly  from  the  haemorrhage  and  require 
iron  in  full  doses,  which  may,  if  necessary,  be  given  hypodermically. 

Surgical  interference  is  indicated:  (1)  For  perforation;  (2)  in  the 
chronic  indurated  ulcer.  Experience  has  shown  that  after  gastro-enterostomy 
the  ulcer  heals  rapidly,  and  in  some  cases  the  ulcer  itself  may  be  located; 
(3)  in  all  cases  when  the  ulcer  has  caused  mechanical  interference  with  the 
passage  of  the  gastric  contents;  (4)  in  all  cases  associated  with  recurring 
haemorrhages.  In  young  girls  the  single  severe  attack  of  haematemesis  may 


498  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

be  a  simple  gastrorrhexis,  or  from  a  simple  ulcer  that  heals  readily,  but  in 
men  severe  haematemesis  is  almost  always  from  the  chronic  ulcer;  (5)  in 
the  perigastric  adhesions  after  chronic  ulcer  operation  is  sometimes  helpful; 
(6)  in  chronic  cases  in  which  medical  treatment  fails  to  give  relief. 

In  the  present  state  of  our  knowledge  it  is  not  easy  to  determine  the  lim- 
its of  medical  and  surgical  practice  in  the  treatment  of  peptic  ulcer.  The 
old  statistics  are  not  of  much  avail,  since  it  is  quite  clear  that  scores  of  cases 
have  been  masquerading  under  the  names  of  hyperchlorhydria,  acid  dyspepsia, 
and  so  forth.  The  simple  non-indurated  ulcer  is,  in  the  majority  of  cases,  a 
medical  disease.  A  chronic  indurated  form,  is  best  treated  surgically. 


VI.    CANCER    OF    THE    STOMACH 

Etiology. — INCIDENCE. — In  an  analysis  of  30,000  cases  of  cancer,  W.  H. 
Welch  found  the  stomach  involved  in  21.4  per  cent.,  this  organ  thus  standing 
next  to  the  uterus  in  order  of  frequency.  Among  8,464  cases  admitted  to  my 
wards,  there  were  150  cases  of  cancer  of  the  stomach.  There  were  39  cases 
among  the  first  1,000  autopsies  in  the  post  mortem  room  of  the  Johns  Hop- 
kins Hospital.  The  disease  is  more  common  in  some  countries.  Figures  in- 
dicate that  cancer  of  the  stomach,  as  of  other  organs,  is  increasing  in  fre- 
quency. 

SEX. — In  150  cases  from  my  wards  there  were  126  males  and  24  females 
(McCrae).  Welch  gives  the  ratio  as  5  to  4. 

AGE. — Of  our  150  cases  the  ages  were  as  follows:  Between  twenty  and 
thirty,  6 ;  from  thirty  to  forty,  17 ;  forty  to  fifty,  38 ;  fifty  to  sixty,  49 ;"  sixty 
to  seventy,  36;  seventy  to  eighty,  4.  Fifty-eight  per  cent,  occurred  between 
the  ages  of  forty  and  sixty.  Of  the  6  cases  occurring  under  the  thirtieth 
year,  the  youngest  was  twenty-two.  Of  the  large  number  of  cases  analyzed 
by  Welch,  three-fourths  occurred  between  the  fortieth  and  seventieth  years. 
Congenital  cancer  of  the  stomach  has  been  described,. and  cases  have  been  met 
with  in  children. 

RACE. — Among  our  150  cases,  131  were  white;  19  were  negroes. 

HEREDITY. — Of  the  150  cases  in  only  11  was  there  a  positive  history  of 
cancer  in  the  family.  In  some  families,  as  the  Bonapartes,  the  disease  seems 
to  prevail.  In  our  series  a  very  much  larger  number — 38 — had  a  family 
history  of  tuberculosis. 

PREVIOUS  DISEASES,  HABITS,  ETC. — A  history  of  dyspepsia  was  present  in 
only  33  cases;  of  these,  17  had  had  attacks  at  intervals,  11  had  had  chronic 
stomach  trouble,  and  5  had  had  dyspepsia  for  one  or  two  years  before  the 
symptoms  of  cancer  developed.  Napoleon,  discussing  this  interesting  point 
with  his  physician  Antommarchi,  said  that  he  had  always  had  a  stomach  of 
iron  and  felt  no  inconvenience  until  the  onset  of  what  proved  to  be  his  fatal 
illness. 

ALCOHOL. — Seventy-seven  of  our  patients  had  used  it  regularly,  65  of 
these  moderately  (  ?),  8  excessively. 

TRAUMA. — Only  one  case  gave  a  positive  history.  In  one  case  the  cancer 
followed  rapidly  upon  a  blow  on  the  stomach,  and  the  patient  lost  sixty  pounds 
in  weight  in  three  months. 


CANCER    OF   THE    STOMACH  499 

GASTRIC  ULCER. — The  relation  to  this  condition  is  in  dispute — the  physi- 
cians are  against,  the  surgeons  are  in  favor.  In  only  4  cases  in  my  series  was 
there  a  history  pointing  to  ulcer.  On  the  other  hand,  in  the  Mayo  clinic 
nearly  75  per  cent,  of  the  cancers  are  believed  to  originate  in  ulcer. 

Morbid  Anatomy. — The  most  common  varieties  of  gastric  cancer  are  the 
cylindrical-celled  adeno-carcinoma  and  the  encephaloid  or  medullary  carci- 
noma; next  in  frequency  is  scirrhous,  and  then  colloid  cancer.  With  refer- 
ence to  the  situation  of  the  tumor,  Welch  analyzed  1,300  cases,  in  which  the 
distribution  was  as  follows:  Pyloric  region,  791;  lesser  curvature,  148; 
cardia,  104;  posterior  wall,  68;  the  whole  or  greater  part  of  the  stomach, 
61;  multiple  tumors,  45;  greater  curvature,  34;  anterior  wall,  30;  fundus,  19. 

The  medullary  cancer  occurs  in  soft  masses,  which  involve  all  the  coats 
of  the  stomach  and  usually  ulcerate  early.  The  tumor  may  form  villous 
projections  or  cauliflower-like  outgrowths.  It  is  soft,  grayish-white  in  color, 
and  contains  much  blood.  The  cylindrical-celled  epithelioma  may  also  form 
large  irregular  masses,  but  the  consistence  is  usually  firmer,  particularly  at 
the  edges  of  the  cancerous  ulcers.  Cysts  are  not  uncommon  in  this  form. 
The  scirrhous  variety  is  characterized  by  great  hardness,  due  to  the  abun- 
dance of  the  stroma  and  the  limited  amount  of  alveolar  structures.  It  is  seen 
most  frequently  at  the  pylorus,  where  it  is  a  common  cause  of  stenosis.  It 
may  be  combined  with  the  medullary  form.  It  may  be  diffuse,  involving  all 
parts  of  the  organ,  and  leading  to  a  condition  which  can  not  be  recognized 
macroscopically  from  cirrhosis.  This  form  has  also  been  seen  in  the  stomach 
secondary  to  cancer  of  the  ovaries.  In  connection  with  the  diffuse  carcinoma- 
tosis  there  may  be  simultaneous  involvement  of  the  small  and  large  intes- 
tines. The  colloid  cancer  is  peculiar  in  its  wide-spread  invasion  of  all  the 
coats.  It  also  spreads  with  greater  frequency  to  the  neighboring  parts,  and  it 
occasionally  causes  extensive  secondary  growths  of  the  same  nature  in  other 
organs.  The  appearance  on  section  is  very  distinctive,  and  even  with  the 
naked  eye  large  alveoli  can  be  seen  filled  with  the  translucent  colloid  mate- 
rial. The  term  alveolar  cancer  is  often  applied  to  this  form.  Ulceration  is 
not  constantly  present,  and  there  are  instances  in  which,  with  most  exten- 
sive disease,  digestion  has  been  but  slightly  disturbed.  There  is  a  specimen 
in  the  Warren  Museum,  at  the  Harvard  Medical  School,  of  the  most  wide- 
spread colloid  cancer,  in  which  the  stomach  contained  after  death  large  pieces 
of  undigested  beef-steak. 

SECONDARY  CANCER  OF  THE  STOMACH. — Of  37  cases  collected  by  Welch, 
17  were  secondary  to  cancer  of  the  breast.  Among  the  first  1,000  autopsies  at 
the  Johns  Hopkins  Hospital  there  were  3  cases  of  secondary  cancer. 

CHANGES  IN  THE  STOMACH. — Cancer  at  the  cardia  is  usually  associated 
with  wasting  of  the  organ  and  reduction  in  its  size.  The  oesophagus  above 
the  obstruction  may  be  greatly  dilated.  On  the  other  hand,  annular  cancer 
at  the  pylorus  causes  stenosis  with  great  dilatation  of  the  organ.  In  a  few 
rare  instances  the  pylorus  has  been  extremely  narrowed  without  any  increase 
in  the  size  of  the  stomach.  In  diffuse  scirrhous  cancer  the  stomach  may  be 
very  greatly  thickened  and  contracted.  It  may  be  displaced  or  altered  in 
shape  by  the  weight  of  the  tumor,  particularly  in  cancer  of  the  pylorus;  in 
such  cases  it  has  been  found  in  every  region  of  the  abdomen,  and  even  in 
the  true  pelvis.  The  mobility  of  the  tumors  is  at  times  extraordinary  and 


500  DISEASES    OF   THE   DIGESTIVE    SYSTEM 

very  deceptive,  and  they  may  be  pushed  into  the  right  hypochondrium  or 
into  the  splenic  region,  entirely  beneath  the  ribs.  Adhesions  very  frequently 
occur,  particularly  to  the  colon,  the  liver,  and  the  anterior  abdominal  wall. 

Secondary  cancerous  growths  in  other  organs  are  very  frequont,  as  shown 
by  the  following  analysis  by  Welch  of  1,574  cases :  Metastasis  occurred  in  the 
lymphatic  glands  in  551;  in  the  liver  in  475;  in  the  peritoneum,  omentum, 
and  intestine  in  357;  in  the  pancreas  in  122;  in  the  pleura  and  lung  in  98; 
in  the  spleen  in  26;  in  the  brain  and  meninges  in  9;  in  other  parts  in  92. 
The  lymph  glands  affected  are  usually  those  of  the  abdomen,  but  the  cervical 
and  inguinal  glands  are  not  infrequently  attacked,  and  give  an  important  clue 
in  diagnosis.  Secondary  metastatic  growths  occur  subcutaneously,  either  at 
the  navel  or  beneath  the  skin  in  the  vicinity,  and  are  of  great  value  in  diag- 
nosis. 

PERFORATION. — This  occurred  into  the  peritoneum  in  17  of  the  507  cases 
of  cancer  of  the  stomach  collected  by  Brinton.  In  our  series  perforation 
occurred  in  4  cases.  When  adhesions  form,  the  most  extensive  destruction 
of  the  walls  may  take  place  without  perforation  into  the  peritoneal  cavity. 
In  one  instance  which  came  under  my  observation  a  large  portion  of  the  left 
lobe  of  the  liver  lay  within  the  stomach.  Occasionally  a  gastro-cutaneous 
fistula  is  established.  Perforation  may  occur  into  the  colon,  the  small  bowel, 
the  pleura,  the  lung,  or  into  the  pericardium. 

Symptoms. — LATENT  CARCINOMA. — The  cases  are  not  very  infrequent. 
There  may  be  no  symptoms  pointing  to  the  stomach,  and  the  tumor  may  be 
discovered  accidentally  after  death.  In  a  second  group  the  symptoms  of 
carcinoma  are  present,  not  of  the  stomach,  but  of  the  liver  or  some  other  or- 
gan, or  there  are  subcutaneous  nodules,  or,  as  in  one  of  our  cases,  secondary 
masses  on  the  ribs  and  vertebras.  In  a  third  group,  seen  particularly  in  elderly 
persons  in  institutions,  there  is  gradual  asthenia,  without  nausea,  vomiting, 
or  other  local  symptoms. 

FEATURES  OF  ONSET. — Of  the  150  cases  in  our  series,  48  complained  of 
pain,  44  of  dyspepsia,  21  of  vomiting,  13  of  loss  in  weight,  3  of  difficulty  in 
swallowing,  1  of  tumor.  In  7  the  features  of  onset  suggested  pernicious 
anaemia.  In  37  cases  there  was  a  history  of  sudden  onset. 

GENERAL  SYMPTOMS. — Loss  of  Weight. — Progressive  emaciation  is  one  of 
the  most  constant  features  of  the  disease.  In  79  of  our  cases  in  which  exact 
figures  were  taken:  To  30  pounds,  32  cases;  30  to  50  pounds,  36  cases;  50  to 
60  pounds,  5  cases;  60  to  70  pounds,  4;  over  70  pounds,  1;  100  pounds,  a 
case  of  cancer  at  the  cardiac  end  with  obstruction  to  swallowing.  The  loss  in 
weight  is  not  always  progressive.  We  see  increase  in  weight  under  three  con- 
ditions :  (a)  Proper  dieting,  with  treatment  of  the  associated  catarrh  of  the 
stomach;  (6)  in  cases  of  cancer  of  the  pylorus  after  relief  of  the  dilatation 
of  the  organ  by  lavage,  etc.;  (c)  after  a  profound  mental  impression.  I  have 
known  a  gain  of  ten  pounds  to  follow  the  visit  of  an  optimistic  consultant. 
In  Keen  and  D.  D.  Stewart's  case  there  was  a  gain  of  seventy  pounds  after 
an  exploratory  operation! 

Loss  in  strength  is  usually  proportionate  to  the  loss  in  weight.  One  sees 
sometimes  remarkable  vigor  almost  to.  the  close,  but  this  is  exceptional. 

Ancemia  is  present  in  a  large  proportion  of  all  cases,  and  with  the  emacia- 
tion gives  the  picture  of  cachexia.  There  is  often  a  yellow  or  lemon  tint  of 


CANCER    OF    THE    STOMACH  501 

the  skin.  In  59  cases  careful  blood-counts  were  made ;  in  3  the  red  corpuscles 
were  above  6,000,000  per  c.  mm.  This  occurs  in  the  concentrated  condition 
of  the  blood  in  certain  cases  of  cancer  of  the  pylorus  with  dilatation  of  the 
stomach.  The  average  count  in  the  59  cases  was  3,712,186  per  c.  mm.  In 
only  8  cases  was  the  count  below  2,000,000,  and  in  none  below  1,000,000.  The 
average  of  the  haemoglobin  was  44:9  per  cent.  In  only  9  was  it  below  30  per 
cent.  In  62  cases  in  which  the  leucocytes  were  counted  there  were  only  18 
cases  in  which  they  were  above  12,000  per  c.  mm. ;  in  only  3  cases  were  they 
above  20,000.  The  features  of  onset  may  suggest  a  primary  anaamia. 

Among  other  general  symptoms  may  be  mentioned  fever,  which  was  present 
at  some  time  in  74  of  our  150  cases.  In  only  13  of  these  did  the  temperature 
rise  above  101°.  In  2  it  was  above  103°.  Fifteen  presented  fairly  constant 
elevation  of  temperature.  Eight  presented  sudden  rises.  Two  cases  had 
chill,  with  elevation  to  103°  and  104°.  Chills  may  be  associated  with  sup- 
puration at  the  base  of  the  cancer. 

Urine. — There  may  be  no  changes  throughout;  in  65  of  our  cases  there 
were  no  alterations,  in  36  albumin  was  found,  and  in  34  albumin  with  tube- 
casts.  Glycosuria,  peptonuria,  and  acetonuria  have  been  described.  Indican 
is  common. 

(Edema. — Swelling  of  the  ankles  is  of  frequent  occurrence  toward  the 
close.  In  some  cases  there  is  even  early  a  general  anasarca,  usually  in  com- 
bination with  extreme  anaamia.  The  cancer  is  usually  overlooked. 

The  bowels  are  often  constipated.  In  only  12  cases  in  our  series  was 
diarrhoea  present.  In  2  cases  blood  was  passed  per  rectum.  There  are  no 
special  cardiac  symptoms;  the  pulse  becomes  progressively  weaker.  Throm- 
bosis of  one  femoral  vein  may  occur,  'or,  as  in  one  of  our  cases,  wide-spread 
thrombosis  in  the  superficial  veins  of  the  body. 

.  Symptoms  on  the  part  of  the  nervous  system  are  rare;  consciousness  is 
often  retained  to  the  end.  Coma  may  occur  similar  to  that  seen  in  diabetes, 
and  is  believed  to  be  due  to  an  acid  intoxication. 

FUNCTIONAL  DISTURBANCES. — Anorexia,  loss  of  desire  for  food,  is  a  fre- 
quent and  valuable  symptom,  more  constant  perhaps  than  any  other.  Nausec. 
is  a  striking  feature  in  many  cases;  there  is  often  a  sudden  repulsion  at  the 
sight  of  food.  In  exceptional  cases  the  appetite  is  retained  throughout. 

Vomiting  may  come  on  early,  or  only  after  the  dyspepsia  has  persisted 
for  some  time.  It  occurred  in  128  cases  in  our  series.  At  first  it  is  at  long 
intervals,  but  subsequently  it  is  more  frequent,  and  may  recur  several  times 
in  the  day.  There  are  cases  in  which  it  comes  on  in  paroxysms  and  then 
subsides;  in  other  cases  it  sets  in  early,  persists  with  great  violence,  and 
may  cause  a  fatal  termination  within  a  few  weeks.  Vomiting  is  more  fre- 
quent when  the  cancer  involves  the  orifices,  particularly  the  pylorus,  in 
which  case  it  is  usually  delayed  for  an  hour  or  more  after  taking  the  food. 
When  the  cardiac  orifice  is  involved  it  may  follow  at  a  shorter  interval.  Ex- 
tensive disease  of  the  fundus  or  of  the  anterior  or  posterior  wall  may  be  pres- 
ent without  the  occurrence  of  vomiting.  The  food  is  sometimes  very  little 
changed,  even  after  it  has  remained  in  the  stomach  for  twenty-four  hours. 

Haemorrhage  occurred  in  36  of  our  150  cases;  in  32  the  blood  was  dark 
and  altered,  in  3  it  was  bright  red.  In  2  cases  vomiting  of  blood  was  the 
first  symptom.  The  bleeding  is  rarely  profuse;  more  commonly  there  is 


t>02  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

slight  oozing,  and  the  blood  is  mixed  with,  or  altered  by,  the  secretions,  and, 
when  vomited,  the  material  is  dark  brown  or  black,  the  so-called  "coffee- 
ground"  vomit.  The  blood  can  be  recognized  by  the  microscope  as  shadows 
of  the  red  blood-corpuscles  and  irregular  masses  of  altered  blood  pigment. 
Occult  blood  may  be  found  in  the  faeces. 

Pain,  an  early  and  important  symptom,  was  present  in  130  of  our  cases. 
It  is  very  variable  in  situation  and,  while  most  common  in  the  epigastrium, 
it  may  be  referred  to  the  shoulders,  the  back,  or  the  loins.  The  pain  is  de- 
scribed as  dragging,  burning,  or  gnawing  in  character,  and  very  rarely  occurs 
in  severe  paroxysms,  as  in  gastric  ulcer.  As  a  rule,  the  pain  is  aggravated 
by  taking  food.  There  is  usually  marked  tenderness  on  pressure  in  the  epi- 
gastric region.  The  areas  of  skin  tenderness  are  referred,  as  Head  has  shown, 
to  the  region  between  the  nipple  and  the  umbilicus  in  front  and  behind  from 
the  fifth  to  the  twelfth  thoracic  spine. 

THE  STOMACH  CONTEXTS. — The  finding  of  pus  and  blood  in  the  empty 
stomach  and  pus.  blood  and  mucus  two  hours  after  the  test  meal  is  suggestive. 
Diminished  motility  may  be  an  early  finding  in  pyloric  cancer.  There  is  often 
a  downward  trend  in  the  curve  of  acid  secretion.  The  protein  curve  often 
shows  a  marked  divergence  from  the  acid  curve  which  increases  as  digestion 
goes  on  and  is  most  marked  in  cases  of  subacidity  or  achylia.  The  test  for 
soluble  albumin  ( Wolff- Junghans)  is  of  value,  especially  two  hours  after  the 
test  meal.  The  tryptophan  test  and  ereptic  reaction  are  of  doubtful  value 
owing  to  frequent  regurgitation  of  duodenal  contents.  Bacteria  in  large  num- 
bers occur,  one,  the  Oppler-Boas  bacillus — an  unusually  long  non-motile  form 
— is  supposed  to  be  of  diagnostic  value,  and  to  be  largely  responsible  for  the 
formation  of  lactic  acid.  Blood  is  a  most  important  ingredient ;  the  persistent 
presence  microscopically  of  red  corpuscles  in  the  early  morning  washings  is 
always  very  suspicious.  Later,  when  coffee-ground  vomiting  takes  place,  the 
macroscopic  evidence  is  sufficient.  Fragments  of  the  new  growth  may  be 
vomited  or  may  appear  in  the  washings. 

Examination  of  the  Test  Breakfast. — The  Ewald  test  meal,  consisting 
of  a  slice  of  stale  bread  and  a  large  cup  of  weak  tea  without  cream  or  sugar, 
is  given  at  7  a.  m.  and  withdrawn  at  8  a.  m.  The  Boas  test  meal,  consisting 
of  a  gruel  made  of  a  tablespoonful  of  oatmeal  flour  in  a  litre  of  water,  is 
used  in  the  estimation  of  lactic  acid.  As  an  outcome  of  the  enormous  num- 
ber of  observations  made  of  late  years,  it  may  be  said  that  free  HC1  is  absent 
in  a  large  proportion  of  all  cases  of  cancer  of  the  stomach.  Of  94  cases  in 
which  the  contents  were  examined  in  84  free  HC1  was  absent.  In  5  un- 
doubted cases  the  reaction  was  good;  in  2  of  these  the  history  suggested 
previous  ulcer.  HC1  may  be  absent  in  chronic  gastritis  and  in  atrophy  of  the 
gastric  mucosa.  The  presence  of  lactic  acid  after  Boas'  test  meal  is  regarded 
as  a  valuable  sign. 

PHYSICAL  EXAMINATION. — Inspection. — After  a  preliminary  survey,  em- 
bracing the  facies,  state  of  nutrition,  etc.,  particular  attention  is  given  to  the 
abdomen.  An  all-important  matter  is  to  have  the  patient  in  a  good  light. 
Fullness  in  the  epigastric  region,  inequality  in  the  infracostal  grooves,  the 
existence  of  peristalsis,  a  wide  area  of  aortic  pulsation,  the  presence  of  sub- 
cutaneous nodules  or  small  masses  about  the  navel,  and,  lastly,  a  well-defined 
tumor  mass — these,  together  or  singly,  may  be  seen  on  careful  inspection 


CANCER    OF    THE    STOMACH  503 

I  can  not  emphasize  too  strongly  the  value  of  this  method  of  examination. 
In  62  of  the  150  cases  a  positive  tumor  could  be  seen.  In  52  the  tumor 
descended  with  inspiration;  in  36  peristalsis  was  visible;  in  3  cases  move- 
ments were  visible  in  the  tumor  itself.  In  10  cases  with  visible  peristalsis 
no  tumor  was  seen,  but  could  be  felt  on  palpation.  Inflation  with  carbonic- 
acid  gas  may  be  tried,  except  when  haemorrhage  has  been  profuse  or  the  can- 
cer is  very  extensive.  The  dilatation  often  renders  evident  the  peristalsis  or 
may  bring  a  tumor  into  view.  The  presence  of  subcutaneous  and  umbilical 
nodules  is  sometimes  a  very  great  help.  They  were  found  in  5  of  our  series. 

Palpation. — In  115  cases  a  tumor  could  be  felt;  in  48  in  the  epigastric  re- 
gion, in  25  in  the  umbilical,  in  18  in  the  left  hypochondriac,  in  17  in  the  right 
hypochondriac  region,  while  in  7  cases  a  mass  descended  in  deep  inspiration 
from  beneath  the  left  costal  margin.  These  figures  illustrate  in  how  large  a 
proportion  of  the  cases  the  tumor  is  in  evidence.  In  rare  cases  examination 
in  the  knee-elbow  position  is  of  value.  Mobility  in  gastric  tumor  is  a  point 
of  much  importance.  First,  the  change  with  respiration,  already  referred  to ; 
a  mass  may  descend  3  or  4  inches  in  deep  inspiration;  secondly,  the  com- 
municated pulsation  from  the  aorta,  which  is  often  in  its  extent  suggestive: 
thirdly,  the  intrinsic  movements  in  the  hypertrophied  muscularis  in  the 
neighborhood  of  the  cancer.  This  may  give  a  remarkable  character  to  the 
mass,  causing  it  to  appear  and  disappear,  lifting  the  abdominal  wall  in  the 
epigastric  region ;  and,  fourthly,  mechanical  movements,  with  inflation,  with 
change  of  posture,  or  communicated  with  the  hand.  Tumors  of  the  pylorus 
are  the  most  movable,  and  in  extreme  cases  can  be  displaced  to  either  hypo- 
chondrium  or  pushed  far  down  below  the  navel  (see  illustrative  cases  in  my 
Lectures  on  the  Diagnosis  of  Abdominal  Tumors) .  Pain  on  palpation  is  com- 
mon; the  mass  is  usually  hard,  sometimes  nodular.  Gas  can  at  times  be  felt 
gurgling  through  the  tumor  at  the  pyloric  region. 

Percussion  gives  less  important  indications — the  note  over  a  tumor  is 
rarely  flat,  more  often  a  flat  tympany.  Auscultation  may  reveal  the  gurgling 
through  the  pylorus;  sometimes  a  systolic  bruit  is  transmitted  from  the 
aorta,  and  when  a  local  peritonitis  exists  a  friction  may  be  heard. 

Complications. — Secondary  growths  are  common.  In  44  autopsies  in  our 
series  there  were  metastases  in  38;  in  29  the  lymph-glands  were  involved; 
in  23  the  liver.,  in  11  the  peritoneum,  in  8  the  pancreas,  in  8  the  bowel,  in 
4  the  lung,  in  3  the  pleura,  in  4  the  kidneys,  and  in  2  the  spleen.  In  8  no 
deposits  were  found. 

Perforation  may  lead  to  peritonitis,  but  in  3  of  our  4  cases  there  was  no 
general  involvement.  Cancerous  ascites  is  not  very  uncommon.  Dock  has 
called  attention  to  the  value  of  the  examination  of  the  fluid  in  such  cases 
as  a  help  to  diagnosis.  The  cells  show  mitoses  and  are  very  characteristic. 
Secondary  cancer  of  the  liver  is  very  common;  the  enlargement  may  be  very 
great,  and  such  cases  are  not  infrequently  mistaken  for  primary  cancer  of 
the  organ.  Involvement  of  the  lymph-glands  may  give  valuable  indications. 
There  may  be  early  enlargement  of  a  gland  at  the  posterior  border  of  the 
left  sterno-cleido-mastoid  muscle;  later  adjacent  glands  may  become  affected. 
This  occurs  also  in  uterine  cancer. 

A  very  remarkable  picture  is  presented  when  the  cancer  sloughs  or  be- 
comes gangrenous ;  the  vomitus  has  a  foul  odor,  often  of  a  penetrating  nature, 


504  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

to  be  perceived  throughout  the  room.  In  cases  in  which  the  ulcer  perforates 
the  colon  the  vomiting  may  be  faecal.  I  have,  however,  met  with  the  faecal 
odor  in  a  case  with  incessant  vomiting  in  which  there  was  no  perforation  of 
the  colon  at  autopsy. 

Course. — While  usually  chronic  and  lasting  from  a  year  to  eighteen, 
months,  acute  cancer  of  the  stomach  is  by  no  means  infrequent.  Of  the  69 
cases  in  which  we  could  determine  accurately  the  duration,  15  lasted  under 
three  months,  16  from  three  to  six  months,  14.  from  six  to  twelve  months — 
a  total  of  45  under  one  year.  Four  cases  lasted  for  two  years  or  over.  One 
case  lived  for  at  least  two  years  and  a  half. 

Diagnosis. — In  115  of  our  150  cases  a  tumor  existed,  and  with  this  the 
recognition  is  rarely  in  doubt.  The  chief  difficulty  is  in  cases  with  gastric 
symptoms  or  anaemia,  or  both,  without  the  presence  of  tumor.  In  the  one  a 
chronic  gastritis  is  suspected;  in  the  other  a  primary  anaemia.  In  chronic 
gastritis  the  history  of  long-standing  dyspepsia,  the  absence  of  cachexia, 
the  absence  of  lactic  acid  in  the  test  meal,  and  the  less  striking  blood  changes 
are  the  important  points  for  consideration.  The  cases  with  grave  amentia 
without  tumor  offer  the  greatest  difficulty.  The  blood-count  is  rarely  so  low 
as  in  pernicious  anaemia,  a  point  on  which  F.  P.  Henry  has  laid  special  stress. 
In  only  8  of  our  59  cases  with  careful  blood  examination  was  the  number 
below  2,000,000  per  c.  mm.  The  lower  color  index,  as  in  secondary  anaemia, 
the  absence  of  megaloblasts,  and  a  leucocytosis  speak  for  cancer.  With 
metastases  in  the  bone  marrow  the  blood  picture  may  be  that  of  pernicious 
anaemia  (Harrington  and  Teacher).  Some  lay  stress  on  the  differential  count 
of  the  leucocytes,  but  there  is  not  evidence  enough  to  enable  us  to  speak 
positively  on  this  point.  The  chemical  findings  are  of  greater  value.  From  a 
recent  careful  study  at  the  London  Hospital  Panton  and  Tidy  conclude  that 
in  carcinoma  the  Gunsberg  reaction  is  always  negative  and  the  average  total 
acidity  is  26,  while  in  ulcer  the  reaction  is  positive,  the  average  free  hydro- 
chloric acid  is  above  normal,  and  the  total  acidity  58. 

From  ulcer  of  the  stomach  malignant  disease  is,'  as  a  rule,  readily  recog- 
nized. The  ulcus  carcinomatosum  usually  presents  a  well-marked  history  of 
ulcer  for  years.  The  greatest  difficulty  is  offered  when  there  is  ulcer  with 
tumor  due  to  cicatricial  contraction  about  the  pylorus.  In  3  such  cases  we 
mistook  the  mass  for  cancer,  and  even  at  operation  it  may  (as  in  one  of  them) 
be  impossible  to  say  whether  a  neoplasm  is  present.  The  persistent  hyper- 
chlorhydria  is  the  most  important  single  feature  of  ulcer,  and,  taken  with 
the  gastralgic  attacks  and  the  haemorrhages,  rarely  leaves  doubt  as  to  the  con- 
dition. The  X-rays  are  sometimes  an  aid. 

Nowadays,  when  exploratory  laparotomy  may  be  advised  with  such  safety, 
the  surgeon  often  makes  the  diagnosis. 

The  practitioner  should  recognize  the  fact  that  there  are  cases  of  cancer 
of  the  stomach  in  which  a  positive  diagnosis  can  not  be  reached  for  weeks 
or  months  by  any  known  means  at  our  command  except  exploration. 

Treatment. —In  early  surgical  treatment  lies  the  only  hope,  but  there  is 
great  difficulty  in  the  diagnosis.  Operated  upon  early,  complete  removal  is 
sometimes  possible.  In  a  majority  of  cases  the  operation  is  only  palliative. 
In  suitable  cases  early  exploration  should  be  advised;  the  Operation  per  se 
is  sometimes  bereficial  and  the  patient  is  rarely  the  worse  for  it.  To  January 


HYPERTROPHIC    STENOSIS    OF    THE    PYLORUS  505 

27th,  1910,  627  cases  were  operated  upon  at  the  Mayo  clinic,  of  which  206 
were  in  a  hopeless  condition.  In  169  gastrostomy  was  performed,  in  266  a 
tumor  was  resected,  and  among  these  there  were  34  deaths.  The  after-results 
are  given  as  far  as  possible:  in  39  cases  whose  condition  was  known,  who  had 
been  operated  upon  over  5  years  before,  7  were  alive;  of  64,  condition  known, 
over  4  years,  13  alive;  of  88,  condition  known,  over  3  years,  18  alive  and  well. 

The  diet  should  consist  of  readily  digested  substances  of  all  sorts.  Many 
patients  do  best  on  milk  alone.  Washing  out  the  stomach,  which  may 
be  done  with  a  soft  tube  without  any  risk,  is  particularly  advantageous  when 
there  is  obstruction  at  the  pylorus,  and  is  by  far  the  most  satisfactory  means 
of  combating  the  vomiting.  The  excessive  fermentation  is  also  best  treated  by 
lavage.  When  the  pain  becomes  severe,  particularly  if  it  disturbs  the  rest  at 
night,  morphia  must  be  given.  One-eighth  of  a  grain,  combined  with  car- 
bonate of  soda  (gr.  v),  bismuth  (gr.  v-x),  usually  gives  prompt  relief,  and 
the  dose  does  not  always  require  to  be  increased.  Creasote  (iTi  j-ij)  and 
carbolic  acid  are  very  useful.  The  bleeding  in  gastric  cancer  is  rarely  amen- 
able to  treatment. 

Other  Forms  of  Tumor. — Non-cancerous  tumors  of  the  stomach  rarely 
cause  inconvenience.  Polypi  (polyadenomata)  are  common  and  they  may  be 
numerous;  as  many  as  150  have  been  reported  in  one  case.  There  is  a  form 
in  which  the  adenoma  exists  as  an  extensive  area  slightly  raised  above  the 
level  of  the  mucosa — polyadenome  en  nappe  of  the  French.  An  extraordinary 
multiple  adenoma  associated  with  multiple  tumors  throughout  the  intestines 
and  subcutaneous  haBmangio-endotheliomata  has  been  described  by  Winter- 
nitz.  H.  B.  Anderson  has  described  a  case  of  remarkable  multiple  cysts  in  the 
walls  of  the  stomach  and  small  intestine.  Sarcomata  are  very  rare.  Fibro- 
mata and  lipomata  have  been  described.  External  polypoid  tumors,  myo-  or 
fibre-sarcomata  may  grow  from  the  peritoneal  surface,  usually  the  posterior, 
of  which  Sherran  has  collected  18  cases. 

Foreign  bodies  occasionally  produce  remarkable  tumors  of  the  stomach. 
The  most  extraordinary  is  the  hair  tumor,  of  which  there  are  many  cases  in  the 
literature.  The  cases  occur  in  hysterical  women  who  have  been  in  the  habit 
of  eating  their  own  hair.  A  specimen  in  the  medical  museum  of  McGill 
University  is  in  two  sections,  which  form  an  exact  mold  of  the  stomach. 
The  tumors  are  large,  very  puzzling,  and  are  usually  mistaken  for  cancer. 
Of  7  cases  operated  upon,  6  recovered;  in  9  cases  the  condition  was  found 
post  mortem  (Schulten). 

VII    HYPERTROPHIC    STENOSIS    OF   THE    PYLORUS 

In  Adults. — Microscopically,  the  condition  is  found  to  be  very  largely 
hypertrophy  of  the  muscularis  and  submucosa  of  the  pylorus.  It  was  well 
described  by  the  older  writers.  The  symptoms  are  those  of  dilatation  of  the 
stomach.  The  question  is  whether  some  of  these  cases  may  not  really  be 
congenital,  as  there  have  been  instances  reported  in  girls  as  early  as  the 
twelfth  and  sixteenth  years. 

Congenital. — This  remarkable  affection,  first  recognized  by  Beardsley  of 
Connecticut,  has  been  thoroughly  studied  of  late  years  by  Hirschsprung,  John 
Thomson,  and  others. 
34 


506  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

ETIOLOGY. — Whether  congenital  or  not  is  much  discussed;  certainly  in  a 
majority  of  cases  there  are  no  symptoms  at  first.  It  is  much  more  common 
in  boys  than  in  girls,  and  fully  one-third  of  the  cases  are  in  first  children. 
The  causation  is  unknown.  Two  views  prevail :  (a)  that  it  is  a  congenital 
hypertrophy,  and  (6)  that  in  the  early  days  of  life  spasm  of  the  pylorus  oc^ 
curs  with  consecutive  hypertrophy  and  stenosis.  The  association  with  an 
early  acid  dyspepsia  is  very  doubtful.  In  any  case  the  part  played  by  spasm 
must  be  considerable,  as  the  degree  of  obstruction  varies;  many  patients  re- 
cover permanently,  and  the  condition  of  hypertrophy  may  exist  long  after  the 
symptoms  have  disappeared. 

SYMPTOMS. — Vomiting  of  food  and  wasting  are  constantly  present;  the 
former  begins,  as  a  rule,  during  the  second  or  third  week,  and  in  a  few 
instances  at  birth;  it  occurs  usually  two  cr  three  times  a  day,  or  it  may  be 
much  more  frequent.  It  is  often  of  the  expulsive  type;  the  wasting  becomes 
extreme,  there  are  marked  constipation,  great  weakness,  sometimes  terminal 
diarrhoea,  or  a  sudden  fatal  syncope. 

PHYSICAL  SIGNS. — These  are  distinctive — visible  peristalsis  and  palpable 
tumor.  The  peristalsis  is  best  seen  after  feeding,  when  the  waves  pass  at 
intervals,  in  characteristic  form,  from  left  to  right  above  the  navel;  two  or 
three  waves  may  be  seen  at  once.  The  pyloric  tumor  may  be  felt  as  a  firm, 
hard,  freely  movable  body,  which  varies  in  size  and  consistency,  and  through 
which  gas  may  sometimes  be  felt  to  gurgle.  When  in  doubt  the  X-ray  exam- 
ination with  bismuth  may  be  made. 

TREATMENT. — Whether  this  should  be  medical  or  surgical  is  under  dis- 
cussion, but  the  former  appears  to  have  given  the  best  results.  The  collected 
statistics  of  Hutchinson,  Heubner,  Starck,  and  Bendix  give  85  cases  with  80 
recoveries  (Semon) ;  while  the  surgical  mortality  was  as  high  as  50  per  cent, 
it  has  been  greatly  reduced.  The  hospital  cases  admitted  late  do  badly ;  of  64 
cases  at  Great  Ormond  Street  Hospital  treated  medically  78  per  cent.  died. 
Careful  feeding  and  lavage  are  the  important  measures.  The  bottle-fed  baby 
may  recover  with  a  wet-nurse.  Feedings  of  an  ounce  an  hour  with  lavage 
morning  and  evening,  and  occasional  rectal  feeding  or  saline  injections, 
should  be  given  a  trial  before  operation. 


VIH.    HEMORRHAGE   FROM   THE   STOMACH 

(Hcematemesis) 

Etiology. — Gastrorrhagia,  as  this  symptom  is  called,  may  result  from 
many  conditions,  local  or  general,  (a)  In  local  disease:  (1)  cancer;  (2) 
ulcer;  (3)  disease  of  the  blood-vessels,  such  as  miliary  aneurisms  and  occa- 
sionally varicose  veins;  (4)  acute  congestion,  as  in  gastritis,  and  possibly  in 
vicarious  haemorrhage;  (5)  following  operations  in  the  abdomen,  particularly 
when  the  omentum  is  wounded,  erosions  of  the  gastric  mucosa  may  occur, 
from  which  ha?morrhage  takes  place.  Many  cases  have  followed  operation 
for  appendicitis.  It  is  a  very  fatal  complication,  as  it  is  usually  associated 
with  peritonitis  (Richardson). 

it)  Passive  congestion  due  to  obstruction  in  the  portal  system.    This  may 


HEMORRHAGE    FROM    THE    STOMACH  507 

be  either  (1)  hepatic,  as  in  cirrhosis  of  the  liver,  thrombosis  of  the  portal 
vein,  or  pressure  upon  the  portal  vein  by  tumor,  and  secondarily  in  cases  of 
chronic  disease  of  the  heart  and  lungs.  (2)  Splenic.  Gastrorrhagia  is  by 
no  means  an  uncommon  symptom  in  enlarged  spleen,  and  is  explained  by  the 
intimate  relations  which  exist  between  the  vasa  brevia  and  -the  splenic  cir- 
culation. 

(c)  Toxic:  (1)  The  poisons  of  the  specific  fevers,  small-pox,  measles,  yel- 
low fever;  (2)  poisons  of  unknown  origin,  as  in  acute  yellow  atrophy  and  in 
purpura;  (3)  phosphorus. 

(d)  Traumatism:  (1)  Mechanical  injuries,  such  as  blows  and  wounds,  and 
occasionally  by  the  stomach-tube;  (2)  the  result  of  severe  corrosive  poisons. 

(e)  Certain  constitutional  diseases:  (1)  Haemophilia;  (2)  profound  .anae- 
mias,  whether  idiopathic  or  due  to  splenic  enlargements  or  to  malaria;  (3) 
cholsemia. 

(/)  In  certain  nervous  affections,  particularly  hysteria,  and  occasionally 
in  progressive  paralysis  of  the  insane  and  epilepsy. 

(g)  The  blood  may  not  always  come  primarily  from  the  stomach.  Thus 
it  may  belong  to  the  nose  or  the  pharynx.  In  haemoptysis  some  of  the  blood 
may  find  its  way  into  the  stomach.  Again,  in  bleeding  from  the  oesophagus 
blood  may  trickle  into  the  stomach,  from  which  it  is  ejected.  This  occurs 
in  the  case  of  rupture  of  aneurism  and  of  the  oesophageal  varices.  A  child 
may  draw  blood  with  the  milk  from  the  mother's  breast  even  in  considerable 
quantities  and  then  vomit  it. 

(h)  Gastrostaxis. — Under  this  name  Hale  White  describes  cases  of  haemor- 
rhage from  the  stomach  in  young  girls  without  any  lesion  of  the  mucosa. 
They  are  often  mistaken  for  ulcer.  He  has  collected  29  cases.  Surgeons 
have  taught  us  that  the  condition  is  by  no  means  uncommon.  At  operation 
the  blood  has  been  seen  oozing  from  points  in  the  mucosa.  There  may  be 
no  pain  or  any  of  the  ordinary  features  of  ulcer. 

(i)  Miscellaneous  causes:  Aneurism  of  the  aorta  or  of  its  branches  may 
rupture  into  the  stomach.  There  are  instances  in  which  a  patient  has  vom- 
ited blood  once  without  ever  having  a  recurrence  or  without  developing 
symptoms  pointing  to  disease  of  the  stomach. 

In  new-born  infants  hsematemesis  may  occur  alone  or  in  connection  with 
bleeding  from  other  mucous  membranes. 

In  medical  practice,  haemorrhage  from  the  stomach  occurs  most  frequently 
in  connection  with  cirrhosis  of  the  liver  and  ulcer  of  the  stomach. 

Morbid  Anatomy. — When  death  has  occurred  from  the  haematemesis  there 
are  signs  of  intense  anaemia.  The  lesion  is  evident  in  cancer  and  in  ulcer  of 
the  stomach.  It  is  to  be  borne  in  mind  that  fatal  haemorrhage  may  come 
from  a  small  miliary  aneurism  communicating  with  the  surface  by  a  pin- 
hole  perforation,  or  the  bleeding  may  be  due  to  the  rupture  of  a  submucous 
vein  and  the  erosion  in  the  mucosa  may  be  small  and  readily  overlooked. 
It  may  require  a  careful  and  prolonged  search  to  avoid  overlooking  such 
lesions.  In  the  large  group  associated  with  portal  obstruction,  whether  due 
to  hepatic  or  splenic  disease,  the  mucosa  is  usually  pale,  smooth,  and  shows 
no  trace  of  any  lesion.  In  cirrhosis,  fatal  by  haemorrhage,  one  may  some- 
times search  in  vain  for  any  focal  lesion  to  account  for  the  gastrorrhagia, 
and  we  must  conclude  that  it  is  possible  for  even  the  most  profuse  bleeding  to 


508  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

occur  by  diapedesis.  The  stomach  may  be  distended  with  blood  and  yet  the 
source  of  the  haemorrhage  be  not  apparent  either  in  the  stomach  or  in  the 
portal  system.  In  such  cases  the  oesophagus  should  be  examined,  as  the 
bleeding  may  come  from  that  source.  In  toxic  cases  there  are  invariably 
haemorrhages  in  the  mucous  membrane  itself. 

Symptoms. — In  rare  instances  fatal  syncope  may  occur  without  any  vom- 
iting. In  a  case  of  the  kind,  in  which  the  woman  had  fallen  over  and  died 
in  a  few  minutes,  the  stomach  contained  between  three  and  four  pounds  of 
blood.  The  sudden  profuse  bleedings  rapidly  lead  to  profound  anaemia. 
When  due  to  ulcer  or  cirrhosis  the  bleeding  usually  recurs  for  several  days. 
Fatal  haemorrhage  from  the  stomach 'is  met  with  in  ulcer,  cirrhosis,  enlarge- 
ment of  the  spleen,  and  in  instances  in  which  an  aneurism  ruptures  into  the 
Btomach  or  oesophagus.  Gastrorrhagia  may  occur  in  splenic  anosmia  or  in 
leukaemia  before  the  condition  has  aroused  attention. 

The  vomited  blood  may  be  fluid  or  clotted;  it  is  usually  dark  in  color, 
but  in  the  basin  the  outer  part  rapidly  becomes  red  from  the  action  of  the 
air.  The  longer  blood  remains  in  the  stomach  the  more  altered  is  it  when 
ejected. 

The  amount  of  blood  lost  is  very  variable,  and  in  the  course  of  a  day  the 
patient  may  bring  up  three  or  four  pounds,  or  even  more.  In  a  case  under 
the  care  of  George  Ross,  in  the  Montreal  General  Hospital,  the  patient  lost 
during  seven  days  ten  pounds,  by  weight,  of  blood.  The  usual  symptoms  of 
anaemia  develop  rapidly,  and  there  may  be  slight  fever,  and  subsequently 
oedema  may  occur.  Syncope,  convulsions,  and  occasionally  hemiplegia  occur 
after  very  profuse  haemorrhage.  Blindness  may  follow,  the  result  either  of 
thrombosis  of  the  retinal  arteries  or  veins,  or  an  acute  degeneration  of  the 
ganglion  cells  of  the  retina. 

Diagnosis.- — In  a  majority  of  instances  there  is  no  question  as  to  the 
origin  of  the  blood.  Occasionally  it  is  difficult,  particularly  if  the  case  has 
not  been  seen  during  the  attack.  Examination  of  the  vomit  readily  deter- 
mines whether  blood  is  present  or  not.  The  material's  vomited  may  be  stained 
by  wine,  the  juice  of  strawberries,  raspberries,  or  cranberries,  which  give  a 
color  very  closely  resembling  that  of  fresh  blood,  while  iron  and  bismuth 
and  bile  may  produce  the  blackish  color  of  altered  blood.  In  such  cases  the 
microscope  will  show  clearly  the  presence  of  the  shadowy  outlines  of  the  red 
blood-corpuscles,  and,  if  necessary,  spectroscopic  and  chemical  tests  may  be 
applied. 

Deception  is  sometimes  practiced  by  hysterical  patients,  who  swallow 
and  then  vomit  blood  or  colored  liquids.  With  a  little  care  such  cases  can 
usually  be  detected.  The  cases  must  be  excluded  in  which  the  blood  passes 
from  the  nose  or  pharynx,  or  in  which  infants  swallow  it  with  the  milk. 

There  is  not  often  difficulty  in  distinguishing  between  haemoptysis  and 
haematemesis,  though  the  coughing  and  the  vomiting  are  not  infrequently 
combined.  The  following  are  points  to  be  borne  in  mind  in  the  diagnosis : 

HAEMATEMESIS  HEMOPTYSIS 

1.  Previous  history  points  to  gas-  1.  Cough  or  signs  of  some  pul- 

tric,  hepatic,  or  splenic  disease.  monary  or  cardiac  disease  precedes, 

in  many  cases,  the  haemorrhage. 


NEUROSES    OF    THE    STOMACH  509 

2.  The   blood    is    brought    up    by  2.  The  blood  is  coughed  up,  and 
vomiting,  prior  to  which  the  patient  is  usually  preceded  by  a  sensation  of 
may  experience  a  feeling  of  giddiness  tickling  in  the  throat.     If  vomiting 
or  faintness.  occurs,  it  follows  the  coughing. 

3.  The    blood    is    usually    clotted,  3.  The  blood  is  frothy,  bright  red 
mixed  with  particles  of  food,  and  has  in    color,    alkaline    in    reaction.      If 
an  acid  reaction.     It  may  be   dark,  clotted,  rarely  in  such  large  coagula, 
grumous,  and  fluid.  and  muco-pus  may  be  mixed  with  it. 

4.  Subsequent   to  the  attack   the  4.    The    cough    persists,   physical 
patient  passes  tarry  stools,  and  signs  signs   of   local    disease   in   the   chest 
of  disease  of  the  abdominal  viscera  may    usually    be    detected,    and    the 
may  be  detected.  sputum    may    be    blood-stained    for 

many  days. 

Prognosis. — Except  in  the  case  of  rupture  of  an  aneurism  or  of  large 
veins,  haematemesis  rarely  proves  fatal.  In  my  experience  death  has  followed 
more  frequently  in  cases  of  cirrhosis  and  splenic  enlargement  than  in  ulcer 
or  cancer.  In  ulcer  it  is  to  be  remembered  that  in  the  chronic  hsemorrhagic 
form  the  bleeding  may  recur  for  years.  The  treatment  of  hsematemesis  is 
considered  under  gastric  ulcer. 


IX.    NEUROSES  OF   THE   STOMACH 

(Nervous  Dyspepsia) 

Serious  functional  disturbances  of  the  stomach  may  occur  without  any 
discoverable  anatomical  basis.  The  cases  are  met  with  most  frequently  in 
those  who  have  either  inherited  a  nervous  constitution  or  who  have  grad- 
ually, through  indiscretions,  brought  about  a  condition  of  nervous  prostra- 
tion. Not  infrequently,  however,  the  gastric  symptoms  stand  so  far  in  the 
foreground  that  the  general  neuropathic  character  of  the  patient  quite 
escapes  notice.  Sometimes  the  gastric  manifestations  have  apparently  a 
reflex  origin  depending  on  organic  disturbances  in  other  parts,  such  as  the 
appendix  or  gall-bladder. 

The  nervous  derangements  of  the  stomach  may  be  divided  into  motor, 
secretory,  and  sensory  neuroses.  These  disturbances  rarely  occur  singly ;  they 
are  usually  met  with  in  combined  forms.  The  clinical  picture  resulting  from 
such  a  complex  of  gastric  neuroses  is  known  as  nervous  dyspepsia.  As  Leube 
has  pointed  out,  the  sensory  disturbances  usually  play  the  more  important 
part. 

The  sufferer  from  nervous  dyspepsia  presents  a  varying  picture.  All 
grades  occur,  from  the  emaciated  skeleton-like  patient  with  anorexia  nervosa 
to  the  well-nourished,  healthy-looking,  fresh-complexioned  individual  whose 
only  complaint  is  distress  and  uneasiness  after  eating. 

Motor  Neuroses. — (a)  HYPERKINESIS  OR  SUPERMOTILITT. — An  increase 
in  the  normal  motor  activity  of  the  stomach  results  in  too  early  a  discharge 
of  the  ingesta  into  the  intestine.  It  is  more  commonly  a  secondary  neurosis 
dependent  upon  superacidity  or  supersecretion  of  the  gastric  juice;  but  it 


510  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

may  occur  primarily,  possibly  from  reflex  causes.  The  diagnosis  is  to  be 
reached  only  by  means  of  the  stomach-tube.  It  gives  rise  to  no  character- 
istic clinical  symptoms. 

(6)  PERISTALTIC  UNREST. — This  condition,  as  described  by  Kussmaul,  is 
an  extremely  common  and  distressing  symptom.  Shortly  after  eating  the 
peristaltic  movements  of  the  stomach  are  increased,  and  borborygmi  and 
gurgling  may  be  heard,  even  at  a  distance.  The  subjective  sensations  are 
most  annoying,  and  it  would  appear  as  if  in  the  hyperaesthetic  condition  of 
the  nervous  system  the  patient  felt  normal  peristalsis,  just  as  in  these  states 
the  usual  beating  of  the  heart  may  be  perceptible  to  him.  A  further  analogy 
is  afforded  by  the  fact  that  emotion  increases  this  peristalsis.  It  may  extend 
to  the  intestines,  particularly  to  the  duodenum,  and  on  palpation  over  this 
region  the  gurgling  is  most  marked.  The  movement  may  be  anti-peristalsis, 
in  which  the  wave  passes  from  right  to  left,  a  condition  which  may  also 
extend  to  the  intestines.  There  are  cases  on  record  in  which  colored  enemata 
or  even  scybala  have  been  discharged  from  the  mouth. 

(c)  NERVOUS  ERUCTATIONS. — Aerophagia. — In  this  condition  severe  at- 
tacks of  noisy  eructations,  following  one  another  often  in  rapid  succession, 
occur.    When  violent  they  last  for  hours  or  days.    At  other  times  they  occur 
in  paroxysms,  depending  often  upon  mental  excitement.     They  are  more 
commonly  observed  in  hysterical  women  and  neurasthenics,  but  also,  not  in- 
frequently, in  children.     The  hysterical  nature  of  the  affection  is  sometimes 
testified  to  by  the  occurrence,  especially  in  children,  of  several  instances 
in  one  household.    The  expelled  gas  in  these  cases  is  atmospheric  air,  which 
is  swallowed  or  aspirated  from  without.     Sometimes  the  whole  process  may 
be  clearly  observed,  but  in  other  instances  the  act  of  swallowing  may  be  al- 
most or  quite  imperceptible. 

(d)  NERVOUS  VOMITING. — A  condition  which  is  not  associated  with  ana- 
tomical changes  in  the  stomach  or  with  any  state  of  the  contents,  but  is  due 
to  nervous  influences  acting  either  directly   or  indirectly  upon  the  centres 
presiding  over  the  act  of  vomiting.     The  patients'  are,  as  a  rule,  women — 
usually  brunettes — and  the  subject  of  more  or  less  marked  hysterical  mani- 
festations.    A  special  feature  of  this  form  is  the  absence  of  the  preliminary 
nausea  and  of  the  straining  efforts  of  the  ordinary  act  of  vomiting.     It  is 
rather  a  regurgitation,  and  without  visible  effort  and  without  gagging  the 
mouth  is  filled  with  the  contents  of  the  stomach,  which  are  then  spat  out. 
It  comes  on,  as  a  rule,  after  eating,  but  may  occur  at  irregular  intervals.    In 
some  cases  the  nutrition  is  not  impaired,  a  feature  which  may  give  a  clew  to 
the  true  nature  of  the  disease,  as  there  may  be  no  other  hysterical  manifesta- 
tion present.     As  noted  by  Tuckwell,  it  may  occur  in  children,  and  Edsall 
suggests  that  this  recurring  vomiting  is  an  acid  intoxication,  as  in  some  cases 
acetone  and  diacetic  acid  have  been  found  in  the  urine.     Treatment  with  full 
doses  of  bicarbonate  of  soda  every  two  hours  has  been  found  to  relieve  it. 
Nervous  vomiting  may  be  a  very  serious  condition.     We  have  had  at  least 
two  fatal  cases.    In  some  instances,  after  persisting  for  weeks  or  months  at 
home,  the  patient  gets  well  in  a  few  days  in  hospital.    In  other  instances  the 
course  is  protracted,  and  the  cases  are  among  the  most  trying  we  are  called 
upon  to  treat. 

A  type  of  vomiting  is  that  associated  with  certain  diseases  of  the  nervous 


NEUROSES    OF    THE    STOMACH  511 

system — particularly  locomotor  ataxia — forming  part  of  the  gastric  crises. 
Leyden  has  reported  cases  of  primary  periodic  vomiting,  which  he  regards 
as  a  neurosis. 

(e)  RUMINATION;  MERYCISMUS. — In  this  remarkable  and  rare  condition 
the  patients  regurgitate  and  chew  the  cud  like  ruminants.  It  occurs  in 
neurasthenic  or  hysterical  persons,  epileptics,  and  idiots.  In  some  patients 
it  is  hereditary.  There  is  an  instance  in  which  a  governess  taught  it  to  two 
children.  The  habit  may  persist  for  years,  and  does  not  necessarily  impair 
the  health. 

(/)  SPASM  OF  THE  CARDIA. — Spasmodic,  usually  painful,  contraction  of 
the  circular  muscle  fibres  at  the  cardiac  orifice  may  follow  the  introduction 
of  a  sound,  hasty  eating,  or  the  taking  of  too  hot  or  too  cold  food.  It  may 
occur  in  tetanus  and  also  in  hysterical  and  neurasthenic  individuals,  especial- 
ly in  air  swallowers,  in  whom,  if  it  be  combined  with  pyloric  spasm,  it  may 
result  in  painful  gastric  distention — "pneumatosis."  Here  the  spasm  may 
be  of  considerable  duration.  The  condition  is  rare  and  practically  not  of 
much  moment. 

(g)  PYLORIC  SPASM. — This  is  usually  a  secondary  occurrence,  following 
superacidity,  supersecretion,  ulcer,  or  the  introduction  into  the  stomach  of 
irritating  substances.  The  spasm  often  causes  pain  in  the  region  of  the 
pylorus  and  increased  gastric  peristalsis.  In  cases  where  the  spasm  is  com- 
bined with  superacidity  and  supersecretion  marked  dilatation  with  atony  may 
follow.  Sometimes  the  pylorus  may  be  felt  as  an  oval,  hard  tumor,  which 
relaxes  under  the  fingers  as  gas  passes  through  it.  It  is  not  easy  to  distin- 
guish organic  stricture  and  pylorospasm,  but  Einhorn's  duodenal  bucket  will 
pass  the  latter,  and  the  thread  next  it  is  bile-stained. 

(h)  ATONY  OF  THE  STOMACH. — Motor  insufficiency  of  the  stomach  is  gen- 
erally due  to  injudicious  feeding,  to  organic  disease  of  the  stomach  itself,  or 
to  general  wasting  processes.  In  some  otherwise  normal  individuals  of  neu- 
rotic temperaments  an  atony  may,  however,  occur  which  possibly  deserves  to 
be  classed  among  the  neuroses.  The  symptoms  are  usually  those  of  a  moder- 
ate dilatation,  and  are  often  associated  with  marked  sensory  disturbances — 
feelings  of  weight  and  pressure,  distention,  eructations,  and  so  forth. 

Great  care  must  be  taken  in  the  diagnosis  to  rule  out  all  other  possible 
causes. 

(i)  INSUFFICIENCY  OR  INCONTINENCE  OF  THE  PYLORUS. — This  condition 
was  described  first  by  de  Sere  and  later  by  Ebstein.  It  may  be  recognized  by 
the  rapid  passing  of  gas  from  the  stomach  into  the  bowel  on  attempts  at 
inflation  of  the  former,  as  well  as  by  the  presence  of  bile  and  intestinal  con- 
tents in  the  stomach.  There  are  no  distinctive  clinical  symptoms. 

(/)  INSUFFICIENCY  OF  THE  CARDIA. — This  condition  is  only  recognized  by 
the  occurrence  of  eructations  or  in  rumination. 

Secretory  Neuroses. — (a)  HYPERACIDITY;  SUPERACIDITY;  HYPERCHLOR- 
HYDRIA. — In  nervous  dyspepsia  with  hyperacidity  of  the  gastric  juices  the 
symptoms  depend  upon  the  secretion  of  an  abnormally  acid  gastric  juice 
at  the  time  of  digestion.  This  is  a  common  form  of  dyspepsia  in  young  and 
neurotic  individuals,  and  in  chlorotic  girls.  The  symptoms  are  very  variable. 
They  do  not,  as  a  rule,  immediately  follow  the  ingestion  of  food,  but  occur 
one  to  three  hours  later,  at  the  height  of  digestion.  There  is  a  sense  of 


512  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

weight  and  pressure,  sometimes  of  burning  in  the  epigastrium,  commonly 
associated  with  acid  eructations.  If  vomiting  occurs,  the  pain  is  relieved. 
The  patient  is  usually  relatively  well  nourished,  and  the  appetite  is  often 
good,  though  the  sufferer  may  be  afraid  to  eat  on  account  of  the  anticipated 
pain.  Its  association  with  ulcer  has  been  referred  to.  There  is  commonly 
constipation. 

(6)    SUPERSECRETION,   INTERMITTENT  AND  CONTINUOUS. — This   IS  a    form 

of  dyspepsia  which  has  been  long  recognized,  but  specially  studied  by  Reich- 
mann  and  others.  The  increased  flow  of  the  gastric  juice  may  be  intermit- 
tent or  continuous.  The  secretion  under  such  circumstances  is  usually  su- 
peracid,  though  this  is  not  always  the  case.  The  periodical  form — the  gas- 
troxynsis  of  Rossbach — may  be  quite  independent  of  the  time  of  digestion. 
Great  quantities  of  highly  acid  gastric  juice  may  be  secreted  in  a  very  small 
space  of  time.  Such  cases  are  rare,  and  are  especially  associated  either  with 
profound  neurasthenia  or  with  locomotor  ataxia.  The  attack  may  last  for 
several  days.  It  usually  sets  in  with  a  gnawing,  unpleasant  sensation  in  the 
stomach,  severe  headache,  and  shortly  after  the  patient  vomits  a  clear,  watery 
secretion  of  such  acidity  that  the  throat  is  irritated  and  made  raw  and  sore. 
As  mentioned,  the  attacks  may  be  quite  independent  of  food.  Continuous 
supersecretion  is  more  common.  The  constant  presence  of  fluid  in  the  stom- 
ach, together  with  the  pyloric  spasm,  which  commonly  results  from  the  irri- 
tation of  the  overacid  gastric  juice,  are  followed  by  a  more  or  less  extensive 
dilatation.  Digestion  of  the  starches  is  retarded,  and  there  are  eructations 
of  acid  fluid  and  gastric  distress.  This  secretion  of  highly  acid  gastric  juice 
may  continue  when  the  stomach  is  free  from  food.  In  these  cases  pain, 
burning  acid  eructations,  and  even  vomiting,  occurring  during  the  night  and 
early  in  the  morning,  are  rather  characteristic. 

(c)  NERVOUS  SUBACIDITY  OR  ANACIDITY;  ACHYLIA  GASTRICA  NERVOSA. — 
Lack  of  the  normal  amount  of  acid  is  found  in  chronic  catarrh,  and  particu- 
larly in  cancer.  As  Leube  has  shown,  a  reduction  in  the  normal  amount  of 
acid  may  exist  with  the  most  pronounced  symptoms 'of  nervous  dyspepsia  and 
yet  the  stomach  will  be  free  from  food  within  the  regular  time.  A  condition 
in  which  free  acid  is  absent  in  the  gastric  juice  may  occur  in  cancer,  in  ex- 
treme sclerosis  of  the  mucous  membrane,  as  a  nervous  manifestation,  and 
occasionally  in  tabes.  In  most  of  these  cases,  though  there  be  no  free  acid, 
yet  the  other  digestive  ferments — pepsin  and  the  curdling  ferments — or  their 
zymogens  are  to  be  demonstrated  in*  the  gastric  juice.  There  may,  however, 
be  a  complete  absence  of  the  gastric  secretion.  To  these  cases  Einhorn  has 
given  the  name  of  achylia  gastrica.  This  condition  was  at  first  thought  to 
occur  only  in  cases  of  total  atrophy  of  the  gastric  mucosa,  but  recent  observa- 
tions have  shown  that  it  may  occur  as  a  neurosis.  In  a  case  of  Einhorn's 
the  gastric  secretions  returned  after  five  years  of  total  achylia  gastrica. 

The  symptoms  of  subacidity,  or  even  of  achylia  gastrica,  vary  greatly  in 
intensity;  they  may  be  almost  or  quite  absent  in  cases  of  advanced  atrophy  of 
the  mucosa,  and,  as  a  rule,  are  not  marked  so  long  as  the  motor  activity 
of  the  stomach  remains  good.  If  atony,  however,  occurs  and  abnormal  fer- 
mentative processes  arise,  severe  gastric  and  intestinal  symptoms  may  follow. 
In  the  cases  associated  with  hysteria  and  neurasthenia,  even  though  the  food 
may  be  well  taken  care  of  by  the  intestines,^  there  are  very  commonly  grave 


XEUROSES    OF   THE    STOMACH  513 

sensory  disturbances  in  the  region  of  the  stomach,  in  addition  to  tke  general 
nervous  symptoms. 

Sensory  Neuroses. —  (a)  HYPEILESTHESIA. — In  this  condition  the  pa- 
tients complain  of  fullness,  pressure,  weight,  burning,  and  so  forth,  during 
digestion,  just  such  symptoms  as  accompany  a  variety  of  organic  diseases  of 
the  stomach,  and  yet  in  all  other  respects  the  gastric  functions  appear  quite 
normal.  Sometimes  these  distressing  sensations  are  present  even  when  the 
stomach  is  empty.  These  symptoms  are  usually  associated  with  other  mani- 
festations of  hysteria  and  neurasthenia.  The  pain  often  follows  particular 
articles  of  food.  An  hysterical  patient  may  apparently  suffer  excruciating 
pain  after  taking  the  smallest  amount  of  food  of  any  sort,  while  anything 
prescribed  as  a  medicine  may  be  well  borne.  In.  severe  cases  the  patient 
may  be  reduced  to  an  extreme  degree  by  starvation. 

(&)  GASTRALGIA;  GASTRODYNIA. — Severe  pains  in  the  epigastrium,  parox- 
ysmal in  character,  occur  (1)  as  a  manifestation  of  a  functional  neurosis,  in- 
dependent of  organic  disease,  and  usually  associated  with  other  nervous  symp- 
toms (it  is  this  form  which  will  here  be  described) ;  (2)  in  chronic  disease 
of  the  nervous  system,  forming  the  so-called  gastric  crises;  and  (3)  in  or- 
ganic disease  of  the  stomach,  such  as  ulcer  or  cancer. 

The  functional  neurosis  occurs  chiefly  in  women,  very  commonly  in  con- 
nection with  disturbed  menstrual  function  or  with  pronounced  nervous  symp- 
toms. The  affection  may  set  in  as  early  as  puberty,  but  it  is  more  common  at 
the  menopause.  Anasmic,  constipated  women  who  have  worries  and  anxieties 
at  home  are  most  prone  to  the  affection.  It  is  more  frequent  in  brunettes  than, 
in  blondes.  Attacks  of  it  sometimes  occur  in  robust,  healthy  men.  More 
often  it  is  only  one  feature  in  a  condition  of  general  neurasthenia  or  a  mani- 
festation of  that  form  of  nervous  dyspepsia  in  which  the  gastric  juice  or 
hydrochloric  acid  is  secreted  in  excess.  I  am  very  skeptical  as  to  the  existence 
of  a  gastralgia  of  purely  malarial  origin. 

The  symptoms  are  very  characteristic;  the  patient  is  suddenly  seized  with 
severe  pains  in  the  epigastrium,  which  pass  toward  the  back  and  around 
the  lower  ribs.  The  attack  is  usually  independent  of  the  taking  of  food,  and 
may  recur  at  definite  intervals,  a  periodicity  which  has  given  rise  to  the  sup- 
position in  some  cases  that  the  affection  is  due  to  malaria.  The  most  marked 
periodicity,  however,  may  be  in  the  gastralgic  attacks  of  ulcer.  They  fre- 
quently come  on  at  night.  Vomiting  is  rare;  more  commonly  the  taking  of 
food  relieves  the  pain.  To  this,  however,  there  are  striking  exceptions.  Pres- . 
sure  upon  the  epigastrium  commonly  gives  relief,  but  deep  pressure  may  be 
painful.  It  seems  scarcely  necessary  to  separate  the  forms,  as  some  have 
done,  into  irritative  and  depressive,  as  the  cases  insensibly  merge  into  each 
other.  Stress  has  been  laid  upon  the  occurrence  of  painful  points,  but  they 
are  so  common  in  neurasthenia  that  very  little  importance  can  be  attributed 
to  them. 

The  diagnosis  offers  many  difficulties.  Organic  disease  either  of  the  stom- 
ach or  of  the  nervous  system,  particularly  the  gastric  crises  of  locomotor 
ataxia,  must  be  excluded.  In  the  case  of  ulcer  or  cancer  this  is  not  always 
easy.  The  fact  that  the  pain  is  most  marked  when  the  stomach  is  empty  and 
is  relieved  by  the  taking  of  food  is  sometimes  regarded  as  pathognomonic  of 
simple  gastralgia,  but  to  this  there  are  many  exceptions,  and  in  ulcer  the 


514  DISEASES   OF   THE   DIGESTIVE   SYSTEM 

pains  may  be  relieved  on  eating.  The  prolonged  intervals  between  the  attacks 
and  their  independence  of  diet  are  important  features  in  simple  gastralgia; 
but  in  many  instances  it  is  less  the  local  than  the  general  symptoms  of  .the 
ease  which  enable  us  to  make  the  diagnosis.  In  gall-stone  colic  jaundice  is 
frequently  absent,  and  in  any  long-standing  case  of  gastralgia,  in  which  the 
attacks  recur  at  intervals  for  years,  the  question  of  cholelithiasis  should  be 
considered.  There  may  be  hyperacidity  associated  with  gastric  atony.  Such 
a  case  may  be  treated  for  months  as  one  of  nervous  dyspepsia  until  a  more 
severe  attack  than  usual  is  followed  by  jaundice. 

(c)  ANOMALIES  OF  THE  SENSE  or  HUNGER  AND  KEPLETION;  BULIMIA. — 
Abnormally  excessive  hunger  coming  on  often  in  paroxysmal  attacks,  which 
cause  the  patient  to  commit  extraordinary  excesses  in  eating.  This  condition 
may  occur  in  diabetes  mellitus  and  sometimes  in  gastric  disorders,  particu- 
larly those  associated-  with  supersecretion.  It  is,  however,  more  commonly 
seen  in  hysteria  and  in  psychoses.  It  may  occur  in  cerebral  tumors,  in 
Graves'  disease,  and  in  epilepsy. 

The  attacks  often  begin  suddenly  at  night,  the  patient  waking  with  a 
feeling  of  faintness  and  pain,  and  an  uncontrollable  desire  for  food.  Some- 
times such  attacks  occur  immediately  after  a  large  meal.  The  attack  may 
be  relieved  by  a  small  amount  of  food,  while  at  other  times  enormous  quan- 
tities may  be  taken.  In  obstinate  cases  gastritis,  atony,  and  dilatation  fre- 
quently result  from  the  abuse  of  the  stomach. 

Akoria. — An  absence  of  the  sense  of  satiety.  This  condition  is  commonly 
associated  with  bulimia  and  polyphagia,  but  not  always.  The  patient  always 
feels  "empty."  There  are  usually  other  well-marked  manifestations  of  hys- 
teria or  neurasthenia. 

Anorexia  Nervosa. — This  condition,  which  is  a  manifestation  of  a  neurotic 
temperament,  is  discussed  subsequently  under  the  general  heading  of  Hys- 
teria. 

Treatment  of  Neuroses  of  the  Stomach. — The  most  important  part  of 
the  treatment  of  nervous  dyspepsia  is  often  that  directe'd  toward  the  improve- 
ment of  the  general  physical  and  mental  condition  of  the  patient.  The  pos- 
sibility that  the  symptoms  may  be  of  reflex  origin  should  be  borne  in  mind. 
The  possibility  of  eye-strain,  cholelithiasis,  or  chronic  appendicitis  should  be 
considered.  A  large  proportion  of  cases  of  nervous  dyspepsia  are  dependent 
upon  mental  and  physical  exhaustion  or  worry,  and  a  vacation  or  a  change 
of  scene  will  often  accomplish  what  years  of  treatment  at  home  have  failed 
to  do.  The  manner  of  life  of  the  patient  should  be  investigated  and  a  proper 
amount  of  physical  exercise  in  the  open  air  and  systematic  hydrotherapy 
insisted  upon.  This  alone  will  in  some  cases  be  sufficient  to  cause  the  dis- 
appearance of  the  symptoms. 

Many  cases  of  nervous  dyspepsia  with  marked  neurasthenic  or  hysterical 
symptoms  do  well  on  the  Weir  Mitchell  treatment,  and  in  obstinate  forms 
it  should  be  given  a  thorough  trial.  The  most  striking  results  are  perhaps 
seen  in  the  case  of  anorexia  nervosa,  which  will  be  referred  to  subsequently. 
It  is  also  of  value  in  nervous  vomiting. 

In  cardiac  spasm  care  should  be  taken  to  eat  slowly,  to  avoid  swallowing 
too  large  morsels  or  irritating  substances.  The  methodical  introduction  of 
thick  sounds  may  be  of  value. 


NEUROSES    OF   THE    STOMACH  515 

The  treatment  in  atony  of  the  stomach  should  be  similar  to  that  adopted 
in  moderate  dilatation — the  administration  of  small  quantities  of  food  at 
frequent  intervals;  the  limitation  of  the  fluids,  which  should  also  be  taken 
in  small  amounts  at  a  time;  lavage.  Strychnine  in  full  doses  may  be  of 
value. 

In  the  distressing  cases  of  hyperacidity,  in  addition  to  the  treatment  of 
the  general  neurotic  condition,  alkalies  must  be  employed  either  in  the  form 
of  magnesia  or  bicarbonate  of  soda.  These  should  be  given  in  large  doses 
and  at  the  height  of  digestion.  The  burning  acid  eructations  may  be  re- 
lieved in  this  way.  In  hyperacidity  and  hypersecretion  the  use  of  atropine 
frequently  gives  relief.  It  should  be  given  before  food  and  in  small  doses 
at  first,  beginning  with  1/150  grain  (0.0004  gm.)  and  gradually  increas- 
ing. The  combination  of  bromide  and  codeia  is  sometimes  useful.  The 
diet  should  be  mainly  albuminous,  and  should  be  administered  in  a  non- 
irritating  form.  Stimulating  condiments  and  alcohol  should  be  avoided. 
Starches  should  be  sparingly  allowed,  and  only  in  most  digestible  forms. 
Fats  are  fairly  well  borne. 

Limiting  the  patient  to  a  strictly  meat  diet  is  a  valuable  procedure  in 
many  cases  of  dyspepsia  associated  with  hyperacidity.  The  meat  should  be 
taken  either  raw  or,  if  an  insuperable  objection  exists  to  this,  very  slightly 
cooked.  It  is  best  given  finely  minced  or  grated  on  stale  bread.  An  ample 
dietary  is  S1^  ounces  (100  grams)  of  meat,  two  medium  slices  of  stale 
bread,  and  an  ounce  (30  grams)  of  butter.  This  may  be  taken  three  times 
a  day  with  a  glass  of  Apollinaris  water,  soda  water,  or,  what  is  just  as  sat- 
isfactory, spring  water.  The  fluid  should  not  be  taken  too  cold.  The  use  of 
fats,  as  cream,  butter,  and  olive  oil,  is  often  of  value.  Special  care  should 
be  taken  in  the  examination  of  the  meat  to  guard  against  tape-worm  infec- 
tion, but  suitable  instructions  on  this  point  can  be  given.  This  is  sufficient 
for  an  adult  man,  and  many  obstinate  cases  yield  satisfactorily  to  a  month 
or  six  weeks  of  this  treatment,  after  which  time  the  less  readily  digested 
articles  of  food  may  be  gradually  added  to  the  dietary. 

In  supersecretion  the  use  of  the  stomach-tube  is  of  the  greatest  value.  In 
the  periodical  form  it  should  be  used  as  soon  as  the  attack  begins.  The 
stomach  may  be  washed  with  alkaline  solutions  or  solutions  of  nitrate  of 
silver,  1  to  1,000,  may  be  used.  Where  this  is  impracticable  the  taking  of 
albuminous  food  may  give  relief.  One  of  my  patients  used  to  have  by  his 
bedside  two  hard-boiled  eggs,  by  the  eating  of  which  nocturnal  attacks  were 
alleviated.  Alkalies  in  large  doses  are  also  indicated. 

In  cases  of  continued  supersecretion  there  are  usually  atony  and  dilata- 
tion. The  diet  here  should  be  much  as  in  superacidity,  but  should  be  admin- 
istered in  smaller  quantities  at  frequent  intervals.  Lavage  with  alkaline 
solutions  or  with  nitrate  of  silver  is  of  great  value.  To  relieve  pain  large 
quantities  of  bicarbonate  of  soda  or  magnesia  should  be  given  at  the  height 
of  digestion. 

In  subacidity  a  carefully  regulated,  easily  digestible  mixed  diet,  not  too 
rich  in  albuminoids,  is  advisable.  Bitter  tonics  before  meals  are  sometimes 
of  value.  In  achylia  gastrica  the  use  of  predigested  foods  and  of  hydro- 
chloric acid  in  full  doses  may  be  of  assistance. 

In  marked  hypercesthesia,  beside  the  treatment  of  the  general  condition, 


516  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

nitrate  of  silver  in  doses  of  gr.  %-%  (0.01G  to  0.032  gin.),  taken  in  three 
or  four  ounces  of  water  on  an  empty  stomach,  is  advised  by  Eosenheim. 
In  some  instances  rectal  feeding  may  have  to  be  resorted  to. 

For  pain  large  doses  of  alkalies  should  be  given,  of  which  the  light  mag- 
nesia and  bicarbonate  of  soda  are  the  best.  A  teaspoonful  of  either  or  of  a 
mixture  of  equal  parts  may  be  given  after  food  and  when  required.  A 
combination  of  potassium  bromide  (gr.  xv,  1  gm.)  with  codeia  (gr.  1/3, 
0.02  gm.)  is  sometimes  useful.  Opium  is  rarely  necessary,  but,  if  used,  should 
be  given  by  mouth. 

Chloroform  in  small  doses  or  Hoffman's  anodyne  will  sometimes  allay  the 
severe  pains.  The  general  condition  should  receive  careful  attention,  and  in 
many  cases  the  attacks  recur  until  the  health  is  restored  by  change  of  air 
with  the  prolonged  use  of  arsenic.  If  there  is  anaemia  iron  may  be  given 
freely.  Nitrate  of  silver  in  doses  of  gr.  1/4  to  y2  in  a  large  claret-glass  of 
water  taken  on  an  empty  stomach  is  useful  in  some  cases. 

There  are  forms  of  nervous  dyspepsia  occurring  in  women  who  are  often 
well  nourished  and  with  a  good  color,  yet  who  suffer — particularly  at  night — 
with  flatulency  and  abdominal  distress.  The  sleep  may  be  quiet  and  undis- 
turbed for  two  or  three  hours,  after  which  they  are  aroused  with  painful 
sensations  in  the  abdomen  and  eructations.  The  appetite  and  digestion  may 
appear  to  be  normal.  Constipation  is,  however,  usually  present.  In  many 
of  these  patients  the  condition  seems  rather  intestinal  dyspepsia,  and  the 
distress  is  due  to  the  accumulation  of  gases,  the  result  of  excessive  putrefac- 
tion. The  fats,  starches,  and  sugars  should  be  restricted.  A  diastase  fer- 
ment is  sometimes  useful.  The  flatulency  may  be  treated  by  the  methods 
above  mentioned.  Naphthalin,  salicylate  of  bismuth,  and  salol  have  been 
recommended.  Some  of  these  cases  obtain  relief  from  thorough  irrigation 
of  the  colon  at  bedtime. 

In  all  forms  of  gastric  neurosis  special  care  should  be  taken  to  prevent 
constipation. 


G.    DISEASES   OF   THE   INTESTINES 

I.    DISEASES    OF    THE    INTESTINES   ASSOCIATED    WITH 

DIARRHOEA 

CATAEEHAL    ENTEEITIS;    DIAEEHCEA 

In  the  classification  of  catarrhal  enteritis  the  anatomical  divisions  of  the 
bowel  have  been  too  closely  followed,  and  a  duodenitis,  jejunitis,  ileitis,  typhli- 
tis, colitis,  and  proctitis  have  been  recognized ;  whereas  in  a  majority  of  cases 
the  entire  intestinal  tract,  to  a  greater  or  lesser  extent,  is  involved,  some- 
times the  small  most  intensely,  sometimes  the  large  bowel;  but  during  life 
it  may  be  quite  impossible  to  say  which  portion  is  specially  affected. 

Etiology. — The  causes  may  be  either  primary  or  secondary.  Among  the 
causes  of  primary  catarrhal  enteritis  are:  (a)  Improper  food,  one  of  the  most 
frequent,  especially  in  children,  in  whom  it  follows  overeating,  or  the  in- 
gestion  of  unripe  fruit.  In  some  individuals  special  articles  of  diet  will 


DISEASES    OF    THE    INTESTINES  517 

always  produce  a  slight  diarrhoea,  which  may  not  be  due  to  a  catarrh  of  the 
mucosa,  but  to  increased  peristalsis  induced  by  the  offending  material.  (&) 
Various  toxic  substances.  Many  of  the  organic  poisons,  such  as  those  pro- 
duced in  the  decomposition  of  milk  and  articles  of  food,  excite  the  most 
intense  intestinal  catarrh.  Certain  inorganic  substances,  as  arsenic  and 
mercury,  act  in  the  same  way.  (c)  Changes  in  the  weather.  A  fall  in  the 
temperature  of  from  twenty  to  thirty  degrees,  particularly  in  the  spring  or 
autumn,  may  induce — how,  it  is  difficult  to  say — an  acute  diarrhoea.  We 
speak  of  this  as  a  catarrhal  process,  the  result  of  cold  or  of  chill.  On  the 
other  hand,  the  diarrhoaal  diseases  of  children  are  associated  in  a  very  special 
way  with  the  excessive  heat  of  summer  months,  (d)  Changes  in  the  con- 
stitution of  the  intestinal  secretions.  We  know  too  little  about  the  succus 
enterictis  to  be  able  to  speak  of  influences  induced  by  change  in  its  quantity 
or  quality.  It  has  long  been  held  that  an  increase  in  the  amount  of  bile 
poured  into  the  bowel  might  excite  a  diarrhoea;  hence  the  term  bilious  diar- 
rhoea, so  frequently  used  by  the  older  writers.  Possibly  there  are  conditions 
in  which  an  excessive  amount  of  bile  is  poured  into  the  intestine,  increasing 
the  peristalsis,  and  hurrying  on  the  contents;  but  the  opposite  state,  a 
scanty  secretion,  by  favoring  the  natural  fermentative  processes,  much  more 
commonly  causes  an  intestinal  catarrh.  Absence  of  the  pancreatic  secre- 
tion from  the  intestine  has  been  associated  in  certain  cases  with  a  fatty 
diarrhoea,  (e)  Nervous  influences.  It  is  by  no  means  clear  how  mental  states 
act  upon  the  bowels,  and  yet  it  is  an  old  and  trustworthy  observation,  which 
every-day  experience  confirms,  that  the  mental  state  may  profoundly  affect 
the  intestinal  canal.  These  influences  should  not  properly  be  considered 
under  catarrhal  processes,  as  they  result  simply  from  increased  peristalsis 
or  increased  secretion,  and  are  usually  described  under  the  heading  nervous 
diarrhoea.  In  children  it  frequently  follows  fright.  It  is  common,  too,  in 
adults  as  a  result  of  emotional  disturbances.  Canstatt  mentions  a  surgeon 
who  always,  before  an  important  operation,  had  watery  diarrhoea.  In  hys- 
terical women  it  is  seen  as  an  occasional  occurrence,  due  to  transient  ex- 
citement, or  as  a  chronic,  protracted  diarrhoea,  which  may  last  for  months 
or  even  years. 

Among  the  secondary  causes  of  intestinal  catarrh  may  be  mentioned:  (a) 
Infectious  diseases.  Dysentery,  cholera,  typhoid  fever,  pyaBmia,  septicaemia, 
tuberculosis,  and  pneumonia  are  occasionally  associated  with  intestinal  ca- 
tarrh. In  dysentery  and  typhoid  fever  the  ulceration  is  in  part  responsible 
for  the  catarrhal  condition,  but  in  cholera  it  is  probably  a  direct  influence 
of  the  bacilli  or  of  the  toxic  materials  produced  by  them.  (6)  The  exten- 
sion of  inflammatory  processes  from  adjacent  parts.  Thus,  in  peritonitis, 
catarrhal  swelling  and  increased  secretion  are  always  present  in  the  mucosa. 
In  cases  of  invagination,  hernia,  tuberculosis,  or  cancerous  ulceration  catar- 
rhal processes  are  common,  (c)  Circulatory  disturbances  cause  a  catarrhal 
enteritis,  usually  of  a  very  chronic  character.  This  is  common  in  diseases 
of  the  liver,  such  as  cirrhosis,  and  in  chronic  affections  of  the  heart  and 
lungs — all  conditions,  in  fact,  which  produce  engorgement  of  the  terminal 
branches  of  the  portal  vessels,  (d)  In  the  cachectic  conditions  met  with  in 
cancer,  profound  anemia,  Addison's  disease,  and  Bright's  disease  intestinal 
catarrh  may  occur  as  a  terminal  event. 


518 

Morbid  Anatomy. — It  is  rare  to  see  the  mucous  membrane  injected ;  more 
commonly  it  is  pale  and  covered  with  mucus.  In  the  upper  part  of  the  small 
intestine  the  tips  of  the  valvulaa  conniventcs  may  be  deeply  injected.  Even  in 
extreme  grades  of  portal  obstruction  intense  hypergemia  is  not  often  seen. 
The  entire  mucosa  may  be  softened  and  infiltrated,  the  lining  epithelium 
swollen,  or  even  shed,  and  appearing  as  large  flakes  among  the  intestinal 
contents.  This  is,  no  doubt,  a  post  mortem  change.  The  lymph  follicles  are 
almost  always  swollen,  particularly  in  children.  The  Foyer's  patches  may 
be  prominent  and  the  solitary  follicles  in  the  large  and  small  bowel  may 
stand  out  with  distinctness  and  present  in  the  centres  little  erosions,  the 
so-called  follicular  ulcers.  This  may  be  a  striking  feature  in  the  intestine 
in  all  forms  of  catarrhal  enteritis  in  children,  quite  irrespective  of  the  in- 
tensity of  the  diarrhoea. 

When  the  process  is  more  chronic  the  mucosa  is  firmer,  in  some  instances 
thickened,  in  others  distinctly  thinned,  and  the  villi  and  follicles  present  a 
slaty  pigmentation. 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  The  important 
symptom  of  both  is  diarrhoea,  which,  in  the  majority  of  instances,  is  the  sole 
indication  of  this  condition.  It  is  not  to  be  supposed  that  diarrhoea  is  in- 
variably caused  by,  or  associated  with,  catarrhal  enteritis,  as  it  may  be  pro- 
duced by  nervous  and  other  influences.  It  is  probable  that  catarrh  of  the 
jejunum  may  exist  without  any  diarrhoea;  indeed,  it  is  a  very  common  cir- 
cumstance to  find  post  mortem  a  catarrhal  state  of  the  small  bowel  in  per- 
sons who  have  not  had  diarrhoea  during  life.  The  stools  vary  extremely  in 
character.  The  color  depends  upon  the  amount  of  bile  with  which  they  are 
mixed,  and  they  may  be  of  a  dark  or  blackish  brown,  or  of  a  light  yellow,  or 
even  of  a  grayish-white  tint.  The  consistence  is  usually  very  thin  and 
watery,  but  in  some  instances  the  stools  are  pultaceous  like  thin  gruel.  Por- 
tions of  undigested  food  can  often  be  seen  (lienteric  diarrhoea),  and  flakes  of 
yellowish-brown  mucus.  Microscopically  there  ar§  innumerable  micro-or- 
ganisms, epithelium  and  mucous  cells,  crystals  of  phosphate  of  lime,  oxalate 
of  lime,  and  occasionally  cholesterin  and  Charcot's  crystals. 

Pain  in  the  abdomen  is  usually  present  in  the  acute  catarrhal  enteritis, 
particularly  when  due  to  food.  It  is  of  a  colicky  character,  and  when  the 
colon  is  involved  there  may  be  tenesmus.  More  or  less  tympanites  exists, 
and  there  are  gurgling  noises  or  borborygmi,  due  to  the  rapid  passage  of  fluid 
and  gas  from  one  part  to  another.  In  the  very  acute  attacks  there  may 
be  vomiting.  Fever  is  not,  as  a  rule,  present,  but  there  may  be  a  slight  eleva- 
tion of  one  or  two  degrees.  The  appetite  is  lost,  there  is  intense  thirst,  and 
the  tongue  is  dry  and  coated.  In  very  acute  cases,  when  the  quantity  of 
fluid  lost  is  great  and  the  pain  excessive,  there  may  be  collapse  symptoms. 
The  number  of  evacuations  varies  from  four  or  five  to  twenty  or  more  in  the 
course  of  the  day.  The  attack  lasts  for  two  or  three  days,  or  may  be  prolonged 
for  a  week  of  ten  days. 

Chronic  catarrh  of  the  bowels  may  follow  the  acute  form,  or  may  come  on 
gradually  as  an  independent  affection  or  as  a  sequence  of  obstruction  in  the 
portal  circulation.  It  is  characterized  by  diarrhoea,  with  or  without  colic. 
The  dejections  vary;  when  the  small  bowel  is  chiefly  involved  the  diarrhoea 
is  of  a  lienteric  character,  and  when  the  colon  is  affected  the  stools  are  thin 


DISEASES    OF    THE    INTESTINES  519 

and  mixed  with  much  mucus.  A  special  form  of  mucous  diarrhoea  will  be 
subsequently  described.  The  general  nutrition  in  these  chronic  cases  is 
greatly  disturbed;  there  may  be  much  loss  of  flesh  and  great  pallor.  The 
patients  are  inclined  to  suffer  from  low  spirits,  or  hypochondriasis  may 
develop. 

Diagnosis. — It  is  important,  in  the  first  place,  to  determine,  if  possible, 
whether  the  large  or  small  bowel  is  chiefly  affected.  In  catarrh  of  the  small 
bowel  the  diarrhoea  is  less  marked,  the  pains  are  of  a  colicky  character,  bor- 
borygmi  are  not  so  frequent,  the  fasces  usually  contain  portions  of  food, 
and  are  more  yellowish-green  or  grayish-yellow  and  flocculeiit  and  do  not  con- 
tain much  mucus.  When  the  large  intestine  is  at  fault  there  may  be  no  pain 
whatever,  as  in  the  catarrh  of  the  large  intestine  associated  with  tubercu- 
losis and  Bright's  disease.  When  present,  the  pains  are  most  intense,  and, 
if  the  lower  portion  of  the  bowel  is  involved,  there  may  be  marked  tenesmus. 
The  stools  have  a  uniform  soupy  consistence;  they  are  grayish  in  color  and 
granular  throughout,  with  here  and  there  flakes  of  mucus,  or  they  may  con- 
tain very  large  quantities  of  mucus. 

There  are  no  positive  symptoms  by  which  the  diagnosis  of  duodenitis  can 
be  made.  It  is  usually  associated  with  acute  gastritis  and,  if  the  process 
extends  into  the  bile-duct,  with  jaundice.  Neither  jejunitis  nor  ileitis  can 
be  separated  from  general  intestinal  catarrh. 

The  Cceliac  Affection. — Under  this  heading  Gee  has  described  an  intestinal 
disorder,  most  commonly  met  with  in  children  between  the  ages  of  one  and 
five,  characterized  by  the  occurrence  of  pale,  loose  stools,  not  unlike  gruel  or 
oatmeal  porridge.  They  are  bulky,  not  watery,  yeasty,  frothy,  and  extremely 
offensive.  The  affection  has  received  various  names,  such  as  diarrhoea  alba  or 
diarrhoea  chylosa.  It  is  not  associated  with  tuberculosis  or  other  hereditary 
disease.  It  begins  insidiously  and  there  are  progressive  wasting,  weakness, 
and  pallor.  The  belly  becomes  doughy  and  inelastic.  There  is  often  flatu- 
lency. Fever  is  usually  absent.  The  disease  is  lingering  and  a  fatal  termina- 
tion is  common.  So  far  nothing  is  known  of  the  pathology  of  the  disease. 
TJlceration  of  the  intestines  has  been  met  with,  but  it  is  not  constant. 

Sprue  or  Psilosis. — A  remarkable  disease  of  the  tropics,  characterized  by 
"a  peculiar,  inflamed,  superficially  ulcerated,  exceedingly  sensitive  condition 
of  the  mucous  membrane  of  the  tongue  and  mouth;  great  wasting  and  anae- 
mia; pale,  copious,  and  often  loose,  frequent,  and  frothy  fermenting  stools; 
very  generally  by  more  or  less  diarrhoea;  and  also  by  a  marked  tendency  to 
relapse"  (Manson).  It  is  very  prevalent  in  India,  China,  and  Java.  Noth- 
ing definite  is  known  as  to  its  cause. 

When  fully  established  the  chief  symptoms  are  a  disturbed  condition  cf 
the  bowels,  pale,  yeasty-looking  stools,  a  raw,  bare,  sore  condition  of  the 
tongue,  mouth,  and  gullet,  sometimes  with  actual  superficial  ulceration.  With 
these  gastro-intestinal  symptoms  there  are  associated  anasmia  and  general 
wasting.  It  is  very  chronic  with  numerous  relapses.  There  are  no  charac- 
teristic anatomical  changes.  There  are  usually  ulcers  in  the  colon,  and  the 
French  think  it  is  a  form  of  dysentery. 

Manson  recommends  rest  and  a  milk  diet  as  curative  in  a  large  propor- 
tion of  the  cases.  The  monograph  by  Thin  and  the  article  by  Manson  ir 
Allbutt  and  Kolleston's  System  give  very  full  descriptions  of  the  disease. 


520  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

DIPHTHEEOID    OE   CEOUPOUS    ENTEEITIS 

A  croupous  or  diphtheroid  inflammation  of  the  mucosa  of  the  small  and 
large  intestines  occurs  (a)  most  frequently  as  a  secondary  process  in  the 
infectious  diseases — pneumonia,  pyaemia  in  its  various  forms,  and  typhoid 
fever;  (&)  as  a  terminal  process  in  many  chronic  affections,  such  as  Bright's 
disease,  cirrhosis  of  the  liver,  or  cancer;  and  (c)  as  an  effect  of  certain  poisons 
— mercury,  lead,  and  arsenic. 

There  are  three  different  anatomical  pictures.  In  one  group  of  cases  the 
mucosa  presents  on  the  top  of  the  folds  a  thin  grayish-yellow  diphtheroid 
exudate  situated  upon  a  deeply  congested  base.  In  some  cases  all  grades  'may 
be  seen  between  the  thinnest  film  of  superficial  necrosis  and  involvement  of 
the  entire  thickness  of  the  mucosa.  In  the  colon  similar  transversely  ar- 
ranged areas  of  necrosis  are  seen  situated  upon  hypersemic  patches,  and  it 
may  be  here  much  more  extensive  and  involve  a  large  portion  of  the  mem- 
brane. There  may  be  most  extensive  inflammation  without  any  involve- 
ment of  the  solitary  follicles  of  the  large  or  small  bowel. 

In  a  second  group  of  cases  the  membrane  has  rather  a  croupous  charac- 
ter. It  is  grayish-white  in  color,  more  flake-like  and  extensive,  limited, 
perhaps,  to  the  caecum  or  to  a  portion  of  the  colon;  thus,  in  several  cases  of 
pneumonia  I  found  this  flaky  adherent  false  membrane,  in  one  instance  form- 
ing patches  1  to  2  cm.  in  diameter,  which  in  form  were  not  unlike  rupia 
crusts. 

In  a  third  group  the  affection  is  really  a  follicular  enteritis,  involving 
the  solitary  glands,  which  are  swollen  and  capped  with  an  area  of  diph- 
theroid necrosis  or  are  in  a  state  of  suppuration.  Follicular  ulcers  are  com- 
mon in  this  form.  The  disease  may  run  its  course  without  any  symptoms, 
and  the  condition  is  unexpectedly  met  with  post  mortem.  In  other  instances 
there  are  diarrhoea,  pain,  but  not  often  tenesmus  or  the  passage  of  blood- 
stained mucus.  In  the  toxic  cases  the  intestinal  symptoms  may  be  very 
marked,  but  in  the  terminal  colitis  of  the  fevers  and  of  constitutional  affec- 
tions the  symptoms  are  often  trifling. 

The  ulcerative  colitis  of  chronic  disease  may  be  only  a  terminal  event  in 
these  diphtheroid  processes. 

PHLEGMONOUS    ENTEEITIS 

As  an  independent  affection  this  is  excessively  rare,  even  less  frequent 
than  its  counterpart  in  the  stomach.  It  is  seen  occasionally  in  connection 
with  intussusception,  strangulated  hernia,  and  chronic  obstruction.  Apart 
from  these  conditions  it  occurs  most  frequently  in  the  duodenum,  and  leads 
to  suppuration  in  the  submucosa  and  abscess  formation.  Except  when  as- 
sociated with  hernia  or  intussusception  the  affection  can  not  be  diagnosed. 
The  symptoms  usually  resemble  those  of  peritonitis. 

TJLCEEATIVE   ENTEEITIS 

In  addition  to  the  specific  ulcers  of  tuberculosis,  syphilis,  and  typhoid 
fever,  the  following  forms  of  ulceration  occur  in  the  bowels: 


DISEASES    OF   THE    INTESTINES  521 

Follicular  Ulceration. — As  previously  mentioned,  this  is  met  with  very 
commonly  in  the  diarrhoeal  diseases  of  children,  and  also  in  the  secondary 
or  terminal  inflammations  in  many  fevers  and  constitutional  disorders.  The 
ulcers  are  small,  punched  out,  with  sharply  cut  edges,  and  they  are  usually 
limited  to  the  follicles.  With  this  form,  may  be  placed  the  catarrhal  ulcers 
of  some  writers. 

Stercoral  ulcers,  which  occur  in  long-standing  cases  of  constipation.  Very 
remarkable  indeed  are  the  cases  in  which  the  sacculi  of  the  colon  become 
filled  with  rounded  small  scybala,  some  of  which  produce  distinct  ulcers  in 
the  mucous  membrane.  The  faecal  masses  may  have  lime  salts  deposited  in 
them,  and  thus  form  little  enteroliths. 

Simple  Ulcerative  Colitis. — Simple  idiopathic  or  innominate  ulcerative 
colitis  has  been  differentiated  from  amcebic  and  bacillary  dysentery  by  Hale 
White  and  others.  It  is  a  disease  of  adults,  of  unknown  origin.  The  sexes 
are  equally  affected;  of  177  cases  collected  by  Eric  Smith,  89  were  in  males. 
Some  patients  have  had  previous  bowel  trouble;  sometimes  there  have  been 
intermittent  attacks  of  diarrhoea  and  constipation.  When  established,  the 
main  features  are: 

(a)  Diarrhoea:  the  motions  very  frequent  in  the  day,  up  to  20  or  30, 
usually  small,  bile-stained,  with  mucus  and  blood,  sometimes  mixed  with  the 
motion  or  separate.  There  may  be  clotted  lumps  of  blood,  or  the  blood  is 
uniformly  mixed,  and  the  motions  look  like  anchovy  sauce.  The  pain,  while 
severe,  is  usually  diffuse,  abdominal,  and  colicky,  and,  not  so  frequently,  in 
the  rectum.  Many  of  the  motions  pass  without  pain. 

(&)  Fever,  which  occurs  in  the  majority  of  the  cases,  though  severe 
forms  may  be  free  throughout. 

(c)  Wasting,  debility,  and  progressive  anaemia. 

The  disease  may  run  a  very  acute  course,  but  most  frequently  it  is 
chronic,  lasting  from  eight  weeks  to  three  or  four  months.  Transient  im- 
provement may  follow,  and  a  relapse.  Death  is  most  commonly  from  ex- 
haustion, occasionally  from  haemorrhage,  and  in  a  few  instances  from  per- 
foration. Post  mortem,  the  colon  is  dilated,  often  without  hypertrophied 
walls;  the  ulceration,  as  a  rule,  limited  to  it  and  very  extensive,  the  ulcers 
ranging  in  size  from  a  pin's  head  to  large  areas,  with  infiltrated,  rarely  un- 
dermined, edges.  The  Shiga  bacillus  is  not  present;  the  colon  bacilli  are 
found  in  various  forms,  but  no  one  organism  has  apparently  any  definite 
relation  to  the  disease. 

TJlceration  from  External  Perforation. — This  may  result  from  the  ero- 
sion of  new  growths  or,  more  commonly,  from  localized  peritonitis  with  ab- 
scess formation  and  perforation  of  the  bowel.  This  is  .met  with  most  fre- 
quently in  tuberculous  peritonitis,  but  it  may  occur  in  the  abscess  which 
follows  perforation  of  the  appendix  or  suppurative  or  gangrenous  pancreatitis. 
Fatal  haemorrhage  may  result  from  the  perforation. 

Cancerous  Ulcers. — In  very  rare  instances  of  multiple  cancer  or  sar- 
coma the  submucous  nodules  break  down  and  ulcerate.  In  one  case  the  ilenm 
contained  eight  or  ten  sarcomatous  ulcers  secondary  to  an  extensive  sarcoma 
in  the  neighborhood  of  the  shoulder-joint. 

Solitary  Ulcer. — Occasionally  a  solitary  ulcer  is  met  with  in  the  caecum  or 
colon,  which  may  lead  to  perforation.  Two  instances  of  ulcer  of  the  caecum, 
35 


522  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

both,  with  perforation,  have  come  under  my  observation,  and  in  one  instance 
a  simple  ulcer  of  the  colon  perforated  and  led  to  fatal  peritonitis. 

Diagnosis  of  Intestinal  Ulcers.  — As  a  rule,  diarrhoea  is  present  in  all 
cases,  but  exceptionally  there  may  be  extensive  ulceration,  particularly  in  the 
small  bowel,  without  diarrhoea.  Very  limited  ulceration  in  the  colon  may 
be  associated  with  frequent  stools.  The  character  of  the  dejections  is  of  great 
importance.  Pus,  shreds  of  tissue,  and  blood  are  the  most  valuable  indica- 
tions. Pus  occurs  most  frequently  in  connection  with  ulcers  in  the  large 
intestine,  but  when  the  bowel  alone  is  involved  the  amount  is  rarely  great, 
and  the  passage  of  any  quantity  of  pure  pus  is  an  indication  that  it  has  come 
from  without,  most  commonly  from  the  rupture  of  a  pericsecal  abscess,  or 
in  women  of  an  abscess  of  the  broad  ligament.  Pus  may  also  be  present  in 
cancer  of  the  bowel,  or  it  may  be  due  to  local  disease  in  the  rectum.  A 
purulent  mucus  may  be  present  in  the  stools  in  cases  of  ulcer,  but  it  has  not 
the  same  diagnostic  value.  The  swollen,  sago-like  masses  of  mucus  which 
are  believed  by  some  to  indicate  follicular  ulceration  are  met  with  also  in 
mucous  colitis.  Haemorrhage  is  an  important  and  valuable  symptom  of 
ulcer  in  the  bowel,  particularly  if  profuse.  It  occurs  under  so  many  condi- 
tions that  taken  alone  it  may  not  be  specially  significant,  but  with  other 
coexisting  circumstances  it  may  be  the  most  important  indication  of  all. 

Fragments  of  tissue  are  occasionally  found  in  the  stools  in  ulcer,  particu- 
larly in  the  extensive  and  rapid  sloughing  in  dysenteric  processes.  Definite 
portions  of  mucosa,  shreds  of  connective  tissue,  and  even  bits  of  the  muscu- 
lar coat  may  be  found.  Pain  occurs  in  many  cases,  either  of  a  diffuse,  colicky 
character,  or  sometimes,  in  the  ulcer  of  the  colon,  very  limited  and  well 
defined. 

Perforation  is  an  accident  liable  to  happen  when  the  ulcer  extends  deep- 
ly. In  the  small  bowel  it  leads  to  a  localized  or  general  peritonitis.  In  the 
large  intestine,  too,  a  fatal  peritonitis  may  result,  or,  if  perforation  takes 
place  in  the  posterior  wall  of  the  ascending  or  descending  colon,  the  produc- 
tion of  a  large  abscess  cavity  in  the  retro-peritoneum. 

Treatment  of  the  Previous  Conditions 

Acute  Dyspeptic  Diarrhoea.— All  solid  food  should  be  withheld.  If  vom- 
iting is  present  ice  may  be  given,  and  small  quantities  of  milk  and  soda 
water  may  be  taken.  If  the  attack  has  followed  the  eating  of  large  quanti- 
ties of  indigestible  material,  castor  oil  or  calomel  is  advisable,  but  is  not 
necessary  if  the  patient  has  been  freely  purged.  If  the  pain  is  severe,  20 
drops  (1.3  c.  c.)  of  laudanum  and  a  drachm  (4  c.  c.)  of  spirit  of  chloro- 
form may  be  given,  or,  if  the  colic  is  very  intense,  a  hypodermic  of  a  quar- 
ter of  a  grain  (0.016  gm.)  of  morphia.  It  is  not  well  to  check  the  diarrhoea 
unless  it  is  profuse,  as  it  usually  stops  spontaneously  within  forty-eight  hours. 
If  persistent,  the  aromatic  chalk  powder  or  large  doses  of  bismuth  (30  to  40 
grains,  2  gm.)  may  be  given.  .A  small  enema  of  starch  (2  ounces,  60  c.  c.), 
with  20  drops  (1.3  c.  c.)  of  laudanum,  every  six  hours,  is  a  most  valuable 
remedy. 

Chronic  diarrhoea,  including  chronic  catarrh  and  ulcerative  enteritis.  It 
is  important,  in  the  first  place,  to  ascertain,,  if  possible,  the  cause  and  whether 


DISEASES    OP   THE   INTESTINES  523 

ulceration  is  present  or  not.  So  much  ;n  treatment  depends  upon  the  careful 
examination  of  the  stools — as  to  the  amount  of  mucus,  the  presence  of  pus, 
the  occurrence  of  parasites,  and,  above  all,  the  state  of  digestion  of  the  food— 
that  the  practitioner  should  pay  special  attention  to  them.  Many  patients 
simply  require  rest  in  bed  and  a  restricted  diet.  Chronic  diarrhoea  of  many 
months'  or  even  of  several  years'  duration  may  be  sometimes  cured  by  strict 
confinement  to  bed  and  a  diet  of  boiled  milk  and  albumen  water. 

In  that  form  in  which  immediately  after  eating  there  is  a  tendency  to 
loose  evacuations  it  is  usually  found  that  some  one  article  of  diet  is  at  fault. 
The  patient  should  rest  for  an  hour  or  more  after  meals.  Sometimes  this 
alone  is  sufficient  to  prevent  the  occurrence  of  the  diarrhoea.  In  those  forms 
which  depend  upon  abnormal  conditions  in  the  small  intestine,  either  too 
rapid  peristalsis  or  faulty  fermentative  processes,  bismuth  is  indicated.  It 
must  be  given  in  large  doses — from  half  a  drachm  to  a  drachm  (2  to  4  gm.) 
three  times  a  day.  The  smaller  doses  are  of  little  use.  Naphthalin  prepara- 
tions here  do  much  good,  given  in  doses  of  from  10  to  15  grains  (1  gm.) 
four  or  five  times  a  day.  Larger  doses  may  be  needed.  Salol  and  the  sali~ 
cylate  of  bismuth  may  be  tried. 

An  extremely  obstinate  and  intractable  form  is  the  diarrhoea  of  hysterical 
women.  A  systematic  rest  cure  will  be  found  most  advantageous,  and  if  a 
milk  diet  is  not  well  borne  the  patient  may  be  fed  exclusively  on  egg  al- 
bumen. The  condition  seems  to  be  associated  in  some  cases  with  increased 
peristalsis,  and  in  such  the  bromides  may  do  good,  or  preparations  of  opium 
may  be  necessary.  There  are  instances  which  prove  most  obstinate  and  resist 
all  forms  of  treatment,  and  the  patient  may  be  greatly  reduced.  A  change  of 
air  and  surroundings  may  do  more  than  medicines. 

In  a  large  group  of  the  chronic  diarrhoeas  the  mischief  is  seated  in  the 
colon  and  is  due  to  ulceration.  Medicines  by  the  mouth  are  here  of  little 
value.  The  stools  should  be  carefully  watched  and  a  diet  arranged  which 
shall  leave  the  smallest  possible  residue.  Boiled  or  peptonized  milk  may  be 
oiven,  but  the  stools  should  be  examined  to  see  whether  there  is  an  excess  of 

O  ' 

food  or  of  curds.  Meat  is,  as  a  rule,  badly  borne  in  these  cases.  The  diar- 
rhoea is  best  treated  by  enemata.  The  starch  and  laudanum  should  be  tried, 
but  when  ulceration  is  present  it  is  better  to  use  astringent  injections.  From 
2  to  4  pints  of  warm  water,  containing  from  half  a  drachm  to  a  drachm 
(2  to  4  gm.)  of  nitrate  of  silver,  may  be  used.  In  the  chronic  diarrhoea 
which  follows  dysentery  this  is  particularly  advantageous.  In  giving  large 
injections  the  patient  should  be  in  the  dorsal  position,  with  the  hips  ele- 
vated, and  it  is  best  to  allow  the  injection  to  flow  in  gradually  from  a  siphon 
bag.  In  this  way  the  entire  colon  can  be  irrigated  and  the  patient  can  retain 
the  injection  for  some  time.  The  silver  injections  may  be  very  painful,  but 
they  are  invaluable  in  all  forms  of  ulcerative  colitis.  Acetate  of  lead, 
boracic  acid,  sulphate  of  copper,  sulphate  of  zinc,  and  salicylic  acid  may 
be  used  in  1  per  cent,  solutions.  In  obstinate  cases  appendicostomy.  should 
be  done  and  the  bowel  irrigated  through  the  opening. 

In  the  intense  forms  of  choleraic  diarrhoea  in  adults  associated  with  con- 
stant vomiting  and  frequent  watery  discharges  the  patient  should  be  given  at 
once  a  hypodermic  of  a  quarter  of  a  grain  of  morphia,  which  should  be  re- 
peated in  an  hour  if  the  pains  return  or  the  purging  persists.  This  give* 


524  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

prompt  relief,  and  is  often  the  only  medicine  needed  in  the  attack.  The 
patient  should  be  given  stimulants,  and,  when  the  vomiting  is  allayed  hy 
suitable  remedies,  small  quantities  of  milk  and  lime  water. 


II.     DIARRHCEAL    DISEASES    IN    CHILDREN 

Children  are  particularly  susceptible  to  disorders  of  the  alimentary  tract. 
Although  several  forms  are  recognized,  they  so  often  merge  the  one  into  the 
other  that  a  sharp  differentiation  is  impossible. 

General  Etiology. — Certain  factors  predispose  to  diarrhoea.  AGE. — The 
largest  number  of  cases  occur  just  after  the  nursing  period;  the  highest 
mortality  is  in  the  second  half  of  the  first  year,  when  this  period  falls  in  the 
hot  weather;  hence  the  dread  of  the  "second  summer." 

DIET. — Diarrhoea  is  most  frequent  in  artificially  fed  babies.  Of  nineteen 
hundred  and  forty-three  fatal  cases  collected  by  Holt,  only  3  per  cent,  were 
breast-fed.  The  recent  agitation  for  pure  milk  in  the  large  cities  has  de- 
creased materially  the  number  of  diarrhoea  cases  among  bottle-fed  infants. 

Among  the  poor  the  bowel  complaint  comes  with  artificial  feeding,  and 
is  due  either  to  milk  ill-suited  in  quantity  or  poor  in  quality,  or  to  indigestible 
articles  of  diet.  Very  many  of  the  fatal  cases  have  been  fed  upon  condensed 
milk. 

TEMPERATURE. — The  relation  of  the  atmospheric  temperature  to  the  preva- 
lence of  the  disease  in  children  has  long  been  recognized.  The  mortality 
curve  begins  to  rise  in  May,  increases  in  June,  reaching  the  maximum  in 
July,  and  gradually  sinks  through  August  and  September.  The  maximum 
corresponds  closely  with  the  highest  mean  temperature,  yet  we  can  not  re- 
gard the  heat  itself  as  the  direct  agent,  but  only  as  one  of  several  factors. 
Thus  the  mean  temperature  of  June  is  only  four  or  five  degrees  lower  than 
that  of  July,  and  yet  the  mortality  is  not  more  than  one-third.  Seibert, 
who  has  carefully  analyzed  the  mortality  and  the  ^temperature  month  by 
month  in  New  York  for  ten  years,  fails  to  find  a  constant  relation  between 
the  degrees  of  heat  and  the  number  of  cases  of  diarrhoea.  Neither  barometric 
pressure  nor  humidity  appears  to  have  any  influence. 

BACTERIOLOGY. — The  discovery  by  Duvall  and  Bassett,  working  at  the 
Thomas  Wilson  Sanitarium,  in  the  dejecta  of  children  suffering  from  sum- 
mer diarrhoea,  of  a  bacillus  apparently  identical  with  the  organism  shown 
by  Shiga  to  be  the  cause  of  epidemic  dysentery  in  Japan,  has  awakened 
renewed  interest  in  the  relation  of  bacteria  to  these  disorders  in  children. 

The  Rockefeller  Institute  research  showed  that  this  organism  was  present 
in  a  large  number  of  cases  of  so-called  "summer  diarrhoea/'  No  instances 
of  cholera  infantum  were  studied.  The  laboratory  studies  of  Martini  and 
Lentz,  Flexner,  Hiss,  Parke,  and  others  indicate  that  there  is  a  group  of 
closely .  allied  forms  "of  bacilli  differing  slightly  from  the  original  Shiga 
bacillus  in  their  action  on  certain  sugars  and  in  agglutinating  properties. 

The  type  of  organisms  most  frequently  associated  with  the  diarrhoeas  of 
children  belongs  to  the  so-called  "acid  type,"  and,  unlike  the  Shiga  cultures, 
ferments  mannite  with  acid  production. 

The  causal  connection  of  this  group  of  bacteria  with  all  the  diarrhoeal 


525 

diseases  of  children  has  not  been  proved.  In  the  hands  of  some  workers  they 
have  been  found  in  the  faeces  of  a  large  proportion  of  all  cases  examined, 
and  also  less  frequently  in  the  sporadic  diarrhoeas  occurring  throughout  the 
year.  These  organisms  are  often  found  in  comparatively  small  numbers, 
and  are  more  easily  isolated  from  mucus  or  blood-stained  stools.  They  occur 
in  the  acute  primary  intestinal  infection  in  children,  in  subacute  infection 
without  previous  symptoms  coincident  with  or  following  other  acute  dis- 
eases such  as  measles,  pneumonia,  etc.,  and  in  the  terminal  intestinal  infec- 
tion following  malnutrition  or  marasmus.  They  have  been  found  in  breast- 
fed infants  as  well  as  bottle-babies. 

The  mode  of  entrance  of  the  organism  has  not  been  determined.  Simul- 
taneous outbreaks  of  many  cases  in  remote  parts  of  a  community  where  there 
can  be  no  common  milk  supply,  and  occurrence  of  the  disease  in  breast-  and 
condensed-milk-fed  babies,  indicate  that  cow's  milk  is  not  the  only  conveyor 
of  the  infection,  and  point  to  some  common  cause,  possibly  to  the  water,  as 
a  means  of  contamination,  although  dysentery  bacilli  have  not  yet  been  iso- 
lated from  city  water. 

The  importance  of  other  organisms  must  not  be  overlooked.  The  observa- 
tions of  Escherich  showed  the  remarkable  simplicity  of  bacterial  flora  in  the 
intestines  of  healthy  milk-fed  children,  Bacterium  lactis  cerogenes  being  pres- 
ent in  the  upper  portion  of  the  bowel  and  Bacterium  coli  commune  in  the 
lower  bowel,  each  almost  in  pure  culture. 

When  diarrhoaa  is  set  up  the  number  and  varieties  of  bacteria  are  greatly 
increased,  although  heretofore  no  forms  had  been  found  to  bear  a  constant 
or  specific  relationship  to  the  diarrhceal  fa?ces. 

Certain  diarrhoeas  in  children  are  apparently  induced  by  the  lactic  acid 
organisms  in  milk,  others  by  colon  or  proteus  bacilli,  and  others,  again,  by 
the  pyogenic  cocci  and  other  forms ;  all  these  bacteria  may  be  associated  with, 
the  dysentery  bacilli. 

There  is  considerable  evidence  to  support  the  view  that  the  destructive 
lesions  of  the  intestines  may  be  produced  by  the  Streptococcus  pyogenes  after 
an  initial  infection  with  a  member  of  the  dysentery  group. 

Morbid  Anatomy. — In  mild  cases  there  may  be  only  a  slight  catarrhal 
swelling  of  the  mucosa  of  both  small  and  large  bowel,  with  enlargement  of 
the  lymph  follicles.  The  mucous  membrane  may  be  irregularly  congested; 
often  this  is  most  marked  at  the  summit  of  the  folds.  The  submucosa  is 
usually  infiltrated  with  serum  and  small  round  cells.  In  more  severe  cases 
ulceration  may  take  place.  The  loss  of  substance  begins,  usually,  in  the 
mucosa,  over  swollen  lymph  follicles.  About  the  ulcer  there  is  a  more  or  less 
distinctly  marked  inflammatory  zone.  The  destruction  of  the  tissue  is  lim- 
ited to  the  region  of  the  follicles  and  becomes  progressive  by  the  union  of 
several  adjoining  ulcers.  This  process  is  usually  confined  to  the  lower  bowel, 
and  may  be  so  extensive  as  to  leave  only  ribbons  of  intact  mucosa.  The  ulcers 
never  perforate.  Earely  there  is  a  croupous  or  pseudo-membranous  enteritis 
affecting  the  lower  ilium,  colon,  and  rectum.  The  constant  features  are 
the  increased  secretion  of  mucus  and  the  lymphoid  hyperplasia.  The  mesen- 
teric  glands  are  enlarged. 

The  changes  in  the  other  organs  are  neither  numerous  nor  characteristic. 
Broncho-pneumonia  occurs  in  many  cases.  The  liver  is  often  fatty,  the 


526  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

spleen  may  be  swollen.  Brain  lesions  are  rare;  the  membranes  and  sub- 
stance are  often  anaemic,  but  meningitis  or  thrombosis  is  very  uncommon. 

Clinical  Forms. — ACUTE  INTESTINAL  INDIGESTION. — This  form  occurs  in 
children  of  all  ages,  and  is  associated  with  improper  food.  The  symptoms 
often  begin  abruptly  with  nausea  and  vomiting,  or,  especially  in  stronger 
children,  several  hours  or  a  day  or  two  after  the  disturbing  diet.  The  local 
symptoms  are  colicky  pains,  moderate  tympanites,  and  diarrhoea.  The  stools 
are  four  to  ten  in  twenty-four  hours;  at  first  faecal,  then  fluid,  with  more 
or  less  mucus  and  particles  from  undigested  material.  There  is  no  blood. 
The  usual  intestinal  bacteria  are  found.  Occasionally,  when  there  is  mucus, 
dysentery  bacilli  are  present.  There  is  always  fever.  It  is  rarely  very  high, 
and  never  continues.  The  pulse  may  be  rapid  and  the  prostration  marked  in 
very  young  or  weak  children.  These  symptoms  usually  subside  shortly  after 
the  emptying  of  the  bowel. 

In  weakened  infants,  or  when  the  treatment  has  been  delayed  or  the  diet 
remains  unchanged,  this  disturbance  may  lead  to  more  serious  conditions. 
Attacks  of  intestinal  indigestion  tend  to  recur. 

ACUTE  DYSPEPSIA,  OR  FERMENTATIVE  DIARRIKEA. — This  form  is  charac- 
terized by  more  severe  constitutional  symptoms.  It  may  begin  after  an  in- 
testinal indigestion  of  several  days  in  which  the  stools  are  fluid  and  offen- 
sive, and  contain  undigested  food  and  curds.  In  other  cases  the  disease  sets 
in  abruptly  with  vomiting,  griping  pains,  and  fever,  which  may  rapidly 
reach  104°-105°F. 

Nervous  symptoms  are  usually  prominent.  The  child  is  irritable  and 
Bleeps  poorly.  Convulsions  may  usher  in  the  acute  symptoms  or  occur  later. 
An  increasing  drowsiness,  ending  in  coma,  has  been  noted  in  many  cases. 
The  stools,  which  vary  from  four  to  twenty  in  twenty-four  hours,  soon  lose 
their  faecal  character  and  become  fluid.  Later  they  consist  largely  of  green 
or  translucent  mucus.  An  occasional  fleck  of  blood  is  noticed  in  the  mucus, 
but  this  is  never  present  in  large  amounts. 

Microscopically,  besides  the  food  residue  and  mucous  strands  are  a  mod- 
erate number  of  leucocytes  and  red  blood-corpuscles.  Epithelial  cells  are 
found  with  numerous  bacteria. 

The  acute  symptoms  generally  pass  away  in  a  few  days  with  judicious 
treatment.  Relapses  are  frequent,  following  any  indiscretion.  The  attack 
may  be  the  beginning  of  severe  ileo-colitis. 

These  gastro-intestinal  intoxications  are  largely  confined  to  the  summer 
months  and  form  an  important  group  of  the  summer  diarrhoeas  of  chil- 
dren. 

CHOLERA  INFANTUM. — This  term  should  be  reserved  for  the  fulminating 
form  of  gastro-intestinal  intoxication.  The  typical  cases  are  rare  and  form 
only  a  very  small  proportion  of  the  diarrhoeal  diseases  of  infants.  The  disease 
sets  in  with  vomiting,  which  is  incessant  and  is  excited  by  an  attempt  to 
take  food  or  drink.  The  stools  are  profuse  and  frequent;  at  first  fa?cal  in 
character,  brown  or  yellow  in  color,  and  finally  thin,  serous,  and  watery. 
The  stools  first  passed  are  very  offensive ;  subsequently  they  are  odorless.  The 
thin,  serous  stools  axe  alkaline.  There  is  fever,  but  the  axillary  temperature 
may  register  three  or  more  degrees  below  that  of  the  rectum.  From  the 
outset  there  is  marked  prostration ;  the  eyes  are  sunken,  the  features  pinched. 


DIARRHCEAL    DISEASES    IN    CHILDREN  527 

the  fontanelles  depressed,  and  the  skin  has  a  peculiar  ashy  pallor.  At  first 
restless  and  excited,  the  child  subsequently  becomes  heavy,  dull,  and  listless. 
The  tongue  is  coated  at  the  onset,  but  subsequently  becomes  red  and  dry.  As 
in  all  choleraic  conditions,  the  thirst  is  insatiable;  the  pulse  is  rapid  and 
feeble,  and  toward  the  end  becomes  irregular  and  imperceptible.  Death  may 
occur  within  twenty-four  hours,  with  symptoms  of  collapse  and  great  eleva- 
tion of  the  internal  temperature.  Before  the  end  the  diarrhoea  and  vomit- 
ing may  cease.  In  other  instances  the  intense  symptoms  subside,  but  the 
child  remains  torpid  and  semi-comatose,  with  fingers  clutched,  and  there  may 
be  convulsions.  The  head  may  be  retracted  and  the  respirations  interrupted, 
irregular,  and  of  the  Cheyne-Stokes  type.  The  child  may  remain  in  this  con- 
dition for  some  days  without  any  signs  of  improvement.  It  was  to  this 
group  of  symptoms  in  infantile  diarrhoea  that  Marshall  Hall  gave  the  term 
"hydrencephaloid,"  or  spurious  hydrocephalus.  As  a  rule,  no  changes  in  the 
brain  or  other  organs  are  found.  The  condition  of  sclerema  is  described  as 
a  sequel  of  cholera  infantum.  The  skin  and  subcutaneous  tissue  becomes 
hard  and  firm,  and  the  appearance  has  been  compared  to  that  of  a  half- 
frozen  cadaver. 

No  constant  organism  has  been  found  in  these  cases.  Baginsky  considers 
the  disease  the  result  of  the  action  on  the  system  of  the  poisonous  products 
of  decomposition  encouraged  by  the  various  bacteria  present — a  Fdulniss 
disease.  The  clinical  picture  is  that  produced  by  an  acute  bacterial  infec- 
tion, as  in  Asiatic  cholera. 

Diagnosis. — The  diagnosis  is  readily  made.  There  is  no  other  intestinal 
affection  in  children  for  which  it  can  be  mistaken.  The  constant  vomiting, 
the  frequent  watery  discharges,  the  collapse  symptoms,  and  the  elevated  tem- 
perature make  an  unmistakable  clinical  picture.  The  outlook  in  the  majority 
of  cases  is  bad,  particularly  in  children  artificially  fed.  Hyperpyrexia,  ex- 
treme collapse,  and  incessant  vomiting  are  the  most  serious  symptoms. 

ILEO-COLITIS  (Eniero-colitis,  Inflammatory  Diarrhoea). — In  this  form 
there  is  evidence  of  an  inflammatory  alteration  of  the  intestinal  wall,  usually 
of  the  lower  ilemn  and  large  intestine.  Several  sub-varieties  are  recognized 
according  to  the  nature  and  site  of  the  lesions.  Many  of  the  cases  are  grafted 
on  the  simple  forms  above  described.  The  mucous  discharges  continue, 
mingled  with  food  residue  and  often  streaked  with  blood.  Pus  cells  are  nu- 
merous under  the  microscope.  The  temperature  remains  elevated  or  may  be 
remittent.  After  two  or  three  weeks  the  symptoms  gradually  subside,  the 
stools  become  fewer  in  number,  and  the  faecal  character  returns. 

In  other  instances  the  severe  involvement  of  the  intestines  seems  evident 
within  a  few  hours  of  the  onset,  with  abdominal  pain,  vomiting,  and  fever. 
Blood  and  pus  may  be  present  in  nearly  every  stool.  Tenesmus  is  frequent 
and  prolapsus  ani  is  not  uncommon.  In  severe  attacks  the  prostration  is 
marked,  the  tongue  is  dry,  the  mouth  covered  with  sordes,  and  death  may 
ensue  in  a  few  days  from  profound  sepsis,  or,  if  the  acute  stage  is  survived, 
the  patient  may  continue  desperately  ill  for  weeks,  gradually  recover,  or  die 
from  asthenia. 

Hemorrhage  of  large  amounts  of  blood  is  extremely  rare.  The  appear- 
ance of  bright  red  stains  on  the  napkin  indicates,  usually,  ulceration  of  the 
lower  bowel  or  rectum.  When  the  blood  is  dark  brown  the  lesion  is  in  the 


528  DISEASES    OP    THE   DIGESTIVE    SYSTEM 

ileum  or  near  the  valve.  The  extent  of  the  ulceration  can  not  be  accurately 
determined  by  the  quantity  of  the  blood  passed. 

Membranous-colitis  is  usually  only  to  be  distinguished  by  the  discovery 
of  the  membrane  in  the  rectum  through  a  speculum  or  in  prolapsus,  or  by 
the  passage  of  a  fragment  of  the  membrane  in  the  stools. 

Inflammation  of  the  colon  often  occurs  in  marantic  infants.  It  may  con- 
sist of  a  catarrhal  or  follicular  inflammation  of  the  lower  bowel  without  de- 
structive lesion,  and  is  frequently  a  terminal  infection. 

Ileo-colitis  may  become  chronic  and  persist  for  months.  The  signs  of 
active  inflammation  subside;  there  is  little  pain  or  fever,  but  more  or  less 
mucus  remains  in  the  stools.  The  general  condition  of  the  child  suffers. 
There  is  a  continuous  loss  in  weight;  the  skin  is  dry  and  hangs  in  folds; 
nervous  symptoms  are  always  present.  There  may  be  stiffness  and  contrac- 
tion of  the  extremities,  with  opisthotonos.  The  progress  of  the  disease  is 
irregular,  marked  by  short  periods  of  improvement.  Death  is  often  due  to  a 
relapse,  to  asthenia,  or  to  broncho-pneumonia.  In  many  of  these  cases, 
both  acute  and  chronic,  the  dysentery  bacilli  have  been  found  in  association 
with  other  organisms. 

Prevention. — Unquestionably,  most  of  the  intestinal  disorders  of  children 
can  be  prevented.  In  many  of  our  large  cities  the  mortality  from  the  sum- 
mer diarrhoeas  has  been  greatly  reduced  by  prophylactic  measures. 

The  infant  should  have  abundance  of  air-space  in  the  home,  with  plenty 
of  sunlight  and  fresh  air.  In  hot  weather  it  may  be  well  for  him  to  sleep 
out  of  doors,  day  and  night.  His  clothing  must  not  be  too  heavy  in  midsum- 
mer; often  only  a  binder  and  thin  dress.  This  clothing  should  be  altered 
with  every  change  of  the  temperature.  The  greatest  cleanliness  should  sur- 
round the  life  of  the  baby,  and  the  nursing-bottles  and  nipples  are  to  be 
boiled  each  day  and  kept  scrupulously  clean.  Breast-feeding  is  continued 
whenever  possible. 

With  bottle-babies,  in  warm  weather,  the  diet  should  be  reduced  in 
strength — i.  e.,  weaker  milk  mixtures  used  and  more  water  given.  In  all 
crowded  communities  the  milk  should  be  sterilized  or  pasteurized  during  the 
summer  months,  and  all  the  water  given  the  baby,  either  with  or  between 
the  nourishment,  boiled.  It  is  better  that  a  child  should  be  in  the  country 
during  the  hot  weather,  but  when  this  is  impossible  the  various  parks  in  our 
large  cities  afford  much  relief. 

Treatment. — HYGIENIC  MANAGEMENT. — Even  after  the  illness  has  begun, 
much  can  be  done  by  hygienic  measures  to  diminish  the  severity.  Change  of 
air  to  seashore  or  mountain  is  often  followed  by  a  marked  improvement  in 
the  child's  condition.  The  patient  must  not  be  too  warmly  clad.  The  tem- 
perature may  be  lowered  and  nervous  symptoms  allayed  by  hydrotherapy. 
Baths,  warm  and  cool,  are  helpful.  Colon  irrigations  serve  the  double  pur- 
pose of  flushing  the  bowel  and  stimulating  the  nervous  system.  They  should 
be  given  cool  when  there  is  much  fever. 

MEDICINAL. — In  all  cases  of  diarrhoea  there  are  more  or  less  congestion  of 
the  intestinal  mucosa,  hypersecretion  of  mucus,  and  increased  peristalsis  due 
in  part  to  the  irritant  action  of  improper  food.  In  certain  forms  toxic  symp- 
toms from  the  absorption  of  poisons  from  the  intestinal  tract  are  early  no- 
ticed. In  other  instances  inflammatory  lesions  in  the  wall  of  the  bowel  are 


DIARRHCEAL    DISEASES    IN    CHILDREN  529 

present.  The  keynote,  then,  of  the  treatment  is  promptness.  Nature's'  ef- 
fort to  remove  the  disturbing  cause  should  be  assisted,  not  checked,  and  care 
must  be  taken  to  introduce  food  that  will  afford  the  least  pabulum  for  the 
disturbing  bacteria. 

Castor  oil  and  calomel  are  to  be  preferred  as  purgatives,  especially  for 
infants.  A  drachm  (4  c.  c/)  of  the  former,  repeated,  if  necessary,  will  usu- 
ally sweep  the  intestinal  tract  and  relieve  the  irritation.  Where  there  is 
much  nausea  or  intestinal  fermentation,  calomel  is  indicated.  It  may  be 
given  in  divided  doses  at  short  intervals  until  one  or  two  grains  (0.065  or 
0.13  gm.)  have  been  taken,  or  until  the  characteristic  green  stools  appear. 
Very  early  in  the  attack,  if  nausea  is  a  marked  symptom,  nothing  relieves  so 
quickly  as  gastric  lavage  with  warm  water,  or  a  weak  soda  solution  when  there 
is  much  acidity.  In  older  children  a  large  draught  of  boiled  water  may  be 
substituted.  In  many  cases  irrigation  of  the  lower  bowel  with  large  quanti- 
ties of  salt  solution  flushes  the  colon,  removing  the  irritating  material,  and 
diminishes  the  absorption  of  toxins.  It  also  reduces  the  temperature  and 
allays  nervous  symptoms.  The  irrigating  fluid  should  be  cool  when  there  is 
much  fever.  The  infant  is  placed  in  the  dorsal  position  or  turned  a  little  to 
the  left,  with  hips  elevated,  and  the  fluid  from  a  fountain  syringe,  about 
three  feet  above  the  patient,  is  allowed  to  flow  into  the  rectum  through  a 
large  soft  rubber  catheter.  Usually  about  a  pint  can  be  retained  before  ex- 
pulsion. If  desired,  the  catheter  can  be  gently  pushed  into  the  bowel  as  it 
becomes  distended  with  fluid.  Two  or  three  quarts  should  be  used  at  one 
irrigation,  which  may  be  repeated  several  times  in  twenty-four  hours  if  it  is 
beneficial. 

Where  there  is  ulceration  of  the  lower  bowel  various  astringents,  such  as 
alum,  witch  hazel  (one  or  two  teaspoonfuls  to  one  quart),  silver  nitrate, 
1-4,000,  or  a  weak  solution  of  permanganate  of  potassium,  may  be  used  as 
the  irrigating  fluid. 

When  there  is  much  loss  of  fluid  from  the  body  or  when  toxic  symptoms 
are  marked  infusion  of  normal  salt  solution  under  the  skin  may  be  tried. 
One  to  three  hundred  c.  c.  of  the  solution  can  be  readily  introduced.  This 
procedure  is  not  so  permanently  helpful  as  it  was  thought  to  be  some  years 
ago.  There  is  rarely  any  necessity  to  transfuse. 

Of  the  many  drugs  vaunted  as  intestinal  astringents  and  antiseptics,  bis- 
muth, either  as  subgallate  or  subnitrate,  has  proven  most  serviceable.  It 
should  not  be  given  until  the  disturbing  material  has  been  removed  and  the 
temperature  is  falling;  then  it  should  be  administered  in  large  doses,  5  to  10 
grains  (0.3  to  0.6  gm.)  every  hour,  until  there  is  discoloration  of  the  stools. 
In  some  cases  this  may  be  hastened  by  lac  sulphur  in  grain  doses.  Opium 
should  be  very  sparingly  used,  and  then  only  for  a  specific  purpose,  to  check 
excessive  peristalsis,  violent  colic,  or  very  numerous  passages.  It  may  be 
given  to  an  infant  as  Dover's  powder,  %-l  grain  (0.016  to  0.065  gm.)  ;  or 
paregoric,  5-10  minims  (0.3  to  0.6  c.  c.)  every  four  hours;  or  morphia, 
hypodermically,  1/200-1/50  grain  (0.00032  to  0.0013  gm.),  when  prompt 
action  is  desired.  Occasionally  it  is  well  to  combine  it  with  atropia,  1/1,000- 
1/250  grain.  The  bowels  should  not  be  locked  when  the  stools  are  foul  or 
the  temperature  is  high. 

In  all  cases  where  there  is  prostration  stimulants  are  indicated.    Alcohol, 


530  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

such  as  brandy  or  whisky,  %  to  1  ounce  in  twenty-four  hours  in  frequent 
doses,  diluted  six  to  ten  times  with  water,  or,  where  there  is  much  nausea, 
champagne  with  cracked  ice,  is  most  helpful.  Strychnine,  1/200-1/100 
grain  (0.0003  to  0.0006  gm.),  or  digitalin  in  similar  doses,  may  be  indicated. 
Camphor  is  also  an  excellent  stimulant. 

SERUM  THERAPY. — Thus  far  the  results  of  serum  therapy  have  been  dis- 
appointing. Of  83  cases  collected  during  the  summer  of  1903  by  the  Bocke- 
feller  Institute,  there  were  no  cures  which  could  be  certainly  ascribed  to  the 
serum,  nor  was  the  mortality,  as  compared  with  previous  years,  appreciably 
lowered  by  serum  prepared  from  either  the  so-called  acid  or  alkaline  type  of 
organism.  In  nearly  all  instances,  however,  in  which  the  serum  was  given 
several  days  had  elapsed  after  the  onset  of  the  illness.  It  was  only  in  the 
very  early  cases  that  any  improvement  at  all  was  noticed.  It  may  be  that 
an  earlier  trial  will  be  followed  by  better  results. 

Certainly  the  marked  reduction  in  the  mortality  in  adult  dysentery  in 
Japan,  reported  by  Shiga,  should  encourage  the  further  trial  of  this  treat- 
ment in  the  epidemic  diarrhoea,  as  no  ill  effects  whatever  have  been  ascribed 
to  its  use.  It  is  given  in  10-40  c.  c.  doses,  hypodermically. 

DIET. — The  dietetic  management  is  of  the  utmost  importance.  In  acute 
cases  with  fever  the  milk,  whether  breast  or  cow's  milk,  and  all  its  modifica- 
tions, must  be  stopped  at  once.  It  is  best  to  give  the  infant  nothing  but 
water  for  several  hours,  it  may  be  for  two  or  three  days,  or  until  the  acute 
symptoms  subside ;  a  cereal  water  may  then  be  substituted,  preferably  dextrin- 
ized,  to  which  may  be  added  egg  albumen,  broth,  or  beef  juice.  Preparations 
of  broth  and  beef  juice,  and  occasionally  a  weak  tea,  may  be  given.  The 
time  at  which  it  is  safe  to  return  to  a  milk  diet  varies  with  each  case,  and 
no  definite  rules  can  be  laid  down.  It  is  usually  better  to  defer  milk  until 
the  temperature  is  nearly  normal. 

If  the  stools  are  offensive  from  proteid  decomposition,  a  diet  consisting 
largely  of  carbohydrates — i.  e.,  barley  water — is  indicated;  whereas  proteid 
diet,  such  as  beef  juice  and  egg  albumen,  is  more' helpful  when  the  stools 
are  strongly  acid. 

Experience  has  shown  that  the  ingredient  in  the  milk  that  is  not  well 
borne  is  the  fat ;  hence  skimmed  milk,  diluted  or  partially  digested,  can  often 
be  safely  given  before  diluted  whole  milk.  Whey  is  often  helpful.  In  Ger- 
many buttermilk  has  been  widely  used  in  convalescence  from  intestinal  dis- 
turbances. The  various  proprietary  foods,  or  condensed  milk  mixed  with 
water,  although  not  to  be  given  over  long  periods,  may  be  found  serviceable 
in  the  gradual  return  of  the  child  to  a  normal  diet. 

In  children  from  three  *to  seven  years  of  age  these  acute  derangements  are 
rarely  serious,  and  usually  respond  promptly  after  purgation  and  restricted 
diet,  consisting  largely  of  boiled  milk. 

It  must  be  borne  in  mind  that  injudicious  treatment,  either  in  diet,  or 
medication,  may  interrupt  what  otherwise  would  be  a  prompt  recovery  and 
bring  on  the  most  serious  intestinal  lesions.  The  chronic  cases,  both  in  in- 
fants and  older  children,  especially  those  with  ileo-colitis  and  ulceration, 
present  unusual  difficulties.  Each  case  must  be  studied  by  itself.  Food 
which  is  digested  in  the  upper  portion  of  the  intestinal  tract  is  preferable. 
Milk,  properly  modified  with  cereal  water  or  predigested,  if  intelligently  pre- 


APPENDICITIS  531 

scribed,  offers  the  best  chance  of  success.  The  so-called  percentage  system  of 
milk  modification,  which  enables  the  physician  to  alter  at  will  the  propor- 
tion of  fat  or  carbohydrate  present  in  the  milk  mixture,  is  of  great  service  in 
feeding  these  long-standing  cases. 

Care  must  be  taken  not  to  over-feed,  although  occasionally,  when  there  is 
persistent  anorexia,  gavage  may  be  necessary.  This  is  best  accomplished 
through  a  nasal  tube.  Some  infants  will  retain  food  given  through  a  catheter 
when  they  will  vomit  the  same  mixture  taken  from  a  'bottle.  Beef  juice  or 
one  of  the  beef-peptone  preparations  is  frequently  useful.  They  should 
always  be  given  with  considerable  fluid.  In  a  large  majority  of  instances 
ulceration  is  confined  to  the  large  intestine,  and  can  be  reached  by  local 
treatment.  Irrigations  which  flush  the  injured  surface  are  of  service.  They 
should  be  discontinued  if  much  exhaustion  follows,  but  this  is  rare. 

No  very  definite  results  have  followed  the  various  astringent  preparations 
recommended.  Probably  warm  salt  or  weak  soda  solutions  are  as  useful. 
Silver  nitrate  is  stimulating  and  healing  where  the  ulcerations  are  in  the 
rectum.  In  great  local  irritation  and  tenesmus,  enemata  (2  ounces,  60  c.  c.) 
of  flaxseed  or  starch,  with  2  to  5  drops  (0.12  to  0.3  c.  c.)  of  laudanum,  are 
soothing  and  beneficial. 

TREATMENT  OF  CHOLEEA  INFASTTUM. — In  cholera  infantum  serious 
symptoms  may  occur  with  great  rapidity,  and  here  the  incessant  vomiting 
and  frequent  purging  render  the  administration  of  remedies  extremely  diffi- 
cult. Irrigation  of  the  stomach  and  large  bowel  is  of  great  service,  and  when 
the  fever  is  high  ice-water  injections  may  be  used,  or  a  graduated  bath.  As 
in  the  acute  choleraic  diarrhoea  of  adults,  morphia  hypodermically  is  the 
remedy  which  gives  greatest  relief,  and  in  the  conditions  of  extreme  vomiting 
and  purging,  with  restlessness  and  collapse  symptoms,  this  drug  alone  com- 
mands the  situation.  A  child  of  one  year  may  be  given  from  1/100  to  1/80 
of  a  grain  (0.00065  to  0.0008  gm.)  to  be  repeated  in  an  hour,  and  again  if 
not  better. 

In  all  cases  of  diarrhoea  convalescence  requires  very  careful  management. 
An  infant  which  has  suffered  from  a  severe  attack  should  be  especially 
watched  throughout  the  remainder  of  the  hot  weather.  During  this  time  it 
is  rarely  safe  to  return  to  a  full  diet. 


in.    APPENDICITIS 

Inflammation  of  the  vermiform  appendix  is  the  most  important  of  acute 
intestinal  disorders.  Formerly  the  "iliac  phlegmon"  was  thought  to  be  due 
to  disease  of  the  csecum— typhlitis— or  of  the  peritoneum  covering  it— peri- 
typhlitis  ;  but  we  now  know  that  with  rare  exceptions  the  caecum  itself  is  not 
affected,  and  even  the  condition  formerly  described  as  stercoral  typhlitis  is  in 
reality  appendicitis.  The  contribution  of  Fitz  in  1886  served  to  put  the 
whole  question  on  a  rational  basis.  For  historical  and  special  details  the 
reader  is  referred  to  the  monograph  of  Kelly  and  Hurdon. 

Etiology. The  exciting  causes  of  appendicitis  are  not  always  evident. 

An  infection  is  the  essential  factor.  The  lumen  of  the  appendix  forms  a 
sort  of  test-tube,  in  which  the  fasces  lodge  and  are  with  difficulty  discharged, 


532  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

so  that  the  mucosa  is  liable  to  injury  from  retention  of  the  secretions  or  from 
the  presence  of  inspissated  faeces  or  occasionally  foreign  bodies.  In  some  in- 
stances the  appendicitis  is  a  local  expression  of  a  general  infection.  The 
causes  of  the  undoubted  increase  of  the  disease  are  not  known;  some  have 
attributed  it  to  the  prevalence  of  influenza.  By  others  the  poison  of 
rheumatic  fever  is  believed  to  be  a  cause,  and  just  as  it  may  excite  tonsil- 
litis, so  it  may  cause  inflammation  of  the  lymphatic  tissues  of  the  appendix. 
It  is  remarkable,  too,  that  there  may  be  two  or  three  cases  of  appendicitis  at 
the  same  time  in  one  family.  The  acute  catarrhal  form  may  be  associated 
with  pneumonia  or  typhoid  fever  or  any  of  the  acute  infections.  Direct  in- 
jury, as  in  straining  and  heavy  lifting,  is  an  occasional  exciting  cause. 

The  BACTERIOLOGY  of  the  disease  is  most  varied.  The  Bacillus  coli  is 
present  in  a  large  number  of  cases,  and  the  pyogenic  organisms,  particularly 
the  Streptococcus  pyogenes.  -  The  disease  may  be  produced  experimentally  in 
rabbits  by  the  intravenous  injection  of  pneumococci  and  other  organisms; 
Poynton  and  Paine  have  caused  it  with  the  organism  isolated  from  rheu- 
matic cases. 

AGE. — Appendicitis  is  a  disease  of  young  persons,  50  per  cent,  of  the  cases 
occurring  before  the  twentieth  year.  It  has  been  met  with  as  early  as  the 
seventh  week,  but  it  is  rarely  seen  prior  to  the  fifth  year.  Of  1,223  cases  at 
the  Johns  Hopkins  Hospital  only  9  cases  were  under  5  years,  59  in  chil- 
dren under  10,  140  between  11  and  15,  199  between  16  and  20,  and  255 
between  21  and  25  (Churchman). 

SEX. — It  is  about  equally  common  in  males  and  in  females. 

OCCUPATION. — Persons  whose  work  necessitates  the  lifting  of  heavy 
weights  seem  more  prone  to  the  disease.  Trauma  plays  a  very  definite  role, 
and  in  a  number  of  cases  the  symptoms  have  followed  very  closely  a  fall  or  a 
blow. 

Indiscretions  in  diet  are  very  prone  to  bring  on  an  attack,  particularly  in 
the  recurring  form  of  the  disease,  in  which  pain  in  the  appendix  region  not 
infrequently  follows  the  eating  of  indigestible  articles  of  food. 

Varieties. — McCarty  from  a  study  of  5,000  appendices  removed  at  the 
Mayo  clinic  makes  the  following  classification: 

(a)  APPENDICITIS  CATARRHALIS  ACUTA,  a  condition  in  which  the  muco&a 
is  infiltrated  with  leucocytes  and  congested  with  inflammatory  reaction  in  the 
lymph  follicles  and  lymphatic  tissues  of  the  submucosa. 

(6)  APPENDICITIS  CATARRITALIS  CHRONICA,  following  repeated  mild  or 
severe  acute  catarrh,  marked  by  increase  of  scar  tissue,  and  distortion  of  the 
normal  regularity  of  the  structure.  Blood  pigment  is  often  present. 

(c)  APPENDICITIS  PURULENTA  NECROTICA,  an  advanced  stage  of  the  acute 
catarrhal  condition,  plus  the  formation  of  intramural  abscesses,  necrosis,  and 
perforation. 

(d)  PERI-APPENDICITIS  ACUTA,  an  extension  to  the  peritoneum  of  the 
conditions  just  described. 

(e)  OBLITERATION,  a  condition  of  the  lumen,  the  result  of  destruction  of 
the  mucosa  and  the  formation  of  scar  tissue,  occurring  in  about  24  per  cent, 
of  all  cases,  and  an  inflammatory,  not  an  involutionary,  process. 

There  are  cases,  too,  in  which  the  appendix  becomes  sphacelated  en  masse, 
and  may  slough  off. 


APPENDICITIS  533 

Faecal  Concretions.— The  lumen  of  the  appendix  may  contain  a  mould  of 
faces,  which  can  readily  be  squeezed  out.  Even  while  soft  the  contents  of  the 
tube  may  be  moulded  in  two  or  three  sections  with  rounded  ends.  Concretions 
— enteroliths,  coproliths — are  also  common.  Of  700  cases  of  foreign  bodies 
there  were  45  per  cent,  of  facal  concretions  (J.  F.  Mitchell).  The  entero-- 
liths  often  resemble  date  stones  in  shape.  The  importance  of  these  concre- 
tions is  shown  by  the  great  frequency  with  which  they  are  found  in  all  acute 
inflammations  of  the  appendix. 

Foreign  Bodies.— Of  1,400  cases  of  appendicitis  collected  by  J.  F.  Mitchell 
these  were  present  in  7  per  cent.;  in  28  cases  pins  were  found.  It  is  well  to 
bear  in  mind  that  some  of  the  concretions  bear  a  very  striking  resemblance 
to  cherry  and  date  stones. 

Symptoms. — In  a  large  proportion  of  all  cases  of  acute  appendicitis  the 
following  symptoms  are  present :  (a)  Sudden  pain  in  the  abdomen,  usually 
referred  to  the  right  iliac  fossa;  (&)  fever,  often  of  moderate  grade;  (c) 
gastro-intestinal  disturbance — nausea,  vomiting,  and  frequently  constipation; 
(d)  tenderness  or  pain  on  pressure  in  the  appendix  region. 

PAIN. — A  sudden,  violent  pain  in  the  abdomen  is,  according  to  Fitz,  the 
most  constant,  first,  decided  symptom  of  perforating  inflammation  of  the  ap- 
pendix, and  occurred  in  84  per  cent,  of  the  cases  analyzed  by  him.  In  fully 
half  of  the  cases  it  is  localized  in  the  right  iliac  fossa,  but  it  may  be  central, 
diffuse,  but  usually  in  the  right  half  of  the  abdomen.  Even  in  the  cases  in 
which  the  pain  is  at  first  not  in  the  appendix  region  it  is  usually  felt  here 
within  thirty-six  or  forty-eight  hours.  It  may  extend  toward  the  perineum 
or  testicle.  It  is  sometimes  very  sharp  and  colic-like,  and  cases  have  been 
mistaken  for  nephritic  or  for  biliary  colic.  Some  patients  speak  of  it  as  a 
sharp,  intense  pain — serous-membrane  pain;  others  as  a  dull  ache — connec- 
tive-tissue pain.  While  a  very  valuable  symptom,  pain  is  at  the  same  time 
one  of  the  most  misleading.  Some  of  the  forms  of  recurring  pain  in  the 
appendix  region  Talamon  has  called  appendicular  colic.  The  condition  is 
believed  to  be  due  to  partial  occlusion  of  the  lumen,  leading  to  violent  and 
irregular  peristaltic  action  of  the  circular  and  longitudinal  muscles  in  the 
expulsion  of  the  mucus. 

FEVER. — Fever  is  always  present  in  the  early  stage,  even  in  the  mildest 
forms,  and  is  a  most  important  feature.  J.  B.  Murphy  states  that  he  would 
not  operate  on  a  case  in  which  he  was  confident  that  no  fever  had  been  present 
in  the  first  thirty-six  hours  of  the  disease.  An  initial  chill  is  very  rare.  The 
fever  may  be  moderate,  from  100°  to  102°;  sometimes  in  children  at  the 
very  outset  the  thermometer  may  register  above  103.5°.  The  thermometer 
is  one  of  the  most  trustworthy  guides  in  the  diagnosis  of  acute  appendicitis. 
Appendicular  colic  of  great  severity  may  occur  without  fever.  When  a 
localized  abscess  has  formed,  and  in  some  very  virulent  cases  of  general 
peritonitis,  the  temperature  may  be  normal,  but  at  this  stage  there  are  other 
symptoms  which  indicate  the  gravity  of  the  situation.  The  pulse  is  quick- 
ened in  proportion  to  the  fever. 

GASTRO-INTESTINAL  DISTURBANCE. — The  tongue  is  usually  furred  and 
moist,  seldom  dry.  Nausea  and  vomiting  are  symptoms  which  may  be  absent, 
but  which  are  commonly  present  in  the  acute  perforative  cases.  The  vomit- 
ing rarely  persists  beyond  the  second  day  in  favorable  cases.  Constipation 


534 

is  the  rule,  but  the  attack  may  set  in  with  diarrhoea,  particularly  in  chil- 
dren. 

LOCAL  SIGNS. — Inspection  of  the  abdomen  is  at  first  negative;  there  is 
no  distention,  and  the  iliac  fossae  look  alike.  On  palpation  there  are  usually 
from  the  outset  two  important  signs — namely,  great  tension  of  the  right  rec- 
tus  muscle,  and  tenderness  or  actual  pain  on  deep  pressure.  The  muscular 
rigidity  may  be  so  great  that  a  satisfactory  examination  can  not  be  made  with- 
out an  anaesthetic.  McBurney  has  called  attention  to  the  value  of  a  localized 
point  of  tenderness  on  deep  pressure,  which  is  situated  at  the  intersection  of 
a  line  drawn  from  the  navel  to  the  anterior-superior  spine  of  the  ilium, 
with  a  second,  vertically  placed,  corresponding  to  the  outer  edge  of  the  right 
rectus  muscle.  Firm,  deep,  continuous  pressure  with  one  finger  at  this  spot 
causes  pain,  often  of  the  most  exquisite  character.  In  addition  to  the  ten- 
derness, rigidity,  and  actual  pain  on  deep  pressure,  there  is  to  be  felt,  in  a 
majority  of  the  cases,  an  induration  or  swelling.  In  some  cases  this  is  a 
boggy,  ill-defined  mass  in  the  situation  of  the  caecum;  more  commonly  the 
swelling  is  circumscribed  and  definite,  situated  in  the  iliac  fossa,  two  or  three 
fingers'  breadth  above  Poupart's  ligament.  Some  have  been  able  to  feel  and 
roll  beneath  the  fingers  the  thickened  appendix.  The  later  the  case  comes 
under  observation  the  greater  the  probability  of  the  existence  of  a  well- 
marked  tumor  mass.  It  is  not  to  be  forgotten  that  there  may  be  neither 
tumor  mass  nor  induration  to  be  felt  in  some  of  the  most  intensely  virulent 
cases  of  perforative  appendicitis.  The  pain  may  be  mistaken  for  that  of 
hip  joint  disease. 

In  addition  may  be  mentioned  great  irritability  of  the  bladder,  which 
may  be  a  very  early  symptom.  The  urine  is  scanty  and  often  contains  al- 
bumin and  indican.  The  attitude  is  somewhat  suggestive,  the  decubitus 
is  dorsal,  and  the  right  leg  is  semi-flexed.  Examination  per  rectum  in  the 
early  stages  rarely  gives  any  information  of  value.  The  symptoms  may  be 
entirely  pelvic  when  the  appendix  dips  over  the  brim  and  the  inflamed  area 
is  in  direct  contact  with  the  uterine  adnexa. 

LEUCOCYTOSIS. — The  blood  picture  is  of  value  equal  to  the  pulse  and  tem- 
perature. As  a  rule,  in  acute  attacks  there  is  a  leucocytosis  of  12,000  to 
15,000,  chiefly  of  the  polynuclears.  In  mild  catarrhal  cases  there  may  be  no 
increase.  Usually  the  degree  is  an  expression  of  the  peritoneal  irritation.  A 
low  leucocytosis  or  a  leucopenia  with  increase  in  the  mononuclear  neutro- 
philes,  what  is  called  Arnette's  blood  picture,  is  an  indication  of  a  virulent 
infection. 

Albuminuria  is  common.  Sometimes  there  is  an  acute  nephritis,  and 
Dieulafoy  has  described  an  acute  toxic  form.  He  thinks  that  the  kidneys 
are  not  infrequently  damaged  in  the  disease. 

There  are  three  possibilities  in  any  case:  (1)  Gradual  recovery,  (2)  the 
formation  of  a  local  abscess,  and  (3)  general  peritonitis. 

RECOVERY  is  the  rule  in  the  mild  catarrhal  cases.  The  pain  lessens  at 
the  end  of  the  second  or  third  day,  the  temperature  falls,  the  tongue  be- 
comes cleaner,  the  vomiting  ceases,  the  local  tenderness  is  less  marked,  and 
the  bowels  are  moved.  By  the  end  of  a  week  the  acute  symptoms  have  sub- 
sided. So  liable  is  the  attack  to  recur  that  relapsing  appendicitis  is  spoken  of. 

LOCAL  ABSCESS  FORMATION. — As  a  result  of  ulceration  and  perforation. 


APPENDICITIS  535 

sometimes  following  the  necrosis,  by  the  end  of  the  fourth  or  fifth  day  there 
is  an  extensive  area  of  induration  in  the  right  iliac  fossa,  with  great  tender- 
ness, and  operations  have  shown  that  even  at  this  very  early  date  an  abscess 
cavity  may  have  formed.  Though  'as  a  rule  the  fever  becomes  aggravated 
with  the  onset  of  suppuration,  this  is  not  always  the  case.  The  two  most 
important  elements  in  the  diagnosis  of  abscess  formation  are  the  gradual 
increase  of  the  local  tumor  and  the  aggravation  of  the  general  symptoms. 
Nowadays,  when  operation  is  so  frequent,  we  have  opportunities  of  seeing  the 
abscess  in  various  stages  of  development.  Quite  early  the  pus  may  lie  between 
the  cascum  and  the  coils  of  the  ileum,  with  the  general  peritoneum  shut  off 
by  fibrin,  or  there  is  a  sero-fibrinous  exudate  with  a  slight  amount  of  pus 
between  the  lower  coils  of  the  ileum.  The  abscess  cavity  may  be  small  and 
lie  on  the  psoas  muscle,  or  at  the  edge  of  the  promontory  of  the  sacrum,  and 
never  reach  a  palpable  size.  The  sac,  when  larger,  may  be  roofed  in  by  the 
small  bowel  and  present  irregular  processes  and  pockets  leading  in  different 
directions.  In  larger  collections  in  the  iliac  fossa  the  roof  is  generally  formed 
by  the  abdominal  wall.  Some  of  the  most  important  of  the  localized  abscesses 
are  those  which  are  situated  entirely  within  the  pelvis.  The  various  directions 
and  positions  into  which  the  abscess  may  pass  or  perforate  have  already  been 
referred  to  under  morbid  anatomy,  but  it  may  be  here  mentioned  again  that, 
left  alone,  it  may  discharge  externally,  or  burrow  in  various  directions,  or  be 
emptied  through  the  rectum,  vagina,  or  bladder.  Death  may  be  caused  by 
septicaemia,  by  perforation  into  an  artery  or  vein,  or  by  pylephlebitis. 

GENERAL  PERITONITIS. — This  may  be  caused  by  direct  perforation  of  the 
appendix  and  general  infection  of  the  peritoneum  before  any  delimiting  in- 
flammation is  excited.  In  a  second  group  of  cases  there  has  been  an  attempt 
at  localizing  the  infective  process,  but  it  fails,  and  the  general  peritoneum 
becomes  involved.  In  a  third  group  of  cases  a  localized  focus  of  suppuration 
exists  about  an  inflamed  appendix,  and  from  this  perforation  takes  place. 

Death  in  appendicitis  is  due  usually  to  general  peritonitis. 

The  gravity  of  appendix  disease  lies  in  the  fact  that  from  the  very  onset 
the  peritoneum  may  be  infected;  the  initial  symptoms  of  pain,  with  nausea 
and  vomiting,  fever,  and  local  tenderness,  present  in  all  cases,  may  indicate 
a  wide-spread  infection  of  this  membrane.  The  onset  is  usually  sudden,  the 
pain  diffuse,  not  always  localized  in  the  right  iliac  fossa,  but  it  is  not  so 
much  the  character  as  the  greater  intensity  of  the  symptoms  from  the  out- 
set that  makes  one  suspicious  of  a  general  peritonitis.  Abdominal  disten- 
tion,  diffuse  tenderness,  and  absence  of  abdominal  movements  are  the  most 
trustworthy  local  signs,  but  they  are  not  really  so  trustworthy  as  the  general 
symptoms.  The  initial  nausea  and  vomiting  persist,  the  pulse  becomes  more 
rapid,  the  tongue  is  dry,  the  urine  scanty.  In  very  acute  cases,  by  the  end  of 
twenty-four  hours  the  abdomen  may  be  distended.  By  the  third  and  fourth 
days  the  classical  picture  of  a  general  peritonitis  is  well  established — a  dis- 
tended and  motionless  abdomen,  a  rapid  pulse,  a  dry  tongue,  dorsal  decubitus 
with  the  knees  drawn  up,  and  an  anxious,  pinched,  Hippocratic  facies.  The 
picture  may  be  that  of  septicopyaemia  or  sapragmia;  high  fever,  chills,  sweats, 
without  local  reaction.  These  are  generally  acute,  gangrenous  cases  with 
anomalous  position  of  the  appendix,  behind  the  colon,  or  deep  in  the  pel- 
vis. Even  when  looked  for  carefully  there  may  be  no  local  indications. 


536  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

Sometimes  there  have  been  gastrointestinal  symptoms  for  a  few  days  be- 
fore, to  which  no  attention  has  been  paid  by  the  family.  In  one  case,  seen 
by  the  family  physician  at  2  p.  m.  for  the  first  time,  by  me  at  4.30  p.  m.,  at 
7  p.  m.  by  a  surgeon  who  refused  to  operate,  death  occurred  within  12  hours 
after  the  physician  was  first  called. 

Remote  Effects. — The  remote  effects  of  perforative  appendicitis  are  inter- 
esting. Haemorrhage  may  occur.  In  one  of  my  cases  the  appendix  was  ad- 
herent to  the  promontory  of  the  sacrum,  and  the  abscess  cavity  had  perfo- 
rated in  two  places  into  the  ileum.  Death  resulted  from  profuse  hemorrhage. 
Cases  are  on  record  in  which  the  internal  iliac  artery  or  the  deep  circum- 
flex iliac  artery  has  been  opened.  Suppurative  pylephlebitis  may  result  from 
inflammation  of  the  mesenteric  veins  near  the  perforated  appendix.  The 
appendix  may  perforate  in  a  hernial  sac.  .  Many  instances  of  this  have  been 
recorded. 

After  operation,  thrombosis  of  the  iliac  or  femoral  veins  is  not  uncom- 
mon, and  sudden  death  from  pulmonary  embolism  has  followed.  The  leg 
may  be  permanently  enlarged.  Hernia  may  occur  in  the  wound.  Strangu- 
lation of  the  bowel  is  an  occasional  sequence.  Eecurrence  of  the  symptoms 
after  operation  has  been  noted,  due  in  some  cases  to  incomplete  removal. 

Diagnosis. — Appendicitis  is  by  far  the  most  common  inflammatory  con- 
dition, not  only  in  the  ca3cal  region,  but  in  the  abdomen  generally  in  persons 
under  thirty.  The  surgeons  have  taught  us  that,  almost  without  exception, 
sudden  pain  in  the  right  iliac  fossa,  with  fever  and  localized  tenderness, 
with  or  without  tumor,  means  appendix  disease.  There  are  certain  diseases 
of  the  abdominal  organs  characterized  by  pain  which  are  apt  to  be  confound- 
ed with  appendicitis.  Biliary  colic,  kidney  colic,  and  the  colicky  pains  at 
the  menstrual  period  in  women  have  in  some  cases  to  be  most  carefully  con- 
sidered. 

Diseases  of  the  tubes  and  pelvic  peritonitis  may  simulate  appendicitis 
very  closely,  but  the  history  and  the  local  examination  under  ether  should 
in  most  cases  enable  the  practitioner  to  reach  a  diagnosis.  I  have  seen  sev- 
eral cases  supposed  to  be  recurring  appendicitis  which  proved  to  be  tubo- 
ovarian  disease. 

The  Dietl's  crises  in  floating  kidney  have  been  mistaken  for  appendicitis. 

Acute  haemorrhagic  pancreatitis  may  also  produce  symptoms  very  like 
those  of  appendicitis  with  general  peritonitis.  The  relation  of  typhoid 
fever  and  appendicitis  is  interesting.  The  gastro-intestinal  symptoms,  par- 
ticularly the  pain  and  the  fever,  may  at  the  onset  suggest  appendicitis. 
Operations  have  been  comparatively  frequent.  In  the  second  and  third  weeks 
of  typhoid  fever  perforation  of  the  appendix  may  occur,  and  occasionally  late 
in  the  convalescence  perforation  of  an  unhealed  ulcer  of  the  appendix. 

In  a  great  many  patients  with  chronic  appendicitis  stomach  symptoms 
predominate,  and  an  appendicular  dyspepsia  has  been  recognized  particularly 
by  the  French  writers  and  by  surgeons.  Many  of  the  patients  are  neurotic. 
The  dyspeptic  symptoms  are  irregular,  and  food  rarely  gives  relief,  as  in  ulcer. 
Pain  is  the  prevailing  symptom,  often  caused  by  food,  and  more  abdominal 
than  epigastric,  without  radiation,  and  there  are  frequently  pain  and  tender- 
ness at  McBurney's  point.  Vomiting  is  rare,  but  there  is  usually  much  flatu- 
lency. Without  being  seriously  ill,  the  .patient's  condition  is  constantly 


APPENDICITIS  537 

below  par,  and  he  may  go  the  rounds  of  physicians  for  years.  In  an  analysis 
of  100  cases  of  this  type  at  the  Mayo  clinic  by  Graham  and  Guthrie,  reported 
on  a  year  after  operation,  77  per  cent,  were  cured  by  the  removal  of  the  ap- 
pendix. As  a  majority  of  these  patients  are  neurotic,  it  is  not  easy  to  say 
how  far  the  good  results  have  been  due  directly  to  the  removal  of  the  ap- 
pendix, the  pathological  condition  of  which,  as  reporter!  upon  by  Graham  and 
Guthrie,  did  not  seem  to  differ  much  from  that  which  is  met  with,  according 
to  Aschoff,  in  a  majority  of  individuals  in  the  fourth  decade.  I  can  testify 
that  in  a  certain  number  of  these  patients  the  relief  after  removal  of  the 
appendix  has  not  been  permanent. 

There  is  a  well-marked  appendicular  hypochondriasis.  Through  the  per- 
nicious influence  of  the  daily  press,  appendicitis  has  become  a  sort  of  fad, 
and  the  physician  has  often  to  deal  with  patients  who  have  almost  a  fixed 
idea  that  they  have  the  disease.  The  worst  cases  of  this  class  which  I  have 
seen  have  been  in  members  of  our  profession,  and  I  know  of  at  least  one 
instance  in  which  a  perfectly  normal  appendix  was  removed.  The  question 
really  has  its  ludicrous  side.  A  well-known  physician  in  a  Western  city  hav- 
ing one  night  a  bellyache,  and  feeling  convinced  that  his  appendix  had  per- 
forated, summoned  a  surgeon,  who  quickly  removed  the  supposed  offender ! 

Hysteria  may  of  course  simulate  appendicitis  very .  closely,  and  it  may 
require  a  very  keen  judgment  to  make  a  diagnosis.  Mucous  colitis  with 
enteralgia  in  nervous  women  is  sometimes  mistaken  for  appendicitis. 

Perinephritic  and  pericsecal  abscess  from  perforation  of  ulcer,  either  sim- 
ple or  cancerous,  and  circumscribed  peritonitis  in  this  region  from  other 
causes,  can  rarely  be  differentiated  until  an  exploratory  incision  is  made. 

Chronic  obliterative  appendicitis  can  not  always  be  differentiated  from 
the  perforative  form,  and  in  intensity  of  pain,  severity  of  symptoms,  and,  in 
rare  instances,  even  in  the  production  of  peritonitis,  the  two  may  be  iden- 
tical. 

Briefly  stated,  localized  pain  in  the  right  iliac  fossa,  with  or  without  in- 
duration or  tumor,  the  existence  of  McBurney's  tender  point,  fever,  furred 
tongue,  vomiting,  with  constipation  or  diarrhoea,  indicate  appendicitis.  The 
occurrence  of  general  peritonitis  is  suggested  by  increase  and  diffusion  of  the 
abdominal  pain,  tympanites  (as  a  rule),  marked  aggravation  of  the  constitu- 
tional symptoms,  particularly  elevation  of  fever  and  increased  rapidity  of 
the  pulse.  Obliteration  of  hepatic  dulness  is  rarely  present,  as  the  peri- 
toneum in  these  cases  does  not  often  contain  gas. 

Appendicitis  and  Pregnancy. — The  association  is  not  uncommon.  Of  103 
perforative  or  gangrenous  cases  89  were  operated  upon,  with  36  deaths.  Of 
14  cases  not  operated  upon  all  died.  Of  the  103  cases  80  aborted  before  or 
after  operation.  Of  104  non-perforative  cases  50  were  operated  upon  with 
1  death;  of  the  remaining  54,  4  died;  13  of  these  non-perforative  cases 
aborted  (Babler).  Mild  cases  recover;  in  the  severer  forms  it  is  safer  to 
operate  at  once. 

Prognosis. — There  would  be  no  percentage  of  deaths  from  appendicitis 
if  every  case  commencing  with  acute  pain  and  developing  tenderness  and 
rigidity  of  the  abdomen  and  quickening  of  the  pulse  were  operated  upon  with- 
in twelve  hours  (Rutherford  Morison). 

Treatment, — Gradually  the  profession  has  learned  to  recognize  that  ap- 


538  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

pendicitis  is  a  surgical  disease.  In  hospital  practice  the  cases  should  be  ad- 
mitted directly  to  the  surgical  wards.  Many  lives  are  lost  by  temporizing. 
The  general  practitioner  does  well  to  remember — whether  his  leanings  be 
toward  the  conservative  or  the  radical  methods  of  treatment — that  the  sur- 
geon is  often  called  too  late,  never  too  early. 

There  is  no  medicinal  treatment  of  appendicitis.  There  are  remedies 
which  will  allay  the  pain,  but  there  are  none  capable  in  any  way  of  con- 
trolling the  course  of  the  disease.  Rest  in  bed,  a  light  diet,  measures  directly 
to  allay  the  vomiting — upon  these  all  are  agreed.  The  practice  of  giving 
opium  in  some  form  in  appendicitis  and  peritonitis  is  decreasing,  but  is  still 
too  common.  Surgeons  almost  unanimously  condemn  the  practice,  as  obscur- 
ing the  clinical  picture  and  tending  to  give  a  false  sense  of  security;  and 
since  they  control  the  situation,  we  should  not  give  opium,  and  trust  to  the 
persistent  use  of  ice  locally  to  relieve  the  pain.  General  opinion  among  the 
best  surgeons  is,  I  believe,  opposed  to  the  use  of  saline  purges. 

Operation  is  indicated  in  all  cases  of  acute  inflammatory  trouble  in  the 
caecal  region,  whether  tumor  is  present  or  not,  when  the  general  symptoms 
are  severe,  and  when  at  the  end  of  twelve  hours,  or  even  earlier,  the  features 
of  the  case  point  to  a  progressive  lesion.  The  mortality  from  early  operation 
under  these  circumstances  is  very  slight. 

In  recurring  appendicitis,  when  the  attacks  are  of  such  severity  and  fre- 
quency as  seriously  to  interrupt  the  patient's  occupation,  the  mortality  in  the 
hands  of  capable  operators  is  very  small. 


IV.    INTESTINAL   OBSTRUCTION 

Intestinal  obstruction  may  be  caused  by  strangulation,  intussusception, 
twists  and  knots,  strictures  and  tumors,  by  abnormal  contents,  and  by  par- 
alysis of  the  muscular  coat  of  the  bowel. 

Etiology  and  Pathology. — (a)  STRANGULATION. — This  is  the  most  fre- 
quent cause  of  acute  obstruction,  and  occurred  in  34  per  cent,  of  the  295  cases 
analyzed  by  Fitz,  and  in  35  per  cent,  of  the  1,134  cases  of  Leichtenstern.  Of 
the  101  cases  of  strangulation  in  Fitz's  table,  which  has  the  special  value  of 
having  been  carefully  selected  from  the  literature  since  1880,  the  following 
were  the  causes:  Adhesions,  63;  vitelline  remains,  21;  adherent  appendix,  6; 
mesenteric  and  omental  slits,  6 ;  peritoneal  pouches  and  openings,  3 ;  adherent 
tube,  1 ;  peduncular  tumor,  1.  The  bands  and  adhesions  result,  in  a  majority 
of  cases,  from  former  peritonitis.  A  number  of  instances  have  been  reported 
following  operations  upon  the  pelvic  organs  in  women.  The  strangulation 
may  be  recent  and  due  to  adhesion  of  the  bowel  to  the  abdominal  wound  or 
a  coil  may  be  caught  between  the  pedicle  of  a  tumor  and  the  pelvic  wall. 
Such  cases  are  only  too  common.  Late  occlusion  after  recovery  from  the 
operation  is  due  to  bands  and  adhesions. 

The  vitelline  remains  are  represented  by  Meckel's  Jiverticulum,  which 
forms  a  finger-like  projection  from  the  ileum,  usually  within  eighteen  inches 
of  the  ileo-caxjal  valve.  It  is  a  remnant  of  the  omphalo-mesenteric  duct, 
through  which,  in  the  early  embryo,  the  intestine  communicated  with  the 
^oik-sac.  The  end,  though  commonly  free,  may  be  attached  to  the  abdominal 


INTESTINAL    OBSTEUCTION  539 

wall  near  the  navel,  or  to  the  mesentery,  and  a  ring  is  thus  formed  through, 
which  the  gut  may  pass. 

Seventy  per  cent,  of  the  cases  of  obstruction  from  strangulation  occur 
in  males;  40  per  cent,  of  all  the  cases  occur  between  the  ages  of  fifteen  and 
thirty  years.  In  90  per  cent,  of  the  cases  of  obstruction  from  these  causes 
the  site  of  the  trouble  is  in  the  small  bowel;  the  position  of  the  strangulated 
portion  was  in  the  right  iliac  fossa  in  67  per  cent,  of  the  cases,  and  in  the 
lower  abdomen  in  83  per  cent. 

(&)  INTUSSUSCEPTION. — In  this  condition  one  portion  of  the  intestine 
slips  into  an  adjacent  portion,  forming  an  invagination  or  intussusception. 
The  two  portions  make  a  cylindrical  tumor,  which  varies  in  length  from, 
a  half  inch  to  a  foot  or  more.  The  condition  is  always  a  descending  intus- 
susception, and,  as  the  process  proceeds,  the  middle  and  inner  layers  in- 
crease at  the  expense  of  the  outer  layer.  An  intussusception  consists  of  three 
layers  of  bowel:  the  outermost,  known  as  the  intussuscipiens,  or  receiving 
layer;  a  middle  or  returning  layer;  and  the  innermost  or  entering  layer. 
The  student  can  obtain  a  clear  idea  of  the  arrangement  by  making  the  end 
of  a  glove-finger  pass  into  the  lower  portion.  The  actual  condition  can  be 
very  clearly  studied  in  the  post  mortem  invaginations  which  are  so  common 
in  the  small  bowel  of  children.  In  the  statistics  of  Fitz,  93  of  295  cases  of 
acute  intestinal  obstruction  were  due  to  this  cause.  Of  these,  52  were  in 
males  and  27  in  females.  The  cases  are  most  common  in  early  life,  34  per 
cent,  under  one  year  and  56  per  cent,  under  the  tenth  year.  Of  103  cases 
in  children,  nearly  50  per  cent,  occurred  in  the  fourth,  fifth,  and  sixth 
months  (Wiggin).  No  definite  causes  could  be  assigned  in  42  of  the  cases; 
in  the  others  diarrhoea  or  habitual  constipation  had  existed. 

The  site  of  the  invagination  varies.  We  may  recognize  (1)  an  ileo-ccecal, 
when  the  ileo-cascal  valve  descends  into  the  colon.  There  are  cases  in  which 
this  is  so  extensive  that  the  valve  has  been  felt  per  rectum.  This  form  oc- 
curred in  75  per  cent,  of  the  cases ;  in  89  per  cent,  of  Wiggin's  collected  cases. 
In  the  ileo-colic  the  lower  part  of  the  ileum  parses  through  the  ileo-csecal 
valve.  (2)  The  Heal,  in  which  the  ileum  is  alone  involved.  (3)  The  colic,  in 
which  it  is  confined  to  the  large  intestine.  (4)  Colico-rectal,  in  which  the 
colon  and  rectum  are  involved.  (5)  Intussusception  of  the  appendix  is  rare, 
but  there  are  about  30  cases  on  record,  most  of  them  in  children. 

Irregular  peristalsis  is  the  essential  cause  of  intussusception.  Nothnagel 
found  in  the  localized  peristalsis  caused  by  the  faradic  current  that  it  was 
not  the  descent  of  one  portion  into  the  other,  but  the  drawing  up  of  the 
receiving  layer  by  contraction  of  the  longitudinal  coat.  Invagination  may 
follow  any  limited,  sudden,  and  severe  peristalsis. 

In  the  post  mortem  examination,  in  a  case  of  death  from  intussuscep- 
tion, the  condition  is  very  characteristic.  Peritonitis  may  be  present  or  an 
acute  injection  of  the  serous  membrane.  When  death  occurs  early,  as  it  may 
do  from  shock,  there  is  little  to  be  seen.  The  portion  of  bowel  affected  is 
large  and  thick,  and  forms  an  elongated  tumor  with  a  curved  outline.  The 
parts  are  swollen  and  congested,  owing  to  the  constriction  of  the  mesentery 
between  the  layers.  The  entire  mass  may  be  of  a  deep  livid-red  color.  In 
very  recent  processes  there  is  only  congestion,  and  perhaps  a  thin  layer  of 
lymph,  and  the  intussusception,  can  be  reduced,  but  when  it  has  lasted  for  a 


540  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

few  days,  lymph  is  thrown  out,  the  layers  are  glued  together,  and  the  en- 
tering portion  of  the  gut  can  not  be  withdrawn. 

The  anatomical  condition  accounts  for  the  presence  of  the  tumor,  which 
exists  in  two-thirds  of  all  cases ;  and  the  engorgement,  which  results  from  the 
compression  of  the  mesenteric  vessels,  explains  the  frequent  occurrence  of 
blood  in  the  discharges,  which  has  so  important  a  diagnostic  value.  If  the 
patient  survives,  necrosis  and  sloughing  of  the  invaginated  portion  may  oc- 
cur, and,  if  union  has  taken  place  between  the  inner  and  outer  layers,  the 
calibre  of  the  gut  may  be  restored  and  a  cure  in  this  way  effected.  Many 
cases  of  the  kind  are  on  record.  In  the  Museum  of  the  Medical  Faculty  of 
the  McGill  University  are  17  inches  of  small  intestine,  which  were  passed 
by  a  lad  who  had  symptoms  of  internal  strangulation,  and  who  made  a  com- 
plete recovery. 

(c)  TWISTS,  KNOTS,  AND  TRACTION  KINKS. — Volvulus  or  twist  occurred 
in  42  of  the  295  cases  (Fitz).     Sixty-eight  per  cent,  were  in  males.     It  is 
most  frequent  between  the  ages  of  thirty  and  forty.     In  the  great  majority 
of  all  cases  the  twist  is  axial  and  associated  with  an  unusually  long  mesen- 
tery.    In  50  per  cent,  of  the  cases  it  was  in  the  sigmoid  flexure.     The  next 
most  common  situation  is  about  the  caecum,  which  may  be  twisted  upon  its 
axis  or  bent  upon  itself.    As  a  rule,  in  volvulus  the  loop  of  bowel  is  simply 
twisted  upon  its  long  axis,  and  the  portions  at  the  end  of  the  loop  cross  each 
other  and  so  cause  the  strangulation.    It  occasionally  happens  that  one  por- 
tion of  the  bowel  is  twisted  about  another. 

Traction  kinks  occur  at  three  regions — the  third  portion  of  the  duodenum, 
the  last  part  of  the  ileum,  and  the  sigmoid  flexure.  What  is  known  as  gastro- 
mesenteric  ileus  is  caused  by  compression  of  the  lower  portion  of  the  duo- 
denum by  the  root  of  the  mesentery  with  its  contained  blood-vessels.  The 
condition  has  been  described  under  acute  dilatation  of  the  stomach. 

The  ileum  kink  occurs  within  a  few  inches  of  the  cascum.  This  portion 
has  a  short  tight  mesentery  and  a  large  loose  cascum  sags  over  the  brim  of 
the  pelvis  and  may  cause  a  definite  kink  of  the'  ileum  with  constipation, 
pain  in  the  right  iliac  fossa,  and  symptoms  which  simulate  appendicitis. 

Traction  of  a  very  full  sigmoid  flexure  may,  without  any  special  twist, 
compress  and  obstruct  a  neighboring  coil  of  the  colon. 

(d)  STRICTURES   AND  TUMORS. — These -are  very  much  less   important 
causes  of  acute  obstruction,  as  may  be  judged  by  the  fact  that  there  are  only 
15  instances  out  of  the  295  cases,  in  14  of  which  the  obstruction  occurred 
in  the  large  intestine  (Fitz).     On  the  other  hand,  they  are  common  causes 
of  chronic  obstruction. 

Lipoma  may  occur,  growing  from  the  submucosa,  and  cause  intussuscep- 
tion. In  a  number  of  cases  the  tumor  has  been  passed  per  rectum.  S.  B. 
Ward  has  collected  9  cases. 

The  obstruction  may  result  from:  (1)  Congenital  stricture.  These  are 
exceedingly  rare.  Much  more  commonly  the  condition  is  that  of  complete 
occlusion,  either  forming  the  imperforate  anus  or  the  congenital  defect  by 
which  the  duodenum  is  not  united  to  the  pylorus.  (2)  Simple  cicatricial 
stenosis,  which  results  from  ulceration,  tuberculous  or  syphilitic,  more  rarely 
from  dysentery,  and  most  rarely  of  all  from  typhoid  ulceration.  (3)  New 
growths.  The  malignant  strictures  are  due  chiefly  to  cylindrical  epithelioma, 


'INTESTINAL    OBSTRUCTION  541 

which  forms  an  annular  tumor,  most  commonly  met  with  !n  the  large  bowel.' 
about  the  sigmoid  flexure,  or  the  descending  colon.  Of  benign  growths, 
papillomata,  adenomata,  lipomata,  and  fibromata  occasionally  induce  ob- 
struction. (4)  Compression  and  traction.  Tumors  of  neighboring  organs, 
particularly  of  the  pelvic  viscera,  may  cause  obstruction  by  adhesion  and 
traction.  In  the  healing  of  tuberculous  peritonitis  the  contraction  of  the 
thick  exudate  may  cause  compression  and  narrowing  of  the  coils. 

(e)  ABNORMAL  CONTENTS. — Foreign  bodies,  such  as  fruit  stones,  coins, 
pins,  needles,  or  false  teeth,  are  occasionally  swallowed  accidentally,  or  by 
lunatics  on  purpose.  Round  worms  may  become  rolled  into  a  tangled  mass 
and  cause  obstruction.  In  reality,  however,  the  majority  of  foreign  bodies, 
such  as  coins,  buttons,  and  pins,  swallowed  by  children,  cause  no  inconveni- 
ence whatever,  but  in  a  day  or  two  are  found  in  the  stools.  Occasionally  such 
a  foreign  body  as  a  pin  will  pass  through  the  oesophagus  and  will  be  found 
lodged  in  some  adjacent  organ,  as  in  the  heart  (Peabody),  or  a  barley  ear 
may  reach  the  liver  (Dock). 

Medicines,  such  as  magnesia  or  bismuth,  have  been  known  to  accumulate 
in  the  bowels  and  produce  obstruction,  but  in  the  great  majority  of  the  cases 
the  condition  is  caused  by  fasces,  gall-stones,  or  enteroliths.  Of  44  cases,  in 
23  the  obstruction  was  by  gall-stones,  in  19  by  faeces,  and  in  2  by  enteroliths. 
Obstruction  by  fasces  may  happen  at  any  period  of  life.  As  mentioned  when 
speaking  of  dilatation  of  the  colon,  it  may  occur  in  young  children  and  per- 
sist for  weeks.  •  In  faecal  accumulation  the  large  bowel  may  reach  an  enor- 
mous size  and  the  contents  become  very  hard.  The  retained  masses  may  be 
channeled,  and  small  quantities  of  faecal  matter  are  passed  until  a  mass  too 
large  enters  the  lumen  and  causes  obstruction.  There  may  be  very  few 
symptoms,  as  the  condition  may  be  borne  for  weeks  or  even  for  months. 

Obstruction  by  gall-stones  is  not  very  infrequent,  as  may  be  gathered  from 
the  fact  that  23  cases  were  reported  in  the  literature  in  eight  years.  Eighteen 
of  these  were  in  women  and  5  in  men.  In  six-sevenths  of  the  cases  it  occurred 
about  the  fiftieth  year.  The  obstruction  is  usually  in  the  ileo-caecal  region, 
but  it  may  be  in  the  duodenum.  These  large  solitary  gall-stones  ulcerate 
through  the  gall-bladder,  usually  into  the  small  intestine,  occasionally  into 
the  colon.  In  the  latter  case  they  rarely  cause  obstruction.  Courvoisier  has 
collected  131  cases  in  the  literature. 

Enteroliths  may  be  formed  of  masses  of  hair,  more  commonly  of  the  phos- 
phates of  lime  and  magnesia,  with  a  nucleus  formed  of  a  foreign  body  or  of 
hardened  faeces.  Nearly  every  museum  possesses  specimens  of  this  kind. 
They  are  not  so  common  in  men  as  in  ruminants,  and,  as  indicated  in  Fitz's 
statistics,  are  very  rare  causes  of  obstruction. 

(/)  PARALYTIC  ILEUS. — Without  any  obstruction  in  the  lumen,  in  a 
localized  area  or  in  a  wide  section  of  the  bowel,  the  muscular  walls  may  be 
so  paralyzed  that  no  movement  of  the  contents  occurs,  causing  a  condition 
which  virtually  amounts  to  obstruction.  The  best  illustrations  of  local  par- 
alytic ileus  are  seen  in  the  embolic  and  thrombotic  processes  in  the.mesen- 
teric  arteries,  when  the  corresponding  portions  of  the  intestinal  wall-  are 
in  a  state  of  infarct.  This  is  the  condition  which  occurs  in  the  verminous 
aneurism  in  a  horse,  and  is  associated  with  the  common  intestinal  colic. 
It  is  more  common  in  the  small  than  in  the  large  bowel,  but  I  saw  an  in- 


542  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

stance  of  paralytic  ileus  due  to  localized  involvement  of  about  eight  inches 
of  the  wall  of  the  transverse  colon  without,  so  far  as  one  could  discover,  any 
affection  of  the  blood-vessels,  and  the  symptoms  were  those  of  acute  obstruc- 
tion. 

Following  operations,  particularly  on  the  abdomen,  after  injuries,  fol- 
lowing paracentesis  in  ascites,  in  pneumonia,  pleurisy,  and  occasionally  in 
heart  disease,  a  paralytic  state  of  the  bowel  may  occur,  with  cessation  of 
peristalsis,  distention  of  the  abdomen,  vomiting,  and  other  signs  of  ob- 
struction. There  are  remarkable  cases  of  hysteria  with  symptoms  of  chronic 
obstruction  of  the  bowels  and  faecal  vomiting — the  so-called  ileus  hystericus. 

Symptoms. — (a)  ACUTE  OBSTRUCTION. — Constipation,  pain  in  the  abdo- 
men, and  vomiting  are  the  three  important  symptoms.  Pain  sets  in  early 
and  may  come  on  abruptly  while  the  patient  is  walking,  or,  more  common- 
ly, during  the  performance  of  some  action.  It  is  at  first  colicky  in  charac- 
ter, but  subsequently  it  becomes  continuous  and  very  intense.  Vomiting 
follows  quickly  and  is  a  constant  and  most  distressing  symptom.  At  first 
the  contents  of  the  stomach  are  voided,  and  then  greenish,  bile-stained  ma- 
terial, and  soon,  in  cases  of  acute  and  permanent  obstruction,  the  material 
vomited  is  a  brownish-black  liquid,  with  a  distinctly  faecal  odor.  This  se- 
quence of  gastric,  bilious,  and,  finally,  stercoraceous  vomiting  is  perhaps 
the  most  important  diagnostic  feature  of  acute  obstruction.  The  constipation 
may  be  absolute,  without  the  discharge  of  either  fasces  or  gas.  Very  often 
the  contents  of  the  bowel  below  the  stricture  are  discharged:  Distention  of 
the  abdomen  usually  occurs,  and,  when  the  large  bowel  is  involved,  it  is 
extreme.  On  the  other  hand,  if  the  obstmction  is  .high  up  in  the  small  in- 
testine, there  may  be  very  slight  tympany.  At  first  the  abdomen  is  not 
painful,  but  subsequently  it  may  become  acutely  tender. 

The  constitutional  symptoms  from  the  outset  are  severe.  The  face  is 
pallid  and  anxious,  and  finally  collapse  symptoms  supervene.  The  eyes 
become  sunken,  the  features  pinched,  and  the  skin  is  covered  with  a  cold, 
clammy  sweat.  The  pulse  becomes  rapid  and  feeble.  There  may  be  no 
fever;  the  axillary  temperature  is  often  subnormal.  The  tongue  is  dry  and 
parched  and  the  thirst  is  incessant.  The  urine  is  high-colored,  scanty,  and 
there  may  be  suppression,  particularly  when  the  obstruction  is  high  up  in 
the  bowel.  This  is  probably  due  to  the  constant  vomiting  and  the  small 
amount  of  liquid  which  is  absorbed.  The  case  terminates,  as  a  rule,  in  from 
three  to  six  days.  In  some  instances  the  patient  dies  from  shock  or  sinks 
into  coma.  A  leucocytosis  of  75,000  or  80,000  per  c.  mm.  may  be  present. 

(&)  SYMPTOMS  OF  CHRONIC  OBSTRUCTION. — When  due  to  fsecal  impac- 
tion,  there  is  a  history  of  long-standing  constipation.  There  may  have  been 
discharge  of  mucus,  or,  in  some  instances,  the  faecal  masses  have  been  chan- 
neled, and  so  have  allowed  the  contents  of  the  upper  portion  of  the  bowel  to 
pass  through.  In  elderly  persons  this  is  not  infrequent;  but  examination, 
either  per  rectum  or  externally,  in  the  course  of  the  colon,  will  reveal  the 
presence  of  hard  scybalous  masses.  There  may  be  retention  of  faeces  for 
weeks  without  exciting  serious  symptoms.  In  other  instances  there  are  vom- 
iting, pain  in  the  abdomen,  gradual  distention,  and  finally  the  ejecta  become 
faecal.  The  hardened  masses  may  excite  an  intense  colitis  or  even  peritonitis. 

In  stricture,  whether  cicatricial  or  cancerous,  the  symptoms  of  obstruc- 


INTESTINAL    OBSTRUCTION  543 

tion  are  very  diverse.  Constipation  gradually  comes  on,  is  extremely  vari- 
able, and  it  may  be  months  or  even  years  before  there  is  complete  obstruction. 
There  are  transient  attacks,  in  which  from  some  cause  the  faeces  accumu- 
late above  the  stricture,  the  intestine  becomes  greatly  distended,  and  in  the 
swollen  abdomen  the  coils  can  be  seen  in  active  peristalsis.  In  such  attacks 
there  may  be  vomiting,  but  it  is  very  rarely  of  a  faecal  character.  In  the  ma- 
jority of  these  cases  the  general  health  is  seriously  impaired;  the  patient 
gradually  becomes  anaemic  and  emaciated,  and,  finalty,  in  an  attack  in  which 
the  obstruction  is  complete,  death  occurs  with  all  the  features  of  acute  occlu- 
sion, or  the  case  may  be  prolonged  for  ten  or  twelve  days. 

Diagnosis. — (a)  THE  SITUATION  OF  THE  OBSTRUCTION. — Hernia  must  be 
excluded,  which  is  by  no  means  always  easy,  as  fatal  obstruction  may  occur 
from  the  involvement  of  a  very  limited  portion  of  the  gut  in  the  external 
ring  or  in  the  obturator  foramen.  A  thorough  rectal  and,  in  women,  a 
vaginal  examination  should  be  made,  which  will  give  important  information 
as  to  the  condition  of  the  pelvic  and  rectal  contents,  particularly  in  cases  of 
intussusception,  in  which  the  descending  bowel  can  sometimes  be  felt.  In 
cases  of  obstruction  high  up  the  empty  coils  sink  into  the  pelvis  and  can  there 
be  detected.  Rectal  exploration  with  the  entire  hand  is  of  doubtful  value. 
In  the  inspection  of  the  abdomen  there  are  important  indications,  as  the 
special  prominence  in  certain  regions,  the  occurrence  of  well-defined  masses, 
and  the  presence  of  hypertrophied  coils  in  active  peristalsis.  John  "Wyllie 
has  called  attention  to  the  great  value  in  diagnosis  of  the  "patterns  of  ab- 
dominal tumidity."  In  obstruction  of  the  lower  end  of  the  large  intestine 
not  only  may  the  horseshoe  of  the  colon  stand  out  plainly,  when  the  bowel  is 
in  rigid  spasm,  but  even  the  pouches  of  the  gut  may  be  seen.  When  the  cae- 
cum  or  lower  end  of  the  ileum  is  obstructed  the  tumidity  is  in  the  lower 
central  region,  and  during  spasm  the  coils  of  the  small  bowel  may  stand  out 
prominently,  one  above  the  other,  either  obliquely  or  transversely  placed — 
the  so-called  "ladder  pattern."  In  obstruction  of  the  duodenum  or  jejunum 
there  may  only  be  slight  distention  of  the  upper  part  of  the  abdomen,  asso- 
ciated usually  with  rapid  collapse  and  anuria. 

In  the  ileum  and  caecum  the  distention  is  more  in  the  central  portion  of 
the  abdomen;  the  vomiting  is  distinctly  faecal  and  occurs  early.  In  obstruc- 
tion of  the  colon  tympanites  is  much  more  extensive  and  general.  Tenesmus 
is  more  common,  with  the  passage  of  mucus  and  blood.  The  course  is  not 
so  quick,  the  collapse  does  not  supervene  so  rapidly,  and  the  urinary  secre- 
tion is  not  so  much  reduced. 

In  obstruction  from  stricture  or  tumor  the  situation  can  in  some  cases 
be  accurately  localized,  but  in  others  it  is  very  uncertain.  Digital  examina- 
tion of  the  rectum  should  first  be  made.  The  rectal  tube  may  then  be  passed, 
but  it  is  impossible  to  get  beyond  the  sigmoid  flexure.  In  the  use  of  the  rigid 
tube  there  is  danger  of  perforation  of  the  bowel  in  the  neighborhood  of  a 
stricture.  The  quantity  of  fluid  which  can  be  passed  into  the  large  intestine 
should  be  estimated.  The  capacity  of  the  large  bowel  is  about  six  quarts. 
Wiggin  advises  about  a  pint  and  a  half  from  a  height  of  three  feet  for  an 
infant.  To  thoroughly  irrigate  the  bowel  the  patient  should  be  chloroformed 
and  should  lie  on  the  back  or  on  the  side — best  on  the  back,  with  the  hips 
elevated.  Treves  suggests  that  the  caecal  region  should  be  auscultated  during 


544  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

the  passage  of  the  fluid.  For  diagnostic  purposes  the  rectum  may  he  in- 
flated, either  by  the  bellows  or  by  the  use  of  bicarbonate  of  soda  and  tartaric 
acid.  In  certain  cases  these  measures  give  important  indications  as  to  the 
situation  of  the  obstruction  in  the  large  bowel. 

(&)  NATURE  OF  THE  OBSTRUCTION. — This  is  often  difficult,  not  infre- 
quently impossible,  to  determine.  Strangulation  is  not  common  in  very  early 
life.  In  many  instances  there  have  been  previous  attacks  of  abdominal  pain, 
or  there  are  etiological  factors  which  give  a  clew,  such  as  old  peritonitis  or 
operation  on  the  pelvic  viscera.  Neither  the  onset  nor  the  character  of  the 
pain  gives  us  any  information.  In  rare  instances  nausea  and  vomiting  may 
be  absent.  The  vomiting  usually  becomes  faecal  from  the  third  to  the  fifth 
day.  A  tumor  is  not  common  in  strangulation,  and  was  present  in  only 
one-fifth  of  the  cases.  Fever  is  not  of  diagnostic  value. 

Intussusception  is  an  affection  of  childhood,  and  is  of  all  forms  of  in- 
ternal obstruction  the  one  most  readily  diagnosed.  The  presence  of  tumor, 
bloody  stools,  and  tenesmus  are  the  important  factors.  The  tumor  is  usu- 
ally sausage-shaped  and  felt  in  the  region  6f  the  transverse  colon.  It  existed 
in  66  of  93  cases.  It  became  evident  the  first  day  in  more  than  one-third  of 
the  cases,  on  the  second  day  in  more  than  one-fourth,  and  on  the  third  day 
in  more  than  one-fifth.  Blood  in  the  stools  occurs  in  at  least  three-fifths  of 
the  cases,  either  spontaneously  or  following  the  use  of  an  enema.  The  blood 
may  be  mixed  with  mucus.  Tenesmus  is  present  in  one-third  of  the  cases. 
Faecal  vomiting  is  not  very  common  and  was  present  in  only  12  of  the  93 
instances.  Abdominal  tympany  is  a  symptom  of  slight  importance,  occurring 
in  only  one-third  of  the  cases. 

Volvulus  can  rarely  be  diagnosed.  The  frequency  with  which  it  involves 
the  sigmoid  flexure  is  to  be  borne  in  mind.  The  passage  of  a  flexible  tube 
or  injecting  fluids  might  in  these  cases  give  valuable  indications. 

In  fcecal  obstruction  the  condition  is  usually  clear,  as  the  faeces  can  be 
felt  per  rectum  and  also  in  the  distended  colon.  Faecal  vomiting,  tympany, 
abdominal  pain,  nausea,  and  vomiting  are  late  and  -are  not  so  constant.  In 
obstruction  by  gall-stone  a  few  of  the  cases  gave  a  previous  history  of  gall- 
stone colic.  Jaundice  was  present  in  only  2  of  the  23  cases.  Pain  and 
vomiting,  as  a  rule,  occur  early  and  are  severe,  and  fascal  vomiting  is  pres- 
ent in  two-thirds  of  the  cases.  A  tumor  is  rarely  evident. 

(c)  DIAGNOSIS  FROM  OTHER  CONDITIONS. — Acute  enteritis  with  great  re- 
laxation of  the  intestinal  coils,  vomiting,  and  pain  may  be  mistaken  for 
obstruction.  Of  late  years  many  instances  have  been  reported  in  which  peri- 
tonitis following  disease  of  the  appendix  has  been  mistaken  for  acute  obstruc- 
tion. The  intense  vomiting,  the  general  tympany  and  abdominal  tenderness, 
and,  in  some  instances,  the  suddenness  of  the  onset  are  very  deceptive.  In 
appendix  disease  the  temperature  is  more  frequently  elevated,  the  vomiting 
is  never  faecal,  and  in  many  cases  there  is  a  history  of  previous  attacks  in 
the  caecal  region.  Acute  hsemorrhagic  pancreatitis  may  produce  symptoms 
which  simulate  closely  intestinal  obstruction. 

Treatment — Purgatives  should  not  be  given.  For  the  pain  hypodermic 
injections  of  morphia  are  indicated.  To  allay  the'  distressing  vomiting,  the 
stomach  should  be  washed  out.  Not  only  is  this  directly  beneficial,  but 
Kussmaul  claims  that  the  abdominal  distention  is  relieved,  the  pressure  in 


CONSTIPATION  545 

the  bowel  above  the  seat  of  obstruction  is  lessened,  and  the  violent  peristal- 
sis is  diminished.  It  may  be  practiced  three  or  four  times  a  day,  and  in 
some  instances  has  proved  beneficial ;  in  others  curative.  Thorough  irrigation 
of  the  large  bowel  with  injections  should  be  practiced,  the  warm  fluid  being 
allowed  to  flow  in  from  a  fountain  syringe,  and  the  amount  carefully  esti- 
mated. 

Inflation  may  also  be  tried,  by  forcing  the  air  into  the  rectum  with  the 
bellows  or  with  a  Davidson's  syringe.  It  is  a  measure  not  without  risk,  as 
instances  of  rupture  of  the  bowel  have  been  reported.  Of  39  cases  in  chil- 
dren treated  by  inflation  or  enemata  16  recovered  (Wiggin).  In  cases  of 
acute  obstruction  surgical  measures  should  be  resorted  to  early. 

For  the  tympanites  turpentine  stupes  and  hot  applications  may  be  ap- 
plied. In  cases  of  chronic  obstruction  the  diet  must  be  carefully  regulated, 
and  opium  and  belladonna  are  useful  for  the  paroxysmal  pains.  Enemata 
should  be  employed,  and,  if  the  obstruction  becomes  complete,  resort  must  be 
had  to  surgical  measures. 

V.    CONSTIPATION 

(Costiveness) 

Definition. — Retention  of  faeces  from  any  cause. 

Constipation  in  Adults. — The  causes  are  varied  and  may  be  classed  as 
general  and  local. 

GENEKAL  CAUSES. — (a.)  Constitutional  peculiarities:  Torpidity  of  the 
bowels  is  often  a  family  complaint  and  is  found  more  often  in  dark  than  in 
fair  persons.  (&)  Sedentary  habits,  particularly  in  persons  who  eat  too  much 
and  neglect  the  calls  of  nature,  (c)  Certain  diseases,  such  as  anaemia,  neuras- 
thenia, and  hysteria,  chronic  affections  of  the  liver,  stomach,  and  intestines, 
and  the  acute  fevers.  Under  this  heading  may  appropriately  be  placed  that 
most  injurious  of  all  habits,  drug-taking,  (d)  Either  a  coarse  diet,  which 
leaves  too  much  residue,  or  a  diet  which  leaves  too  little. 

LOCAL  CAUSES. — Weakness  of  the  abdominal  muscles  in  obesity  or  from 
overdistention  in  repeated  pregnancies.  Atony  of  the  large  bowel  from  chronic 
disease  of  the  mucosa;  the  presence  of  tumors,  physiological  or  pathological, 
pressing  upon  the  bowel;  enteritis;  foreign  bodies,  large  masses  of  scybala, 
and  strictures  of  all  kinds.  An  important  local  cause  is  atony  of  the  colon, 
particularly  of  the  muscles  of  the  sigmoid  flexure  by  which  the  faeces  are 
propelled  into  the  rectum.  An  obstinate  form  is  that  associated  with  a  con- 
tracted state  of  the  bowel,  sometimes  spoken  of  as  spasmodic  constipation. 
This  is  met  with — first,  as  a  sequence  of  chronic  dysentery  or  ulcerative  eo- 
•litis;  secondly,  in  protracted  cases  of  hysteria  and  neurasthenia  in  women, 
particularly  in  association  with  uterine  disease;  and,  thirdly,  in  very  old 
persons  often  without  any  definite  cause.  It  may  be  that  the  sigmoid  flexure 
and  lower  colon  are  in  a  condition  of  contraction  and  spasm,  while  the  trans- 
verse and  ascending  parts  are  in  a  state  of  atony  and  dilatation.  The  most 
characteristic  sign  of  this  variety  is  the  presence  of  hard,  globular  masses, 
or,  more  rarely,  small  and  sausage-like  faeces. 

Radiography  has  taught  us  much  of  the  conditions  favoring  intestinal 


546  DISEASES    OP    THE    DIGESTIVE    SYSTEM 

stasis.  The  upward  position  in  man  favors  visceroptosis,  with  which  we  find 
associated  many  of  the  most  obstinate  cases  of  constipation.  Arbuthnot 
Lane  has  emphasized  the  fact  of  this  dropping  or  dragging  of  the  intestines, 
particularly  at  certain  points — e.  g.,  the  third  part  of  the  duodenum,  at  the 
end  of  which  there  may  be  an  abrupt  kink  associated  with  a  considerable  dila- 
tation of  the  duodenum  itself.  This  is  of  course  relieved  immediately  when 
the  patient  lies  down.  The  second  is  the  ileal  kink,  already  spoken  of,  caused 
by  a  dropping  of  the  caecum,  and  the  lower  coil  of  the  ileum  itself.  The 
obstruction  may  result  in  considerable  dilatation  of  the  end  of  the  ileum, 
with  delay  in  the  passage  of  the  fluid  faeces.  A  third  point  is  the  fixed  splenic 
flexure  of  the  colon,  and  the  X-ray  may  show  an  ascending  colon  as  low  as 
the  level  of  the  iliac  crest,  and  the  transverse  in  the  pelvis  necessarily  causing 
delay  in  the  passage  of  the  faces  past  this  angle.  The  sigmoid  loop  seems 
specially  designed  to  promote  stasis ;  the  rectum  may  also  present  an  elongated 
S-shaped  loop,  and,  finally,  there  is  the  sharp  pelvi-rectal  flexure,  above  which 
the  faeces  accumulate. 

The  studies  of  Hertz,  Jordan,  and  others  have  shown  how  accurately  the 
rate  of  the  passage  of  the  faeces  through  the  large  bowel  may  be  estimated 
with  the  X-rays.  After  a  bismuth  meal  the  caecum  is  reached  in  about  four 
hours,  the  hepatic  flexure  two  hours  later,  the  splenic  flexure  three  hours  after 
that,  and  the  beginning  of  the  pelvic  colon  twelve  hours  after  the  commence- 
ment of  the  meal.  The  faces  do  not  pass  beyond  the  pelvi-rectal  flexure  until 
just  before  defalcation. 

Hertz  divides  all  cases  of  constipation  into  two  main  groups.  In  one  the 
delay  occurs  in  the  passage  through  the  colon,  particularly  in  the  distal 
half;  in  the  other  the  passage  as  far  as  the  pelvic  colon  is  normal,  but  de- 
faecation  is  not  properly  performed.  Every  case  of  chronic  constipation 
ought  to  be  carefully  studied  with  the  X-rays. 

SYMPTOMS. — The  most  persistent  constipation  for  weeks  or  even  months 
may  exist  with  fair  health.  Debility,  lassitude,  and  a  mental  depression 
are  frequent  symptoms  in  constipation,  particularly  -in  persons  of  a  nervous 
temperament.  Headache,  loss  of  appetite,  a  furred  tongue,  and  foul  breath 
may  also  occur.  In  girls  the  skin  is  "muddy,"  acne  is  common,  chlorosis  may 
follow,  and  there  is  a  flabby  state  of  the  system  generally.  Lane  claims 
that  chronic  mastitis,  chronic  pancreatitis  and  gall-stones  may  follow  in- 
testinal stasis. 

When  persistent,  the  accumulation  of  fasces  leads  to  unpleasant,  some- 
times serious,  local  symptoms,  such  as  piles,  ulceration  of  the  colon,  disten- 
tion  of  the  sacculi,  perforation,  enteritis,  and  occlusion.  In  women  pressure 
may  cause  pain  at  the  time  of  menstruation  and  a  sensation  of  fullness  and 
distention  in  the  pelvic  organs.  Neuralgia  of  the  sacral  nerves  may  be 
caused  by  an  overloaded  sigmoid  flexure.  The  faeces  collect  chiefly  in  the 
colon.  Even  in  extreme  grades  of  constipation  it  is  rare  to  find  dry  faces 
in  the  caecum.  The  faeces  may  form  large  tumors  at  the  hepatic  or  splenic 
flexures,  or  a  sausage-like,  doughy  mass  above  the  navel,  or  an  irregular 
lumpy  tumor  in  the  left  inguinal  region.  In  old  persons  the  sacculi  of  the 
colon  become  distended  and  the  scybala  may  remain  in  them  and  undergo 
calcification,  forming  enteroliths. 

In  cases  with  prolonged  retention  the  faecal  masses  become  channeled  and 


CONSTIPATION  547 

diarrhoea  may  occur  for  days  before  the  true  condition  is  discovered  by  rec- 
tal or  external  examination.  In  women  who  have  been  habitually  constipated 
attacks  of  diarrhoea  with  nausea  and  vomiting  should  excite  suspicion  and 
lead  to  a  thorough  examination  of  the  large  bowel.  Fever  may  occur  in  these 
cases,  and  Meigs  has  reported  an  instance  in  which  the  condition  simulated 
typhoid  fever. 

Captivated  by  the  theories  of  Metchnikoff  we  have  been  for  some  years  on 
the  crest  of  a  colonic  wave,  and  intestinal  toxaemia  has  been  held  responsible 
for  many  of  the  worst  of  the  ills  that  flesh  is  heir  to,  more  particularly  ar- 
terio-sclerosis  and  old  age.  The  seniles  and  preseniles  of  two  continents  have 
been  taking  sour  milk  and  lacto-bacillary  compounds,  to  the  great  benefit  of 
the  manufacturing  chemists !  But  the  fad  is  passing,  not,  I  hope,  to  be  re- 
placed by  one  even  more  serious,  in  which  operation  is  advised  for  every  case 
of  severe  intestinal  stasis. 

Constipation  in  infants  is  a  common  and  troublesome  disorder.  The 
causes  are  congenital,  dietetic,  and  local.  There  are  instances  in  which  the 
child  is  constipated  from  birth  and  may  not  have  a  natural  movement 
for  years,  and  yet  thrive  and  develop.  There  are  cases  of  enormous  dila- 
tation of  the  large  bowel  with  persistent  constipation.  The  condition  ap- 
pears sometimes  to  be  a  congenital  defect.  In  some  of  these  patients  there 
may  be  constricting  bands,  or,  as  in  a  case  of  Cheever's,  a  congenital  stric- 
ture. 

Dietetic  causes  are  more  common.  In  sucklings  it  often  arises  from  an 
unnatural  dryness  of  the  small  residue  which  passes  into  the  colon,  and  it 
may  be  very  difficult  to  decide  whether  the  fault  is  in  the  mother's  milk  or 
in  the  digestion  of  the  child:  Most  probably  it  is  in  the  latter,  as  some 
babies  may  be  persistently  costive  on  natural  or  artificial  foods.  Deficiency 
of  fat  in  the  milk  is  believed  by  some  writers  to  be  the  cause.  In  older  chil- 
dren it  is  of  the  greatest  importance  that  regular  habits  should  be  enjoined. 
Carelessness  on  the  part  of  the  mother  in  this  matter  often  lays  the  founda- 
tion of  troublesome  constipation  in  after  life.  Impairment  of  the  contractil- 
ity of  the  intestinal  wall  in  consequence  of  inflammation,  disturbance  in  the 
normal  intestinal  secretions,  and  mechanical  obstruction  by  tumors,  twists, 
and  intussusception  are  the  chief  local  causes. 

Treatment. — Much  may  be  done  by  systematic  habits,  particularly  in  the 
young.  The  patient  should  go  to  stool  at  a  fixed  hour  every  day,  whether 
there  is  desire  or  not,  and  the  desire  should  always  be  granted.  Exercise  in 
moderation  is  helpful.  In  stout  persons  and  in  women  with  pendulous  ab- 
domens the  muscles  should  have  the  support  of  a  bandage.  Friction  or  reg- 
ularly applied  massage  is  invaluable  in  the  more  chronic  cases.  A  good 
substitute  is  a  metal  ball  weighing  from  four  to  six  pounds,  which  may  be 
rolled  over  the  abdomen  every  morning  for  five  or  ten  minutes.  The  diet 
should  be  light,  with  plenty  of  fruit  and  vegetables,  particularly  salads  and 
tomatoes.  Oatmeal  is  usually  laxative,  though  not  to  all;  brown  bread  is 
better  than  that  made  from  fine  white  flour.  Of  liquids,  water  and  aerated 
mineral  waters  may  be  taken  freely.  A  tumblerful  of  hot  or  cold  water  on. 
rising,  taken  slowly,  is  efficacious  in  many  cases.  A  glass  of  hot  water  at 
night  may  also  be  tried  alone.  A  pipe  or  a  cigar  after  breakfast  is  with 
many  men  an  infallible  remedy. 


548  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

When  the  condition  is  not  very  obstinate  it  is  well  to  try  to  relieve  it  by 
hygienic  and  dietetic  measures.  If  drugs  must  be  used  they  should  be  the 
milder  saline  laxatives  or  the  compound  liquorice  powder.  Enemata  are  of- 
ten necessary,  and  it  is  'much  preferable  to  employ  them  early  than  to  con- 
stantly use  purgative  pills.  Glycerine  either  in  the  form  of  suppository  or 
as  a  small  injection  is  very  valuable.  Half  a  drachm  of  boric  acid  placed 
within  the  rectum  is  sometimes  efficacious.  The  injections  of  tepid  water, 
with  or  without  soap,  may  be  used  for  a  prolonged  period  with  good  effect  and 
without  damage.  The  patient  should  be  in  the  dorsal  position  with  the  hips 
elevated,  and  it  is  best  to  let  the  fluid  flow  in  slowly  from  a  fountain  syringe. 

The  usual  remedies  employed  are  often  useless  in  the  constipation  asso- 
ciated with  contracted  bowel.  A  very  satisfactory  measure  is  the  olive  or 
cotton  seed  oil  injection,  as  recommended  by  Kussmaul.  The  patient  lies 
on  the  back  with  the  hips  elevated,  and  with  a  cannula  and  tube  from  15 
to  20  ounces  of  pure  oil  are  allowed  to  flow  slowly  (or  are  injected)  into 
the  bowel.  The  operation  should  take  at  least  fifteen  minutes.  This  may  be 
repeated  every  day  until  the  intestine  is  cleared,  and  subsequently  a  smaller 
injection  every  few  days  will  suffice.  In  the  cases  with  a  spastic  colon  the 
injection  of  oil  at  bedtime,  which  is  retained  during  the  night,  is  often 
effectual. 

There  are  various  drugs  which  are  of  special  service,  particularly  the 
combination  of  ipecacuanha,  nux  vomica,  or  belladonna,  with  aloes,  or  podo- 
phyllin.  Cascara  sagrada,  phenolphthalein,  and  agar  agar  are  useful.  Per- 
sistent effort  should  be  made  to  reduce  the  dosage  by  attention  to  hygienic 
measures.  In  anaemia  and  chlorosis,  a  sulphur  confection  taken  in  the 
morning,  and  a  pill  of  iron,  rhubarb,  and  aloes  throughout  the  day,  are  very 
serviceable.  Certain  very  severe  cases  are  benefited  by  "short-circuiting,"  the 
lower  end  of  the  ileum  being  joined  to  the  lower  end  of  the  colon. 

In  children  the  indications  should  be  met,  as  far  as  possible,  by  hygienic 
and  dietetic  measures.  In  the  constipation  of  sucklings  a  change  in  the  diet 
of  the  mother  may  be  tried,  or  from  one  to  three  teaspoonfuls  of  cream  may 
be  given  before  each  nursing.  In  artificially  fed  children  the  top  milk  with 
the  cream  should  be  used.  Drinking  of  water,  barley  water,  or  oatmeal  water 
will  sometimes  obviate  the  difficulty.  If  laxatives  are  required,  simple  syrup, 
manna,  or  olive  oil  may  be  sufficient.  The  conical  piece  of  soap,  so  often 
seen  in  nurseries,  is  sometimes  efficacious.  Massage  along  the  colon  may  be 
tried.  Small  injections  of  cold  water  may  be  used.  Large  injections  should 
be  avoided,  if  possible.  If  it  is  necessary  to  give  a  laxative  by  the  mouth, 
castor  oil  or  the  fluid  magnesia  is  the  best.  The  saline  purgatives  appear 
to  act  by  increasing  the  muscular  and  glandular  activity  of  the  bowel.  If 
there  are  signs  of  gastro-intestinal  irritation,  rhubarb  and  soda  or  gray 
powder  may  be  given.  In  older  children  the  diet  should  be  carefully  regu- 
lated. 

VI.    ENTEROPTOSIS 

(GUnard's  Disease) 

Definition. — "Dropping  of  the  viscera,"  visceroptosis,  is  not  a  disease, 
but  a  symptom  group  characterized  by  looseness  of  the  mesenteric  and 


ENTEROPTOSIS  549 

peritoneal  attachments,  so  that  the  stomach,  the  intestines,  particularly  the 
transverse  colon,  the  liver,  the  kidneys,  and  the  spleen  occupy  an  abnormally 
low  position  in  the  abdominal  cavity. 

Symptoms  and  Physical  Signs. — It  is  important  to  recognize  two  groups 
of  cases.  In  one  the  splanchnoptosis  follows  the  loss  of  normal  support  of 
the  abdominal  wall  in  consequence  of  repeated  pregnancies  or  recurring 
ascites.  The  condition  may  be  extreme  without  the  slightest  distress  on  the 
part  of  the  patient. 

The  second  and  more  important  group  occurs  usually  in  young  persons, 
who  present,  with  splanchnoptosis,  the  features  of  more  or  less  marked  neu- 
rasthenia. 

In  the  first  group  inspection  of  the  abdomen  shows  a  very  relaxed  abdom- 
inal wall,  and,  as  a  rule,  the  linese  albicantes  of  recurring  pregnancies. 
Peristalsis  of  the  intestines  may  be  seen,  and  in  extreme  cases  the  outlines 
of  the  stomach  itself  with  its  waves  of  peristalsis.  On  inflating  the  stomach 
with  carbonic-acid  gas  the  organ  stands  out  with  great  prominence,  and  tfre 
lesser  and  greater  curvatures  are  seen,  the  latter  extending  perhaps  a  hand's 
breadth  below  the  level  of  the  navel.  The  waves  of  peristalsis  are  feeble  and 
without  the  vigor  and  force  of  those  seen  in  the  stomach  dilated  from  stric- 
ture of  the  pylorus.  The  condition  of  descensus  ventriculi  with  atony  is  best 
studied  in  this  group  of  cases.  An  important  point  to  remember  is  that  it 
may  exist  in  an  extreme  grade  without  symptoms. 

In  the  other  group  is  embraced  a  somewhat  motley  series  of  cases,  in 
which,  with  a  pronounced  nervous  or,  as  we  call  it  now,  neurasthenic  basis, 
there  are  displacements  of  the  viscera  with  symptoms.  The  patients  are 
usually  young,  more  frequently  women  than  men,  and  of  spare  habit.  The 
condition  may  follow  an  acute  illness  with  wasting.  They  complain,  as  a 
rule,  of  dyspepsia,  throbbing  in  the  abdomen,  and  dragging  pains  or  weak- 
ness in  the  back,  and  inability  to  perform  the  usual  duties  of  life.  A  very 
considerable  proportion  of  all  the  cases  of  neurasthenia  present  the  local  fea- 
tures of  enteroptosis.  When  preparing  for  the  examination  one  notices 
usually  an  erythematous  flushing  of  the  skin;  the  scratch  of  the  nail  is  fol- 
lowed instantly  by  a  line  of  hyperaBmia,  less  often  of  marked  pallor.  The 
pulsation  of  the  abdominal  aorta  is  readily  seen. 

Radiography  has  given  much  information  of  the  position  of  the  viscera 
and  the  patients  should  be  examined  carefully  after  a  bismuth  meal.  The 
stomach  is  vertically  placed  and  reaches  far  below  the  navel ;  its  motility  may 
be  normal,  hut  there  may  be  stasis  from  associated  pyloric  spasm  or  from 
kinking  of  the  duodenum.  Inflated  with  gas  the  outlines  may  be  seen  through 
the  thin  skin.  Clapotage  or  splashing  is  usually  distinct. 

Nephroptosis,  or  displacement  of  the  kidney,  is  one  of  the  most  constant 
phenomena  in  enteroptosis.  It  is  well,  perhaps,  to  distinguish  between  the 
kidney  which  one  can  just  touch  on  deep  inspiration — palpable  kidney — one 
which  is  freely  movable,  and  which  on  deep  inspiration  descends  so  that 
one  can  put  the  fingers  of  the  palpating  hand  above  it  and  hold  it  down, 
and,  thirdly,  a  floating  kidney,  which  is  entirely  outside  the  costal  arch,  is 
easily  grasped  in  the  hand,  readily  moved  to  the  middle  line,  and  low  down 
toward  the  right  iliac  fossa.  It  is  held  by  some  that  the  designation  floating 
kidney  should  be  restricted  to  the  cases  in  which  there  is  a  meso-nephron, 


550  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

but  this  is  excessively  rare,  while  extreme  grades  of  renal  mobility  are  com- 
mon. Some  of  the  more  serious  sequences  of  movable  kidney,  namely, 
Dietl's  crises  and  intermittent  hypdronephrosis,  will  be  considered  with  dis- 
eases of  the  kidney. 

Displacement  of  the  liver  is  very  much  less  common.  In  thin  women 
who  have  laced,  the  organ  is  often  tilted  forward,  so  that  a  very  large  sur- 
face of  the  lobes  comes  in  contact  with  the  abdominal  wall ;  it  is  a  very  com- 
mon mistake  under  these  circumstances  to  think  that  the  organ  is  enlarged. 
Dislocation  of  the  liver  itself  will  be  considered  later. 

Mobility  of  the  spleen  is  sometimes  very  marked  in  enteroptosis.  In  an 
extreme  grade  it  may  be  found  in  almost  any  region  of  the  abdomen.  It  is 
very  frequently  mistaken  for  a  fibroid  or  ovarian  tumor.  A  considerable 
proportion  of  the  cases  come  first  under  the  care  of  the  gynecologist. 

There  is  usually  much  relaxation  of  the  mesentery  and  of  the  peritoneal 
folds  which  support  the  intestines.  The  colon  is  displaced  downward  (colop- 
tosis),  with  consequent  kinking  at  the  flexures.  The  descent  may  be  so  low 
that  the  transverse  colon  is  at  the  brim  of  or  even  in  the  pelvis.  It  may 
indeed  be  fixed  or  bent  in  the  form  of  a  V.  It  is  frequently  to  be  felt,  as 
Glenard  states,  as  a  firm  cord  crossing  the  abdomen  at  or  below  the  level 
of  the  navel.  This  kinking  may  take  place  not  only  in  the  colon,  but  at  the 
pylorus,  where  the  duodenum  passes  into  the  jejunum,  and  where  the  ileum 
enters  the  caecum. 

The  explanation  of  the  phenomena  accompanying  enteroptosis  is  by  no 
means  easy.  It  has  been  suggested  by  Glenard  and  others  that  overfilling  of 
the  splanchnic  vessels  in  consequence  of  displacements  and  kinking  accounts 
for  the  feelings  of  exhaustion  and  general  nervousness.  In  a  large  propor- 
tion of  the  cases,  however,  no  symptoms  occur  until  after  an  illness  or  some 
protracted  nervous  strain. 

Treatment. — In  a  majority  of  all  cases  four  indications  are  present:  To 
treat  the  existing  neurasthenia,  to  relieve  the  nervous  dyspepsia,  to  over- 
come the  constipation,  and  to  afford  mechanical  support  to  the  organs.  Three 
of  these  are  considered  under  their  appropriate  sections.  In  cases  in  which 
the  enteroptosis  has  followed  loss  in  weight  after  an  acute  illness  or  worries 
and  cares  an  important  indication  is  to  fatten  the  patient. 

A  well-adapted  abdominal  bandage  is  one  of  the  most  important  meas- 
ures in  enteroptosis.  In  many  of  the  milder  grades  it  alone  suffices.  I  know 
of  no  single  simple  measure  which  affords  relief  to  distressing  symptoms  in 
so  many  cases  as  the  abdominal  bandage.  It  is  best  made  of  linen,  should 
fit  snugly,  and  should  be  arranged  with  straps  so  that  it  can  not  ride  up  over 
the  hips.  A  special  form  must  be  used,  as  will  be  mentioned  later,  for  mov- 
able kidney.  In  some  cases  support  may  be  given  by  the  use  of  adhesive 
strapping.  Some  of  the  more  aggravated  types  of  enteroptosis  are  combined 
with  such  features  of  neurasthenia  that  a  rigid  Weir  Mitchell  treatment  is 
indicated.  In  a  few  very  refractory  cases  surgical  interference  may  be  called 
for. 

And,  lastly,  the  physician  must  be  careful  in  dealing  with  the  subjects 
of  enteroptosis  not  to  lay  too  much  stress  on  the  disorder.  It  is  well  never 
to  tell  the  patient  that  a  kidney  is  movable;  the  symptoms  may  date  from 
a  knowledge  of  the  existence  of  the  condition. 


MUCOUS    COLITIS  551 

VII.    MISCELLANEOUS   AFFECTIONS 

I.     MUCOUS    COLITIS 

KnowE.  by  various  names,  such  as  membranous  enteritis,  tubular  diarrhoea,, 
mucous  colic,  and  myxoneurosis  intestinalis,  this  remarkable  disease  has  been 
recognized  for  several  centuries.  An  exhaustive  description  of  it  is  given  by 
Woodward  in  vol.  ii  of  the  Medical  and  Surgical  Keports  of  the  Civil  War. 
The  passage  of  mucus  in  large  quantities  from  the  bowel  is  met  with,  first, 
in  catarrh  of  the  intestine,  due  to  various  causes.  It  is  not  uncommon  in 
children,  and  may  be  associated  with  disturbances  of  digestion  and  slight 
colic.  Secondly,  in  local  disease  or  irritation  of  the  bowel,  in  cancer  of  the 
colon  and  of  the  rectum.  In  tubo-ovarian  disease  much  mucus  and  slime 
may  be  passed.  Thirdly,  true  mucous  colitis,  a  secretion  neurosis  of  the  large 
intestine  met  with  particularly  in  nervous  and  hysterical  patients.  It  is 
more  common  in  women  than  in  men.  It  has  increased  greatly  of  late  years, 
and  has  become  the  fashionable  complaint,  displacing  neuritis  to  a  great 
extent.  There  is  an  abnormal  secretion  of  a  tenacious  mucus,  which  may  be 
slimy  and  gelatinous,  like  frog-spawn,  or  it  is  passed  in  strings  or  strips, 
more  rarely  as  a  continuous  tubular  membrane.  I  have  twice  seen  this  mem- 
brane in  situ,  closely  adherent  to  the  mucosa,  but  capable  of  separation  with- 
out any  lesion  of  the  surface.  Microscopically  the  casts  are  mucoid,  of  a 
uniform  granular  ground  substance  through  which  there  are  remnants  of 
cells,  some  of  which  have  undergone  a  definite  hyaline  transformation. 
Triple  phosphate,  cholesterin,  and  fatty  crystals  are  present,  and  occasionally 
fine,  sand-like  concretions.  The  epithelium  of  the  mucosa  seems  to  be  intact. 

Symptoms. — In  a  large  proportion  of  all  the  cases  the  subjects  are  nerv- 
ous in  greater  or  less  degree.  Some  cases  have  had  hysterical  outbreaks,  and 
there  may  be  hypochondriasis  or  melancholia.  The  patients  are  self-centred 
and  often  much  worried  about  the  mucous  stools.  Some  of  the  cases  are 
among  the  most  distressing  with  which  we  have  to  deal,  invalids  of  from 
ten  to  twenty  years'  standing,  neurasthenic  to  an  extreme  degree,  with  recur- 
ring attacks  of  pain  and  the  passage  of  large  quantities  of  mucus  or  even  of 
intestinal  casts. 

In  many  cases  the  attacks  may  come  on  in  paroxysms,  associated  with 
colicky  pains,  or  occasionally  crises  of  the  greatest  severity,  so  that  appen- 
dicitis may  be  suspected.  Emotional  disturbances,  worry  of  all  sorts,  or  an 
error  in  diet  may  bring  on  an  attack.  Constipation  is  a  special  feature  in 
many  cases.  Sometimes  there  are  attacks  of  nervous  diarrhoea. 

While  the  disease  is  obstinate  and  distressing,  it  is  rarely  serious,  though 
Herringham  states  that  he  knew  of  three  cases  of  mucous  colitis  in  which 
death  occurred  suddenly,  in  all  with  great  pain  in  the  left  side  of  the  abdo- 
men. The  abdomen  itself  is  rarely  distended.  There  is  often  a  very  painful 
spot  just  between  the  navel  and  the  left  costal  border,  tender  on  pressure, 
and  sometimes  the  paroxysms  of  pain  seem  centred  in  this  region.  A  spas- 
tic condition  of  the  colon  frequently  exists  and  is  easily  recognized  by  pal- 
pation. 

Diagnosis. — The  diagnosis  is  rarely  doubtful,  but  it  is  important  not  to 


552  DISEASES    OF   THE   DIGESTIVE    SYSTEM 

mistake  the  membranes  for  other  substances;  thus,  the  external  cuticle  of 
asparagus  and  undigested  portions  of  meat  or  sausage-skins  sometimes  as- 
sume forms  not  unlike  mucous  casts,  but  microscopic  examination  will 
quickly  differentiate  them.  Mucous  colitis  with  severe  pain  may  be  mistaken 
for  appendicitis. 

Treatment. — Drugs  are  of  little  value.  It  is  quite  useless  to  give  bismuth 
and  so-called  intestinal  remedies.  First  the  basic  neurasthenic  state  is  to 
be  dealt  with,  and  this  may  suffice  for  a  cure.  Secondly,  daily  irrigations 
of  the  colon  through  a  long  tube — one  to  two  pints  of  warm  alkaline  fluid. 
At  Plombieres,  Harrogate,  and  other  spas  this  treatment  is  most  successfully 
carried  out.  The  injection  of  olive  oil  at  bedtime  is  sometimes  helpful.  It 
should  be  retained  during  the  night.  Thirdly,  the  coarser  sorts  of  food  which 
leave  a  large  residue  should  be  eaten,  and,  lastly,  should  these  measures  fail, 
the  question  of  epening  the  colon  or  irrigating  through  the  appendix  may 
be  considered. 

II.     DILATATION    OF    THE    COLON 
i 

There  are  four  groups  of  cases.  In  the  first  the  distention  is  entirely 
gaseous,  and  occurs  not  infrequently  as  a  transient  condition.  In  many  cases 
it  has  an  important  influence,  inasmuch  as  it  may  be  extreme,  pushing  up  the 
diaphragm  and  seriously  impairing  the  action  of  the  heart  and  lungs.  It  is 
an  occasional  cause  of  sudden  heart-failure.  In  pneumonia  and  other  acute 
diseases  this  inflation  of  the  colon  may  be  extreme. 

In  the  second  group  are  the  cases  in  which  the  distention  of  the  colon 
is  caused  by  solid  substances,  as  faecal  matter,  occasionally  by  foreign  bodies 
introduced  from  without,  and  more  rarely  by  gall-stones.  In  institutions, 
particularly  in  insane  asylums,  it  is  not  infrequent  to  find  the  aged  with 
great  distention  of  the  colon. 

When,  thirdly,  the  dilatation  is  due  to  an  organic  obstruction  in  front 
of  the  dilated  gut,  the  colon  may  reach  a  very  large  size.  These  cases  are 
common  enough  in  malignant  tumors  and  sometimes  in  volvulus.  Dilata- 
tion of  the  sigmoid  flexure  occurs  particularly  when  this  portion  of  the  bowel 
is  congenitally  very  long.  In  such  cases  the  bowel  may  be  so  distended  that 
it  occupies  the  greater  part  of  the  abdomen,  pushing  up  the  liver  and  the  dia- 
phragm. An  acute  condition  is  sometimes  caused  by  a  twist  in  the  meso-colon. 
And,  fourthly — 

Idiopathic  Dilatation. — Hirschsprung's  disease.  The  cases  are  not  un- 
common, occurring  in  children  and  in  young  adults.  The  sigmoid  flexure 
alone  or  the  entire  colon  is  involved,  and  the  size  may  be  colossal.  In  For- 
mad's  case  the  circumference  of  the  colon  was  from  fifteen  to  thirty  inches, 
and  the  weight  of  the  contents  forty-seven  pounds.  The  origin  is  obscure.  In 
some  the  condition  is  congenital,  and  the  dilatation  and  hypertrophy  increase 
progressively;  in  others  there  is  an  unusually  long  sigmoid  flexure;  in  others 
again  narrowing  of  the  terminal  portion  of  the  descending  colon  or  a  valve- 
like  structure  has  been  found.  The  symptoms  are  very  definite — constipa- 
tion, an  enlarged  abdomen,  attacks  of  pain  with  increasing  distention,  and 
then  diarrhoea,  either  natural  or  induced,  with  relief.  Such  attacks  may 
occur  from  birth  and  continue  to  the  twentieth  or  thirtieth  year.  The  ab- 
dominal picture  is  distinctive — the  great  enlargement  of  the  upper  half  of 


MISCELLANEOUS    AFFECTIONS  553 

the  abdomen,  the  spreading  of  the  costal  arch,  the  remarkable  length  from 
the  ensiform  cartilage  to  the  navel,  and  in  the  attacks  the  coils  of  the  colon 
stand  out  prominently,  and  even  the  longitudinal  bands  may  be  seen. 

The  outlook  is  uncertain.  Medical  treatment  is  of  little  avail.  I  have 
seen  one  case  in  a  young  child  in  which  scrupulous  care  of  the  bowels  seemed 
to  check  the  progress;  but,  as  a  rule,  it  is  a  progressive  malady  for  which 
surgery  alone  offers  complete  relief.  Resection  of  the  enlarged  colon  has  now 
been  done  in  a  good  many  cases  with  success.  Colotomy  gives  relief;  colos- 
tomy  has  also  been  successful.  Of  44  cases  treated  surgically,  15  were  com- 
pletely cured  and  7  were  improved  (Finney). 

HI.    INTESTINAL  SAND 

"Sable  Intestinal." — There  are  two  groups  of  cases  in  which  sand-like 
material  is  passed  with  the  stools.  The  false,  in  which  it  is  made  up  of  the 
remains  of  vegetable  food  and  fruits  which  have  resisted  digestion  or  which 
have  become  encrusted  with  earthy  salts.  True  intestinal  sand  of  animal 
origin,  gritty  fine  particles,  usually  gray  or  colorless,  sometimes  dark,  is 
formed  in  the  bowel  and  is  made  up  largely  of  lime  salts.  In  mucous 
colitis  this  material  may  be  passed  at  intervals  for  months. 

IV.     DIVERTICULITIS— PERISIGMOIDITIS 

In  the  lower  part  of  the  descending  colon  and  in  the  sigmoid  flexure 
diverticula  occur,  sometimes  congenital,  sometimes  acquired,  most  commonly 
in  women  and  in  association  with  constipation.  Of  81  cases  collected  by 
Telling,  53  were  in  males.  They  are  prone  to  form  at  the  site  of  the  ap- 
pendices epiploicas.  Intestinal  obstruction,  acute  gangrene,  perforation  with 
the  formation  of  abscess,  peritonitis,  vesico-colic  fistula,  and  metastatic  sup- 
puration are  occasional  complications.  In  acute  cases  left-sided  appendicitis 
is  diagnosed,  while  in  the  chronic  cases  the  mimicry  of  cancer  is  very  close. 
The  cases  are  more  common  than  we  have  heretofore  supposed.  Eesection 
of  the  affected  portion  of  the  colon  has  been  successfully  performed. 

V.     AFFECTIONS  OF  THE  MESENTERY 

Haemorrhage  (Hcematoma). — Instances  in  which  the  bleeding  is  confined 
to  the  mesenteric  tissues  are  rare ;  more  commonly  the  condition  is  associated 
with  hsmorrhagic  infiltration  of  the  pancreas  and  with  retroperitoneal  hemor- 
rhage. It  occurs  in  rupture  of  aneurisms,  either  of  the  abdominal  aorta  or  of 
the  superior  mesenteric  artery,  in  malignant  forms  of  the  infectious  fevers, 
small-pox,  and,  lastly,  in  individuals  in  whom  no  predisposing  conditions 
exist. 

Affections  of  the  Mesenteric  Vessels. — (a)  ANEURISM  (see  under  Ar- 
teries). 

(&)  EMBOLISM  AND  THROMBOSIS. — Infarction  of  the  Bowel. — When  the 
mesenteric  vessels  are  blocked  by  emboli  or  thrombi  the  condition  of  infarc- 
tion follows  in  the  territory  supplied,  which  may  pass  on  to  gangrene  or  to 
perforation  and  peritonitis,  If  the  superior  mesenteric  artery  is  blocked 

27 


554  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

the  result  is  fatal.  In  the  veins  the  thrombosis  may  be  primary,  following 
infective  processes  in  the  intestines,,  particularly  about  the  appendix,  or  ifr 
occurs  in  cachectic  states.  Secondary  thrombosis  is  met  with  in  cirrhosis  of 
the  liver,  syphilis,  and  pylephlebitis,  or  may  result  from  the  stasis  caused 
by  arterial  emboli.  Jackson,  Porter,  and  Quimby  have  made  an  exhaustive 
study  of  30  Boston  cases,  and  have  collected  214  cases.  They  recognize  two 
groups — acute  and  chronic.  In  the  former  the  onset  is  sudden,  with  colic, 
nausea,  vomiting,  and  a  bloody  diarrhosa,  so  that  the  picture  is  one  of  acute 
obstruction.  The  abdomen  becomes  distended  and  death  occurs  in  collapse 
within  a  few  days.  In  the  chronic  cases  the  onset  is  insidious,  and  there 
may  be  no  symptoms  referable  to  the  abdomen.  Of  the  214  cases,  64  per 
cent,  were  in  men.  The  diagnosis  is  extremely  difficult,  and  the  acute  cases 
are  usually  regarded. as  obstruction.  Exploratory  operation  has  been  made  in 
47  cases,  4  of  which  have  recovered.  In  J.  W.  Elliot's  successful  case  48 
inches  of  the  bowel  were  resected.  In  the  horse,  infarction  of  the  intestine, 
commonly  in  connection  with  the  verminous  aneurisms  of  the  mesenteric 
arteries,  is  the  usual  cause  of  colic. 

Diseases  of  the  Mesenteric  Veins. — Dilatation  and  sclerosis  occur  in  cir- 
rhosis of  the  liver.  In  instances  of  prolonged  obstruction  there  may  be  large 
saccular  dilatations  with  calcification  of  the  intima,  as  in  a  case  of  oblitera- 
tion of  the  venae  portaa  described  by  me.  Suppuration  of  the  mesenteric 
veins  is  not  rare,  and  occurs  usually  in  connection  with  pylephlebitis.  The 
mesentery  may  be  much  swollen  and  is  like  a  bag  of  pus,  and  it  is  only  on 
careful  dissection  that  one  sees  that  the  pus  is  really  within  channels  repre- 
senting extremely  dilated  mesenteric  veins. 

Disorders  of  the  Chyle  Vessels. — Varicose,  cavernous,  and  cystic  chy- 
langiomata  are  met  with  in  the  mucosa  and  submucosa  of  the  small  intes- 
tine, occasionally  of  the  stomach.  Extravasation  of  chyle  into  the  mesenteric 
tissue  is  sometimes  seen.  Chylous  cysts  are  found.  I  saw  one  the  size  of  an 
egg  at  the  root  of  the  mesentery.  Bramann  records  a  case  in  a  man  aged 
sixty-three,  in  which  a  cyst  of  this  kind  the  size  of  a  child's  head  was  healed 
by  operation.  There  is  an  instance  on  record  of  a.  congenital  malformation 
of  the  thoracic  duct,  in  which  the  receptaculum  formed  a  flattened  cyst  which 
discharged  into  the  peritoneum,  and  a  chylous  ascitic  fluid  was  withdrawn  on 
several  occasions.  Homans  reported  the  case  of  a  girl  who,  from  the  third  to 
the  thirteenth  year,  had  an  enlarged  abdomen.  Laparotomy  showed  a  series 
of  cysts  containing  clear  fluid.  They  were  supposed  to  be  dilated  lymph  ves- 
sels connected  with  the  intestines. 

Cysts  of  the  Mesentery. — They  may  be  either  dermoid,  hydatid,  serous, 
sanguineous,  or  chylous.  They  occur  at  any  portion  of  the  mesentery,  and 
range  from  a  few  inches  in  diameter  to  large  masses  occupying  the  entire 
abdomen.  They  are  frequently  adherent  to  the  neighboring  organs,  to  the 
liver,  spleen,  uterus,  and  sigmoid  flexure. 

The  symptoms  usually  are  those  of  a  progressively  enlarging  tumor  in 
the  abdomen.  Sometimes  a  mass  develops  rapidly,  particularly  in  the  hasmor- 
rhagic  forms.  Colic  and  constipation  are  present  in  some  cases.  The  general 
health,  as  a  rule,  is  well  maintained  in  spite  of  the  progressive  enlargement 
of  the  abdomen,  which  is  most  prominent  in  the  umbilical  region.  Mesen- 
teric cysts  may  persist  for  many  years,  even  ten  or  twenty. 


JAUNDICE  555 

The  diagnosis  is  extremely  uncertain,  and  no  single  feature  is  in  any  way 
distinctive.  The  important  signs  are:  the  great  mobility,  the  situation  in 
the  middle  line,  and  the  zone  of  tympany  in  front  of  the  tumor.  Of  these, 
the  second  is  the  only  one  which  is  at  all  constant,  as  when  the  tumors  are 
large  the  mobility  disappears,  and  at  this  stage  the  intestines,  too,  are  pushed 
to  one  side.  It  is  most  frequently  mistaken  for  ovarian  tumor.  Movable 
kidney,  hydronephrosis,  and  cysts  of  the  omentum  have  also  been  confused 
with  it.  In  certain  instances  puncture  may  be  made  for  diagnostic  pur- 
poses, but  it  is  better  to  advise  laparotomy  for  the  purpose  of  drainage,  or,  if 
possible,  enucleation  may  be  practiced. 


H.    DISEASES  OF  THE  LIVER 

I.    JAUNDICE 

(Icterus) 

Definition. — Jaundice  or  icterus  is  a  condition  characterized  by  coloration 
of  the  skin,  mucous  membranes,  and  fluids  of  the  body  by  the  bile-pigment. 

Like  albuminuria,  jaundice  is  a  symptom  and  not  a  disease,  and  is  met 
with  in  a  variety  of  conditions. 

1.     OBSTRUCTIVE    JAUNDICE 

The  chief  causes  of  obstructive  jaundice  are:  (1)  Obstruction  by  for- 
eign bodies  within  the  ducts,  as  gall-stones  and  parasites;  (2)  by  inflammatory 
tumefaction  of  the  duodenum  or  of  the  lining  membrane  of  the  duct;  (3)  by 
stricture  or  obliteration  of  the  duct;  (4)  by  tumors  closing  the  orifice  of  the 
duct  or  growing  in  its  interior;  (5)  by  pressure  on  the  duct  from  without, 
as  by  tumors  of  the  liver  itself,  of  the  stomach,  pancreas,  kidney,  or  omentum ; 
by  pressure  of  enlarged  glands  in  the  fissures  of  the  liver,  and,  more  rarely,  of 
abdominal  aneurism,  faecal  accumulation,  or  the  pregnant  uterus. 

In  these  case  of  extra-hepatic  or  obstructive  jaundice  the  pressure  within 
the  biliary  capillaries,  usually  low,  becomes  increased  and  the  bile  is  absorbed 
by  the  lymphatics  of  the  liver  and  not  by.  the  blood  capillaries.  To  these 
causes  some  add  lowering  of  the  blood  pressure  in  the  portal  system  so  that  the 
tension  in  the  smaller  bile-ducts  is  greater  than  in  the  blood-vessels.  For  this 
view,  however,  there  is  no  positive  evidence.  In  this  class  may  perhaps  be 
placed  the  cases  of  jaundice  from  mental  shock  or  depressed  emotions,  which 
"may  conceivably  cause  spasm  and  reversed  peristalsis  of  the  bile-duct"  (W. 
Hunter) . 

General  Symptoms  of  Obstructive  Jaundice. — (a)  Icterus,  or  tinting  of 
the  skin  and  conjunctiva.  The  color  ranges  from  a  lemon-yellow  in  catarrhal 
jaundice  to  a  deep  olive-green  or  bronzed  hue  in  permanent  obstruction.  In 
some  instances  the  color  of  the  skin  is  greenish  black,  the  so-called  "black 
jaundice."  Except  the  central  nervous  system,  all  of  the  tissues  are  stained. 


556  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

(&)  In  the  more  chronic  forms  pruritus  is  a  most  distressing  symptom. 
There  is  a  curious  preicteric  itching,  which  Eiessman  thinks  is  suggestive  of 
cancer,  but  I  have  seen  it  most  marked  in  gall-stcne  cases.  Sweating  is  com- 
mon, and  may  be  curiously  localized  to  the  abdomen  or  to  the  palms  of  the 
hands.  Lichen,  urticaria,  and  boils  may  occur.  Xanihoma  multiplex  is  rare. 
Only  two  cases  have  occurred  under  my  observation.  Usually  in  the  flat  form, 
rarely  nodular,  they  are  most  common  in  the  eyelids  and  on  the  hands  and 
feet.  They  may  be  very  numerous  over  the  whole  body.  Occasionally  the 
tumors  are  found  in  the  bile  duct.  After  persisting  for  years  they  may  dis- 
appear. In  very  chronic  cases  telangiectases  develop  in  the  skin,  sometimes 
in  large  numbers  over  the  body  and  face,  occasionally  on  the  mucous  mem- 
brane of  the  tongue  and  lips,  forming  patches  of  a  bright  red  color  from  1  to 
2  cm.  in  breadth. 

(c)  The  secretions  are  colored  with  bile-pigment.     The  sweat  tinges  the 
iinen;  the  tears  and  saliva  and  milk  are  rarely  stained.     The  expectoration 
is  not  often  tinted  unless  there  is  inflammation,  as  when  pneumonia  coexists 
with  jaundice.     The  urine  may  contain  the  pigment  before  it  is  apparent  in 
the  skin  or  conjunctiva.     The  color  varies  from  light  greenish  yellow  to  a 
deep  black-green.    In  cases  of  jaundice  of  long  standing  or  great  intensity  the 
urine  usually  contains  albumin  and  always  bile-stained  tube-casts. 

(d)  No  bile  passes  into  the  intestine.    The  stools  therefore  are  of  a  pale 
drab  or  slate-gray  color,  and  usually  very  fetid  and  pasty.     The  "clay-color" 
of  the  stools  is  also  in  part  due  to  the  presence  of  undigested  fat  which, 
according  to  Miiller,  may  be  increased  from  7  to  10  per  cent.,  which  is  normal, 
to  55  or  78.5  per  cent.    There  may  be  constipation ;  in  many  instances,  owing 
to  decomposition,  there  is  diarrhoea. 

(e)  Slow  pulse.    The  heart's  action  may  fall  to  40,  30,  or  even  to  20  per 
minute.    It  is  particularly  noticeable  in  the  cases  of  catarrhal  and  recent  jaun- 
dice, and  is  not  as  a  rule  an  unfavorable  symptom.    Whether  this  is  due  to  in- 
terrupted conductivity  or  to  direct  poisoning  of  the  auriculo-ventricular  bundle 
has  not  been  determined.    It  occurs  only  in  the  early  stages  of  jaundice.    At 
this  time  bile  acids  pass  into  the  blood,  but  are  produced  in  very  small  quan- 
tities when  jaundice  is  established.    The  respirations  may  fall  to  10  or  even  to 
7  per  minute.    Xanthopsia,  or  yellow  vision,  may  occur. 

(/)  Hcemorrhage.  The  tendency  to  bleeding  in  chronic  icterus  is  a  serious 
feature.  It  has  been  shown  that  the  blood-coagulation  time  may  be  much 
retarded,  and  instead  of  from  three  minutes  and  a  half  to  four  minutes  and  a 
half  we  have  found  it  in  some  cases  as  late  as  eleven  or  twelve  minutes.  This 
is  a  point  which,  should  be  taken  account  of  by  surgeons,  inasmuch  as  incon- 
trollable  haemorrhage  is  a  well-recognized  accident  in  operating  upon  patients 
with  chronic  obstructive  jaundice.  Purpura,  large  subcutaneous  extravasa- 
tions, more  rarely  haemorrhages  from  the  mucous  membranes,  occur  in  pro- 
tracted jaundice,  and  in  the  more  severe  forms. 

(g)  Cerebral  symptoms.  Irritability,  great  depression  of  spirits,  or  even 
melancholia  may  be  present.  In  any  case  of  persistent  jaundice  special  nerv- 
ous phenomena  may  develop  and  rapidly  prove  fatal — such  as  sudden  coma, 
acute  delirium,  or  convulsions.  Usually  the  patient  has  a  rapid  pulse,  slight 
fever,  and  a  dry  tongue,  and  he  passes  into  the  so-called  "typhoid  state." 
These  features  are  not  nearly  so  common  in  -obstructive  as  in  febrile  jaundice, 


JAUNDICE  557 

but  they  not  infrequently  terminate  a  chronic  icterus  in  whatever  way  pro- 
duced. The  group  of  symptoms  has  been  termed  cholcemia,  or,  on  the  suppo- 
sition that  cholesterin  is  the  poison,  cholestercemia;  but  its  true  nature  has 
not  vet  been  determined.  In  some  of  the  cases  the  symptoms  may  be  due  to 
uraemia. 

2.     TOX^EMIC   AND    HJEMOLYTIC   JAUNDICE 

The  term  hasmatogenous  jaundice  was  formerly  applied  to  this  group  in 
contradistinction  to  the  hepatogenous  jaundice,  associated  with  manifest  ob- 
structive changes  in  the  bile-passages.  The  toxic  jaundice  cases  are  essentially 
obstructive  in  origin,  and  it  is  doubtful  whether  there  are  any  true  non-obstruc- 
tive cases.  The  manner  in  which  the  jaundice  is  produced  in  these  cases  has 
been  experimentally  worked  out  by  Stadelmann  and  Afanassiew.  The  obstruc- 
tion is  due  to  the  extreme  viscidity  of  the  bile  associated  with  a  mild  angio- 
colitis.  The  sequence  of  events  is  as  follows :  Destruction  of  blood  by  haemoly- 
sis; liberation  of  hemoglobin  with  increased  formation  and  excretion  of  bile 
pigments  (polychromia)  ;  increased  viscidity  of  the  bile,  which,  at  the  low 
pressure  at  which  the  bile  is  excreted,  causes  a  temporary  obstruction,  with 
reabsorption  of  the  bile  and  jaundice ;  finally  the  bile  loses  its  viscid  character, 
the  flow  is  reestablished,  and  the  jaundice  disappears.  Stadelmann  found 
that  a  similar  explanation  applies  to  other  varieties  of  jaundice  associated  with 
increased  blood  destruction.  For  this  type  the  name  "hasmohepatogenous" 
jaundice  has  been  suggested.  Eolleston  refers  to  them  as  cases  of  ''intrahe- 
patic"  jaundice.  Hunter  groups  the  causes  as  follows :  1.  Jaundice  produced 
by  the  action  of  poisons,  such  as  toluylendiamin,  phosphorus,  arsenic,  snake- 
venom.  2.  Jaundice  met  with  in  various  specific  fevers  and  conditions,  such 
as  yellow  fever,  malaria  (remittent  and  intermittent),  pyaemia,  relapsing 
fever,  ^typhus,  enteric  fever,  scarlatina.  3.  Jaundice  met  with  in  various  con- 
ditions of  unknown  but  more  or  less  obscure  infective  nature,  and  variously 
designated  as  epidemic,  infectious,  febrile,  malignant  jaundice,  icterus  gravis, 
Weil's  disease,  acute  yellow  atrophy. 

The  symptoms  are  not  nearly  so  striking  as  in  the  obstructive  variety. 
The  bile  is  present  in  the  stools.  The  skin  has  in  many  cases  only  a  slight 
lemon  tint.  The  urine  may  contain  no  bile-pigment,  but  the  urinary  pigments 
are  considerably  increased.  In  the  severer  forms,  as  in  acute  yellow  atrophy, 
the  color  may  be  more  intense,  but  in  malaria  and  pernicious  anosmia  the  tint 
is  usually  light.  The  constitutional  disturbance  may  be  very  profound,  with 
high  fever,  delirium,  convulsions,  suppression  of  urine,  black  vomit,  and 
cutaneous  hagmorrhages.  In  certain  cases  of  haemolytic  jaundice  the  fragility 
of  the  red  corpuscles  is  greatly  increased  and  they  may  be  smaller  than  nor- 
mal (Widal,  Chauffard)  and  show  granular  degeneration.  This  is  particu- 
larly the  case  in  the  group  of  congenital  icterus  with  enlarged  spleen. 

3.     HEEEDITAEY    ICTERUS 

A  family  form  of  icterus  has  long  been  known.  We  must  recognize,  indeed, 
several  groups.  First,  icterus  neonatorum,  as  in  the  remarkable  instance  de- 
scribed by  Glaister  (Lancet,  March, ,1879),  in  which  a  woman  had  eight  chil- 
dren, six  of  whom  died  of  jaundice  shortly  after  birth ;  one  of  the  cases  had  ste- 


558  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

nosis  of  the  common  duct,  which,  as  John  Thomson  has  shown,  is,  with  angio- 
cholitis,  a  common  lesion  in  this  affection.  Still  more  remarkable  is  it  that  the 
mother  of  this  woman  had  twelve  children,  all  of  whom  were  icteric  after  birth, 
but  the  jaundice  gradually  disappeared.  A  brother  of  the  woman  had  several 
children  who  also  were  jaundiced  at  birth.  Glaister  states  that  all  of  the  chil- 
dren of  Morgagni,  fifteen  in  number,  had  icterus  neonatorum.  Secondly,  the 
congenital  acholuric  icterus.  Minkowski  reported  eight  cases  in  three  genera- 
tions. The  jaundice  is  slight,  the  stools  are  not  clay  colored,  the  urine  has  no 
bile  pigment  but  contains  urobilin,  the  general  health  is  little  if  at  all  dis- 
turbed. Splenic  enlargement  is  a  marked  feature.  Many  cases  have  now  been 
reported  of  this  Minkowski  type,  nearly  all  in  family  groups,  but  Chauffard 
has  met  with  a  case  without  hereditary  basis  and  I  have  seen  at  least  one  case 
of  the  kind.  No  special  changes  have  been  found  in  the  liver  or  bile  passages. 
Thirdly,  a  group  of  cases  with  enlargement  of  the  spleen  and  liver  and 
marked  constitutional  disturbances,  anaemia,  dwarfing  of  stature,  infantilism, 
and  slight  jaundice.  Cases  which  have  been  described  as  Hanot's  cirrhosis 
have  occurred  in  two  or  three  members  of  a  family,  and  the  jaundice  has 
dated  from  early  childhood. 

Jaundice  has  been  described  in  connection  with  the  various  fevers,  malaria, 
yellow  fever,  and  Weil's  disease.  Two  special  affections  may  here  receive  con- 
sideration, the  icterus  of  the  new-born  and  acute  yellow  atrophy. 


II.    ICTERUS  NEONATORUM 

New-born  infants  are  liable  to  jaundice,  which  in  some  instances  rapidly 
proves  fatal.  A  mild  and  a  severe  form  may  be  recognized. 

The  mild  or  physiological  icterus  of  the  new-born  is  a  common  disease 
in  foundling  hospitals,  and  is  not  very  infrequent  in  private  practice.  In  900 
consecutive  births  at  the  Sloane  Maternity  icterus  was  noted  in  300  cases 
(Holt).  The  discoloration  appears  early,  usually  on  the  first  or  second  day, 
and  is  of  moderate  intensity.  The  urine  may  be  bile-stained  and  the  faeces 
colorless.  The  nutrition  of  the  child  is  not  usually  disturbed,  and  in  the 
majority  of  cases  the  jaundice  disappears  within  two  weeks.  This  form  is 
never  fatal.  The  cause  of  this  jaundice  is  not  at  all  clear.  Some  have  attrib- 
uted it  to  stasis  in  the  smaller  bile-ducts,  which  are  compressed  by  the  dis- 
tended radicals  of  the  portal  vein.  Others  hold  that  the  jaundice  is  due  to 
the  destruction  of  a  large  number  of  red  blood-corpuscles  during  the  first 
few  days  after  birth. 

The  severe  form  of  icterus  in  the  new-born  may  depend  upon  (a)  con- 
genital absence  of  the  common  or  hepatic  duct,  of  which  there  are  many 
instances  on  record;  (6)  congenital  syphilitic  hepatitis;  and  (c)  septic  poi- 
soning, associated  with  phlebitis  of  the  umbilical  vein.  This  is  a  severe  and 
fatal  form,  in  which  also  haemorrhage  from  the  cord  may  occur. 

Curiously  enough,  in  contradistinction  to  other  forms,  the  brain  and 
cord  may  be  stained  yellow  in  icterus  neonatorum,  sometimes  diffusely, 
more  rarely  in  definite  foci  corresponding  to  the  ganglion  cells  which  have 
become  deeply  stained  (Schmorl). 


ACUTE  YELLOW  ATROPHY  559 

HI.  ACUTE  YELLOW  ATROPHY 

(Malignant  Jaundice;  Icterus  Gravis) 

Definition. — An  acute  widespread  autolytic  necrosis  of  the  liver  cells  of 
unknown  origin,  characterized  by  jaundice,  toxaemia  and  a  reduction  in  the 
volume  of  the  liver. 

Etiology. — The  first  authentic  account  was  given  by  the  famous  old  Paris 
doctor  Ballonius — sometimes  called  the  French  Hippocrates  (1538-1616). 
Bright  gave  a  good  description  in  1836.  It  is  a  rare  disease,  as  among  28,000 
medical  cases  admitted  to  the  Johns  Hopkins  Hospital  in  nearly  twenty-three 
years  there  were  only  three  cases.  It  varies  in  frequency  in  different  coun- 
tries, and  seems  to  be  more  rare  in  the  United  States  than  in  Germany  and 
England.  The  majority  of  cases  occur  between  the  tenth  and  the  fortieth 
year.  Eolleston  has  collected  22  cases  occurring  within  the  first  ten  years  of 
life. 

Recent  studies  have  thrown  a  good  deal  of  light  upon  the  subject ;  we  now 
know  that  acute  necrosis  of  the  liver  occurs  under  many  conditions :  (a)  In  the 
infections,  syphilis,  typhoid  fever,  diphtheria,  septicaemia,  these  necroses  may 
be  widespread.  (6)  Non-bacterial  poisons.  The  remarkable  delayed  chloro- 
form poisoning  is  a  hepatic  necrosis  resembling  very  closely  acute  yellow 
atrophy.  Phosphorus  produces  a  similar  condition,  and  possibly  mercury. 
(c)  Autogenous  poisons,  produced  in  connection  with  pregnancy  and  parturi- 
tion. The  ordinary  necrotic  foci  of  the  liver  in  pregnancy  are  the  same  kind 
but  less  in  degree  than  those  of  acute  yellow  atrophy. 

An  exaggeration  of  any  of  these  types  may  lead  to  a  clinical  condition 
which  we  call  acute  yellow  atrophy.  Its  association  with  pregnancy  is  re- 
markable. More  than  one-half  of  the  cases  occur  in  women,  and  in  a  large 
proportion  of  these  during  the  middle  or  latter  half  of  pregnancy.  The  dis- 
ease has  followed  a  profound  shock,  or  mental  emotion.  It  occurs  occasionally 
in  syphilis  and  other  acute  infections,  and  there  are  cases  of  cirrhosis  of  the 
liver,  particularly  of  the  hypertrophic  form,  associated  with  diffuse  necrosis, 
intense  jaundice  and  toxaemia.  We  are  as  yet  ignorant  of  the  conditions  under 
which  the  poisons,  bacterial  or  metabolic,  cause  this  widespread  necrosis. 

Morbid  Anatomy. — The  liver  is  greatly  reduced  in  size,  looks  thin  and 
flattened,  and  sometimes  does  not  reach  more  than  one-half  or  even  one-third 
of  its  normal  weight.  It  is  flabby  and  the  capsule  is  wrinkled.  Externally 
the  organ  has  a  greenish-yellow  color.  On  section  the  color  may  be  yellowish- 
brown,  yellowish-red,  or  mottled,  and  the  outlines  of  the  lobules  are  indistinct. 
The  yellow  and  dark-red  portions  represent  different  stages  of  the  same 
process — the  yellow  an  earlier,  the  red  a  more  advanced  stage.  The  organ 
may  cut  with  considerable  firmness.  Microscopically  the  liver-cells  are  seen 
in  all  stages  of  necrosis,  and  in  spots  appear  to  have  undergone  complete 
destruction,  leaving  a  fatty,  granular  debris  with  pigment  grains  and  crystals 
of  leucin  and  tyrosin.  Haemorrhages  occur  between  the  liver-cells.  There  is 
a  cholangitis  of  the  smaller  bile-ducts.  Marchand,  MacCallum,  and  others 
have  described  regenerative  changes  in  the  cases  which  do  not  run  an  acute 
course. 


5GO  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

The  other  organs  show  extensive  bile-staining,  and  there  are  numerous 
haemorrhages.  The  kidneys  may  show  marked  granular  degeneration  of  the 
epithelium,  and  usually  there  is  fatty  degeneration  of  the  heart.  In  a  major- 
ity of  the  cases  the  spleen  is  enlarged. 

Symptoms. — In  the  initial  stage  there  is  gastro-duodenal  catarrh,  and 
at  first  the  jaundice  is  thought  to  be  of  a  simple  nature.  In  some  instances 
this  lasts  only  a  few  days,  in  others  two  or  three  weeks.  Then  severe  pymp- 
toms  set  in — headache,  delirium,  trembling  of  the  muscles,  and,  in  some 
instances,  convulsions.  Vomiting  is  a  constant  symptom,  and  blood  may  be 
brought  up.  Haemorrhages  occur  into  the  skin  or  from  the  mucous  surfaces ; 
in  pregnant  women  abortion  may  occur.  The  jaundice  usually  increases,  coma 
sets  in  and  gradually  deepens  until  death.  The  body  temperature  is  variable; 
in  a  majority  of  the  cases  the  disease  runs  an  afebrile  course,  though  some- 
times just  before  death  there  is  an  elevation.  In  some  instances,  however, 
there  has  been  marked  pyrexia.  The  pulse  is  usually  rapid,  the  tongue  coated 
and  dry,  and  the  patient  is  in  a  "typhoid  state."  There  may  be  complete 
obliteration  of  the  liver  dulness.  This  is  due  to  the  flabby  organ  falling  away 
from  the  abdominal  walls  and  allowing  the  intestinal  coils  to  take  its  place. 

The  urine  is  bile-stained  and  often  contains  tube-casts.  Frequently  albu- 
minuria  and  occasionally  albumosuria  occur.  Urea  is  markedly  diminished. 
There  is  a  corresponding  increase  in  the  percentage  of  nitrogen  present  as 
ammonia.  Herter  finds  it  may  be  increased  from  the  normal  2  to  5  per  cent, 
up  to  17  per  cent.  The  diminution  in  urea  is  probably  partly  due  to  the  liver- 
cells  failing  to  manufacture  urea  from  ammonia,  but  it  may  also  be  in  part 
due  to  organic  acids  seizing  on  the  ammonia,  and  thus  preventing  the  forma- 
tion of  urea  out  of  the  basic  ammonia.  Leucin  and  tyrosin  are  not  constantly 
present;  of  23  cases  collected  by  Hunter,  in  9  neither  was  found;  in  10  both 
were  present;  in  3  tyrosin  only;  in  1  leucin  only.  The  present  view  is  that 
the  leucin  and  tyrosin  are  derived  from  the  liver-cells  themselves  as  a  result  of 
their  extensive  destruction.  In  the  majority  of  cases  no  bile  enters  the  intes- 
tines, and  the  stools  are  clay-colored.  The  disease  is  almost  invariably  fatal. 
In  a  few  instances  recovery  has  been  noted.  I  saw  in  Leube's  clinic,  at  Wiirz- 
burg,  a  case  which  was  convalescent. 

The  duration  and  the  type  of  the  disease  depend  upon  the  extent  and  the 
rapidity  of  progress  of  the  necrosis.  Cases  have  lasted  as  long  as  forty  days, 
while  death  has  occurred  as  early  as  the  second  day.  A  sub-acute  form  has 
been  described  by  Milne,  a  slow  necrosis  lasting  many  months,  associated  with 
jaundice — a  protracted  stage  from  which  recovery  is  possible  by  regeneration 
of  liver  tissue,  but  consecutive  cirrhosis  is  the  rule. 

Diagnosis.— Jaundice  with  vomiting,  diminution  of  the  liver  volume,  de- 
lirium, and  the  presence  of  leucin  and  tyrosin  in  the  urine,  form  a  character- 
istic and  unmistakable  group  of  symptoms.  Leucin  and  tyrosin  are  not, 
however,  distinctive.  They  may  be  present  in  cases  of  afebrile  jaundice  with 
slight  enlargement  of  the  liver. 

It  is  not  to  be  forgotten  that  any  severe  jaundice  may  be  associated  with 
intense  cerebral  symptoms.  The  clinical  features  in  certain  cases  of  hyper- 
trophic  cirrhosis  are  almost  identical,  but  the  enlargement  of  the  liver,  the 
more  constant  occurrence  of  fever,  and  the  absence  of  leucin  and  tyrosin  are 
distinguishing  signs.  Phosphorus  poisoning  may  closely  simulate  acute  yellow 


AFFECTIONS    OF   BLOOD-VESSELS   OF   LIVER  561 

atrophy,  particularly  in  the  haemorrhages,  jaundice,  and  the  diminution  in  the 
liver  volume,  but  the  gastric  symptoms  are  usually  more  marked,  and  leucin 
and  tyrosin  are  stated  not  to  occur  in  the  urine. 

Treatment. — No  known  remedies  have  any  influence  on  the  course  of  the 
disease.  Theoretically,  efforts  should  be  made  to  eliminate  the  toxins  before 
they  produce  their  degenerative  effects  by  free  purgation  and  the  use  of  sub- 
cutaneous and  intravenous  saline  injections.  Gastric  sedatives  may  be  used 
to  allay  the  distressing  vomiting. 

IV.  AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE  LIVER 

Anaemia. — On  the  post  mortem  table,  when  the  liver  looks  anaemic,  as  in 
the  fatty  or  amyloid  organ,  the  blood-vessels,  which  during  life  were  probably 
well  filled,  can  be  readily  injected.  There  are  no  symptoms  indicative  of  this 
f  condition. 

Hyperasmia. — This  occurs  in  two  forms. 

(a)  ACTIVE  HYPEILEMIA. — After  each  meal  the  rapid  absorption  by  the 
portal  vessels  induces  transient  congestion  of  the  organ,  which,  however,  is 
entirely  physiological ;  but  it  is  quite  possible  that  in  persons  who  persistently 
eat  and  drink  too  much  this  active  hyperaemia  may  lead  to  functional  dis- 
turbance, or,  in  the  case  of  drinking  too  freely  of  alcohol,  to  organic  change. 
In  the  fevers  an  acute  hyperaemia  may  be  present. 

The  symptoms  of  active  hyperaemia  are  indefinite.  Possibly  the  sense 
of  distress  or  fullness  in  the  right  hypochondrium,  so  often  metioned  by 
dyspeptics  and  by  those  who  eat  and  drink  freely,  may  be  due  to  this  cause. 
There  are  probably  diurnal  variations  in  the  volume  of  the  liver.  In  cir- 
rhosis with  enlargement  the  rapid  reduction  in  volume  after  a  copious  haem- 
orrhage indicates  the  important  part  which  hyperaemia  plays  even  in  organic 
troubles.  It  is  stated  that  suppression  of  the  menses  or  suppression  of  a 
haemorrhoidal  flow  is  followed  by  hyperaemia  of  the  liver.  Andrew  H.  Smith 
has  described  a  case  of  periodical  enlargement  of  the  liver. 

(&)  PASSIVE  CONGESTION. — This  is  much  more  common  and  results  from 
an  increase  of  pressure  in  the  efferent  vessels  or  sub-lobular  branches  of  the 
hepatic  veins.  Every  condition  leading  to  venous  stasis  in  the  right  heart 
at  once  affects  these  veins. 

In  chronic  valvular  disease,  in  emphysema,  cirrhosis  of  the  lung,  and  in 
intrathoracic  tumors  mechanical  congestion  occurs  and  finally  leads  to  very 
definite  changes.  The  liver  is  enlarged,  firm,  and  of  a  deep-red  color;  the 
hepatic  vessels  are  greatly  engorged,  particularly  the  central  vein  in  each  lob- 
ule and  its  adjacent  capillaries.  On  section  the  organ  presents  a  peculiar 
mottled  appearance,  owing  to  the  deeply  congested  hepatic  and  the  anaemic 
portal  territories ;  hence  the  term  nutmeg  which  has  been  given  to  this  condi- 
tion. Gradually  the  distention  of  the  central  capillaries  reaches  such  a  grade 
that  atrophy  of  the  intervening  liver-cells  is  induced.  Brown  pigment  is 
deposited  about  the  centre  of  the  lobules  and  the  connective  tissue  is  greatly 
increased.  In  this  cyanotic  induration  or  cardiac  liver  the  organ  is  large  in 
the  early  stage,  but  later  it  may  become  contracted.  Occasionally  in  this  form 
the  connective  tissue  is  increased  about  the  lobules  as  well,  but  the  process 
usually  extends  from  the  sub-lobular  and  central  veins. 


562  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

The  symptoms  of  this  form  are  not  always  to  be  separated  from  those 
of  the  associated  conditions.  G astro-intestinal  catarrh  is  usually  present  and 
haematemesis  may  occur.  The  portal  obstruction  in  advanced  cases  leads  to 
ascites,  which  may  precede  the  development  of  general  dropsy.  There  is  often 
slight  jaundice,  the  stools  may  be  clay-colored,  and  the  urine  contains  bile- 
pigment. 

On  examination  the  organ  is  found  to  be  increased  in  size.  It  may  be  a 
full  hand's  breadth  below  the  costal  margin  and  tender  on  pressure.  It  is  in 
this  condition  particularly  that  we  meet  with  pulsation  of  the  liver.  We  must 
distinguish  the  communicated  throbbing  of  the  heart,  which  is  very  common, 
from  the  heaving,  diffuse  impulse  due  to  regurgitation  into  the  hepatic  veins, 
in  which,  when  one  hand  is  upon  the  ensiform  cartilage  and  the  other  upon 
the  right  side  at  the  margin  of  the  ribs,  the  whole  liver  can  be  felt  to  dilate 
with  each  impulse. 

The  indications  for  treatment  in  passive  hyperaemia  are  to  restore  the 
balance  of  the  circulation  and  to  unload  the  engorged  portal  vessels.  In  cases 
of  intense  hyperaemia  18  or  20  ounces  of  blood  may  be  directly  aspirated  from 
the  liver,  as  advised  by  George  Harley  and  practiced  by  many  Anglo-Indian 
physicians.  Good  results  sometimes  follow  this  hepato-phlebotomy.  The 
prompt  relief  and  marked  reduction  in  the  volume  of  the  organ  which  follow 
an  attack  of  haematemesis  or  bleeding  from  piles  suggest  .this  practice.  Salts 
administered  by  Matthew  Hay's  method  deplete  the  portal  system  freely  and 
thoroughly.  As  a  rule,  the  treatment  must  be  that  of  the  condition  with 
which  it  is  associated. 

Diseases  of  the  Portal  Vein. — (a)  THROMBOSIS;  ADHESIVE  PYLEPHLEBI- 
TIS. — Coagulation  of  blood  in  the  portal  vein  is  met  with  in  cirrhosis,  in 
syphilis  of  the  liver,  invasion  of  the  vein  by  cancer,  proliferative  perito- 
nitis involving  the  gastro-hepatic  omentum,  perforation  of  the  vein  by  gall- 
stones, and  occasionally  follows  sclerosis  of  the  walls  of  the  portal  vein  or 
of  its  branches.  In  rare  instances  a  complete  collateral  circulation  is  estab- 
lished, the  thrombus  undergoes  the  usual  change,  and  ultimately  the  vein  is 
represented  by  a  fibrous  cord,  a  condition  which  has  been  called  pyleplilebitis 
adhesiva.  In  a  case  of  this  kind  which  I  dissected  the  portal  vein  was  repre- 
sented by  a  narrow  fibrous  cord;  the  collateral  circulation,  which  must  have 
been  completely  established  for  years,  ultimately  failed,  ascites  and  haemate- 
mesis  supervened  and  rapidly  proved  fatal.  The  diagnosis  of  obstruction  of 
the  portal  vein  can  rarely  be  made.  A  suggestive  symptom,  however,  is  a 
sudden  onset  of  the  most  intense  engorgement  of  the  branches  of  the  portal 
system,  leading  to  haematemesis,  melaena,  ascites,  and  swelling  of  the  spleen. 

Infarcts  are  not  common  in  the  liver  and  may  be  either  anaemic  or  haemor- 
rhagic.  They  are  met  with  in  obstruction  of  the  portal  vessels,  or  of  the  portal 
and  hepatic  veins  at  the  same  time,  occasionally  in  disease  of  the  hepatic  ar- 
tery. 

(6)  SUPPURATIVE  PYLEPHLEBITIS  will  be  considered  in  the  section  on 
abscess. 

Affections  of  the  hepatic  vein  are  extremely  rare.  Dilatation  occurs  in 
cases  of  chronic  enlargement  of  the  right  heart,  from  whatever  cause  pro- 
duced. Emboli  occasionally  pass  from  the  right  auricle  into  the  hepatic  veins. 

Stenosis  of  the  orifices  of  the  hepatic  veins  may  occur  as  a  primary  lesion 


DISEASES    OF   BILE-PASSAGES   AND    GALL-BLADDER     563 

with  a  special  syndrome  which  has  been  described  by  Craven  Moore — a  pro- 
gressive enlargement  of  the  liver,  signs  of  involvement  of  the  inferior  vena 
cava,  and  ascites. 

Hepatic  Artery. — Enlargement  of  this  vessel  is  seen  in  cases  of  cirrhosis 
of  the  liver.  It  may  be  the  seat  of  extensive  sclerosis.  Aneurism  of  the 
hepatic  artery  is  rare,  but  instances  are  on  record,  and  will  be  referred  to  in 
the  section  on  arteries. 


V.     DISEASES   OF   THE   BILE-PASSAGES  AND   GALL-BLADDER 

I.     ACUTE    CATAREH    OF    THE    BILE-DUCTS 
(Catarrhal  Jaundice] 

Definition. — Jaundice  due  to  swelling  and  obstruction  of  the  terminal  por- 
tion of  the  common  duct. 

Etiology. — General  catarrhal  inflammation  of  the  bile-ducts  is  usually  as- 
sociated with  gall-stones.  The  catarrhal  process  now  under  consideration  is 
probably  always  an  extension  of  a  gastro-duodenal  catarrh,  and  the  process  is 
most  intense  in  the  pars  intestinalis  of  the  duct,  which  projects  into  the  duo- 
denum. The  mucous  membrane  is  swollen,  and  a  plug  of  inspissated  mucus 
fills  the  diverticulum  of  Vater,  and  the  narrower  portion  just  at  the  orifice, 
completely  obstructing  the  outflow  of  bile.  It  is  not  known  how  widespread 
this  catarrh  is  in  the  bile-passages,  and  whether  it  really  passes  up  the  ducts. 
It  would,  of  course,  be  possible  to  have  a  catarrh  of  the  finer  ducts  within  the 
liver,  which  some  French  writers  think  may  initiate  the  attack,  but  the  evi- 
dence for  this  is  not  strong,  and  it  seems  more  likely  that  the  terminal  por- 
tion of  the  duct  is  always  first  involved.  In  the  only  instance  which  I  have 
had  an  opportunity  to  examine  post  mortem  the  orifice  was  plugged  with  in- 
spissated mucus,  the  common  and  hepatic  ducts  were  slightly  distended  and 
contained  a  bile-tinged,  not  a  clear,  mucus,  and  there  were  no  observable 
changes  in  the  mucosa  of  the  ducts. 

This  catarrhal  or  simple  jaundice  results  from  the  following  causes: 
(a)  Duodenal  catarrh,  in  whatever  way  produced,  most  commonly  following 
an  attack  of  indigestion.  It  is  most  frequently  met  with  in  young  persons, 
but  may  occur  at  any  age,  and  may  follow  not  only  errors  in  diet,  but  also 
cold,  exposure,  and  malaria,  as  well  as  the  conditions  associated  with  portal 
obstruction,  chronic  heart-disease,  and  Bright's  disease.  (&)  Emotional  dis- 
turbances may  be  followed  by  jaundice,  which  is  believed  to  be  due  to  catar- 
rhal swelling.  Cases  of  this  kind  are  rare  and  the  anatomical  condition  is 
unknown,  (c)  Simple  or  catarrhal  jaundice  may  occur  in  epidemic  form. 
(d)  Catarrhal  jaundice  is  occasionally  seen  in  the  infectious  fevers,  such  as 
pneumonia  and  typhoid  fever.  The  nature  of  acute  catarrhal  jaundice  is 
still  unknown.  It  may  possibly  be  an  acute  infection.  In  favor  of  this 
view  are  the  occurrence  in  epidemic  form  and  the  presence  of  slight  fever. 
The  spleen,  however,  is  not  often  enlarged.  In  only  4  out  of  23  cases  was  it 

palpable. 

Symptoms. — There  may  be  neither  pain  nor  distress,  and  the  patient's 
friends  may  first  notice  the  yellow  tint,  or  the  patient  himself  may  observe  it 


564  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

in  the  looking-glass.  In  other  instances  there  are  dyspeptic  symptoms  and 
uneasy  sensations  in  the  hepatic  region  or  pains  in  the  back  and  limbs.  In 
the  epidemic  form  the  onset  may  be  more  severe,  with  headache,  chill,  and 
vomiting.  Fever  is  rarely  present,  though  the  temperature  may  reach  101 
degrees,  sometimes  102  degrees.  All  the  signs  of  obstructive  jaundice  already 
mentioned  are  present,  the  stools  are  clay-colored,  and  the  urine  contains  bile- 
pigment.  The  skin  has  a  bright-yellow  tint;  the  greenish,  bronzed  color  is 
never  seen  in  the  simple  form.  I  have  once  seen  spider  angiomata  on  the  face 
in  catarrhal  jaundice.  They  disappeared  in  a  few  months.  The  pulse  may  be 
Tiormal,  but  occasionally  it  is  remarkably  slow,  and  may  fall  to  40  or  30  beats 
in  the  minute,  and  the  respirations  to  as  low  as  8  per  minute.  Sleepiness,  too, 
may  be  present.  The  liver  may  be  normal  in  size,  but  is  usually  slightly  en- 
larged, and  the  edge  can  be  felt  below  the  costal  margin.  Occasionally  the 
enlargement  is  more  marked.  As  a  rule  the  gall-bladder  can  not  be  felt.  The 
spleen  may  be  increased  in  size.  The  duration  of  the  disease  is  from  four  to 
eight  weeks.  There  are  mild  cases  in  which  the  jaundice  disappears  within 
two  weeks ;  on  the  other  hand,  it  may  persist  for  three  months  or  even  longer. 
The  stools  should  be  carefully  watched,  for  they  give  the  first  intimation  of 
removal  of  the  obstruction. 

Diagnosis. — This  is  rarely  difficult.  The  onset  in  young,  comparatively 
healthy  persons,  the  moderate  grade  of  icterus,  the  absence  of  emaciation  or 
of  evidences  of  cirrhosis  or  cancer  usually  make  the  diagnosis  easy.  Cases 
which  persist  for  two  or  three  months  cause  uneasiness,  as  the  suspicion  is 
aroused  that  it  may  be  more  than  simple  catarrh.  The  absence  of  pain,  the 
negative  character  of  the  physical  examination,  and  the  maintenance  of  the 
general  nutrition  are  the  points  in  favor  of  simple  jaundice.  There  are 
instances  in  which  time  alone  can  determine  the  true  nature  of  the  case.  The 
possibility  of  Weil's  disease  must  be  borne  in  mind  in  anomalous  types. 

Treatment. — The  diet  should  be  simple  and  the  fats  restricted.  Measures 
should  be  used  to  allay  the  gastric  catarrh,  if  it  is  present.  A  dose  of  calomel 
may  be  given,  and  the  bowels  kept  open  subsequently  by  salines.  The  patient 
should  not  be  violently  purged.  Bismuth  and  bicarbonate  of  soda  may  be 
given,  and  the  patient  should  drink  freely  of  the  alkaline  mineral  waters,  of 
which  Vichy  is  the  best.  Irrigation  of  the  large  bowel  with  cold  water  may 
be  practiced.  The  cold  is  supposed  to  excite  peristalsis  of  the  gall-bladder  and 
ducts,  and  thus  aid  in  the  expulsion  of  the  mucus. 

II.     CHRONIC    CATARRHAL    ANGIOCHOLITIS 

This  may  possibly  occur  also  as  a  sequel  of  the  acute  catarrh.  I  have  never 
met  with  an  instance,  however,  in  which  a  chronic,  persistent  jaundice  could 
be  attributed  to  this  cause.  A  chronic  catarrh  always  accompanies  obstruc- 
tion in  the  common  duct,  whether  by  gall-stones,  malignant  disease,  stricture, 
•or  external  pressure.  There  are  two  groups  of  cases : 

With  Complete  Obstruction  of  the  Common  Duct. — In  this  form  the  bile- 
passages  are  greatly  dilated,  the  common  duct  may  reach  the  size  of  the  thumb 
or  larger,  there  is  usually  dilatation  of  the  gall-bladder  and  of  the  ducts  within 
the  liver.  The  contents  of  the  ducts  and  of  the  gall-bladder  are  a  clear,  color- 
less mucus.  The  mucosa  may  be  everywhere  smooth  and  not  swollen-  The 


DISEASES    OF   BILE-PASSAGES    AND    GALL-BLADDER     5G5 

clear  mucus  is  usually  sterile.  The  patients  are  the  subjects  of  chronic  jaun- 
dice, usually  without  fever. 

With  Incomplete  Obstruction  of  the  Duct. — There  is  pressure  on  the  duct 
or  there  are  gall-stones,  single  or  multiple,  in  the  common  duct  or  in  the 
diverticulum  of  Vater.  The  bile-passages  are  not  so  much  dilated,  and  the 
contents  are  a  bile-stained,  turbid  mucus.  The  gall-bladder  is  rarely  much 
dilated.  In  a  majority  of  all  cases  stones  are  found  in  it. 

The  symptoms  of  this  type  of  catarrhal  angiocholitis  are  sometimes  very 
distinctive.  With  it  is  associated  most  frequently  the  so-called  hepatic  inter- 
mittent fever,  recurring  attacks  of  chills,  fever,  and  sweats.  It  is  most  impor- 
tant to  bear  in  mind  that  the  chills,  fever,  and  sweats  do  not  necessarily  mean 
suppuration. 

III.     SUPPUEATIVE    AND    ULCEEATIVE    ANGIOCHOLITIS 

The  condition  is  a  diffuse,  purulent  angiocholitis  involving  the  larger  and 
smaller  ducts.  In  a  large  proportion  of  all  cases  there  is  associated  suppura- 
tive  disease  of  the  gall-bladder. 

Etiology. — It  is  the  most  serious  of  the  sequels  of  gall-stones.  Occa- 
sionally a  diffuse  suppurative  angiocholitis  follows  the  acute  infectious  chole- 
cystitis; this,  however,  is  rare,  since  fortunately  in  the  latter  condition  the 
cystic  duct  is  usually  occluded.  Cancer  of  the  duct,  or  foreign  bodies,  such  as 
lumbricoids  or  fish  bones,  are  occasional  causes.  There  may  be  extension  from 
a  suppurative  pylephlebitis.  In  rare  instances  suppurative  cholangitis  occurs 
in  the  acute  infections,  as  pneumonia  and  influenza. 

The  common  duct  is  greatly  dilated  and  may  reach  the  size  of  the  index 
finger  or  the  thumb ;  the  walls  are  thickened,  and  there  may  be  fistulous  com- 
munications with  the  stomach,  colon,  or  duodenum.  The  hepatic  ducts  and 
their  extensions  in  the  liver  are  dilated  and  contain  pus  mixed  with  bile.  On 
section  of  the  liver  small  abscesses  are  seen,  which  correspond  to  the  dilated 
suppurating  ducts.  The  gall-bladder  is  usually  distended,  full  of  pus,  and 
with  adhesions  to  the  neighboring  parts,  or  it  may  have  perforated. 

Symptoms. — The  symptoms  of  suppurative  cholangitis  are  usually  very 
severe.  A  previous  history  of  gall-stones,  the  development  of  a  septic  fever,  the 
swelling  and  tenderness  of  the  liver,  the  enlargement  of  the  gall-bladder,  and 
the  leucocytosis  are  suggestive  features.  Jaundice  is  always  present,  but  is 
variable.  In  some  cases  it  is  very  intense,  in  others  it  is  slight.  There  may 
be  very  little  pain.  There  are  progressive  emaciation  and  loss  of  strength.  In 
a  recent  case  parotitis  developed  on  the  left  side,  which  subsided  without  sup- 
puration. 

Ulceration,  stricture,  perforation,  and  fistula?  of  the  bile-passages  will  be 
considered  with  gall-stones. 

IV.     ACUTE    INFECTIOUS    CHOLECYSTITIS 

Etiology. — Acute  inflammation  of  the  gall-bladder  is  usually  due  to  bac- 
terial invasion,  with  or  without  the  presence  of  gall-stones.  Three  varieties  or 
grades  may  be  recognized :  the  catarrhal,  the  suppurative,  and  the  phlegmo- 
nous.  The  condition  is  very  serious,  difficult  to  diagnose,  often  fatal,  and  may 
require  for  its  relief  prompt  surgical  intervention. 


566  DISEASES    OF   THE   DIGESTIVE    SYSTEM 

Acute  non-calculous  cholecystitis  is  a  result  of  bacterial  invasion.  The 
colon  bacillus,  the  typhoid  bacillus,  the  pneumococcus  and  staphylococci  and 
streptococci  have  been  the  organisms  most  often  found.  The  frequency  of 
gall-bladder  infection  in  the  fevers  is  a  point  already  referred  to,  particularly 
in  typhoid  fever. 

The  association  of  appendix  lesions  with  cholecystitis  is  interesting,  fully 
69  per  cent,  at  the  Mayo  clinic ;  but  this  is  not  surprising  in  view  of  studies 
which  show  a  normal  appendix  to  be  a  rarity.  There  are  indications,  however, 
that  chronic  changes  in  this  organ  may  reflexly  disturb  the  mechanism  of  the 
secretion,  storage,  and  outflow  of  bile. 

Condition  of  the  Gall-bladder. — The  organ  is  usually  distended  and  the 
walls  tense.  Adhesions  may  have  formed  with  the  colon  or  the  omentum.  In 
the  acute  stage  the  mucous  membrane  is  swollen  and  the  amount  of  mucin 
increased.  As  the  process  continues  the  mucosa  becomes  thickened,  the  epithe- 
lium desquamates,  there  are  areas  of  necrosis,  and  the  villi  may  be  much 
hypertrophied  and  stand  out,  giving  a  strawberry  appearance.  With  the 
obstruction  of  the  duct  and  pyogenic  infection  there  may  be  acute  necrotic 
cholecystitis,  with  rapid  perforation,  or  a  more  chronic  purulent  cholecystitis 
— empyema  of  the  gall-bladder. 

Symptoms. — Severe  paroxysmal  pain  is,  as  a  rule,  the  first  indication,  most 
commonly  in  the  right  side  of  the  abdomen  in  the  region  of  the  liver.  It 
may  be  in  the  epigastrium  or  low  down  in  the  region  of  the  appendix. 
"Nausea,  vomiting,  rise  of  pulse  and  temperature,  prostration,  distention  of 
the  abdomen,  rigidity,  general  tenderness  becoming  localized"  usually  follow 
(Eichardson).  In  this  form,  without  gall-stones,  jaundice  is  not  often  pres- 
ent. The  local  tenderness  is  extreme,  but  it  may  be  deceptive  in  its  situation. 
Associated  probably  with  the  adhesion  and  inflammatory  processes  between 
the  gall-bladder  and  the  bowel  are  the  intestinal  symptoms,  and  there  may  be 
complete  stoppage  of  gas  and  fasces;  indeed,  the  operation  for  acute  obstruc- 
tion has  been  performed  in  several  cases.  The  distended  gall-bladder  may 
sometimes  be  felt.  As  a  sequel  there  may  be  purulent  distention  or  empyema. 

Diagnosis. — The  diagnosis  is  by  no  means  easy.  The  symptoms  may  not 
indicate  the  section  of  the  abdomen  involved.  Appendicitis  may  be  diagnosed ; 
or  acute  intestinal  obstruction.  The  history  of  the  cases  is  often  a  valuable 
guide.  Occurring  during  the  convalescence  from  typhoid  fever,  after  pneu- 
monia, or  in  a  patient  with  previous  cholecystitis,  such  a  group  of  symptoms 
as  mentioned  would  be  highly  suggestive.  The  differentiation  of  the  variety 
of  the  cholecystitis  can  not  be  made.  In  the  acute  suppurative  and  phleg- 
monous  forms  the  symptoms  are  usually  more  severe,  perforation  is  very  apt 
to  occur,  with  local  or  general  peritonitis,  and  unless  operative  measures  are 
undertaken  death  ensues. 

There  is  an  acute  cholecystitis,  probably  an  infective  form,  in  which  the 
patient  has  recurring  attacks  of  pain  in  the  region  of  the  gall-bladder.  The 
diagnosis  of  gall-stones  is  made,  but  an  operation  shows  simply  an  enlarged 
'  gall-bladder  filled  with  mucus  and  bile,  and  the  mucous  membrane  perhaps 
swollen  and  inflamed.  In  some  of  these  cases  gall-stones  may  have  been  pres- 
ent and  have  passed  before  the  operation. 

Treatment. — In  the  milder  catarrhal  forms  the  inflammation  subsides 
spontaneously;  in  severer  form  operation  is  indicated  and  the  results  are  ex- 


DISEASES    OF   BILE-PASSAGES   AND   GALL-BLADDER     56? 

cellent.    Of  675  cholecystectomies  at  the  Mayo  clinic  there  were  only  seven- 
teen deaths. 

V.     CANCER    OF    THE    BILE-PASSAGES 

Incidence. — Of  3,908  operations  on  the  gall-bladder  and  biliary  passages> 
in  85  or  2.1  per  cent,  cancer  was  found  (Mayo).  It  is  more  common  in 
women,  3  to  1  (Musser),  and  in  three-fourths  of  the  cases  gall-stones  are  or 
have  been  present.  The  fundus  of  the  bladder  is  usually  attacked  first. 

Symptoms. — When  the  disease  involves  the  gall-bladder,  a  tumor  can  be 
detected  extending  diagonally  downward  and  inward  toward  the  navel,  variable 
in  size,  occasionally  very  large,  due  either  to  great  distention  of  the  gall- 
bladder or  to  involvement  of  contiguous  parts.  It  is  usually  very  firm  and 
hard. 

Among  the  important  symptoms  are  jaundice,  which  was  present  in  69 
per  cent,  of  Musser's  cases;  pain,  often  of  great  severity  and  paroxysmal  in 
character.  The  pain  and  tenderness  on  pressure  persist  in  the  intervals  be- 
tween the  paroxysmal  attacks.  There  is  loss  of  weight,  sometimes  fever  and 
sweats.  When  the  liver  becomes  involved  the  picture  is  that  of  carcinoma  of 
the  organ. 

Primary  malignant  disease  in  the  bile-ducts  is  less  common,  and  rarely 
forms  tumors  that  can  be  felt  externally.  The  tumor  is  usually  in  the  com- 
mon duct,  57  of  80  cases  collected  by  Rolleston.  There  is  usually  an  early, 
intense,  and  persistent  jaundice.  The  gall-bladder  is  usually  enlarged  in 
obstruction  of  the  common  duct  by  malignant  disease.  The  dilated  gall- 
bladder may  rupture.  At  best  the  diagnosis  is  very  doubtful,  unless  cleared 
up  by  an  exploratory  operation.  A  very  interesting  form  of  malignant  dis- 
ease of  the  ducts  is  that  which  involves  the  diverticulum  of  Vater.  Rolleston 
has  collected  16  cases. 

VI.     STENOSIS    AND    OBSTRUCTION   OF   THE   BILE-DUCTS 

Stenosis. — Stenosis  or  complete  occlusion  may  follow  ulceration,  most  com- 
monly after  the  passage  of  a  gall-stone.  In  these  instances  the  obstruction  is 
usually  situated  low  down  in  the  common  duct.  Instances  are  extremely  rare. 
Foreign  bodies,  such  as  the  seeds  of  various  fruits,  may  enter  the  duct,  and 
occasionally  round  worms  crawl  into  it.  Liver-flukes  and  echinococci  are  rare 
causes  of  obstruction  in  man. 

Obstruction. — Obstruction  by  pressure  from  without  is  more  frequent. 
Cancer  of  the  head  of  the  pancreas,  less  often  a  chronic  interstitial  inflamma- 
tion, may  compress  the  terminal  portion  of  the  duct;  rarely,  cancer  of  the 
pylorus.  Secondary  involvement  of  the  lymph-glands  of  the  liver  is  a  common 
cause  of  occlusion  of  the  duct,  and  is  met  with  in  many  cases  of  cancer  of  the 
stomach  and  other  abdominal  organs.  Rare  causes  of  obstruction  are  aneu- 
rism of  a  branch  of  the  cceliac  axis  of  the  aorta,  and  pressure  of  very  large 
abdominal  tumors. 

SYMPTOMS. — The  symptoms  produced  are  those  of  chronic  obstructive 
jaundice.  At  first,  the  liver  is  enlarged,  but  in  chronic  cases  it  may  be  re- 
duced in  size,  and  be  found  of  a  deeply  bronzed  color.  The  hepatic  inter- 
mittent fever  is  not  often  associated  with  complete  occlusion  of  the  duct  from 


568  DISEASES    OF   THE   DIGESTIVE    SYSTEM 

any  cause,  but  it  is  most  frequently  met  with  in  chronic  obstruction  by  gall- 
stones. Permanent  occlusion  of  the  duct  terminates  in  death.  In  a  majority 
of  the  cases  the  conditions  which  lead  to  the  obstruction  are  in  themselves 
fatal.  The  liver,  which  is  not  necessarily  enlarged,  presents  a  moderate  grade 
of  cirrhosis.  Cases  of  cicatricial  occlusion  may  last  for  years. 

DIAGNOSIS. — A  history  of  colic,  jaundice  of  varying  intensity,  paroxysms 
of  pain,  and  intermittent  fever  point  to  gall-stones.  In  cancerous  obstruction 
the  tumor  mass  can  sometimes  be  felt  in  the  epigastric  region.  In  cases  in 
which  the  lymph-glands  in  the  transverse  fissure  are  cancerous  the  primary 
disease  may  be  in  the  pelvic  organs  or  the  rectum,  or  there  may  be  a  limited 
cancer  of  the  stomach,  which  has  not  given  any  symptoms.  In  these  cases  the 
examination  of  the  other  lymphatic  glands  may  be  of  value.  Involvement  of 
the  clavicular  groups  of  lymph-glands  may  also  be  serviceable  in  diagnosis. 
The  gall-bladder  is  usually  enlarged  in  obstruction  of  the  common  duct,  ex- 
cept in  the  cases  of  gall-stones  (Courvoisier's  law).  Great  and  progressive  en- 
largement of  the  liver  with  jaundice  and  moderate  continued  fever  is  more 
commonly  met  with  in  cancer. 

Congenital  Obliteration  of  the  Ducts. — John  Thomson,  in  1892,  collected 

49  cases  and  studied  the  condition  thoroughly.     C.  P.  Howard  and  Wolbach, 
reviewing  the  recent  literature,  bring  the  cases  up  to  76,  exclusive  of  those 
associated  with  syphilis.    Jaundice  sets  in  early,  but  may  be  delayed  for  ten 
or  twelve  days,  and  is  progressive  and  deep.    Haemorrhages  in  the  skin,  from 
the  gastro-intestinal  tract,  and  from  the  umbilical  cord  have  occurred  in  fully 

50  per  cent.     Nearly  one-half  of  the  cases  die  within  the  first  month,  a  few 
live  on  for  five  or  six  months,  but  rarely  as  long  as  the  tenth  or  twelfth. 

Thomson  regards  congenital  malformation  as  the  chief  cause,  others  are 
due  to  cholangitis  and  a  few  to  congenital  cirrhosis  of  the  liver. 


VI.    CHOLELITHIASIS 

No  chapter  in  medicine  is  more  interesting  than  that  which  deals  with  the 
question  of  gall-stones.  Few  affections  present  so  many  points  for  study — 
chemical,  bacteriological,  pathological,  and  clinical.  The  past  few  years  have 
seen  a  great  advance  in  our  knowledge  in  two  directions:  First,  as  to  the 
mode  of  formation  of  the  stones,  and,  secondly,  as  to  the  surgical  treatment  of 
the  cases. 

Origin  of  Gall-stones. — Two  important  points  with  reference  to  the  for- 
mation of  calculi  in  the  bile-passages  were  brought  out  by  Naunyn :  (a)  The 
origin  of  the  cholesterin  of  the  bile,  as  well  as  of  the  lime  salts  from  the  mu- 
cous membrane  of  the  biliary  passages,  particularly  when  inflamed;  and  (6) 
the  remarkable  association  of  micro-organisms  with  gall-stones.  It  is  stated 
that  Bristowe  first  noticed  the  origin  of  cholesterin  in  the  gall-bladder  itself, 
but  Naunyn's  observations  showed  that  both  the  cholesterin  and  the  lime  were 
in  great  part  a  production  of  the  mucosa  of  the  gall-bladder  and  of  the  bile- 
ducts,  particularly  when  in  a  condition  of  catarrhal  inflammation  excited  by 
the  presence  of  microbes.  According  to  the  views  of  this  author,  the  lithoge- 
nous  catarrh  (which,  by  the  way,  is  quite  an  old  idea)  modifies  materially  the 
chemical  constitution  of  the  bile  and  favors  the  deposition  about  epithelial 


CHOLELITHIASIS  569 

debris  and  bacteria  of  the  insoluble  salts  of  lime  in  combination  with  the.  bili- 
rubin.  Welch  and  others  have  demonstrated  the  presence  of  micro-organisms 
in  the  centre  of  gall-stones.  Three  additional  points  of  interest  may  be  re- 
ferred to : 

First,  the  demonstration  that  the  gall-bladder  is  a  peculiarly  favorable 
habitat  for  micro-organisms.  The  colon  bacilli,  staphylococci,  streptococci, 
pneumococci,  and  the  typhoid  bacilli  have  all  been  found  here  under  varying 
conditions  of  the  bile.  A  remarkable  fact  is  the  length  of  time  that  they  may 
live  in  the  gall-bladder,  as  was  first  demonstrated  by  Blachstein  in  Welch's 
laboratory.  The  typhoid  bacillus  has  been  isolated  in  pure  culture  20  or  30 
years  after  an  attack. 

Secondly,  the  experimental  production  of  gall-stones  has  been  successfully 
accomplished  by  Gilbert  and  Fournier  by  injecting  micro-organisms  into  the 
gall-bladder  of  animals. 

Thirdly,  the  association  of  gall-stones  with  the  specific  fevers.  Bernheim, 
in  1889,  first  called  attention  to  the  frequency  of  gall-stone  attacks  after 
typhoid. 

While  it  is  probable  that  a  lithogenous  catarrh,  induced  by  micro-organ- 
isms, is  the  most  important  single  factor,  there  are  other  accessory  causes  of 
great  moment. 

Country. — Gall-stones  are  less  frequent  in  the  United  States  than  in  Ger- 
many, 6.94  to  12  per  cent.  (Mosher).  They  are  less  common  in  England  than 
on  the  Continent. 

Age. — Nearly  50  per  cent,  of  all  the  cases  occur  in  persons  above  forty 
years  of  age.  They  are  rare  under  twenty-five.  They  have  been  met  with  in 
the  new-bom,  and  in  infants  (John  Thomson). 

Sex. — Three-fourths  of  the  cases  occur  in  women.  Pregnancy  has  an  im- 
portant influence.  Naunyn  states  that  90  per  cent,  of  women  with  gall-stones 
have  borne  children. 

All  conditions  which  favor  stagnation  of  bile  in  the  gall-bladder  predispose 
to  the  formation  of  stones.  Among  these  may  be  mentioned  corset-wearing, 
enteroptosis,  nephroptosis,  and  occupations  requiring  a  "leaning  forward" 
position.  Lack  of  exercise,  sedentary  occupations,  particularly  when  com- 
bined with  over-indulgence  in  food,  constipation,  and  depressing  mental  emo- 
tions are  also  to  be  regarded  as  favoring  circumstances.  The  belief  prevailed 
formerly  that  there  was  a  lithiac  diathesis  closely  allied  to  that  of  gout. 

Physical  Characters  of  Gall-stones. — They  may  be  single,  in  which  case 
the  stone  is  usually  ovoid  and  may  attain  a  very  large  size.  Instances  are  on 
record  of  gall-stones  measuring  more  than  5  inches  in  length.  They  may  be 
extremely  numerous,  ranging  from  a  score  to  several  hundreds  or  even  several 
thousands,  in  which  case  the  stones  are  very  small.  When  moderately  numer- 
ous, they  show  signs  of  mutual  pressure  and  have  a  polygonal  form,  with 
smooth  facets;  occasionally,  however,  five  or  six  gall-stones  of  medium  size 
are  met  with  in  the  bladder  which  are  round  or  ovoid  and  without  facets. 
They  are  sometimes  mulberry-shaped  and  very  dark,  consisting  largely  of  bile- 
pigments.  Again  there  are  small,  black  calculi,  rough  and  irregular  in  shape, 
and  varying  in  size  from  grains  of  sand  to  small  shot.  These  are  sometimes 
known  as  gall-sand.  On  section,  a  calculus  contains  a  nucleus,  which  consists 
of  bile-pigmen£,  rarely  a  foreign  body..  The  greater  portion  of  the  stone  is 
38 


5?0  DISEASES   OF   THE   DIGESTIVE    SYSTEM 

made  up  of  cholesterin,  which  may  form  the  entire  calculus  and  is  arranged 
in  concentric  laminae  showing  also  radiating  lines.  Salts  of  lime  and  mag- 
nesia, bile  acids,  fatty  acids,  and  traces  of  iron  and  copper  are  also  found  in 
them.  Most  gall-stones  consist  of  from  70  to  80  per  cent,  of  cholesterin,  in 
either  the  amorphous  or  the  crystalline  form.  As  above  stated,  it  is  sometimes 
pure,  but  more  commonly  it  is  mixed  with  the  bile-pigment.  The  outer  layer 
of  the  stone  is  usually  harder  and  brownish  in  color. 

Seat  of  Formation. — Within  the  liver  itself  calculi  are  occasionally  found, 
but  are  here  usually  small  and  not  abundant,  and  in  the  form  of  ovcid,  green- 
ish-black grains.  A  large  majority  of  all  calculi  are  formed  within  the  gall- 
bladder. The  stones  in  the  larger  ducts  have  usually  had  their  origin  in  the 
gall-bladder. 

Symptoms. — In  a  number  of  cases  gall-stones  cause  no  symptoms.  The 
gall-bladder  will  tolerate  the  presence  of  large  numbers  for  an  indefinite 
period  of  time,  and  post  mortem  examinations  show  that  they  are  present  in 
25  per  cent,  of  all  women  over  sixty  years  of  age  (Naunyn).  Moynihan  claims 
that  in  most  cases  there  are  early  symptoms — a  sense  of  fullness,  weight,  and 
oppression  in  the  epigastrium;  a  catch  in  the  breath,  a  feeling  of  faintness 
or  nausea,  and  a  chilliness  after  eating.  Attacks  of  indigestion  are  common, 
and  it  is  important  to  remember  that  persistent  gastric  symptoms  are  often 
due  to  gall-stones.  I  have  seen  two  cases  with  obstinate  attacks  of  urticaria. 

The  main  symptoms  of  cholelithiasis  may  be  divided  into  (1)  the  aseptic, 
mechanical  accidents  in  consequence  of  migration  of  the  stone  or  of  obstruc- 
tion, either  in  the  ducts  or  in  the  intestines;  (2)  the  septic,  infectious  acci- 
dents, either  local  (the  angiocholitis  and  cholecystitis  with  empyema  of  the 
gall-bladder,  and  the  fistulas  and  abscess  of  the  liver  and  infection  of  the 
neighboring  parts)  or  general,  the  biliary  fever  and  the  secondary  visceral 
lesions. 

BILIARY  COLIC. — Gall-stones  may  become  engaged  in  the  cystic  or  the 
common  duct  without  producing  pain  or  severe  symptoms.  More  commonly 
the  passage  of  a  stone  excites  the  violent  symptoms  known  as  biliary  colic.  The 
attack  sets  in  abruptly  with  agonizing  pain  in  the  right  hypochondriac  region, 
which  radiates  to  the  shoulder,  or  is  very  intense  in  the  epigastric  and  in  the 
lower  thoracic  regions.  It  is  often  associated  with  a  rigor  and  a  rise  in  tem- 
perature from  102  degrees  to  103  degrees.  The  pain  is  usually  so  intense  that 
the  patient  rolls  about  in  agony.  There  are  vomiting,  profuse  sweating,  and 
great  depression  of  the  circulation.  There  may  be  marked  tenderness  in  the 
region  of  the  liver,  which  may  be  enlarged,  and  the  gall-bladder  may  become 
palpable  and  very  tender.  In  other  cases  the  fever  is  more  marked.  The 
spleen  is  enlarged  (Naunyn)  and  the  urine  contains  albumin  with  red  blood- 
corpuscles.  Ortner  holds  that  cholecystitis  acuta,  occurring  in  connection  with 
gall-stones,  is  a  septic  (bacterial)  infection  of  the  bile-passages.  The  symp- 
toms of  acute  infectious  cholecystitis  and  those  of  what  we  call  gall-stone  colic 
are  very  similar,  and  surgeons  have  frequently  performed  cholecystotomy  for 
the  former  condition,  believing  calculi  were  present.  In  a  large  number  of  the 
cases  jaundice  occurs,  but  it  is  not  a  necessary  symptom.  Of  course  it  does  not 
happen  during  the  passage  of  the  stone  through  the  cystic  duct,  but  only  when 
it  becomes  lodged  in  the  common  duct.  The  pain  is  due  (a)  to  the  slow 
progress  in  the  cystic  duct,  in  which  the  stone  takes  a  rotary  "course  owing  to 


CHOLELITHIASIS  571 

the  arrangement  of  the  Heisterian  valve;  the  cystic  duct  is  poor  in  muscle 
fibres  but  rich  in  nerves  and  ganglia;  (&)  to  the  acute  inflammation  which 
usually  accompanies  an  attack;  (c)  to  the  stretching  and  distention  of  the 
gall-bladder  by  retained  secretions. 

The  attack  varies  in  duration.  It  may  last  for  a  few  hours,  several  days, 
or  even  a  week  or  more.  If  the  stone  becomes  impacted  in  the  orifice  of  the 
common  duct,  the  jaundice  becomes  intense;  much  more  commonly  it  is  a 
slight  transient  icterus.  The  attack  of  colic  may  be  repeated  at  intervals  for 
some  time,  but  finally  the  stone  passes  and  the  symptoms  disappear. 

Occasionally  accidents  occur,  such  as  rupture  of  the  duct  with  fatal  peri- 
tonitis. Fatal  syncope  during  an  attack  and  the  occurrence  of  repeated  con- 
vulsive seizures  have  come  under  my  observation.  These  are,  however,  rare 
events.  Palpitation  and  distress  about  the  heart  may  be  present,  and  occa- 
sionally a  mitral  murmur  occurs  during  the  paroxysm,  but  the  cardiac  condi- 
tions described  by  some  writers  as  coming  on  acutely  in  biliary  colic  are  possi- 
bly preexistent  in  these  patients. 

The  diagnosis  of  acute  hepatic  colic  is  generally  easy.  The  pain  is  in  the 
upper  abdominal  and  thoracic  regions,  whereas  the  pain  in  nephritic  colic  is 
in  the  lower  abdomen.  A  chill,  with  fever,  is  much  more  frequent  in  biliary 
colic  than  in  gastralgia,  with  which  it  is  liable,  at  times,  to  be  confounded. 
A  history  of  previous  attacks  is  an  important  guide,  and  the  occurrence  of 
jaundice,  however  slight,  determines  the  diagnosis.  To  look  for  the  gall-stones, 
the  stools  should  be  thoroughly  mixed  with  water  and  carefully  filtered  through 
a  narrow-meshed  sieve.  Pseudo-biliary  colic  is  not  infrequently  met  with  in 
nervous  women,  and  the  diagnosis  of  gall-stones  made.  This  nervous  hepatic 
colic  may  be  periodical;  the  pain  may  be  in  the  right  side  a.nd  radiating;  some- 
times associated  with  other  nervous  phenomena,  often  excited  by  emotion, 
fatigue  or  excesses.  The  liver  may  be  tender,  but  there  are  neither  icterus  nor 
inflammatory  conditions.  The  combination  of  colic  and  jaundice,  so  distinctive 
of  gall-stones,  is  not  always  present.  The  pains  may  not  be  colicky,  but  more 
constant  and  dragging  in  character.  A  remarkable  xanthoma  of  the  bile- 
passages  has  been  found  in  association  with  hepatic  colic.  Many  patients 
with  gall-stones  have  stomach  symptoms — flatulency,  regurgitation,  and  dis- 
tress after  eating.  Sometimes  the  pain  may  be  much  increased  by  food  or  on 
exertion.  In  chronic  gall-bladder  cases,  with  adhesions  and  perforation,  the 
clinical  picture  may  resemble  closely  that  of  ulcer. 

OBSTRUCTION  OF  THE  CYSTIC  DUCT. — The  effects  may  be  thus  enumer- 
ated: 

(a)  Dilatation  of  the  gall-bladder — hydrops  vesica?  feller.  In  acute  ob- 
struction the  contents  are  bile  mixed  with  much  mucus  or  muco-purulent  mate- 
rial. In  chronic  obstruction  the  bile  is  replaced  by  a  clear  fluid  mucus.  This 
is  an  important  point  in  diagnosis,  particularly  as  a  dropsical  gall-bladder  may 
form  a  very  large  tumor.  The  reaction  is  not  always  constant.  It  is  either 
alkaline  or  neutral;  the  consistence  is  thin  and  mucoid.  Albumin  is  usually 
present.  A  dilated  gall-bladder  may  reach  an  enormous  size,  and  in  one  in- 
stance Tait  found  it  occupying  the  greater  part  of  the  abdomen.  In  such 
cases,  as  is  not  unnatural,  it  has  been  mistaken  for  an  ovarian  tumor.  I  have 
described  a  case  in  which  it  was  attached  to  the  right  broad  ligament.  The 
dilated  gall-bladder  can  usually  be  felt  below  the  edge  of  the  liver,  and  in 


572  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

many  instances  it  has  a  characteristic  outline  like  a  gourd.  An  enlarged  and 
relaxed  organ  may  not  be  palpable,  and  in  acute  cases  the  distention  may  be 
upward  toward  the  hilus  of  the  liver.  The  dilated  gall-bladder  usually  pro- 
jects directly  downward,  rarely  to  one  side  or  the  other,  though  occasionally 
toward  the  middle  line.  It  may  reach  below  the  navel,  and  in  persons  with 
thin  walls  the  outline  can  be  accurately  defined.  Riedel  has  called  attention 
to  a  tongue-like  projection  of  the  anterior  margin  of  the  right  lobe  in  connec- 
tion with  enlarged  gall-bladder.  It  is  to  be  remembered  that  distention  of  the 
gall-bladder  may  occur  without  jaundice ;  indeed,  the  greatest  enlargement  has 
been  met  with  in  such  cases. 

Gall-stone  crepitus  may  be  felt  when  the  bladder  is  very  full  of  stones  and 
its  walls  not  very  tense.  It  is  rarely  well  felt  unless  the  abdominal  walls  are 
much  relaxed.  It  may  be  found  in  patients  who  have  never  had  any  symptoms 
of  cholelithiasis. 

(6)  Acute  cholecystitis.  The  simple  form  is  common,  and  to  it  are  due 
probably  very  many  of  the  symptoms  of  the  gall-stone  attack.  Phlegmonous 
cholecystitis  is  rare.  Perforation  may  occur  with  fatal  peritonitis. 

(c)  Suppurative  cholecystitis,  empyema  of  the  gall-bladder,  is  much  more 
common,  and  in  the  great  majority  of  cases  is  associated  with  gall-stones. 
There  may  be  enormous  dilatation,  and  over  a  litre  of  pus  has  been  found. 
Perforation  and  the  formation  of  abscesses   in  the  neighborhood  are  not 
uncommon. 

(d)  Calcification  of  the  gall-bladder  is  commonly  a  termination  of  the 
previous  condition.    There  are  two  separate  forms:  incrustation  of  the  mucosa 
with  lime  salts  and  the  true  infiltration  of  the  wall  with  lime,  the  so-called 
ossification. 

(e)  Atrophy  of  the  gall-bladder.    This  is  by  no  means  uncommon.     The 
organ  shrinks  into  a  small  fibroid  mass,  not  larger,  perhaps,  than  a  good-sized 
pea  or  walnut,  or  even  has  the  form  of  a  narrow  fibrous  string;  more  com- 
monly the  gall-bladder  tightly  embraces  a  stone.     This  condition  is  usually 
preceded  by  hydrops  of  the  bladder. 

Occasionally  the  gall-bladder  presents  diverticula,  which  may  be  cut  off 
from  the  main  portion,  and  usually  contain  calculi. 

OBSTRUCTION  OF  THE  COMMON  DUCT. — There  may  be  a  single  stone 
tightly  wedged  in  the  duct  in  any  part  of  its  course,  or  a  series  of  stones, 
sometimes  extending  into  both  hepatic  and  cystic  ducts,  or  a  stone  lies  in 
the  diverticulum  of  Vater.  There  are  three  groups  of  cases :  (a)  In  rare  in- 
stances a  stone  tightly  corks  the  common  duct,  causing  permanent  occlusion; 
or  it  may  partly  rest  in  the  cystic  duct,  and  may  have  caused  thickening  of 
the  junction  of  the  ducts;  or  a  big  stone  may  compress  the  hepatic  or  upper 
part  of  the  common  duct.  The  jaundice  is  deep  and  enduring,  and  there  are 
no  septic  features.  The  pains,  the  previous  attacks  of  colic,  and  the  absence 
of  enlarged  gall-bladder  help  to  separate  the  condition  from  obstruction  by 
new  growths,  although  it  cannot  be  differentiated  with  certainty.  The  ducts 
are  usually  much  dilated  and  everywhere  contain  a  clear  mucoid  fluid. 

(&)  Incomplete  obstruction,  with  infective  cholangitis.  There  may  be  a 
series  of  stones  in  the  common  duct,  a  single  stone  which  is  freely  movable, 
or  a  stone  (ball-valve  stone)  in  the  diverticulum  of  Vater.  These  conditions 
may  be  met  with  at  autopsy,  without  the  subjects  having  had  symptoms  point- 


CHOLELITHIASIS  573 

ing  to  gall-stones;  but  in  a  majority  of  cases  there  are  very  characteristic 
features. 

The  common  duct  may  be  as  large  as  the  thumb;  the  hepatic  duct  and 
its  branches  through  the  liver  may  be  greatly  dilated,  and  the  distention  may 
be  even  apparent  beneath  the  liver  capsule.  Great  enlargement  of  the  gall- 
bladder is  rarer.  The  mucous  membrane  of  the  ducts  is  usually  smooth  and 
clear,  and  the  contents  consist  of  a  thin,  slightly  turbid  bile-stained  mucus. 

ISTaunyn  has  given  the  following  as  the  distinguishing  signs  of  stone  in 
the  common  duct:  "(1)  The  continuous  or  occasional  presence  of  bile  in 
the  faeces;  (2)  distinct  variations  in  the  intensity  of  the  jaundice;  (3)  normal 
size  or  only  slight  enlargement  of  the  liver;  (4)  absence  of  distention  of  the 
gall-bladder;  (5)  enlargement  of  the  spleen ;  (6)  absence  of  ascites ;  (7)  pres- 
ence of  febrile  disturbance;  and  (8)  duration  of  the  jaundice  for  more  than 
a  year." 

In  connection  with  the  ball-valve  stone,  which  is  most  commonly  found 
in  the  diverticulum  of  Vater,  though  it  may  be  in  the  common  duct  itself, 
there  is  a  special  symptom  group:  (a)  Ague-like  paroxysms,  chills,  fever,  and 
sweating;  the  hepatic  intermittent  fever  of  Charcot;  (6)  jaundice  of  varying 
intensity,  which  persists  for  months  or  even  years,  and  deepens  after  each 
paroxysm;  (c)  at  the  time  of  the  paroxysm,  pains  in  the  region  of  the  liver 
with  gastric  disturbance.  These  symptoms  may  continue  on  and  off  for  three 
or  four'  years,  without  the  development  of  suppurative  cholangitis.  The  con- 
dition has  lasted  from  eight  months  to  three  years.  The  rigors  are  of  intense 
severity,  and  the  temperature  rises  to  103°  or  105°  F.  The  chills  may  recur 
daily  for  weeks,  and  present  a  tertian  or  quartan  type,  so  that  they  are  often 
attributed  to  malaria,  with  which,  however,  they  have  no  connection.  The 
jaundice  is  variable,  and  deepens  after  each  paroxysm.  The  itching  may  be 
most  intense.  Pain,  which  is  sometimes  severe  and  colicky,  does  not  always 
occur.  There  may  be  marked  vomiting  and  nausea.  As  a  rule  there  is  no 
progressive  deterioration  of  health.  In  the  intervals  between  the  attacks  the 
temperature  is  normal. 

The  clinical  history  and  the  post  mortem  examinations  show  conclusively 
that  this  condition  may  persist  for  years  without  a  trace  of  suppuration 
within  the  ducts.  It  is  probable  that  the  toxic  symptoms  develop  only  when 
a  certain  grade  of  tension  is  reached.  An  interesting  and  valuable  diagnostic 
point  is  the  absence  of  dilatation  of  the  gall-bladder  in  cases  of  obstruction 
from  stone — Courvoisier's  rule. 

(c)  Incomplete  obstruction,  with  suppurative  cholangitis.  When  suppu- 
rative cholangitis  exists  the  mucosa  is  thickened,  often  eroded  or  ulcerated; 
there  may  be  extensive  suppuration  in  the  ducts  throughout  the  liver,  and  even 
empyema  of  the  gall-bladder.  Occasionally  the  suppuration  extends  beyond 
the  ducts,  and  there  is  localized  liver  abscess,  or  there  is  perforation  of  the 
gall-bladder  with  the  formation  of  abscess  between  the  liver  and  stomach. 

Clinically  it  is  characterized  by  a  fever  which  may  be  intermittent,  but 
more  commonly  is  remittent  and  without  prolonged  intervals  of  apyrexia. 
The  jaundice  is  rarely  so  intense,  nor  do  we  see  the  deepening  of  the  color 
after  the  paroxysms.  There  is  usually  greater  enlargement  of  the  liver,  and 
tenderness  and  more  definite  signs  of  septicaemia.  The  cases  run  a  shorter 
course,  and  recovery  never  takes  place. 


574  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

THE  MORE  REMOTE  EFFECTS  OF  GALL-STONES. —  (a)  Biliary  Fistula. — 
(1)  Cutaneous. — 'The  external  fistula  is  the  most  common,  184  out  of  384 
cases  (Naunyn).  A  majority  occur  in  the  region  of  the  navel,  to  which  part 
the  falciform  ligament  directs  the  suppuration.  The  number  of  stones  dis- 
charged varies  from  one  or  two  to  many  hundreds.  Of  the  184  cases  in 
Courvoisier's  statistics  recovery  took  place  in  78.  In  rare  instances  the  fistula 
is  in  the  right  iliac  fossa,  or  even  in  the  thigh. 

(2)  Gastrointestinal  Fistula. — The  duodenal  is  the  most  frequent,  108 
of  384  cases  (Naunyn).    Usually  the  opening  is  between  the  fundus  of  the 
gall-bladder  and  the  first  part  of  the  duodenum.     A  big  stone  may  ulcerate 
through,  leaving  little  or  no  damage.     In  other  instances  the  cicatrization 
leads  to  obstruction.     Communication  with  the  ileum  and  jejunum  is  rare. 

Fistulas  "between  the  common  duct  and  the  duodenum  occurred  in  15  cases 
in  Naunyn's  series.  Biliary  gastric  fistula?  are  rare.  The  vomiting  of  gall- 
stones is  not  necessarily  proof  of  the  perforation,  but  in  the  majority  of  such 
cases  the  stones  probably  pass  up  through  the  pylorus. 

(3)  Broncho-biliary  Fistula. — Of  J.  E.  Graham's  collected  series  of  35 
cases,  19  were  due  to  gall-stones;  11  to  hydatids;  2  to  round-worms;  and  in 
2  the  cause  was  doubtful.     In  a  great  many  cases  the  amoebic  abscess  per- 
forating into  the  lung  is  followed  by  a  permanent  biliary  fistula. 

(4)  Perforation  may  occur  into  the  portal  vein,  of  which  there  are  3  or 
4  cases  on  record,  one  of  which,  according  to  tradition,  was  the  famous 
Ignatius  Loyola. 

(5)  Perforation  into  the  hepatic  artery  or  one  of  its  branches  is  exceed- 
ingly rare.    Either  an  erosion  from  the  common  duct,  or  an  hepatic  aneurism 
may  rupture  into  the  gall-bladder. 

(6)  Fistula  into  the  urinary  passages  may  be  with  the  pelvis  of  the  kidney 
in  which  the  gall-stone  has  been  found,  or  into  the  urinary  bladder,  of  which 
there  are  few  cases  on  record. 

(7)  Lastly,  the  communication  between  the  pericardium  and  the  biliary 
tract  is  referred  to  by  Naunyn  in  a  single  case. 

(b)  Perforation  into   the  Peritoneum. — Of   119   cases    (Courvoisier)    in 
70  the  rupture  occurred  directly  into  the  peritoneal  cavity;  in  49  an  encap- 
sulated abscess  formed.     As  a  rule,  the  condition  is  due  to  an  acute  chole- 
cystitis. 

(c)  Obstruction  of  the  Bowel  by  Gall-stones. — Reference  has  already  been 
made  to  this ;  its  frequency  appears  from  the  fact  that  of  295  cases  of  obstruc- 
tion, occurring  during  eight  years,  analyzed  by  Fitz,  23  were  by  gall-stones. 
Courvoisier's  statistics  give  a  total  number  of  131  cases,  in  6  of  which  the 
calculi  had  a  peculiar  situation,  as  in  a  diverticulum  or  in  the  appendix.    Of 
the  remaining  125  cases,  in  70  the  stone  was  spontaneously  passed,  usually 
with  severe  symptoms.    The  post  mortem  reports  show  that  in  some  of  these 
cases  even  very  large  stones  have  passed  per  viam  naturalem,  as  the  gall-duct 
has  been  enormously  distended,  its  orifice  admitting  the  finger  freely.     This, 
however,  is  extremely  rare.    The  stones  have  been  found  most  commonly  in 
the  ileum. 

Treatment  of  Gall-stones  and  Their  Effects. — GENERAL  TREATMENT. — In 
an  attack  of  biliary  colic  the  patient  should  be  kept  under  morphia,  given 
hypodermically,  in  quarter-grain  doses.  In  an  agonizing  paroxysm  it  is  well 


THE    CIRRHOSES    OF   THE    LIVER  575 

to  give  a  whiff  or  two  of  chloroform  until  the  morphia  has  had  time  to  act. 
Great  relief  is  experienced  from  the  hot  bath  and  from  fomentations  in  the 
region  of  the  liver.  The  patient  should  be  given  laxatives  and  should  drink 
copiously  of  alkaline  mineral  waters.  Olive  oil  has  proved  useless  in  my 
hands.  When  taken  in  large  quantities,  fatty  concretions  are  passed  with 
the  stools,  which  have  been  regarded  as  calculi ;  and  concretions  due  to  eating 
pears  have  been  also  mistaken,  particularly  when  associated  with  colic  attacks. 
Since  the  days  of  Durande,  whose  mixture  of  ether  with  turpentine  is  still 
largely  used  in  France,  various  remedies  have  been  advised  to  dissolve  the 
stones  within  the  gall-bladder,  none  of  which  are  efficacious. 

The  diet  should  be  regulated,  the  patient  should  take  regular  exercise  and 
avoid,  as  much  as  possible,  the  starchy  and  saccharine  foods.  The  soda  salts 
recommended  by  Prout  are  believed  to  prevent  the  concentration  of  the  bile 
and  the  formation  of  gall-stones.  Either  the  sulphate  or  the  phosphate  may 
be  taken  in  doses  of  from  1  to  2  drachms  daily.  For  the  intolerable  itching 
McCall  Andersen's  dusting  powder  may  be  used:  starch,  an  ounce;  camphor, 
a  drachm  and  a  half :  and  oxide  of  zinc,  half  an  ounce.  Some  of  this  should 
be  finely  dusted  over  the  skin  with  a  powder-puff.  Powdering  with  starch, 
strong  alkaline  baths  (hot),  pilocarpin  hypodermically  (gr.  %-%,  0.008- 
0.01  gm.),  and  antipyrin  (gr.  v,  0.3  gm.),  may  be  tried.  Ichthyol  and  lanolin 
ointment  sometimes  gives  relief. 

SURGICAL  TREATMENT. — The  indications  for  operation  are:  (a)  Repeated 
attacks  of  gall-stone  colic.  The  patient  is  much  safer  in  the  hands  of  a  sur- 
geon than  when  left  to  Nature,  with  the  feeble  assistance  of  drugs  and  min- 
eral waters.  (&)  The  presence  of  a  distended  gall-bladder,  associated  with 
attacks  of  pain  or  with  fever,  (c)  When  a  gall-stone  is  permanently  lodged 
in  the  common  duct,  and  the  group  of  symptoms  above  described  are  present, 
the  question,  then,  of  advising  operation  depends  largely  upon  the  personal 
methods  and  success  of  the  surgeon  who  is  available. 

Of  4,000  operations  performed  by  the  Mayo  brothers  to  February  20th, 
1911,  the  mortality  was  2.57  per  cent.  Of  2,920  cases  in  which  the  gall-bladder 
alone  was  involved  the  mortality  was  1.8  per  cent.  Of  492  cases  in  which 
the  common  duct  was  involved  the  mortality  was  8  per  cent.  In  2.25  per 
cent,  there  was  the  complication  of  malignant  disease. 

The  question  comes  up  as  to  the  re-formation  of  stones,  but  the  possibility 
of  this  is  very  slight.  In  the  Mayo  series  there  were  but  3  cases  and  it  is 
probable  that  in  the  majority  of  instances  the  stones  had  not  re-formed,  but 
were  incompletely  removed. 


VII.    THE    CIRRHOSES    OF    THE    LIVER 

General  Considerations. — The  many  forms  of  cirrhoses  of  the  liver  have 
one  feature  in  common — an  increase  in  the  connective  tissue  of  the  organ. 
In  fact,  we  use  the  term  cirrhosis  (by  which  Laennec  characterized  the  tawny, 
yellow  color  of  the  common  atrophic  form)  to  indicate  similar  changes  in 
other  organs. 

Etiology. — There  are  five  types  of  primary  lesion,  any  one  of  which  may 
lead  to  cirrhosis. 


576  DISEASES    0*'    THE    DIGESTIVE    SYSTEM 

1.  Toxic  Cirrhosis. — This  is  the  only  acute  type  and  it   is   seen  post 
partum,  in  chloroform  narcosis  and  sometimes  as  a  terminal  lesion  in  any 
form  of  disease.     There  is  a  central  necrosis  about  the  hepatic  vein  which 
may  be  slight  in  amount,  or  in  some  cases  an  acute  yellow  atrophy,  very 
extensive  so  that  the  liver  is  rapidly  reduced  in  size.    Into  the  necrotic  areas 
leucocytes  migrate,  the  dead  liver  cells  are  quickly  removed  and  there  is  an 
apparent  increase  of  the  connective  tissue.     Great  regeneration  of  the  liver 
cells  is  possible.     Clinically  this  type  can  scarcely  be  spoken  of  as  cirrhosis. 

2.  Infectious  Cirrhosis. — Adami  and  his  school  hold  that  in  many  cases 
the  colon  bacilli  from^he  bowel  pass  to  the  liver  and  there  gradually  excite 
a  slow  proliferation  of  connective  tissue,   regarding  it   as  a  kind  of  sub- 
infection.    Mallpry,  whose  classification  I  am  following,  thinks  that  the  only 
type  of  true  infectious  cirrhosis  is  through  the  bile  ducts,  usually  when  there 
is  bile  stasis  or  gall-stones  or  other  obstructions  are  present.     Cases  are  de- 
scribed in  which  invasion  occurs  along  apparently  normal  bile  ducts  and  the 
organisms  cause  necrosis  of  the  liver  cells,  proliferation  of  the  fibroblasts,  and 
thickening  of  the  walls  of  the  smaller  bile  ducts  which  may  be  dilated  and 
tortuous. 

Clinically  this  type  is  rare,  and  characterized  by  a  chronic  jaundice  and 
enlargement  of  the  liver. 

3.  Pigment  Cirrhosis. — This  may  be  an  external  pigment  as  in  anthra- 
cosis  in  which  the  irritation  of  the  coal  pairticles  reaching  the  liver  through 
the  lymphatics  may  excite  a  moderate  grade  of  cirrhosis.     The  endogenous 
pigment  is  a  transformation  of  haemoglobin  either  as  in  malaria  or  as  in  the 
remarkable  affection  known  as  haBmochromatosis. 

4.  Syphilitic  Cirrhosis. — Whether  congenital  or  acquired,   the  essential 
lesion  is  produced  by  the  Treponema  pallidum,  either  a  diffuse  proliferation 
of  fibroblasts,  or  a  more  localized  lesion,  the  gumma. 

5.  Alcoholic  Cirrhosis. — As  a  result  of  the  toxic  action  of  the  alcohol, 
the  liver  cells,  singly  or  in  groups,  undergo  a  slow  necrosis,  following  which 
there  is  a  multiplication  of  the  fibroblasts  with  a  hyalin  degeneration  of  some 
cells  and  multiplication  of  others  and  an  increase  in  the  smaller  bile  ducts. 
Fatty  infiltration  is  common,  so  that  the  organ  may  be  enlarged. 

Of  these  types  the  toxic  and  one  form  of  the  alcoholic  are  associated  with 
shrinkage,  the  infectious,  the  pigmentary  and  the  fatty  cirrhosis  with  enlarge- 
ment of  the  organ.  Clinically  we  may  consider  four  forms,  the  portal,  the 
hypcrtrophic  (of  Hanot),  the  syphilitic,  and  the  capsular. 


1.     PORTAL    CIRRHOSIS 

Etiology. — The  disease  occurs  most  frequently  in  middle-aged  males  who 
have  been  addicted  to  drink.  Whisky,  gin,  and  brandy  are  more  potent  to 
cause  cirrhosis  than  beer.  It  is  more  common"  in  countries  in  which  strong 
spirits  are  used  than  in  those  in  which  malt  liquors  are  taken.  Among  1,000 
autopsies  in  my  colleague  Welch's  department  of  the  Johns  Hopkins  Hospital 
there  were  63  cases  of  small  atrophic  liver,  and  8  cases  of  the  fatty  cirrhotic 
organ.  Lancereaux  claims  that  the  vin  ordinaire  of  France  is  a  common 
cause  of  cirrhosis.  Of  210  cases,  excess  in  wine  alone  was  present  in  68  cases. 


THE    CIRRHOSES    OF   THE    LIVER  577 

He  thinks  it  is  the  sulphate  of  potash  in  the  plaster  of  Paris  used  to  give  the 
"dry"  flavor  which  damages  the  liver. 

Cirrhosis  of  the  liver  in  young  children  is  not  very  rare.  In  a  certain 
number  of  the  cases  there  is  an  alcoholic  history,  in  others  syphilis  has  been 
present,  while  a  third  group,  due  to  the  poisons  of  the  infectious  diseases, 
embraces  a  certain  number  of  the  cases  of  Hanot's  hypertrophic  cirrhosis. 

Morbid  Anatomy.— Practically  on  the  post  mortem  table  we  see  alcoholic 
cirrhosis  in  two  well-characterized  forms : 

THE  ATROPHIC  CIRRHOSIS  OF  LAENNEC. — The  organ  is  greatly  reduced 
in  size  and  may  be  deformed,  The  weight  is  sometimes  not  more  than  a 
pound  or  a  pound  and  a  half.  It  presents  numerous  granulations  on  the  sur- 
face ;  is  firm,  hard,  and  cuts  with  great  resistance.  The  substance  is  seen  to  be 
made  up  of  greenish-yellow  islands  surrounded  by  grayish-white  connective 
tissue.  W.  G.  MacCallum  has  shown  that  regenerative  changes  in  the  cells 
are  almost  constantly  present.  This  yellow  appearance  of  the  liver  induced 
Laennec  to  give  to  the  condition  the  name  of  cirrhosis. 

THE  FATTY  CIRRHOTIC  LIVER. — Even  in  the  atrophic  form  the  fat  is  in- 
creased, but  in  typical  examples  of  this  variety  the  organ  is  not  reduced  in 
size,  but  is  enlarged,  smooth  or  very  slightly  granular,  anaemic,  yellowish- 
white  in  color,  and  resembles  an  ordinary  fatty  liver.  It  is,  however,  firm, 
cuts  with  resistance,  and  microscopically  shows  a  great  increase  in  the  con- 
nective tissue.  This  form  occurs  most  frequently  in  beer-drinkers. 

The  two  essential  elements  in  cirrhosis  are  destruction  of  liver-cells  and 
obstruction  to  the  portal  circulation. 

In  an  autopsy  on  a  case  of  atrophic  cirrhosis  the  peritoneum  is  usually 
found  to  contain  a  large  quantity  of  fluid,  the  membrane  is  opaque,  and  there 
is  chronic  catarrh  of  the  stomach  and  of  the  small  intestines.  The  spleen  is 
enlarged,  in  part,  at  least,  from  the  chronic  congestion,  possibly  due  in  part 
to  a  toxic  influence  (Parkes  Weber).  The  pancreas  frequently  shows  inter- 
stitial changes.  The  kidneys  are  sometimes  cirrhotic,  the  bases  of  the  lungs 
may  be  much  compressed  by  the  ascitic  fluid,  the  heart  often  shows  marked 
degeneration,  and  arterio-sclerosis  is  usually  present.  A  remarkable  feature 
is  the  association  of  acute  tuberculosis  with  cirrhosis.  In  seven  cases  of  my 
series  the  patients  died  with  either  acute  tuberculous  peritonitis  or  acute 
tuberculous  pleurisy.  Rolleston  has  found  that  tuberculosis  was  present  in 
28  per  cent,  of  706  fatal  cases  of  cirrhosis.  Peritoneal  tuberculosis  was  found 
in  9  per  cent,  of  a  series  of  584  cases. 

The  compensatory  circulation  is  usually  readily  demonstrated.  It  is  car- 
ried out  by  the  following  set  of  vessels:  (1)  The  accessory  portal  system  of 
Sappey,  of  which  important  branches  pass  in  the  round  and  suspensory  liga- 
ments and  unite  with  the  epigastric  and  mammary  systems.  These  vessels 
are  numerous  and  small.  Occasionally  a  large  single  vein,  which  may  attain 
the  size  of  the  little  finger,  passes  from  the  hilus  of  the  liver,  follows  the 
round  ligament,  and  joins  the  epigastric  veins  at  the  navel.  Although  this 
has  the  position  of  the  umbilical  vein,  it  is  usually,  as  Sappey  showed,  a  para- 
umbilical  vein — that  is,  an  enlarged  vein  by  the  side  of  the  obliterated  umbilical 
vessel.  There  may  be  produced  about  the  navel  a  large  bunch  of  varices,  the 
so-called  caput  Medusae.  Other  branches  of  this  system  occur  in  the  gastro- 
epiploic  omentum,  about  the  gall-bladder,  and,  most  important  of  all,  in  the 


578  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

suspensory  ligamenix  These  latter  form  large  branches,  which  anastomose 
freely  with  the  diaphragmatic  veins,  and  so  unite  with  the  vena  axygos.  '  (2) 
By  the  anastomosis  between  the  oesophageal  and  gastric  veins.  The  veins  at 
the  lower  end  of  the  oesophagus  may  be  enormously  enlarged,  producing 
varices  which  project  on  the  mucous  membrane.  (3)  The  communications 
between  the  haemorrhoidal  and  the  inferior  mesenteric  veins.  The  freedom 
of  communication  in  this  direction  is  very  variable,  and  in  some  instances 
the  haBmorrhoidal  veins  are  not  much  enlarged.  (4)  The  veins  of  Retzius, 
which  unite  the  radicles  of  the  portal  branches  in  the  intestines  and  mesen- 
tery with  the  inferior  vena  cava  and  its  branches.  To  this  system  belong  the 
whole  group  of  retroperitoneal  veins,  which  are  in  most  instances  enormously 
enlarged,  particularly  about  the  kidneys,  and  which  serve  to  carry  off  a  con- 
siderable proportion  of  the  portal  blood. 

Symptoms. — The  most  extreme  grade  of  atrophic  cirrhosis  may  exist  with- 
out symptoms.  So  long  as  the  compensatory  circulation  is  maintained  the 
patient  may  suffer  little  or  no  inconvenience.  The  remarkable  efficiency  of 
this  collateral  circulation  is  well  seen  in  those  rare  instances  of  permanent 
obliteration  of  the  portal  vein.  The  symptoms  may  be  divided  into  two 
groups — obstructive  and  toxic. 

OBSTRUCTIVE. — The  overfilling  of  the  blood-vessels  of  the  stomach  and 
intestine  leads  to  chronic  catarrh,  and  the  patients  suffer  with  nausea  and  vom- 
iting, particularly  in  the  morning;  the  tongue  is  furred  and  the  bowels  are 
irregular.  Haemorrhage  from  the  stomach  may  be  an  early  symptom;  it  is 
often  profuse  and  liable  to  recur.  It  seldom  proves  fatal.  The  amount  vom- 
ited may  be  remarkable  as  in  a  case  already  referred  to,  in  which  ten  pounds 
were  ejected  in  seven  days.  Following  the  haematemesis  mela3na  is  common; 
but  hemorrhages  from  the  bowels  may  occur  for  several  years  without  haBma- 
temesis.  The  bleeding  very  often  comes  from  cesophageal  varices.  Very 
frequently  epistaxis  occurs.  Enlargement  of  the  spleen  may,  as  Parkes  Weber 
suggests,  be  due  to  a  toxemia.  The  organ  can  usually  be  felt.  Evidences 
of  the  establishment  of  the  collateral  circulation  a"re  seen  in  the  enlarged 
epigastric  and  mammary  veins,  more  rarely  in  the  presence  of  the  caput 
Medusae  and  in  the  development  of  hemorrhoids.  The  distended  venules  in 
the  lower  thoracic  zone  along  the  line  of  attachment  of  the  diaphragm  are  not 
specially  marked  in  cirrhosis.  The  most  striking  feature  of  failure  in  the 
compensatory  circulation  is  ascites,  the  effusion  of  serous  fluid  into  the  peri- 
toneal cavity,  which  may  appear  suddenly.  The  conditions  under  which  this 
occurs  are  still  obscure.  In  some  cases  it  is  due  more  to  chronic  peritonitis 
than  to  the  cirrhosis.  The  abdomen  gradually  distends,  may  reach  a  large 
eize,  and  contain  as  much  as  15  to  20  litres.  (Edema  of  the  feet  may  precede 
or  develop  with  the  ascites.  The  dropsy  is  rarely  general. 

Jaundice  is  usually  slight,  and  was  present  in  107  of  293  cases  of  cirrhosis 
collected  by  Rolleston.  The  skin  has  frequently  a  sallow,  slightly  icteroid 
tint.  The  urine  is  often  reduced  in  amount,  contains  urates  in  abundance, 
often  a  slight  amount  of  albumin,  and,  if  jaundice  is  intense,  tube-casts.  The 
disease  may  be  afebrile  throughout,  but  in  many  cases.,  as  shown  by  Carring- 
ton,  there  is  slight  fever,  from  100°  to  102.5°  F. 

Examination  at  any  -early  stage  of  the  disease  may  show  an  enlarged  and 
painful  liver.  In  very  many  of  the  cases  of  alcoholic  cirrhosis  the  organ  is 


THE    CMHOSES    OF   THE   LIVER  579 

"enlarged  at  all  stages  of  the  disease,  and,  whether  enlarged  or  con- 
tracted, the  clinical  symptoms  and  course  are  much  the  same"  (Foxwell). 
The  patient  may  first  come  tinder  observation  for  dyspepsia,  hsematemesis, 
slight  jaundice,  or  nervous  symptoms.  Later  in  the  disease  the  patient  has 
an  unmistakable  hepatic  facies;  he  is  thin,  the  eyes  are  sunken,  the  con- 
junctive watery,  the  nose  and  cheeks  show  distended  venules,  and  the  com- 
plexion is  muddy  or  icteroid.  On  the  enlarged  abdomen  the  vessels  are  dis- 
tended, and  a  bunch  of  dilated  veins  may  surround  the  navel.  A  venous 
hum.  sometimes  accompanied  by  a  thrill,  may  be  present  in  the  epigastrium  or 
over  varicosities.  Xaevi  of  a  remarkable  character  may  appear  on  the  skin, 
either  localized  stellate  varices — spider  angiomata — usually  on  the  face,  neck, 
and  back,  and  also  "mat"  naevi,  as  I  have  called  them — areas  of  skin  of  a 
reddish  or  purplish  color  due  to  the  uniform  distention  of  small  venules. 
When  much  fluid  is  in  the  peritoneum  it  is  impossible  to  make  a  satisfactory 
examination,  but  after  withdrawal  the  area  of  liver  dulness  is  found  to  be 
diminished,  particularly  in  the  middle  line,  and  on  deep  pressure  the  edge 
of  the  liver  can  be  detected,  and  occasionally  the  hard,  firm,  and  even  granu- 
lar surface.  The  spleen  can  be  felt  in  the  left  hypochondriac  region.  Exami- 
nation of  the  anus  may  reveal  the  presence  of  haemorrhoids. 

Toxic  SYMPTOMS. — At  any  stage  of  atrophic  cirrhosis  the  patient  may 
have  cerebral  symptoms,  either  a  noisy,  joyous  delirium,  or  stupor,  coma,  or 
even  convulsions.  The  condition  is  not  infrequently  mistaken  for  uraemia. 
The  nature  of  the  toxic  agent  is  not  yet  settled.  Without  jaundice,  and  not 
attributable  to  cholaemia,  the  symptoms  may  come  on  in  hospital  when  the 
patient  has  not  had  alcohol  for  weeks. 

The  fatty  cirrhotic  liver  may  produce  symptoms  similar  to  those  of  the 
atrophic  form,  but  more  frequently  it  is  latent  and  is  found  accidentally  in 
topers  who  have  died  from  various  diseases.  The  greater  number  of  the  cases 
clinically  diagnosed  as  cirrhosis  with  enlargement  come  in  this  division. 

Diagnosis. — With  ascites,  a  well-marked  history  of  alcoholism,  the  hepatic 
facies,  and  haemorrhage  from  the  stomach  or  bowels,  the  diagnosis  is  rarely 
doubtful.  If,  after  withdrawal  of  the  fluid,  the  spleen  is  found  to  be  en- 
larged and  the  liver  either  not  palpable  or,  if  it  is  enlarged,  hard  and  regular, 
the  probabilities  in  favor  of  cirrhosis  are  very  great.  In  the  early  stages  of 
the  disease,  when  the  liver  is  increased  in  size,  it  may  be  impossible  to  say 
whether  it  is  a  cirrhotic  or  a  fatty  liver.  The  differential  diagnosis  between 
common  and  syphilitic  cirrhosis  can  sometimes  be  made.  A  marked  history 
of  syphilis  or  the  existence  of  other  syphilitic  lesions,  with  great  irregularity 
in  the  surface  or  at  the  edge  of  the  liver,  are  the  points  in  favor  of  the  latter. 
Thrombosis  or  obliteration  of  the  portal  vein  can  rarely  be  differentiated.  In 
a  case  of  fibroid  transformation  of  the  portal  vein  which  came  under  my 
observation,  the  collateral  circulation  had  been  established  for  years,  and  the 
symptoms  were  simply  those  of  extreme  portal  obstruction,  such  as  occur  in 
cirrhosis.  Thrombosis  of  the  portal  vein  may  occur  in  cirrhosis  and  be  char- 
acterized by  a  rapidly  developing  ascites. 

Prognosis. — The  outlook  is  bad.  When  the  collateral  circulation  is  fully 
established  the  patient  may  have  no  symptoms  whatever.  There  are  instances 
of  enlargement  of  the  liver,  slight  jaundice,  cerebral  symptoms,  and  .even 
hffimatemesis,  in  which  the  liver  becomes  reduced  in  size,  the  symptoms  disap- 


580  DISEASES    OF   THE   DIGESTIVE    SYSTEM 

pear,  and  the  patient  may  live  in  comparative  comfort  for  many  years.  There 
are  cases,  too,  possibly  syphilitic,  in  which,  after  one  or  two  tappings,  the 
symptoms  have  disappeared  and  the  patients  have  apparently  recovered. 
Ascites  is  a  very  serious  event,  especially  if  due  to  the  cirrhosis  and  not  to  an 
associated  peritonitis.  Of  34  cases  with  ascites  10  died  before  tapping  was 
necessary ;  14  were  tapped,  and  the  average  duration  of  life  after  the  swelling 
was  first  noticed  was  only  eight  weeks ;  of  10  cases  the  diagnosis  was  wrong  in 
4,  and  in  the  remaining  6,  who  were  tapped  oftener  than  once,  chronic  peri- 
tonitis and  perihepatitis  were  present  (Hale  White). 

2.     HYPERTROPHIC    BILIARY    CIRRHOSIS    (Hanot) 

This  well-characterized  form  was  first  described  by  Eequin  in  1846,  but 
our  accurate  knowledge  of  the  condition  dates  from  the  work  of  Hanot  (1875), 
whose  name  in  France  it  bears — maladie  de  Hanot. 

Cirrhosis  with  enlargement  occurs  in  the  early  stage  of  atrophic  cirrhosis ; 
there  is  an  enlarged  fatty  and  cirrhotic  liver  of  alcoholics,  a  pigmentary  form 
occurs  in  hajmochromatosis,  and  in  association  with  syphilis  the  organ  is 
often  very  large.  The  hypertrophic  cirrhosis  of  Hanot  is  easily  distinguished 
from  these  forms. 

Etiology. — Males  are  more  often  affected  than  females — in  22  of  Schach- 
mann's  26  cases.  The  subjects  are  young;  some  of  the  cases  in  children  prob- 
ably belong  to  this  form.  Alcohol  plays  a  minor  part,  and  not  one  of  my 
patients  had  been  a  heavy  drinker.  The  absence  of  all  known  etiological 
factors  is  a  remarkable  feature. 

Morbid  Anatomy. — The  organ  is  enlarged,  weighing  from  2,000  to  4,000 
grams.  The  form  is  maintained,  the  surface  is  smooth,  or  presents  small 
granulations;  the  color  in  advanced  cases  is  of  a  dark  olive  green;  the  con- 
sistence is  greatly  increased.  The  section  is  uniform,  greenish  yellow  in  color, 
and  the  liver  nodules  may  he  seen  separated  by  connective  tissue.  The  bile- 
passages  present  nothing  abnormal.  The  cirrhosis  is  mono-  or  multilobular, 
with  a  connective  tissue  rich  in  round  cells.  The  bile-vessels  are  the  seat  of  an 
angiocholitis,  catarrhal  and  productive,  and  there  is  an  extraordinary  develop- 
ment of  new  biliary  canaliculi.  The  liver-cells  are  neither  fatty  nor  pigmented, 
and  may  be  increased  in  size  and  show  karyokinetic  figures.  From  the  sup- 
posed origin  about  the  bile-vessels  it  has  been  called  biliary  cirrhosis,  but  the 
histological  details  have  not  yet  been  worked  out  fully,  and  the  separation  of 
this  as  a  distinct  form  should,  for  the  present  at  least,  rest  upon  clinical  rather 
than  anatomical  grounds.  The  spleen  is  greatly  enlarged  and  may  weigh  600 
or  more  grams. 

Symptoms. — As  previously  stated,  the  cases  occur  in  young  persons ;  there 
is  not,  as  a  rule,  an  alcoholic  history,  and  males  are  usually  affected.  The 
features  are :  (a)  A  remarkably  chronic  course  of  from  four  to  six,  or  even 
ten  years.  (&)  Jaundice,  usually  slight,  often  not  more  than  a  lemon  tint, 
or  a  tinging  of  the  conjunctivas.  At  any  time  during  the  course  an  icterus 
gravis,  with  high  fever  and  delirium,  may  develop.  There  is  bile  in  the  urine ; 
the  stools  are  not  clay-colored  as  in  obstructive  jaundice,  but  may  be  very 
dark  and  "bilious."  (c)  Attacks  of  pain  in  the  region  of  the  liver,  which 
may  be  severe  and  associated  with  nausea,  and  vomiting.  The  pain  may  be 


THE   CIRRHOSES   OP   THE   LIVER  581 

slight  and  dragging,  and  in  some  cases  is  not  at  all  a  prominent  symptom. 
The  jaundice  may  deepen  after  attacks  of  pain,  (d)  Enlarged  liver.  A  full- 
ness in  the  upper  abdominal  zone  may  be  the  first  complaint.  On  inspection 
the  enlargement  may  be  very  marked.  In  one  of  my  cases  the  left  lobe  was 
unusually  prominent  and  stood  out  almost  like  a  tumor.  An  exploratory  oper- 
ation showed  only  an  enlarged,  smooth  organ  without  adhesions.  On  palpa- 
tion the  hypertrophy  is  uniform,  the  consistence  is  increased,  and  the  edge 
distinct  and  hard.  The  gall-bladder  is  not  enlarged.  The  vertical  flatness  is 
much  increased  and  may  extend  from  the  sixth  rib  to  the  level  of  the  navel. 
(e)  The  spleen  is  enlarged,  easily  palpable,  and  very  hard.  (/)  Certain  nega- 
tive features  are  of  moment — the  usual  absence  of  ascites  and  of  dilatation  of 
the  subcutaneous  veins  of  the  abdomen.  Among  other  symptoms  may  be 
mentioned  haemorrhages.  One  of  my  patients  had  bleeding  at  the  gums  for  a 
year;  another  had  had  for  years  most  remarkable  attacks  of  purpura  with 
urticaria.  Pruritus,  xanthoma,  lichen,  and  telangiectasis  may  be  present  in 
the  skin.  In  one  of  my  patients  the  skin  became  very  bronzed,  almost  as 
deeply  as  in  Addison's  disease.  Slight  fever  may  be  present,  which  increases 
during  the  crises  of  pain.  There  may  be  a  marked  leucocytosis.  A  curious 
attitude  of  the  body  has  been  seen,  in  which  the  right  shoulder  and  right  side 
appear  dragged  down.  The  patients  die  with  the  symptoms  of  icterus  gravis, 
from  haemorrhage,  from  an  intercurrent  infection,  or  in  a  profound  cachexia. 
Certain  of  the  cases  of  cirrhosis  of  the  liver  in  children  are  of  this  type ;  the 
enlargement  of  the  spleen  may  be  very  pronounced. 

3.     SYPHILITIC  CIRRHOSIS 

This  is  considered  in  the  section  on  syphilis  (p.  273).  I  refer  to  it  again 
to  emphasize  (1)  its  frequency;  (2)  the  great  importance  of  its  differentia- 
tion from  the  alcoholic  form;  (3)  its  curability  in  many  cases;  and  (4)  the 
tumor  formations  in  connection  with  it. 

4.     CAPSULAR   CIRRHOSIS— PERIHEPATITIS 

Local  capsulitis  is  common  in  many  conditions  of  the  liver.  The  form 
of  disease  here  described  is  characterized  by  an  enormous  thickening  of  the 
entire  capsule,  with  great  contraction  of  the  liver,  but  not  necessarily  with 
special  increase  in  the  connective  tissue  of  the  organ  itself.  Our  chief  knowl- 
edge of  the  disease  we  owe  to  the  Guy's  Hospital  physicians,  particularly  to 
Hilton  Fagge  and  to  Hale  White,  who  collected  22  cases  from  the  records. 
The  liver  substance  itself  was  "never  markedly  cirrhotic ;  its  tissue  was  nearly 
always  soft."  Chronic  capsulitis  of  the  spleen  and  a  chronic  proliferative  peri- 
tonitis are  almost  invariably  present.  In  19  of  the  22  cases  the  kidneys  were 
granular.  Hale  White  regards  it  as  a  sequel  of  interstitial  nephritis.  The 
youngest  case  in  his  series  was  twenty-nine.  The  symptoms  are  those  of 
atrophic  cirrhosis— ascites,  often  recurring  and  requiring  many  tappings. 
Jaundice  is  not  often  present.  I  have  met  with  two  groups  of  cases— the  one 
in  adults  usually  with  ascites  and  regarded  as  ordinary  cirrhosis.  I  have 
never  made  a  diagnosis  in  such  a  case.  Signs  of  interstitial  nephritis,  recur- 
ring ascites,  and  absence  of  jaundice  are  regarded  by  Hale  White  as  important 


582  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

diagnostic  points.  In  the  second  group  of  cases  the  perihepatitis,  pcrisplenitis, 
and  proliferative  peritonitis  are  associated  with  adherent  pericardium  and 
chronic  mediastinitis.  In  one  such  case  the  diagnosis  of  capsular  hepatitis  was 
very  clear,  as  the  liver  could  be  grasped  in  the  hand  and  formed  a  rounded, 
smooth  organ  resembling  the  spleen.  The  child  was  tapped  121  times 
(Archives  of  Paediatrics,  1896). 

TREATMENT   OF  THE   CIRRHOSES 

The  portal  function  of  the  liver  may  be  put  out  of  action  without  much 
damage  to  the  body.  There  may  be  an  extreme  grade  of  cirrhotic  atrophy 
without  symptoms ;  the  portal  vein  may  be  obliterated,  or,  experimentally,  the 
portal  vein  may  be  anastomosed  with  the  cava.  So  long  as  there  is  an  active 
compensatory  circulation  a  patient  with  atrophic  cirrhosis  may  remain  well. 
In  the  hypertrophic  form  toxemia  is  the  special  danger.  In  the  hypertrophic 
cirrhosis  we  have  no  means  of  arresting  the  progress  of  the  disease.  In  the 
alcoholic  form  it  is  too  late,  as  a  rule,  to  do  much  after  symptoms  have 
occurred.  In  a  few  cases  an  attack  of  jaundice  or  hsematemesis  may  prove 
the  salvation  of  the  patient,  who  may  afterward  take  to  a  temperate  life.  The 
diet  should  be  very  simple  and  large  amounts  of  water  taken  to  aid  elimina- 
tion. The  bowels  should  be  kept  open,  for  which  the  use  of  the  salines  is 
generally  best.  An  occasional  course  of  potassium  iodide  may  be  given.  With 
the  advent  of  ascites  the  critical  stage  is  reached.  Restriction  of  fluid  intake 
and  free  purgation  may  relieve  a  small  exudate,  rarely  a  large  one,  and  it  is 
best  to  tap  early,  or  to  advise  Talma's  operation.  In  the  syphilitic  cirrhosis 
much  more  can  be  done,  and  a  majority  of  the  cases  of  cure  after  ascites  are  of 
this  variety.  Iodide  of  potassium  in  moderate  doses,  15  to  30  drops  of  the 
saturated  solution,  and  the  Addison  pill  save  a  number  of  cases  even  after 
repeated  tapping.  The  diagnosis  may  be  reached  only  after  removal  of  the 
fluid,  but  in  every  case  with  a  history  of  syphilis,  a  positive  Wassermann  reac- 
tion, or  with  irregularity  of  the  liver  this  treatment  should  be  tried. 

SURGICAL  TREATMENT. —  (a)  Tapping. — When  the  ascites  increases  it  is 
better  to  tap  early.  As  Hale  White  remarks,  a  case  of  cirrhosis  of  the  liver 
which  is  tapped  rarely  recovers,  but  there  are  instances  in  which  early  and 
repeated  paracentesis  is  followed  by  cure.  Accidents  are  rare;  haemorrhage, 
acute  peritonitis,  or  erysipelas  at  the  point  of  puncture  occasionally  follow; 
collapse  may  occur  during  the  operation,  to  guard  against  which  Mead  advised 
the  use  of  the  abdominal  binder.  Continuous  drainage  with  Southey's  tubes 
is  not  often  practicable  and  has  no  special  advantages.  (&)  Laparotomy,  with 
complete  removal  of  the  fluid,  and  freshening  or  rubbing  the  peritoneal  sur- 
faces, to  stimulate  the  formation  of  adhesions,  (c)  Omentopexy,  the  stitching 
of  the  omentum  to  the  abdominal  wall,  and  the  establishment  of  collateral 
circulation  in  this  way  between  the  portal  and  the  systemic  vessels.  This 
operation  is  sometimes  very  successful,  and  may  be  recommended.  In  224 
cases  there  were  84  deaths  and  129  recoveries;  11  cases  doubtful.  Among 
the  129  successful  cases,  in  25  the  ascites  recurred;  70  appeared  to  have  com- 
pletely recovered,  (d)  Fistula  of  Eck.  The  porto-caval  anastomosis  has  been 
performed  once  in  man  in  cirrhosis  of  the  liver  (Widal,  La  Semaine  Medicale, 
1903).  The  patient  lived  for  three  months. 


ABSCESS    OF   THE   LIVEH  583 


VIII.     ABSCESS    OF    THE    LIVER 

Etiology. — Suppuration  within  the  liver,  either  in  the  parenchyma  or  in 
the  blood  or  bile  passages,  occurs  under  the  following  conditions : 

(a)  The  tropical  abscess,  also  called  the  solitary,  commonly  follbws  anarc- 
hic dysentery.    It  frequently  occurs  among  Europeans  in  India,  particularly 
those  who  drink  alcohol  freely  and  are  exposed  to  great  heat.     Cases  may 
occur  without  a  history  of  previous  dysentery,  and  there  have  been  fatal  cases 
without  any  affection  of  the  large  bowel.    In  the  United  States  the  large  soli- 
tary abscess  is  not  very  infrequent.     The  relation  of  this  form  of  abscess  to 
the  Amoeba  dysenteries  has  been  considered. 

(b)  Traumatism  is  an  occasional  cause.     The  injury  is  generally  in  the 
hepatic  region.    Two  instances  of  it  have  come  under  my  notice  in  trainmen 
who  were  injured  while  coupling  cars.    Injury  to  the  head  is  not  infrequently 
followed  by  liver  abscess. 

(c)  Embolic  or  pycemic  abscesses  are  the  most  numerous,  occurring  in  a 
general  pyaemia  or  following  foci  of  suppuration  in  the  territory  of  the  portal 
vessels.    The  infective  agents  may  reach  the  liver  through  the  hepatic  artery, 
as  in  those  cases  in  which  the  original  focus  of  infection  is  in  the  area  of  the 
systemic  circulation;  though  it  may  happen  occasionally  that  the  infective 
agent,  instead  of  passing  through  the  lungs,  reaches  the  liver  through  the 
inferior  vena  cava  and  the  hepatic  veins.    A  remarkable  instance  of  multiple 
abscesses  of  arterial  origin  was  afforded  by  the  case  of  aneurism  of  the  hepatic 
artery  reported  by  Eoss  and  myself.     Infection  through  the  portal  vein  is 
much  more  common.    It  results  from  dysentery  and  other  ulcerative  affections 
of  the  bowels,  appendicitis,  occasionally  after  typhoid  fever,  in  rectal  affec- 
tions, and  in  abscesses  in  the  pelvis.    In  these  cases  the  abscesses  are  multiple 
and,  as  a  rule,  within  the  branches  of  the  portal  vein — suppurative  pylephle- 
bitis. 

(d)  A  not  uncommon  cause  of  suppuration  is  inflammation  of  the  bile- 
passages  caused  by  gall-stones,  more  rarely  by  parasites — suppurative  cho- 
langitis. 

In  some  instances  of  tuberculosis  of  the  liver  the  affection  is  chiefly  of 
the  bile-ducts,  with  the  formation  of  multiple  tuberculous  abscesses  containing 
a  bile-stained  pus 

(e)  Foreign  bodies  and  parasites.    In  rare  instances  foreign  bodies,  such 
as  a  needle,  may  pass  from  the  stomach  or  gullet,  lodge  in  the  liver,  and 
excite  an  abscess,  or,  as  in  several  instances  which  have  been  reported,  a  for- 
eign body,  such  as  a  needle  or  a  fish-bone,  has  perforated  a  branch  or  the  por- 
tal vein  itself  and  induced  pylephlebitis.    Echinocpccus  cysts  frequently  cause 
suppuration,  the  penetration  of  round  worms  into  the  liver  less  commonly, 
and  most  rarely  of  all  the  liver-fluke. 

Morbid  Anatomy. — (a)  OF  THE  SOLITARY  OR  TROPICAL  ABSCESS. — This 
has  been  described  under  amoebic  dysentery. 

(b)  OF  SEPTIC  AND  PY.EMIC  ABSCESSES. — These  are  usually  multiple, 
though  occasionally,  following  injury,  there  may  be  a  large  solitary  collection 

of  pus. 

In  'suppurative  pylephlebitis  the  liver  is  uniformly  enlarged.     The  cap- 


584  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

sule  may  be  smooth,  and  the  external  surface  of  the  organ  of  normal  appear- 
ance. In  other  instances,  numerous  yellowish-white  points  appear  heneath 
the  capsule.  On  section  there  are  isolated  pockets  of  pus,  either  having  a 
round  outline  or  in  some  places  distinctly  dendritic,  and  from  these  the  pus 
may  be  squeezed.  They  look  like  small,  solitary  abscesses,  but,  on  probing,  are 
found  to  communicate  with  the  portal  vein  and  to  represent  its  branches,  dis- 
tended and  suppurating.  The  entire  portal  system  within  the  liver  may  be 
involved ;  sometimes  territories  are  cut  off  by  thrombi.  The  suppuration  may 
extend  into  the  main  branch  or  even  into  the  mesenteric  and  gastric  veins. 
The  pus  may  be  fetid  and  is  often  bile-stained ;  it  may,  however,  be  thick  and 
tenacious.  In  suppurative  cholangitis  there  is  usually  obstruction  by  gall- 
stones, the  ducts  are  greatly  distended,  the  gall-bladder  enlarged  and  full  of 
pus,  and  the  branches  within  the  liver  are  extremely  distended,  so  that  on 
section  there  is  an  appearance  not  unlike  that  described  in  pylephlebitis.  An 
abscess  may  have  a  sponge-like  appearance  due  to  the  fusion  of  numerous 
points  of  suppuration. 

Suppuration  about  the  echinococcus  cysts  may  be  very  extensive,  forming 
enormous  abscesses,  the  characters  of  which  are  at  once  recognized  by  the 
remnants  of  the  cysts. 

Symptoms.' — (a)  OF  THE  LARGE  SOLITARY  ABSCESS. — The  abscess  may  be 
latent  and  run  a  course  without  definite  symptoms;  death  may  occur  sud- 
denly from  rupture. 

Fever,  pain,  enlargement  of  the  liver,  and  a  septic  condition  are  the  iinpor-' 
tant  symptoms  of  hepatic  abscess.  The  temperature  is  elevated  at  the  outset 
and  is  of  an  intermittent  or  septic  type.  It  is  irregular,  and  may  remain 
normal  or  even  subnormal  for  a  few  days;  then  the  patient  has  a  rigor  and 
the  temperature  rises  to  103°  F.  or  higher.  Owing  to  this  intermittent  char- 
acter of  the  fever  the  disease  is  often  mistaken  for  malaria.  The  fever  may 
rise  every  afternoon  without  a  rigor.  Profuse  sweating  is  common,  particu- 
larly when  the  patient  falls  asleep.  In  chronic  cases  there  may  be  little  or  no 
fever.  One  of  my  patients,  with  a  liver  abscess  which  had  perforated  the  lung, 
coughed  up  pus  after  his  temperature  had  been  normal  for  weeks.  The  pain 
is  variable,  and  is  usually  referred  to  the  back  or  shoulder ;  or  there  is  a  dull 
aching  sensation  in  the  right  hypochondrium.  When  turned  on  the  left  side, 
the  patient  often  complains  of  a  heavy,  dragging  sensation,  so  that  he  usually 
prefers  to  lie  on  the  right  side ;  at  least,  this  has  been  the  case  in  a  majority  of 
the  instances  which  have  come  under  my  observation.  Pain  on  pressure  over 
the  liver  is  usually  present,  particularly  on  deep  pressure  at  the  costal  margin 
in  the  nipple  line. 

The  enlargement  of  the  liver  is  most  marked  in  the  right  lobe,  and,  as  the 
abscess  cavity  is  usually  situated  more  toward  the  upper  than  the  under  sur- 
face, the  increase  in  volume  is  upward  and  to  the  right,  not  downward,  as 
in  cancer  and  the  other  affections  producing  enlargement.  Percussion  in  the 
mid-sternal  and  parasternal  lines  may  show  a  normal  limit.  At  the  nipple- 
line  the  curve  of  liver  dulness  begins  to  rise,  and  in  the  mid-axillary  it  may 
reach  the  fifth  rib,  while  behind,  near  the  spine,  the  area  of  dulness  may  be 
almost  on  a  level  with  the  angle  of  the  scapula.  Of  course  there  are  instances 
in  which  this  characteristic  feature  is  not  present,  as  when  the  abscess  occu- 
pies the  left  lobe.  The  enlargement  of  the  liver  may  be  so  great  as  to  cause 


ABSCESS    OF    THE    LIVER  585 

bulging  of  the  right  side,  and  the  edge  may  project  a  hand's-breadth  or  more 
below  the  costal  margin.  In  such  instances  the  surface  is  smooth.  Palpation 
is  painful,  and  there  may  be  fremitus  on  deep  inspiration.  In  some  instances 
fluctuation  may  be  detected.  Adhesions  may  form  to  the  abdominal  wall  and 
the  abscess  may  point  below  the  margin  of  the  ribs,  or  even  in  the  epigastric 
region.  In  many  cases  the  appearance  of  the  patient  is  suggestive.  The  skin 
has  a  sallow,  slightly  icteroid  tint,  the  face  is  pale,  the  complexion  muddy,  the 
conjunctiva?  are  infiltrated,  and  often  slightly  bile-tinged.  There  is  in  the 
facies  and  in  the  general  appearance  of  the  patient  a  strong  suggestion  of  the 
existence  of  abscess.  There  is  no  internal  affection  associated  with  suppura- 
tion which  gives,  I  think,  just  the  same  hue  as  certain  instances  of  abscess  of 
the  liver.  Marked  jaundice  is  rare.  Diarrhcea  may  be  present  and  may  give 
an  important  clew  to  the  nature  of  the  case,  particularly  if  amoebae  are  found 
in  the  stools.  Constipation  may  occur. 

Perforation  of  the  lung  occurred  in  9  of  the  27  cases  in  my  series.  The 
symptoms  are  most  characteristic.  The  extension  may  occur  through  the  dia- 
phragm, without  actual  rupture,  and  with  the  production  of  a  purulent  pleu- 
risy and  invasion  of  the  lung.  With  cough  of  an  aggravated  and  convulsive 
character,  there  are  signs  of  involvement  at  the  base  of  the  right  lung,  de- 
fective resonance,  feeble  tubular  breathing,  and  increase  in  the  tactile  fremi- 
tus; but  the  most  characteristic  feature  is  the  presence  of  a  reddish-brown 
expectoration  of  a  brick-dust  color,  resembling  anchovy  sauce.  This,  which 
was  noted  originally  by  Budd,  was  present- in  our  cases,  and  in  addition  Reese 
and  Lafleur  found  the  amoeba;  coli  identical  with  those  which  exist  in  the  liver 
abscess  and  in  the  stools.  They  are  present  in  variable  numbers  and  display 
active  amoeboid  movements.  The  brownish  tint  of  the  expectoration  is  due  to 
blood-pigment  and  blood-corpuscles,  and  there  may  be  orange-red  crystals  of 
haematoidin. 

The  abscess  may  perforate  externally,  as  mentioned  already,  or  into  the 
stomach  or  bowel;  occasionally  into  the  pericardium.  The  duration  of  this 
form  is  very  variable.  It  may  run  its  course  and  prove  fatal  in  six  or  eight 
weeks  or  may  persist  for  several  years. 

The  prognosis  is  serious,  as  the  mortality  is  more  than  50  per  cent.  The 
death-rate  has  been  lowered  of  late  years,  owing  to  the  great  fearlessness  with 
which  the  surgeons  now  attack  these  cases. 

(6)  OF  THE  PY^EMIC  ABSCESS  AND  SUPPURATIVE  PYLEPHLEBITIS. — Clin- 
ically these  conditions  cannot  be  separated.  Occurring  in  a  general  pyaemia, 
no  special  features  may  be  added  to  the  case.  When  there  is  suppuration 
within  the  portal  vein  the  liver  is  uniformly  enlarged  and  tender,  though 
pain  may  not  be  a  marked  feature.  There  is  an  irregular,  septic  fever,  and 
*  the  complexion  is  muddy,  sometimes  distinctly  icteroid.  The  features  are 
indeed  those  of  pyaemia,  plus  a  slight  icteroid  tinge,  and  an  enlarged  and 
painful  liver.  The  latter  features  alone  are  peculiar.  The  sweats,  chills, 
prostration,  and  fever  have  nothing  distinctive. 

Diagnosis. — Abscess  of  the  liver  may  be  confounded  with  intermittent 
fever,  a  common  mistake  in  malarial  regions.  Practically  an  intermittent 
fever  which  resists  quinine  is  not  malarial.  Laveran's  organisms  are  also 
absent  from  the  blood.  When  the  abscess  bursts  into  the  pleura  a  right-sided 
empyema  is  produced  and  perforation  of  the  lung  usually  follows.  When 
39 


586  DISEASES    OF   THE   DIGESTIVE    SYSTEM 

the  liver  abscess  has  been  latent  and  dysenteric  symptoms  have  not  been 
marked,  the  condition  may  be  considered  empyema  or  abscess  of  the  lung. 
In  such  cases  the  anchovy-sauce-like  color  of  the  pus  and  the  presence  of  the 
amoebae  will  enable  one  to  make  a  definite  diagnosis.  Perforation  externally 
is  readily  recognized,  and  yet  in  an  abscess  cavity  in  the  epigastric  region  it 
may  be  difficult  to  say  whether  it  has  proceeded  from  the  liver  or  is  in  the 
abdominal  wall.  When  the  abscess  is  large,  and  the  adhesions  are  so  firm  that 
the  liver  does  not  descend  during  inspiration,  the  exploratory  needle  does 
not  make  an  up-and-down  movement  during  aspiration.  The  diagnosis  of 
suppurating  echinococcus  cyst  is  rarely  possible,  except  in  Australia  and  Ice- 
land, where  hydatids  are  so  common. 

Perhaps  the  most  important  affection  from  which  suppuration  within  the 
liver  is  to  be  separated  is  the  intermittent  hepatic  fever  associated  with  gall- 
stones. Of  the  cases  reported  a  majority  have  been  considered  due  to  suppu- 
ration, and  in  two  of  my  cases  the  liver  had  been  repeatedly  aspirated.  Post 
mortem  examinations  have  shown  conclusively  that  the  high  fever  and  chills 
may  recur  at  intervals  for  years  without  suppuration  in  the  ducts.  The  dis- 
tinctive features  of  this  condition  are  paroxysms  of  fever  with  rigors  and 
sweats — which  may  occur  with  great  regularity,  but  which  more  often  are 
separated  by  long  intervals — the  deepening  of  the  jaundice  after  the  parox- 
ysms, the  entire  apyrexia  in  the  intervals,  and  the  maintenance  of  the  general 
nutrition.  The  time  element  also  is  important,  as  in  some  of  these  cases  the 
disease  has  lasted  for  several  years.  Finally,  it  is  to  be  remembered  that 
abscess  of  the  liver,  in  temperate  climates  at  least,  is  invariably  secondary,  and 
the  primary  source  must  be  carefully  sought  for,  either  in  dysentery,  slight 
ulceration  of  the  rectum,  suppurating  haemorrhoids,  ulcer  of  the  stomach,  or 
in  suppurative  disease  of  other  parts  of  the  body,  particularly  within  the  skull 
or  in  the  bones. 

Leucocytosis  may  be  absent  in  the  amoebic  abscess  of  the  liver;  in  septic 
cases  it  may  be  very  high. 

In  suspected  cases,  whether  the  liver  is  enlarged  or  not,  exploratory  aspira- 
tion may  be  performed.  The  needle  may  be  entered  in  the  anterior 
axillary  line  in  the  lowest  interspace,  or  in  the  seventh  interspace  in 
the  mid-axillary  line,  or  over  the  centre  of  the  area  of  dulness  behind. 
The  patient  should  be  placed  under  ether,  for  it  may  be  necessary  to 
make  several  deep  punctures.  It  is  not  well  to  use  too  small  an  aspirator. 
No  ill  effects  follow  this  procedure,  even  though  blood  may  leak  into  the 
peritoneal  cavity.  Extensive  suppuration  may  exist,  and  yet  be  missed  in  the 
aspiration,  particularly  when  the  branches  of  the  portal  vein  are  distended 
with  pus. 

Treatment. — Pyaemic  abscess  and  suppurative  pylephlebitis  are  invaria-* 
bly  fatal.  Treves,  however,  reports  a  case  of  pyaemic  abscess  following 
appendicitis  in  which  the  patient  recovered  after  an  exploratory  operation. 
Surgical  measures  are  not  justified  in  these  cases,  unless  an  abscess  shows 
signs  of  pointing.  As  the  abscesses  associated  with  dysentery  are  often 
single,  they  afford  a  reasonable  hope  of  benefit  from  operation.  If,  how- 
ever, the  patient  is  expectorating  the  pus,  if  the  general  condition  is  good 
and  the  hectic  fever  not  marked,  it  is  best  to  defer  operation,  as  many  of 
these  instances  recover  spontaneously.  The  large  single  abscesses  are  the 


NEW   GROWTHS   IN    THE    LIVER  587 

most  favorable  for  operation.     The  general  medical  treatment  of  the  cases 
is  that  of  ordinary  septicaemia. 


IX.    NEW  GROWTHS  IN  THE   LIVER 

These  may  be  cancer,  either  primary  or  secondary,  sarcoma,  or  angioma. 

Etiology. — Cancer  of  the  liver  is  third  in  order  of  frequency  of  internal 
cancer.  It  is  rarely  primary,  usually  secondary  to  cancer  in  other  organs. 
It  is  a  disease  of  late  adult  life.  According  to  Leichtenstern,  over  50  per 
cent,  of  the  cases  occur  between  the  fortieth  and  the  sixtieth  years-.  It 
occasionally  occurs  in  children.  Women  are  attacked  less  frequently  than 
men.  It  is  stated  by  some  authors  that  secondary  cancer  is  more  common 
in  women,  owing  to  the  frequency  of  cancer  of  the  uterus.  Heredity  is 
believed  to  have  an  influence  in  from  15  to  20  per  cent. 

In  many  cases  trauma  is  an  antecedent,  and  cancer  of  the  bile-passages 
is  associated  in  many  instances  with  gall-stones.  Cancer  is  stated  to  be  less 
common  in  the  tropics. 

Morbid  Anatomy. — The  following  forms  of  new  growths  occur  in  the 
liver  and  have  a  clinical  importance: 

CANCER. — Primary  Cancer. — This  is  rare.  Of  163  cases  collected  by 
Eggel,  63.3  per  cent,  were  in  males.  There  are  several  varieties.  Nodular 
forms,  in  which  there  are  scattered  growths  throughout  the  organ;  the 
massive  form  in  which  the  solitary  tumor  occupies  a  large  area,  either  a 
lobe  or  the  greater  part  of  it;  and  small  metastatic  nodules.  A  very  im- 
portant form  is  that  in  which  the  liver  is  diffusely  infiltrated  with  small 
growths,  with  much  hyperplasia  of  the  connective  tissue — the  so-called  can- 
cer with  cirrhosis.  The  course  of  the  disease  is  rapid,  jaundice  often  oc- 
curs, splenic  enlargement  is  not  infrequent,  ascites  and  oedema  are  common 
and  toxic  features  are  frequent  toward  the  close. 

Secondary  Cancer. — The  organ  may  reach  an  enormous  size,  301/£  pounds 
(Osier),  33  pounds  (Christian).  •  The  cancerous  nodules  project  beneath  the 
capsule,  and  can  be  felt  during  life  or  even  seen  through  the  thin  abdominal 
walls.  They  are  usually  disseminated  equally,  though  in  rare  instances  they 
may  be  confined  to  one  lobe.  The  consistence  of  the  nodules  varies;  in  some 
cases  they  are  firm  and  hard  and  those  on  the  surface  show  a  distinct  umbilica- 
tion,  due  to  the  shrinking  of  the  fibrous  tissue  in  the  centre.  These  super- 
ficial cancerous  masses  are  still  sometimes  spoken  of  as  "Farre's  tubercles." 
More  frequently  the  masses  are  on  section  grayish-white  in  color,  or  hamor- 
rhagic.  Rupture  of  blood-vessels  is  not  uncommon  in  these  cases.  In  one 
specimen  there  was  an  enormous  clot  beneath  the  capsule  of  the  liver,  together 
with  haemorrhage  into  the  gall-bladder  and  into  the  peritoneum.  The  sec- 
ondary cancer  shows  the  same  structure  as  the  initial  lesion,  and  is  usually 
either  an  alveolar  or  cylindrical  carcinoma.  Degeneration  is  common  in  these 
secondary  growths;  thus  the  hyaline  transformation  may  convert  large  areas 
into  a  dense,  dry,  grayish-yellow  mass.  Extensive  areas  of  fatty  degeneration 
may  occur,  sclerosis  is  not  uncommon,  and  haemorrhages  are  frequent.  Sup- 
puration sometimes  follows. 

Cancer  of  the  bile-passages  which  has  been  already  considered. 


588  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

SARCOMA. — Of  primary  sarcoma  of  the  liver  very  few  eases  have  been  re- 
ported. Secondary  sarcoma  is  more  frequent,  and  many  examples  of  lympho- 
sarcoma  and  myxo-sarcoma  are  on  record,  less  frequently  glio-sarcoma  or  the 
smooth  or  striped  myoma. 

The  most  important  form  is  the  melano-sarcoma,  secondary  to  sarcoma 
of  the  eye  or  of  the  skin.  Very  rarely  melano-sarcoma  occurs  primarily  in  the 
liver.  In  this  form  the  liver  is  greatly  enlarged,  is  either  uniformly  infiltrated 
with  the  growth,  which  gives  the  cut  surface  the  appearance  of  dark  granite, 
or  there  are  large  nodular  masses  of  a  deep  black  or  marbled  color.  There  are 
usually  extensive  metastases,  and  in  some  instances  every  organ  of  the  body  is 
involved.  Nodules  of  melano-sarcoma  of  the  skin  may  give  a  clew  to  the  diag- 
nosis. 

OTHER  FORMS  OF  LIVER  TUMOR. — One  of  the  commonest  tumors  in  the 
liver  is  the  angioma,  which  occurs  as  a  small,  reddish  body  the  size  of  a  wal- 
nut, and  consists  simply  of  a  series  of  dilated  vessels.  Occasionally  in  children 
angiomata  grow  and  produce  large  tumors. 

Cysts  are  occasionally  found  in  the  liver,  either  single,  which  is  not  very 
uncommon,  or  multiple,  when  they  usually  coexist  with  congenital  cystic 
kidneys. 

Symptoms. — It  is  often  impossible  to  differentiate  primary  and  secondary 
cancer  of  the  liver  unless  the  primary  seat  of  the  disease  is  evident,  as  in  the 
case  of  scirrhus  of  the  breast,  or  cancer  of  the  rectum,  or  of  a  tumor  in  the 
stomach,  which  can  be  felt.  As  a  rule,  cancer  of  the  liver  is  associated  with 
progressive  enlargement;  but  in  some  cases  of  primary  nodular  cancer  and 
in  the  cancer  with  cirrhosis  the  organ  may  not  be  enlarged.  Gastric  disturb- 
ance, loss  of  appetite,  nausea,  and  vomiting  are  frequent.  Progressive  loss 
of  flesh  and  strength  may  be  the  first  symptoms.  Pain  or  a  sensation  of 
uneasiness  in  the  right  hypochondriac  region  may  be  present,  but  enormous 
enlargement  of  the  liver  may  occur  without  the  slightest  pain.  Jaundice, 
which  is  present  in  at  least  half  of  the  cases,  is  usually  of  moderate  extent, 
unless  the  common  duct  is  occluded.  Ascites  is  rare,  except  in  the  form  of 
cancer  with  cirrhosis,  in  which  the  clinical  picture  is  that  of  the  atrophic 
form.  Pressure  by  nodules  on  the  portal  vein  or  extension  of  the  cancer  to  the 
peritoneum  may  also  induce  ascites. 

Inspection  shows  the  abdomen  to  be  distended,  particularly  in  the  upper 
zone.  In  late  stages  of  the  disease,  when  emaciation  is  marked,  the  cancerous 
nodules  can  be  plainly  seen  beneath  the  skin,  and  in  rare  instances  even  the 
umbilications.  The  superficial  veins  are  enlarged.  On  palpation  the  liver  is 
felt,  a  hand's-breadth  or  more  below  the  costal  margin,  descending  with  each 
inspiration.  The  surface  is  usually  irregular,  and  may  present  large  masses 
or  smaller  nodular  bodies,  either  rounded  or  with  central  depressions.  In 
instances  of  diffuse  infiltration  the  liver  may  be  greatly  enlarged  and  present 
a  perfectly  smooth  surface.  The  growth  is  progressive,  and  the  edge  of  the 
liver  may  ultimately  extend  below  the  level  of  the  navel.  Although  generally 
uniform  and  producing  enlargement  of  the  whole  organ,  occasionally  the 
tumor  in  the  left  lobe  forms  a  solid  mass  occupying  the  epigastric  region. 
By  percussion  the  outline  can  be  accurately  limited  and  the  progressive  growth 
of  the  tumor  estimated.  The  spleen  is  rarely  enlarged.  Pyrexia  is  present  in 
many  cases,  usually  a  continuous  fever,  ranging  from  100°  to  102°  F.;  it  may 


NEW   GROWTHS    IN    THE    LIVER  589 

be  intermittent,  with  rigors.  This  may  be  associated  with  the  cancer  alone, 
or,  as  in  one  of  my  cases,  with  suppuration.  (Edema  of  the  feet,  from  anaemia, 
usually  supervenes.  Cancer  of  the  liver  kills  in  from  three  to  fifteen  months. 
One  of  my  patients  lived  for  more  than  two  years. 

Diagnosis. — The  diagnosis  is  easy  when  the  liver  is  greatly  enlarged  and 
the  surface  nodular.  The  smoother  forms  of  diffuse  carcinoma  may  at  first 
be  mistaken  for  fatty  or  amyloid  liver,  but  the  presence  of  jaundice,  the  rapid 
enlargement,  and  the  more  marked  cachexia  will  usually  suffice  to  differen- 
tiate it.  Perhaps  the  most  puzzling  conditions  occur  in  the  rare  cases  of 
enlarged  amyloid  liver  with  irregular  gummata.  The  large  echinococcus  liver 
may  present  a  striking  similarity  to  carcinoma,  but  the  pro jecting  •  nodules 
are  usually  softer,  the  disease  lasts  much  longer,  and  the  cachexia  is  not 
marked. 

Hypertrophic  cirrhosis  may  at  first  be  mistaken  for  carcinoma,  as  the 
jaundice  is  usually  deep  and  the  liver  very  large;  but  the  absence  of  a  marked 
cachexia  and  wasting  and  the  painless,  smooth  character  of  the  enlargement 
are  points  against  cancer.  In  large,  rapidly  growing  secondary  cancers  the 
superficial  rounded  masses  may  almost  fluctuate  and  these  soft  tumor-like 
projections  may  contain  blood.  The  form  of  cancer  with  cirrhosis  can 
scarcely  be  separated  from  atrophic  cirrhosis  itself.  Perhaps  the  wasting  is 
more  extreme  and  more  rapid,  but  the  jaundice  and  the  ascites  are  identical. 
Melano-sarcoma  causes  great  enlargement  of  the  organ.  There  are  frequently 
symptoms  of  involvement  of  other  viscera,  as  the  lungs,  kidneys,  or  spleen. 
Secondary  tumors  may  occur  in  the  skin.  A  very  important  symptom,  not 
present  in  all  cases,  is  melanuria,  the  passage  of  a  very  dark-colored  urine, 
which  may,  however,  when  first  voided,  be  quite  normal  in  color.  The  exist- 
ence of  a  melano-sarcoma  of  the  eye,  or  the  history  of  blindness  in  one  eye, 
with  subsequent  extirpation,  may  indicate  at  once  the  true  nature  of  the 
hepatic  enlargement. 

There  are  several  conditions  in  which  the  liver  itself,  or  portions  of  it, 
may  be  mistaken  for  tumor,  (a)  In  a  progressive  cirrhosis  with  enlargement 
the  left  lobe  may  increase  out  of  all  proportion  to  the  right,  and  form  a 
prominent  mass  in  the  epigastrium.  (&)  Riedel's  tongue-like  lobe  projecting 
from  the  edge  in  the  neighborhood  of  the  gall-bladder,  and  often  associated 
with  distention  of  this  organ,  (c)  The  extreme  left  portion  of  the  organ  may 
be  almost  separated  by  a  broad,  flat  band,  containing  little  or  no  liver  tissue. 
In  a  very  thin  person  this  section  may  feel  like  a  separate  tumor  mass,  as  in  an 
instance  reported  by  J.  P.  Inglis  (Polyclinic,  Jan.,  1911).  A  small  por- 
tion of  the  liver  lay  directly  over  the  coeliac  axis,  connected  with  the  left  lobe 
by  a  mesentery.  The  tumor  was  palpable.  Lastly,  the  contracted,  deformed 
organ  in  perihepatitis  may  form  a  visible,  freely  movable  tumor  in  the  upper 
portion  of  the  abdomen,  without  a  semblance  of  the  normal  liver.  Such  an 
instance  I  figure  in  my  lectures  on  Abdominal  Tumors. 

Treatment. — The  treatment  must  be  entirely  symptomatic.  The  question 
of  surgical  interference  may  be  discussed.  Keen  has  collected  reports  of  76 
cases  of  resection  of  tumors  of  the  liver,  63  of  which  recovered. 


590  DISEASES    OF    THE    DIGESTIVE    SYSTEM 


X.    FATTY    LIVER 

Two  different  forms  of  this  condition  are  recognized — the  fatty  infiltra- 
tion and  fatty  degeneration. 

Fatty  infiltration  occurs,  to  a  certain  extent,  in  normal  livers,  since  the 
cells  always  contain  minute  globules  of  oil. 

In  fatty  degeneration,  which  is  a  much  less  common  condition,  the  proto- 
plasm of  the  liver-cells  is  destroyed  and  the  fat  takes  its  place,  as  seen  in  cases 
of  malignant  jaundice  and  in  phosphorus  poisoning. 

Fatty  liver  occurs  under  the  following  conditions:  (a)  In  association  with 
general  obesity,  in  which  case  the  liver  appears  to  be  one  of  the  storehouses 
of  the  excessive  fat.  (&)  In  conditions  in  which  the  oxidation  processes  are 
interfered  with,  as  in  cachexia,  profound  anemia,  and  in  phthisis.  The  fatty 
infiltration  of  the  liver  in  heavy  drinkers  is  to  be  attributed  to  the  excessive 
demand  made  by  the  alcohol  upon  the  oxygen,  (c)  Certain  poisons,  of  which 
phosphorus  is  the  most  characteristic,  produce  an  intense  fatty  degeneration 
with  necrosis  of  the  liver-cells.  The  poison  of  acute  yellow  atrophy,  whatever 
its  nature,  acts  in  the  same  way. 

The  fatty  liver  is  uniformly  increased  in  size.  The  edge  may  reach  below 
the  level  of  the  navel.  It  is  smooth,  looks  pale  and  bloodless ;  on  section  it  is 
dry,  and  renders  the  surface  of  the  knife  greasy.  The  liver  may  weigh  many 
pounds,  and  yet  the  specific  gravity  is  so  low  that  the  entire  organ  floats  in 
water. 

The  symptoms  of  fatty  liver  are  not  definite.  Jaundice  is  never  present; 
the  stools  may  be  light  colored,  but  even  in  the  most  advanced  grades  the  bile 
is  still  formed.  Signs  of  portal  obstruction  are  rare.  Haemorrhoids  are  not 
very  infrequent.  Altogether,  the  symptoms  are  ill  defined,  and  are  chiefly 
those  of  the  disease  with  which  the  degeneration  is  associated.  In  cases  of 
great  obesity  the  physical  examination  is  uncertain;  but  in  phthisis  and 
cachectic  conditions  the  organ  can  be  felt  to  be  greatly  enlarged,  though 
smooth  and  painless.  Fatty  livers  are  among  the  largest  met  with  at  the 
bedside. 

XI.    AMYLOID    LIVER 

The  waxy,  lardaceous,  or  amyloid  liver  occurs  as  part  of  a  general  degen- 
eration, associated  with  cachexias,  particularly  when  the  result  of  long-stand- 
ing suppuration. 

In  practice,  it  is  found  oftenest  in  the  prolonged  suppuration  of  tubercu- 
lous disease,  either  of  the  lungs  or  of  the  bones.  Next  in  order  of  frequency 
are  the  cases  associated  with  syphilis.  Here  there  may  be  ulceration  of  the 
rectum,  with  which  it  is  often  connected,  or  chronic  disease  of  the  bone,  or  it 
may  be  present  when  there  are  no  suppurative  changes.  It  is  found  occasion- 
ally in  rickets,  in  prolonged  convalescence  from  the  infectious  fevers,  and  in 
the  cachexia  of  cancer. 

The  amyloid  liver  is  large,  and  may  attain  dimensions  equalled  only  by 
those  of  the  cancerous  organ.  Wilks  speaks  of  a  liver  weighing  fourteen 
pounds.  It  is  solid,  firm,  resistant,  on  section  anaemic,  and  has  a  semitranslu- 


ANOMALIES    IN   FORM   AND    POSITION    OF   LIVER       591 

cent,  infiltrated  appearance.  Stained  with  a  dilute  solution  of  iodine,  the 
areas  infiltrated  with,  the  amyloid  matter  assume  a  rich  mahogany-brown 
color. 

There  are  no  characteristic  symptoms  of  this  condition.  Jaundice  does 
not  occur;  the  stools  may  be  light-colored,  but  the  secretion  of  bile  persists. 
The  physical  examination  shows  the  organ  to  "be  uniformly  enlarged  and  pain- 
less, the  surface  smooth,  the  edge  rounded,  and  the  consistence  greatly  in- 
creased. Sometimes  the  edge,  even  in  very  great  enlargement,  is  sharp  and 
hard.  The  spleen  also  may  be  involved,  but  there  are  no  evidences  of  portal 
obstruction. 

The  diagnosis  of  the  condition  is,  as  a  rule,  easy.  Progressive  and  great 
enlargement  in  connection  with  suppuration  of  long  standing  or  with  syphilis 
is  almost  always  of  this  nature.  In  rare  instances,  however,  the  amyloid  liver 
is  reduced  in  size. 

In  leukamia  the  liver  may  attain  considerable  size  and  be  smooth  and  uni- 
form, resembling,  on  physical  examination,  the  fatty  organ.  The  blood  condi- 
tion at  once  indicates  the  true  nature  of  the  case. 


XH.    ANOMALIES   IN   FORM   AND    POSITION    OF    THE    LIVER 

In  transposition  of  the  viscera  the  right  lobe  of  the  organ  may  occupy  the 
left  side.  A  common  and  important  anomaly  is  the  tilting  forward  of  the 
organ,  so  that  the  antero-posterior  axis  becomes  vertical,  not  horizontal.  In- 
stead of  the  edge  of  the  right  lobe  presenting  just  below  the  costal  margin,  a 
considerable  portion  of  the  surface  of  the  lobe  is  in  contact  with  the  abdomi- 
nal parietes,  and  the  edge  may  be  felt  as  low,  perhaps,  as  the  navel.  This  ante- 
version  is  apt  to  be  mistaken  for  enlargement  of  the  organ. 

The  "lacing"  liver  is  met  with  in  two  chief  types.  In  one  the  anterior 
portion,  chiefly  of  the  right  lobe,  is  greatly  prolonged,  and  may  reach  the 
transverse  navel  line,  or  even  lower.  A  shallow  transverse  groove  separates 
the  thin  extension  from  the  main  portion  of  the  organ.  The  peritoneal  coat- 
ing of  this  groove  may  be  fibroid,  and  in  rare  instances  the  deformed  portion 
is  connected  with  the  organ  by  an  almost  tendinous  membrane.  The  liver 
may  be  compressed  laterally  and  have  a  pyramidal  shape,  and  the  extreme 
left  border  and  the  hinder  margin  of  the  left  lobe  may  be  much  folded  and 
incurved.  The  projecting  portion  of  the  liver,  extending  low  in  the  right 
flank,  may  be  mistaken  for  a  tumor,  or  more  frequently  for  a  movable  right 
kidney.  Its  continuity  with  the  liver  itself  may  not  be  evident  on  palpation 
or  on  percussion,  as  coils  of  intestine  may  lie  in  front.  It  descends,  however, 
with  inspiration,  and  usually  the  margin  can  be  traced  continuously  with  that 
of  the  left  lobe  of  the  liver.  The  greatest  difficulty  arises  when  this  anoma- 
lous lappet  of  the  liver  is  either  naturally  very  thick  and  united  to  the  liver  by 
a  very  thin  membrane,  or  when  it  is  swollen  in  conditions  of  great  congestion 
of  the  organ. 

The  other  principal  type  of  lacing  liver  is  quite  different  in  shape.  It  is 
thick,  broader  above  than  below,  and  lies  almost  entirely  above  the  transverse 
line  of  the  cartilages.  There  is  a  narrow  groove  just  above  the  anterior  bor- 
der, which  is  placed  more  transversely  than  normal. 


592  DISEASES    OF   THE    DIGESTIVE    SYSTEM 

Movable  Liver. — This  rare  condition  has  received  much  attention,  and 
J.  E.  Graham  collected  70  reported  cases  from  the  literature.  In  a  very  con- 
siderable number  of  these  there  has  been  a  mistaken  diagnosis.  A  slight  grade 
of  mobility  of  the  organ  is  found  in  the  pendulous  abdomen  of  enteroptosis, 
and  after  repeated  ascites. 

The  organ  is  so  connected  at  its  posterior  margin  with  the  inferior  vena 
cava  and  diaphragm  that  any  great  mobility  from  this  point  is  impossible,  ex- 
cept on  the  theory  of  a  meso-hepar  or  congenital  ligamentous  union  between 
these  structures.  The  ligaments,  however,  may  show  an  extreme  grade  of 
relaxation  (the  suspensory  7.5  cm.,  and  the  triangular  ligament  4  cm.,  in  one 
of  Leube's  cases)  ;  and  when  the  patient  is  in  the  erect  posture  the  organ  may 
drop  down  so  far  that  its  upper  surface  is  entirely  below  the  costal  margin. 
The  condition  is  rarely  met  with  in  men ;  56  of  the  cases  were  in  women. 


I.    DISEASES  OF  THE  PANCREAS 
I.    PANCREATIC  INSUFFICIENCY 

Failure  of  the  internal  secretion  is  followed  by  disturbance  in  the  carbo- 
hydrate metabolism,  of  the  external  secretion  by  disturbances  of  digestion,  or 
by  the  injurious  effects  of  the  retained  secretion.  The  low  sugar  tolerance, 
the  chief  sign  of  impairment  of  the  internal  secretion,  has  been  considered 
under  diabetes.  Insufficiency  of  the  external  secretion  is  indicated  by: 

Changes  in  the  Character  of  the  Stools. — (a)  STEATORRHCEA. — The  pro- 
portion of  fat  in  the  fa?ces  varies;  above  30  per  cent,  of  the  dried  weight  sug- 
gests pancreatic  insufficiency.  The  stools  are  either  oily  like  butter,  or  gray 
like  asbestos.  The  ability  to  digest  fat  differs  greatly  and  there  are  healthy 
persons  who  constantly  have  a  high  percentage  of  fat  in  the  stools.  Steator- 
rhcea  may  last  for  many  years  without  impairment  of-  health.  There  is  also 
a  disturbance  in  the  normal  ratio  between  the  neutral  fats  and  the  fatty  acids. 
Cammidge  gives  the  following  average  figures :  Normal  per  cent.,  total  fats 
21,  neutral  fats  11,  fatty  acids  10;  malignant  disease,  total  fats  77,  neutral 
fats  50,  fatty  acids  27;  chronic  pancreatitis,  total  fats  50,  neutral  fats  32,  fatty 
acids  18. 

(6)  AZOTORRHOSA,  the  presence  of  undigested  proteid  materials  in  the 
stools,  has  long  been  known  as  an  association  of  pancreatic  disease.  Normally 
only  5  or  6  per  cent,  of  the  undigested  proteids  appears  in  the  faeces,  but  in 
pancreatic  disease  as  much  as  30  or  40  per  cent,  may  be  recovered.  Schmidt 
claims  that  the  nuclear  material  of  meat  is  digested  by  the  pancreatic  juice 
alone  and  that  persistence  of  the  nuclei  of  the  meat  fibres  in  the  stools  indi- 
cates defective  tryptic  digestion. 

In  jaundice  due  to  malignant  disease  of  the  head  of  the  pancreas  sterco- 
bilin  is  absent;  in  that  due  to  chronic  pancreatitis  or  gall-stones  it  is  either 
absent  or  present  only  in  traces. 

Cambridge's  Pancreatic  Reaction. — For"  details  of  the  reaction  the  student 
must  consult  special  manuals.  It  is  claimed  that  the  reaction  is  positive  in  all 
cases  of  active  inflammatory  changes  in  the  pancreas,  and  that  by  this  means 


PANCREATIC    NECROSIS  593 

acute  forms  of  pancreatitis  can  be  differentiated  from  intestinal  obstruction, 
and  that  by  it  chronic  pancreatitis  causing  blocking  of  the  common  duct  can  be 
diagnosed  from  gall-stones.  In  malignant  disease  the  reaction  is  negative  in 
about  three-fourths  of  the  cases.  It  is  unfortunate  that  Cammidge's  work 
lacks  confirmation.  The  studies  (1911)  at  the  Mayo  clinic  under  Wilson's 
direction  lead  to  the  conclusion  that  "if  knowledge  of  the  clinical  histories 
and  other  factors  of  the  personal  equation  be  eliminated,  the  end  results, 
judged  by  Cammidge's  own  criteria,  must  be  considered,  as  a  means  of  diag- 
nosing disease  of  the  pancreas,  as  both  valueless  and  misleading."  From 
observations  of  Whipple  and  others  it  seems  that  rapid  disintegration  of  any 
of  the  body  cells,  particularly  the  polynuclear  leucocytes,  may  give  rise  to  the 
reaction. 

II.    PANCREATIC   NECROSIS 

The  entire  series  of  pancreatic  lesions,  from  haemorrhage  to  gangrene,  and 
from  fat  necrosis  to  pancreatic  cyst,  may  result  from  tryptie  auto-digestion 
(Chiari).  This  is  met  with  under  four  conditions:  (a)  Trauma,  as  in  gun- 
shot wounds,  blows,  or  perforation  of  a  peptic  ulcer.  (&)  Primary  thrombosis 
in  the  venous  radicles  of  the  glands,  (c)  Obstruction  of  the  free  flow  of 
secretion  in  the  duct,  (d)  Entrance  of  the  bile  into  the  ducts. 

In  the  mildest  forms  there  are  only  a  few  small  hemorrhages  or  circum- 
scribed areas  of  necrosis  of  the  gland  tissue  with  fat  necrosis  in  the  neigh- 
borhood; in  severer  forms  groups  of  acini  or  the  whole  gland  may  be  involved. 

Fat  necrosis  occurs  whenever  the  pancreatic  juice,  obstructed  from  any 
cause  and  dammed  back  on  the  gland,  infiltrates  its  tissues,  or  escaping  by 
the  lymph  spaces  finds  its  way  to  structures  at  some  distance  from  the  gland. 
The  necrosis  is  due  to  the  fat-splitting  ferment  in  the  secretion  (Opie). 

Balser  first  called  attention  to  this  remarkable  change  which  is  found  in 
the  interlobular  pancreatic  tissue,  in  the  mesentery,  in  the  omentum,  in  the 
abdominal  fatty  tissue  generally,  and  occasionally  in  the  pericardial  and  sub- 
cutaneous fat.  The  necroses  are  most  frequent  in  the  acute  and  necrotic 
forms  of  pancreatitis,  less  common  in  the  suppurative.  In  the  pancreas  the 
lobules  are  seen  to  be  separated  by  a  dead  white  necrotic  tissue,  which  gives 
a  remarkable  appearance  to  the  section.  In  the  abdominal  fat  the  areas  are 
usually  not  larger  than  a  pin's  head ;  they  at  once  attract  attention,  and  may 
be  mistaken,  on  superficial  examination,  for  miliary  tubercles  or  neoplasms. 
They  may  be  larger;  instances  have  been  reported  in  which  they  were  the 
size  of  a  hen's  egg.  On  section  they  have  a  soft  tallowy  consistence,  and  the 
substance  is  a  combination  of  lime  with  certain  fatty  acids.  The  necroses 
may  be  crusted  with  lime,  and  in  a  man  aged  80,  who  died  of  nephritis,  I 
found  the  lobules  of  the  pancreas  entirely  isolated  by  areas  of  fat  necrosis 
with  extensive  deposition  of  lime  salts. 

III.    HAEMORRHAGE 

Both  Spiess  (1866)  and  Zenker  (1874)  were  acquainted  with  haemorrhage 
into  the  pancreas  as  a  cause  of  sudden  death,  but  the  great  medico-legal 


594  DISEASES    OP   THE    DIGESTIVE    SYSTEM 

importance  of  the  subject  was  first  fully  recognized  by  F.  W.  Draper,  of  Bos- 
ton, whose  townsmen,  Harris,  Fitz,  Whitney,  and  others,  have  contributed 
additional  studies.  In  4,000  autopsies  Draper  met  with  19  cases  of  pancreatic 
hemorrhage,  in  9  or  10  of  which  no  other  cause  of  death  was  found.  When 
the  bleeding  is  extensive  the  entire  tissue  of  the  gland  is  destroyed  and  the 
blood  invades  the  retro-peritoneal  tissue.  In  other  instances  the  peritoneal 
covering  is  broken  and  the  blood  fills  the  lesser  peritoneum  (see  haemoperi- 
toneum).  The  haemorrhage  may  be  in  connection  with  an  acute  pancreatitis 
or  with  necrotic  inflammation  of  the  gland. 

The  symptoms  are  thus  briefly  summarized  by  Prince :  "The  patient,  who 
has  previously  been  perfectly  well,  is  suddenly  taken  with  the  illness  which 
terminates  his  life.  .  .  .  When  the  haemorrhage  occurs  the  patient  may 
be  quietly  resting  or  pursuing  his  usual  occupation.  The  pain  which  ushers 
in  the  attack  is  usually  very  severe  and  located  in  the  upper  part  of  the  abdo- 
men. It  steadily  increases  in  severity,  is  sharp  or  perhaps  colicky  in  charac- 
ter. It  is  almost  from  the  first  accompanied  by  nausea  and  vomiting;  the 
latter  becomes  frequent  and  obstinate,  but  gives  no  relief.  The  patient  soon 
becomes  anxious,  restless,  and  depressed;  he  tosses  about,  and  only  with  dif- 
ficulty can  he  be  restrained  in  bed.  The  surface  is  cold  and  the  forehead  is 
covered  with  a  cold  sweat.  The  pulse  is  weak,  rapid,  and  sooner  or  later 
imperceptible.  The  abdomen  becomes  tender,  the  tenderness  being  located  in 
the  upper  part  of  the  abdomen  or  epigastrium.  Tympanites  is  sometimes 
marked.  The  temperature  is  usually  normal  or  subnormal.  The  bowels  are 
constipated." 

IV.    ACUTE   PANCREATITIS 

Acute  Haemorrhagic  Pancreatitis. — In  this  form  the  inflammation  is  com- 
bined with  haemorrhage,  and  it  is  difficult  to  separate  clearly  the  two  processes. 

ETIOLOGY. — A  large  majority  of  the  cases  occur  in  adult  males.  McPhed- 
ran  has  reported  one  in  a  nine  months'  old  child.  IVfany  of  the  patients  had 
been  addicted  to  alcohol;  others  had  suffered  occasionally  with  severe  pains 
and  vomiting  or  with  gall-stone  colic.  Peiser  found  that  8  out  of  121  col- 
lected cases  of  acute  pancreatitis  were  associated  with  parturition.  He  sug- 
gests that  the  changes  bringing  about  the  pancreatitis  in  these  cases  may 
be  analogous  to  those  occurring  in  the  liver,  kidneys,  and  other  organs  in 
eclampsia. 

The  pancreas  is  found  enlarged,  and  the  interlobular  tissue  infiltrated 
with  blood,  and  perhaps  with  clots.  The  relation  of  gall-stones  to  the  condi- 
tion has  been  demonstrated  by  Opie,  and  they  were  present  in  four  of  five 
cases  at  the  Johns  Hopkins  Hospital.  The  calculus  may  be  very  small,  and 
situated  in  the  diverticulum  of  Vater.  Bile  finding  its  way  into  the  pancreas 
may  cause  haemorrhagic  inflammation.  Injection  of  bile  into  the  pancreatic 
ducts  of  dogs  reproduces  the  lesion.  The  anatomical  appearances  are  very 
characteristic.  The  tissues  about  the  gland  are  infiltrated  with  blood  and 
there  may  be  fluid  in  the  lesser  peritoneum.  Areas  of  fat  necrosis  are  seen 
in  the  retroperitoneal  fat,  the  mesocolon  and  mesentery.  The  gland  itself  is 
swollen  and  in  section  the  stroma  has  a  mottled  dark  brown  appearance  and 
the  outlines  of  the  acini  may  be  lost.  In  a  case  which  I  have  reported  the 


ACUTE    PANCREATITIS  595 

semilunar  ganglia  were  swollen,  the  nerve-cells  indistinct,  and  there  was  an 
interstitial  infiltration  of  round  cells.  The  Pacinian  corpuscles  in  the  neigh- 
borhood of  the  pancreas  were  enormously  swollen  and  oedematous. 

SYMPTOMS. — One  of  the  most  characteristic  features  is  the  suddenness  of 
the  onset,  usually  with  violent  colicky  pain  in  the  upper  part  of  the  abdomen. 
Nausea  and  vomiting  follow,  with  collapse  symptoms,  more  or  less  severe 
according  to  the  intensity  of  the  attack.  The  abdomen  becomes  swollen  and 
tense  and  there  is  constipation.  The  temperature  at  first  may  be  low;  sub- 
sequently fever  sets  in,  sometimes  initiated  by  a  chill.  There  may  be  early 
delirium.  Collapse  symptoms  supervene,  and  death  occurs  usually  from  the 
second  to  the  fourth  day,  or  even  earlier.  The  swelling  and  infiltration  in  the 
region  of  the  pancreas  necessarily  involve  the  cceliac  plexus,  and  the  stretch- 
ing of  the  nerves  may  account  for  the  agonizing  pain  and  the  sudden  collapse. 
Deep  pressure  on  the  upper  part  of  the  abdomen  may  give  evidence  of  circum- 
scribed resistance. 

DIAGNOSIS. — Intestinal  obstruction  or  acute  perforating  peritonitis  is  usu- 
ally suspected.  Now  that  the  condition  has  become  better  known,  the  diagno- 
sis intra  vitam  has  been  made.  "Acute  pancreatitis  is  to  be.  suspected  when  a 
previously  healthy  person  or  a  sufferer  from  occasional  attacks  of  indigestion 
is  suddenly  seized  with  a  violent  pain  in  the  epigastrium  followed  by  vomiting 
and  collapse,  and  in  the  course  of  twenty-four  hours  by  a  circumscribed  epi- 
gastric swelling,  tympanitic  or  resistant,  with  slight  elevation  of  temperature. 
Circumscribed  tenderness  in  the  course  of  the  pancreas  and  tender  spots 
throughout  the  abdomen  are  valuable  diagnostic  signs"  (Fitz). 

Acute  Suppurative  Pancreatitis — Pancreatic  Abscess. — ETIOLOGY. — The 
etiology  in  a  majority  of  cases  is  doubtful.  Dyspeptic  disturbances  and  trauma 
have  preceded  the  onset  in  some  instances.  Gall-stones  may  be  present.  In 
many  of  the  cases  it  is  a  sequel  of  acute  hasmorrhagic  pancreatitis.  In  24  cases 
there  was  a  single  abscess;  in  14  there  were  numerous  small  abscesses.  In 
other  instances  there  was  a  diffuse  purulent  infiltration.  Some  of  the  sequels 
are  peri-pancreatic  abscess,  perforation  into  the  stomach,  the  duodenum,  or 
the  peritoneum,  and  thrombosis  of  the  portal  vein. 

SYMPTOMS. — The  symptoms  of  suppurative  pancreatitis  are  not  always 
well  defined.  In  one  case  in  my  wards  Thayer  made  a  correct  diagnosis.  The 
patient,  aged  thirty-four,  had  had  occasional  attacks  of  severe  pain  and  vomit- 
ing. This  was  followed  by  fever  and  delirium.  A  deep-seated  mass  was  felt 
in  the  median  line  just  above  the  umbilicus.  Finney  operated  and  found  dis- 
seminated fat-necrosis  and  a  deep-seated  abscess  with  necrotic  pancreatic  tis- 
sue. The  patient  recovered.  The  course  of  the  suppurative  form  is  much 
more  chronic.  Icterus,  fatty  diarrhoea,  and  sugar  in  the  urine  have  been  met 
with  in  some  cases.  The  presence  of  a  tumor  mass  in  the  epigastrium  is  of 
the  greatest  moment.  -—" 

Gangrenous  Pancreatitis.— Complete  necrosis  of  the  gland,  or  part 
it  may  follow  either  haemorrhage  or  haemorrhagic  inflammation,  and  in  excep- 
tional cases  may  occur  after  suppurative  infiltration  or  aiter  injury  or  the 
perforation  of  an  ulcer  of  the  stomach.  In  Fitz's  monograph  15  cases  are 
reported  Korte  has  increased  its  number  to  40.  Symptoms  of  haemorrhagic 
pancreatitis  may  precede  or  be  associated  with  it.  Death  usually  follows  in 
from  ten  to  twenty  days,  with  symptoms  of  collapse. 


596  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

Anatomically  the  pancreas  may  present  a  dry  necrotic  appearance,  but  as 
a  rule  the  organ  is  converted  into  a  dark  slaty-colored  mass  lying  nearly  free 
in  the  omental  cavity  or  attached  by  a  few  shreds.  In  other  instances  the 
totally  or  partially  sequestrated  organ  may  lie  in  a  large  abscess  cavity,  form- 
ing a  palpable  tumor  in  the  epigastric  region.  In  two  cases,  reported  by 
Chiari,  the  necrotic  pancreas  was  discharged  per  rectum,  with  recovery. 


V.     CHRONIC  PANCREATITIS 

Forms. — Anatomically  there  are  two  forms: 

(a)  Interlobular  pancreatitis  which  follows  occlusion  of  the  duct,  or  an 
infection,  such  as  occurs  in  the  presence  of  calculi,  biliary  or  pancreatic,  with 
which  organisms  of  the  colon  group,  streptococci,  or  occasionally  the  typhoid 
bacillus  are  associated.  Even  in  advanced  sclerosis  of  this  type  the  islands  of 
Langerhans  are  spared.  It  may  occur  as  an  independent  affection.  It  is  not 
at  .all  uncommon  in  the  bodies  of  adults  to  find  the  head  of  the  pancreas 
extraordinarily  hard  and  so  dense  that  it  feels  like  scirrhus;  surgeons  have 
long  noted  this.  The  condition  is  often  present  without  symptoms  of  pan- 
creatic disease  during  life.  A  very  special  form  is  the  chronic  interstitial 
pancreatitis  which  accompanies  hasmochromatosis,  and  which  is  described 
elsewhere.  Mayo  Eobson,  Moynihan  and  other  surgeons  have  called  attention 
to  the  fact  that  sclerosis  of  the  head  of  the  pancreas  may  cause  obstruction  of 
the  duct. 

(6)  Chronic  interacinar  pancreatitis  is  characterized  by  a  diffuse  fibrosis 
penetrating  between  the  acini,  with  little  or  no  involvement  of  the  interlobular 
tissues.  It  may  follow  infection  through  the  duct,  but  is  more  common  in 
association  with  cirrhosis  of  the  liver  and  arterio-sclerosis. 

Symptoms. — It  must  be  confessed  that  the  clinical,  picture  of  chronic  pan- 
creatitis is  very  obscure,  in  spite  of  the  good  work  done  by  our  surgical  col- 
leagues. Cammidge,  who  has  had  the  great  advantage  of  seeing  Mayo  Rob- 
son's  clinical  cases,  describes  four  types:  (a)  The  dyspeptic,  in  which  the 
disease  is  due  to  morbid  conditions  of  the  bowels,  and  the  symptoms  are 
mainly  referred  to  the  digestive  organs.  (6)  The  cholelithic,  associated  with 
the  presence  of  gall-stones  in  the  common  duct ;  there  is  usually  chronic  jaun- 
dice and  the  dominant  symptoms  are  hepatic^  (c)  A  miscellaneous  group  in 
which  the  pancreatitis  is  secondary  to  malignant  disease,  etc.  (d)  The  dia- 
betic group  with  glycosuria,  and  into  which  the  members  of  the  preceding 
groups  may  merge  in  course  of  time. 

Symptoms  of  pancreatic  insufficiency  of  the  internal  or  external  secretion 
are  generally  present;  tl*?re  is  pain  after  food,  very  often  jaundice,  and  on 
deep  pressure  the  head  of  the  pancreas  may  sometimes  be  felt.  Careful  study 
of  the  urine  and  of  the  faeces  gives  important  information.  Cammidge's  pan- 
creatic reaction  in  the  urine  is,  its  author  thinks,  suggestive  of  active  degener- 
ative changes.  Sugar  may  also  be  present.  The  stools  may  show  both  steator- 
rhcea  and  azotorrhcea. 

Treatment.— Owing  to  the  difficulty  of  diagnosis  in  the  early  stages  it  is 
impossible  to  speak  positively  in  a  great  .many  cases,  but  in  the  forms  which 


PANCREATIC    CYSTS  597 

are  associated  with  pain,  jaundice,  the  presence  of  calculi,  and  infection  of  the 
ducts  excellent  results  have  followed  free  drainage  of  the  bile  passages. 

So  much  influenced  is  our  present  picture  of  chronic  pancreatitis  by  per- 
sonal equation  on  the  part  of  surgical  and  laboratory  workers  that  we  are  not 
in  a  position  to  speak  very  definitely  on  several  important  points. 


VI.    PANCREATIC  CYSTS 

Of  121  cases  operated  upon  60  were  in  males  and  56  in  females;  in  5  the 
sex  was  not  given  (Korte).  Sixty-six  of  the  cases  occurred  in  the  fourth 
decade.  T.  C.  Railton's  case  (which  is  not  in  Korte's  series),  an  infant  aged 
six  months,  and  Shattuck's  case  in  a  child  of  thirteen  and  a  half  months  are 
the  youngest  in  the  literature.  According  to  the  origin  Korte  recognizes  three 
varieties. 

Varieties. — TRAUMATIC  CASES. — In  this  list  of  33  cases  30  were  in  men 
and  only  3  in  women.  Blows  on  the  abdomen  or  constantly  repeated  pressure 
are  the  most  common  forms  of  trauma.  One  case  followed  severe  massage. 
Usually  with  the  onset  there  are  inflammatory  symptoms,  pain,  and  vomiting, 
sometimes  suggestive  of  peritonitis.  The  contents  of  the  cyst  are  usually 
bloody,  though  in  13  of  the  traumatic  cases  it  was  clear  or  yellowish. 

CYSTS  FOLLOWING  INFLAMMATORY  CONDITIONS. — In  51  cases  the  trouble 
began  gradually  after  attacks  of  dyspepsia  with  colic,  simulating  somewhat 
that  of  gall-stones.  Occasionally  the  attack  set  in  with  very  severe  symptoms, 
suggestive  of  obstruction  of  the  bowel.  In  this  group  the  tumor  appeared  in 
19  cases  soon  after  the  onset  of  the  pain ;  in  others  it  was  delayed  for  a  period 
of  from  a  few  weeks  to  two  or  three  years.  McPhedran  has  reported  a  remark- 
able instance  in  which  the  tumor  appeared  in  the  epigastrium  with  signs  of 
severe  inflammation.  It  was  opened  and  drained  and  believed  to  be  a  hydrops 
of  the  lesser  peritoneal  cavity.  Three  months  later  a  second  cyst  developed, 
which  appeared  to  spring  directly  from  the  pancreas. 

CYSTS  WITHOUT  ANY  INFLAMMATORY  OR  TRAUMATIC  ETIOLOGY. — Of  33 
cases  in  this  group  26  were  in  women.  A  remarkable  feature  is  the  prolonged 
period  of  their  existence — in  one  case  for  forty-seven  years,  in  one  for  between 
sixteen  and  twenty  years,  in  others  for  sixteen,  nine,  and  eight  years,  in  the 
majority  for  from  two  to  four  years. 

Morbid  Anatomy. — Anatomically  Korte  recognizes  (1)  retention  cysts  due 
to  plugging  of  the  main  duct;  (2)  proliferation  cysts  of  the  pancreatic  tissue 
— and  cysto-adenoma;  (3)  retention  cysts  arising  from  the  alveoli  of  the  gland 
and  of  the  smaller  ducts,  which  become  cut  off  and  dilate  in  consequence  of 
chronic  interstitial  pancreatitis;  (4)  pseudo-cysts  following  inflammatory  or 
traumatic  affections  of  the  pancreas,  usually  the  result  of  injury,  causing  hem- 
orrhage and  hydrops  of  the  lesser  peritoneum. 

Situation.  —In  its  growth  the  cyst  may  (1)  be  in  the  lesser  peritoneum, 
push  the  stomach  upward,  and  reach  the  abdominal  wall  between  the  stomach 
and  the  transverse  colon;  (2)  more  rarely  the  cyst  appears  above  the  lesser 
curvature  and  pushes  the  stomach  downward ;  in  both  of  these  cases  the  situ- 
ation of  the  tumor  is  high  in  the  abdomen;  but  (3)  it  may  develop  between 
the  leaves  of  the  transverse  meso-colon  and  lie  below  both  the  colon  and  the 


598  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

stomach.  The  relation  of  these  two  organs  to  the  tumor  is  variable,  but  in 
the  majority  of  cases  the  stomach  lies  above  and  the  transverse  colon  below 
the  cyst.  Occasionally,  too,  as  in  T.  C.  Railton's  case,  the  cyst  may  arise  in 
the  tail  of  the  pancreas  and  project  far  over  in  the  left  hypochondrium  in  the 
position  of  the  spleen  or  of  a  renal  tumor. 

General  Symptoms. — Apart  from  the  features  of  onset  already  referred 
to,  the  patient  may  complain  of  no  trouble  unless  the  cyst  reaches  a  very 
large  size.  Painful  colicky  attacks,  with  nausea  and  vomiting  and  progressive 
enlargement  of  the  abdomen,  have  frequently  been  noted.  Fatty  diarrhoea 
from  disturbance  of  the  function  of  the  pancreas  is  rare.  Sugar  in  the  urine 
has  been  present  in  a  number  of  cases.  Increased  secretion  of  the  saliva,  the 
so-called  pancreatic  salivation,  is  also  rare.  Pressure  of  the  cyst  may  some- 
times cause  jaundice,  and  in  rare  instances  dyspnoea.  Very  marked  loss  of 
flesh  has  been  present  in  a  number  of  cases.  A  remarkable  feature  often 
noticed  has  been  the  transitory  disappearance  of  the  cyst.  In  one  of  Halsted's 
cases  the  girth  of  the  abdomen  decreased  from  43  to  31  inches  in  ten  days 
with  profuse  diarrhoea.  Sometimes  the  disappearance  has  followed  blows. 

Diagnosis. — The  cyst  occupies  the  upper  abdomen,  usually  forming  a  semi- 
circular bulging  in  the  median  line,  rarely  to  either  side.  In  1G  cases  Korte 
states  that  the  chief  projection  was  below  the  navel.  In  one  case  operated 
upon  by  Halsted  the  tumor  occupied  the  greater  part  of  the  abdomen.  The 
cyst  is  immobile,  respiration  having  little  or  no  influence  on  it.  As  already 
mentioned,  the  stomach,  as  a  rule,  lies  above  it  and  the  colon  below. 

In  a  majority  of  the  cases  the  fluid  is  of  a  reddish  or  dark-brown  color, 
and  contains  blood  or  blood  coloring  matter,  cell  detritus,  fat  granules,  and 
sometimes  cholesterin.  The  consistence  of  the  fluid  is  usually  mucoid,  rarely 
thin.  The  reaction  is  alkaline,  the  specific  gravity  from  1.010  to  1.020.  In 
22  cases  Korte  states  that  the  fluid  was  not  hasmorrhagic. 

The  existence  of  ferments  is  important.  In  54  cases  they  were  present 
in  the  fluid  or  in  the  material  from  the  fistula.  In  20  cases  only  one  ferment 
was  present,  in  20  cases  two,  and  in  14  cases  all  thre^e  of  the  pancreatic  fer- 
ments were  found.  In  view  of  the  wide  occurrence  of  diastatic  and  fat- 
emulsifying  ferments  in  various  exudates,  the  most  important  and  only  posi- 
tive sign  in  the  diagnosis  of  the  pancreatic  secretion  is  the  digestion  of  fibrin 
and  albumin. 

Operation. — Of  160  cases  of  operation  there  were  150  recoveries.  Incision 
and  drainage  was  the  operation  performed  in  138  cases,  in  15  excision  was 
performed. 

VH.    TUMORS    OF    THE    PANCREAS 

Of  new  growths  in  the -organ  carcinoma  is  the  most  frequent.  Sarcoma, 
adenoma,  and  lymphoma  are  rare. 

Frequency. — At  the  General  Hospital  in  Vienna  in  18,069  autopsies  there 
.were  22  cases  of  cancer  of  the  pancreas  (Biach).  In  11,472  post  mortems  at 
Milan  Segre  found  132  tumors  of  the  pancreas,  127  of  which  were  carcino- 
mata,  2  sarcomata,  2  cysts,  and  1  syphiloma.  In  6,000  autopsies  at  Guy's 
Hospital  there  were  only  20  cases  of  primary  malignant  disease  of  the  organ 
(Hale  White).  In  the  first  1,500  autopsies  at  the  Johns  Hopkins  Hospital 


PANCREATIC    CALCULI  599 

there  were  6  cases  of  adeno-carcinoma,  and  1  doubtful  case  in  which  the  exact 
origin  could  not  be  stated.  There  were  8  cases  of  secondary  malignant  disease 
of  the  pancreas.  The  head  of  the  gland  is  most  commonly  involved,  but  the 
disease  may  be  limited  to  the  body  or  to  the  tail.  The  majority  of  the  patients 
are  in  the  middle  period  of  life. 

Symptoms. — The  diagnosis  is  not  often  possible.  The  following  are  the 
most  important  and  suggestive  features:  (a)  Epigastric  pains,  often  occur- 
ring in  paroxysms.  (&)  Jaundice,  due  to  pressure  of  the  tumor  in  the  head 
of  the  pancreas  on  the  bile-duct.  The  jaundice  is  intense  and  permanent,  and 
associated  with  dilatation  of  the  gall-bladder,  which  may  reach  a  very  large 
size,  (c)  The  presence  of  a  tumor  in  the  epigastrium.  This  is  very  variable. 
In  137  cases  Da  Costa  found  the  tumor  present  in  only  13.  Palpation  under 
anaesthesia  with  the  stomach  empty  would  probably  give  a  very  much  larger 
percentage.  As  the  tumor  rests  directly  upon  the  aorta  there  is  usually  a 
marked  degree  of  pulsation,  sometimes  with  a  bruit.  There  may  be  pressure 
on  the  portal  vein,  causing  thrombosis  and  its  usual  sequels,  (d)  Symptoms 
due  to  loss  of  function  of  the  pancreas  are  less  important.  Fatty  diarrhoea  is 
not  very  often  present.  In  consequence  of  the  absence  of  bile  the  stools  are 
usually  very  clay-colored  and  greasy.  Diabetes  also  is  not  common,  (e)  A 
very  rapid  wasting  and  cachexia.  Of  other  symptoms  nausea  and  vomiting 
are  common.  In  some  instances  the  pylorus  is  compressed  and  there  is  great 
dilatation  of  the  stomach.  In  a  few  cases  there  has  been  profuse  salivation. 

The  points  of  greatest  importance  in  the  diagnosis  are  the  intense  and 
permanent  jaundice,  with  dilatation  of  the  gall-bladder,  rapid  emaciation, 
and  the  presence  of  a  tumor  in  the  epigastric  region.  Of  less  importance  are 
features  pointing  to  disturbance  of  the  functions  of  the  gland. 

Of  other  new  growths  sarcoma  and  lymphoma  have  been  occasionally 
found.  Miliary  tubercle  is  not  very  uncommon  in  the  gland.  Syphilis  may 
occur  as  rather  a  chronic  interstitial  inflammation,  or  in  the  form  of  gummata. 

The  outlook  in  tumors  of  the  pancreas  is,  as  a  rule,  hopeless;  but  of  late 
years  a  number  of  successful  cases  of  operation  have  been  reported. 


VIII.     PANCREATIC    CALCULI 

Pancreatic  lithiasis  is  comparatively  rare.  In  1883  George  W.  Johnston 
collected  35  cases  in  the  literature.  In  1,500  autopsies  at  the  Johns  Hopkins 
Hospital  there  were  2  cases. 

The  stones  are  usually  numerous,  either  round  in  shape  or  rough,  spinous 
and  coral-like.  The  color  is  opaque  white.  They  are  composed  chiefly  of  car- 
bonate of  lime.  The  effects  of  the  stones  are:  (1)  A  chronic  interstitial 
inflammation  of  the  gland  substance  with  dilatation  of  the  duct;  sometimes 
there  is  cystic  dilatation  of  the  gland;  (2)  acute  inflammation  with  sup- 
puration; (3)  the  irritation  of  the  stones,  as  in  the  gall-bladder,  may  lead 
to  carcinoma. 

I      Symptoms. — The  cases  are  not  often  diagnosed.    Pains  in  the  epigastrium, 
often  very  severe,  but  not  characteristic ;  the  signs  of  pancreatic  insufficiency 
already  described,  and  the  X-rays,  which  show  the  pancreatic  but  not  the 
biliary  concretions   are  suggestive  features.    An  analysis  of  the  calculi  passed 
' 


600  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

•with  the  stools  may  alone  serve  to  distinguish  a  case  from  one  of  gall-stones. 
Operation  has  been  performed  successfully. 


J.    DISEASES  OF  THE  PERITONEUM 
I.    ACUTE    GENERAL    PERITONITIS 

Definition. — Acute  inflammation  of  the  peritoneum. 

Etiology. — The  condition  may  be  primary  or  secondary. 

(a)  PRIMARY,  IDIOPATHIC  PERITONITIS. — Considering  how  frequently  the 
pleura  and  pericardium  are  primarily  inflamed,  the  rarity  of  idiopathic  in- 
flammation of  the  peritoneum  is  somewhat  remarkable.  It  may  follow  cold 
or  exposure  and  is  then  known  as  "rheumatic"  peritonitis.  In  Bright's  dis- 
ease, gout,  and  arterio-sclerosis  acute  peritonitis  may  occur  as  a  terminal 
event.  Of  102  cases  of  peritonitis  which  came  to  autopsy  at  the  Johns  Hop- 
kins Hospital,  12  were  of  this  form. 

(&)  SECONDARY  PERITONITIS  is  due  to  extension  of  inflammation  from,  or 
perforation  of,  one  of  the  organs  covered  by  the  peritoneum.  Peritonitis  from 
extension  may  follow  inflammation  of  the  stomach  or  intestines,  ulceration  in 
these  parts,  cancer,  acute  suppurative  inflammations  of  the  spleen,  liver,  pan- 
creas, retroperitoneal  tissues,  and  the  pelvic  viscera. 

Perforative  peritonitis  is  the  most  common,  following  external  wounds, 
perforation  .of  an  ulcer  of  the  stomach  or  bowels,  perforation  of  the  gall- 
bladder, abscess  of  the  liver,  spleen,  or  kidneys.  Two  important  causes  are 
appendicitis  and  suppurating  inflammation  about  the  Fallopian  tubes  and 
ovaries.  There  are  instances  in  which  peritonitis  has  followed  rupture  of  an 
apparently  normal  Graafian  follicle. 

Of  the  above  102  cases,  56  originated  in  an  extension  from  some  diseased 
abdominal  viscus.  The  remaining  34  followed  surgical  operations  upon  the 
peritoneum  or  the  contained  organs. 

The  peritonitis  of  septicaemia  and  pyaemia  is  almost  invariably  the  result 
of  a  local  process.  An  exceedingly  acute  form  of  peritonitis  may  be  caused  by 
the  development  of  tubercles  on  the  membrane. 

Morbid  Anatomy. — In  recent  cases,  on  opening  the  abdomen  the  intes- 
tinal coils  are  distended  and  glued  together  with  lymph,  and  the  peritoneum 
presents  a  patchy,  sometimes  a  uniform  injection.  The  exudation  may  be : 
(a)  Fibrinous,  with  little  or  no  fluid,  except  a  few  pockets  of  clear  serum 
between  the  coils.  (6)  Sero-fibrinous.  The  coils  are  covered  with  lymph,  and 
there  is  in  addition  a  large  amount  of  a  yellowish,  sero-fibrinous  fluid.  In 
instances  in  which  the  stomach  or  intestine  is  perforated  this  may  be  mixed 
with  food  or  faeces,  (c)  Purulent,  in  which  the  exudate  is  either  thin  and 
greenish  yellow  in  color,  or  opaque  white  and  creamy,  (d)  Putrid.  Occa- 
sionally in  puerperal  and  perforative  peritonitis,  particularly  when  the  latter 
has  been  caused  by  cancer,  the  exudate  is  thin,  grayish  green  in  color,  and 
has  a  gangrenous  odor,  (e)  Haemorrhagic.  This  is  sometimes  found  as  an 
admixture  in  cases  of  acute  peritonitis  following  wounds,  and  occurs  in  the 
cancerous  and  tuberculous  forms.  (/)  A  rare  form  occurs  in  which  the  injec- 


ACUTE    GENERAL   PERITONITIS  601 

tion  is  present,  but  almost  all  signs  of  exudation  are  wanting.  Close  inspeo 
tion  may  be  necessary  to  detect  a  slight  dulling  of  the  serous  surfaces. 

The  amount  of  the  effusion  varies  from  half  a  litre  to  20  or  30  litres. 
There  are  probably  essential  differences  between  the  various  kinds  of  peri- 
tonitis. 

Bacteriology. — A  large  number  of  organisms  have  been  found  in  connec- 
tion with  the  disease.  In  Flexner's  series.,  in  12  primary  cases  the  strepto- 
coccus was  the  prevailing  organism.  In  the  cases  following  operation  the 
staphylococcus  was  present  alone  in  12  out  of  33,  the  streptococcus  in  5,  and 
the  colon  bacillus  in  5.  Other  organisms  were  the  pneumococcus,  bacillus  pyo- 
cyaneus,  and  bacillus  aerogenes.  Of  56  cases  of  peritonitis  following  intes- 
tinal infections,  the  colon  bacillus  occurred  in  43,  usually  in  connection  with 
streptococci.  The  bacillus  lactis  aerogenes  has  also  been  found  as  the  sole 
organism.  The  gonococcus  is  present  in  the  form  which  arises  from  salpin- 
gitis  and  may  occur  in  the  gonorrhceal  infections  of  children. 

Much  attention  has  been  paid  of  late  to  the  pneumococcus  as  an  agent 
in  the  causation  of  peritonitis,  and  many  cases  are  of  the  primary  form  with- 
out recognizable  portal  of  entry;  but  it  is  to  be  remembered  that  there  are 
many  latent  pneumococcic  lesions,  particularly  those  of  the  middle  ear,  and 
of  the  accessory  sinuses  of  the  nose.  Cameron,  in  a  recent  study,  makes  two 
groups  of  cases;  a  diffuse  form  setting  in  with  abdominal  pain,  high  fever, 
vomiting,  diarrhoea,  in  which  death  may  occur  within  36  hours.  In  the  other 
group  the  peritonitis  is  local,  and  the  symptoms  may  suggest  appendicitis. 
Gradually  a  localized  abscess  develops,  which  may  rupture  internally.  The 
creamy  greenish  yellow  odorless  pus  is  very  characteristic. 

Symptoms. — In  the  perforative  and  septic  cases  the  onset  is  marked  by 
chilly  feelings  or  an  actual  rigor  with  intense  pain  in  the  abdomen.  In  typhoid 
fever,  when  the  sensorium  is  benumbed,  the  onset  may  not  be  noticed.  The 
pain  is  general,  and  is  usually  intense  and  aggravated  by  movements  and  pres- 
sure. A  position  is  taken  which  relieves  the  tension  of  the  abdominal  mus- 
cles, so  that  the  patient  lies  on  the  back  with  the  thighs  drawn  up  and  the 
shoulders  elevated.  The  greatest  pain  is  usually  below  the  umbilicus,  but  in 
peritonitis  from  perforation  of  the  stomach  pain  may  be  referred  to  the  back, 
the  chest,  or  the  shoulder.  The  respiration  is  superficial — costal  in  type — 
as  it  is  painful  to  use  the  diaphragm.  For  the  same  reason  the  action  of 
coughing  is  restrained,  and  even  the  movements  necessary  for  talking  are 
limited.  In  this  early  stage  the  sensitiveness  may  be  great  and  the  abdominal 
muscles  are  often  rigidly  contracted.  If  the  patient  is  at  perfect  rest  the  pain 
may  be  very  slight,  and  there  are  instances  in  which  it  is  not  at  all  marked, 
and  may,  indeed,  be  absent. 

The  abdomen  gradually  becomes  distended  and  tense  and  is  tympanitic  on 
percussion.  The  pulse  is  rapid,  small,  and  hard,  and  often  has  a  peculiar 
wiry  quality.  It  ranges  from  110  to  150.  The  temperature  may  rise  rapidly 
after  the  chill  and  reach  104°  or  105°  F.,  but  the  subsequent  elevation  is 
moderate.  In  some  very  severe  cases  there  may  be  no  fever  throughout.  The 
tongue  at  first  is  white  and  moist,  but  subsequently  becomes  dry  and  often 
red  and  fissured.  Vomiting  is  an  early  and  prominent  feature  and  causes 
great  pain.  The  contents  of  the  stomach  are  first  ejected,  then  a  yellowish  and 
bile  stained  fluid,  and  finally  a  greenish  and,  in  rare  instances,  a  brownish 
40 


602  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

black  liquid  with  slight  fecal  odor.  The  bowels  may  be  loose  at  the  onset  and 
then  constipation  may  follow.  Frequent  micturition  may  be  present,  less 
often  retention.  The  urine  is  usually  scanty  and  high-colored,  and  contains 
a  large  quantity  of  indican. 

The  appearance  of  the  patient  when  these  symptoms  have  fully  developed 
is  very  characteristic.  The  face  is  pinched,  the  eyes  are  sunken,  and  the 
expression  is  very  anxious.  The  constant  vomiting  of  fluids  causes  a  wasted 
appearance,  and  the  hands  sometimes  present  the  washer-woman's  skin. 
Except  in  cholera,  we  see  the  Hippocratic  facies  more'  frequently  in  this  than 
in  any  other  disease — "a,  sharp  nose,  hollow  eyes,  collapsed  temples;  the  ears 
cold,  contracted,  and  their  lobes  turned  out;  the  skin  about  the  forehead  being 
rough,  distended,  and  parched;  the  color  of  the  whole  face  being  brown,  black, 
livid,  or  lead-colored."  There  are  one  or  two  additional  points  about  the  abdo- 
men. The  tympany  is  usually  excessive,  owing  to  the  great  relaxation  of  the 
walls  of  the  intestines  by  inflammation  and  exudation.  The  splenic  dulness 
may  be  obliterated,  the  diaphragm  pushed  up,  and  the  apex  beat  of  the  heari 
dislocated  to  the  fourth  interspace.  The  liver  dulness  may  be  greatly  reduced, 
or  may,  in  the  mammary  line,  be  obliterated.  It  has  been  claimed  that  this  is 
a  distinctive  feature  of  perforative  peritonitis,  but  the  liver  dulness  in  the 
middle  mammary  line  may  be  obliterated  by  tympanites  alone.  In  the  axil- 
lary line,  on  the  other  hand,  the  liver  dulness,  though  diminished,  may  per- 
sist. Pneumo-peritoneum  following  perforation  more  certainly  obliterates  the 
hepatic  dulness.  In  such  cases  the  fluid  effused  produces  a  dulness  in  the 
lateral  region;  but  with  gas  in  the  peritoneum,  if  the  patient  is  turned  on 
the  left  side,  a  clear  note  is  heard  beneath  the  seventh  and  eighth  rib.  Acute 
peritonitis  may  present  a  flat,  rigid  abdomen  throughout  its  course. 

Effusion  of  fluid — ascites — is  usually  present  except  in  some  acute,  rapidly 
fatal  cases.  The  flanks  are  dull  on  percussion.  The  dulness  may  be  movable, 
though  this  depends  altogether  upon  the  degree  of  adhesions.  There  may  be 
considerable  effusion  without  either  movable  dulness  or  fluctuation.  A  fric- 
tion rub  may  be  present,  as  first  pointed  out  by  Bright,  but  it  is  not  nearly  so 
common  in  acute  as  in  chronic  peritonitis. 

Course. — The  acute  diffuse  peritonitis  usually  terminates  in  death.  The 
most  intense  forms  may  kill  within  thirty-six  to  forty-eight  hours ;  more  com- 
monly death  results  in  four  or  five  days,  or  the  attack  may  be  prolonged  to 
eight  or  ten  days.  The  pulse  becomes  irregular,  the  heart-sounds  weak,  the 
breathing  shallow ;  there  are  lividity  with  pallor,  a  cold  skin  with  high  rectal 
temperature — a  group  of  symptoms  indicating  profound  failure  of  the  vital 
functions  for  which  Gee  has  revived  the  old -term  lipothymia.  Occasionally 
death  occurs  with  great  suddenness,  owing,  possibly,  to  paralysis  of  the  heart. 

Diagnosis.— In  typical  cases  the  severe  pain  at  onset,  the  distention  of  the 
abdomen,  the  tenderness,  the  fever,  the  gradual  onset  of  effusion,  collapse, 
and  the  vomiting  give  a  characteristic  picture.  Careful  inquiries  should  at 
once  be  made  concerning  the  previous  condition,  from  which  a  clew  can  often 
be  had  as  to  the  starting-point  of  the  trouble.  In  young  adults  a  considerable 
proportion  of  all  cases  depends  upon  perforating  appendicitis,  and  there  may 
be  an  account  of  previous  attacks  of  pain  in  the  iliac  region,  or  of  constipa- 
tion alternating  with  diarrhoea.  In  women  the  most  frequent  causes  are  sup- 
purative  processes  in  the  pelvic  viscera,  associated  with  salpingitis,  abscesses 


PERITONITIS    IN    INFANTS  603 

in  the  broad  ligaments,  or  acute  puerperal  infection.  Perforation  of  gastric 
ulcer  is  a  more  common  factor  in  women  than  in  men.  It  is  not  always  easy 
to  determine  the  cause.  Many  cases  come  under  observation  for  the  first  time 
with  the  abdomen  distended  and  tender,  and  it  is  impossible  to  make  a  satis- 
factory examination.  In  such  instances  the  pelvic  organs  should  be  examined 
with  the  greatest  care.  In  typhoid  fever,  if  the  patient  is  conscious,  the  sud- 
den onset  of  pain,  the  tenderness,  rigidity,  muscle  spasm,  and  the  aggravation 
of  the  general  symptoms  indicate  what  has  happened.  When  the  patient  is 
in  deep  coma,  on  the  other  hand,  the  perforation  may  be  overlooked.  The  fol- 
lowing conditions  are  most  apt  to  be  mistaken  for  acute  peritonitis : 

(a)  Acute  Entero-colitis. — Here  the  pain  and  distention  and  the  sensitive- 
ness on  pressure  may  be  marked.    The  pain  is  more  colicky  in  character,  the 
diarrhoea  is  more  frequent,  and  the  collapse  is  more  extreme. 

(b)  The  So-called  Hysterical  Peritonitis. — This  has  deceived  the  very 
elect,  as  almost  every  feature  of  genuine  peritonitis,  even  the  collapse,  may 
be  simulated.     The  onset  may  be  sudden,  with  severe  pain  in  the  abdomen, 
tenderness,  vomiting,  diarrhoea,  difficulty  in  micturition,  and  the  character- 
istic decubitus.    Even  the  temperature  may  be  elevated.    There  may  be  recur- 
rence of  the  attack.     A  case  has  been  reported  by  Bristowe  in  which  four 
attacks  occurred  within  a  year,  and  it  was  not  until  special  hysterical  symp- 
toms developed  that  the  true  nature  of  the  trouble  was  suspected. 

(c)  Obstruction  of  the  bowel,  as  already  mentioned,  may  simulate  perito- 
nitis, both  having  pain,  vomiting,  tympanites,  and  constipation  in  common. 
It  may  for  a  couple  of  days  really  be  impossible  to  make  a  diagnosis  in  the 
absence  of  a  satisfactory  history. 

(d)  Rupture  of  an  abdominal  aneurism  or  embolism  of  the  superior  mes- 
enteric  artery  may  cause  symptoms  which  simulate  peritonitis.    In  the  latter, 
sudden  onset  with  severe  pain,  the  collapse  symptoms,  frequent  vomiting,  and 
great  distention  of  the  abdomen  may  be  present. 

(e)  I  have  already  referred  to  the  fact  that  acute  haemorrhagic  pancre- 
atitis may  be  mistaken  for  peritonitis.     Lastly,  a  ruptured  tubal  pregnancy 
may  resemble  acute  peritonitis. 


H.    PERITONITIS    IN    INFANTS 

Peritonitis  may  occur  in  the  fetus  as  a  consequence  of  syphilis,  and  may 
lead  to  constriction  of  the  bowel  by  fibrous  adhesions. 

In  the  new-born  a  septic  peritonitis  may  extend  from  an  inflamed  cord. 
Distention  of  the  abdomen,  slight  swelling  and  redness  about  the  cord,  and 
not  infrequently  jaundice  are  present.  It  is  an  uncommon  event,  and  existed 
in  only  4  of  51  infants  dying  with  inflammation  of  the  cord  and  septicaemia 

(Eunge). 

During  childhood  peritonitis  arises  from  causes  similar  to  those  affecting 
the  adult.  Perforative  appendicitis  is  common.  Peritonitis  following  blows 
or  kicks  on  the  abdomen  occurs  more  frequently  at  this  period.  In  boys  injury 
while  playing  football  may  be  followed  by  diffuse  peritonitis.  A  rare  cause 
in  children  is  extension  through  the  diaphragm  from  an  empyema.  There 
are  on  record  instances  of  peritonitis  occurring  in  several  children  at  the  same 


604  DISEASES    OF   THE   DIGESTIVE    SYSTEM 

school,  and  it  lias  been  attributed  to  sewer-gas  poisoning.  It  was  in  investigat- 
ing an  epidemic  of  this  kind  at  the  Wandsworth  school,  in  London,  that 
Anstie  received  the  post  mortem  wound  of  which  he  died.  It  is  to  be  remem- 
bered that  peritonitis  in  children  may  follow  the  gonorrhceal  vulvitis  so  com- 
mon in  infant  homes  and  hospitals. 


HI.     LOCALIZED   PERITONITIS 

Subphrenic  Peritonitis. — The  general  peritoneum  covering  the  right  and 
left  lobes  of  the  liver  may  be  involved  in  an  extension  from  the  pleura  of  sup- 
purative,  tuberculous,  or  cancerous  processes.  In  various  affections  of  the 
liver — cancer,  abscess,  hydatid  disease,  and  in  affections  of  the  gall-bladder — 
the  inflammation  may  be  localized  to  the  peritoneum  covering  the  upper  sur- 
face of  the  organ.  These  forms  of  localized  subphrenic  peritonitis  in  the 
greater  sac  are  not  so  important  in  reality  as  those  which  occur  in  the  lesser 
peritoneum.  The  anatomical  relations  of  this  structure  are  as  follows:  It 
lies  behind  and  below  the  stomach,  the  gastro-hepatic  omentum,  and  the 
anterior  layer  of  the  great  omentum.  Its  lower  limit  forms  the  upper  layer 
of  the  transverse  meso-colon.  On  either  side  it  reaches  from  the  hepatic  to 
the  splenic  flexure  of  the  colon,  and  from  the  foramen  of  Winslow  to  the 
hilus  of  the  spleen.  Behind  it  covers  and  is  tightly  adherent  to  the  front  of 
the  pancreas.  Its  upper  limit  is  formed  by  the  transverse  fissure  of  the  liver, 
and  by  that  portion  of  the  diaphragm  which  is  covered  by  the  lower  layer  of 
the  right  lateral  ligament  of  the, liver;  the  lobus  Spigelii  lies  bare  in  the  cav- 
ity. The  foramen  of  Winslow,  through  which  the  lesser  communicates  with 
the  greater  peritoneum,  is  readily  closed  by  inflammation. 

Inflammatory  processes,  exudates,  and  haemorrhages  may  be  confined  en- 
tirely to  the  lesser  peritoneum.  The  exudate  of  tuberculous  peritonitis  may 
be  confined  to  it.  Perforations  of  certain  parts  of  the  stomach,  of  the  duode- 
num, and  of  the  colon  may  excite  inflammation  in  it  alone;  and  in  various 
affections  of  the  pancreas,  particularly  trauma  and  hemorrhage,  the  effusion 
into  the  sac  has  often  been  confounded  with  cyst  of  this  organ. 

Special  mention  must  be  made  of  the  remarkable  form  of  subphrenic 
abscess  containing  air,  which  may  simulate  closely  pneumothorax,  and  hence 
was  called  by  Leyden  pyo-pneumothorax  subphrenicus.  The  affection  has 
been  thoroughly  studied  by  Scheurlen,  Mason,  Meltzer,  and  Lee  Dickinson. 
In  142  out  of  170  recorded  cases  the  cause  was  known.  In  a  few  instances, 
as  in  one  reported  by  Meltzer,  the  subphrenic  abscess  seemed  to  have  followed 
pneumonia.  Pyothorax  is  an  occasional  cause.  By  far  the  most  frequent 
condition  is  gastric  ulcer,  which  occurred  in  80  of  the  cases.  Duodenal  ulcer 
was  the  cause  in  6  per  cent.  In  about  10  per  cent,  of  the  cases  the  appendix 
was  the  starting-point  of  the  abscess.  Cancer  of  the  stomach  is  an  occasional 
cause.  Other  rare  causes  are  trauma,  which  was  present  in  one  of  my  cases, 
perforation  of  an  hepatic  or  a  renal  abscess,  lesions  of  the  spleen,  abscess,  and 
cysts  of  the  pancreas. 

In  a  majority  of  all  the  cases  in  which  the  stomach  or  duodenum  is  per- 
forated— sometimes,  indeed,  in  the  cases  following  trauma,  as  in  Case  8  of  my 
series — the  abscess  contains  air. 


LOCALIZED    PERITONITIS  G05 

The  symptoms  of  subphrenic  abscess  vary  very  considerably,  depending  a 
good  deal  upon  the  primary  cause.  The  onset,  as  a  rule,  is  abrupt,  particularly 
when  due  to  perforation  of  a  gastric  ulcer.  There  are  severe  pain,  vomiting, 
often  of  bilious  or  of  bloody  material;  respiration  is  embarrassed,  owing  to 
the  involvement  of  the  diaphragm;  then  the  constitutional  symptoms  occur 
associated  with  suppuration,  chills,  irregular  fever,  and  emaciation.  Subse- 
quently perforation  may  take  place  into  the  pleura  or  into  the  lung,  with 
severe  cough  and  abundant  purulent  expectoration. 

The  perihepatic  abscess  beneath  the  arch  of  the  diaphragm,  whether  to  the 
right  or  left  of  the  suspensory  ligament,  when  it  does  not  contain  air,  is  almost 
invariably  mistaken  for  empyema.  Remarkable  features  are  superadded  when 
the  abscess  cavity  contains  air.  On  the  right  side,  when  the  abscess  is  in  the 
greater  peritoneum,  above  the  right  lobe  of  the  liver,  the  diaphragm  may  be 
pushed  up  to  the  level  of  the  second  or  third  rib,  and  the  physical  signs  on 
percussion  and  auscultation  are  those  of  pneumothorax,  particularly  the  tym- 
panitic  resonance  and  the  movable  dulness.  The  liver  is  usually  greatly  de- 
pressed and  there  is  bulging  on  the  right  side.  Still  more  obscure  are  the 
cases  of  air-containing  abscesses  due  to  perforation  of  the  stomach  or  duode- 
num, in  which  the  gas  is  contained  in  the  lesser  peritoneum.  Here  the  dia- 
phragm is  pushed  up  and  there  are  signs  of  pneumothorax  on  the  left  side. 
In  a  large  majority  of  all  the  cases  which  follow  perforation  of  a  gastric  ulcer 
the  effusion  lies  between  the  diaphragm  above,  and  the  spleen,  stomach,  and 
the  left  lobe  of  the  liver  below. 

The  prognosis  in  subphrenic  abscess  is  not  very  hopeful.  Of  the  cases  on 
record  about  20  per  cent,  only  have  recovered. 

Appendicular. — The  most  frequent  cause  of  localized  peritonitis  in  the 
male  is  inflammation  of  the  appendix  vermiformis.  The  situation  varies  with 
the  position  of  this  extremely  variable  organ.  The  adhesion,  perforation,  and 
intraperitoneal  abscess  cavity  may  be  within  the  pelvis,  or  to  the  left  of  the 
median  line  in  the  iliac  region,  in  the  lower  right  quadrant  of  the  umbilical 
region — a  not  uncommon  situation — or,  of  course,  most  frequently  in  .the 
right  iliac  fossa.  In  the  most  common  situation  the  localized  abscess  lies  upon 
the  psoas  muscle,  bounded  by  the  caecum  on  the  right  and  the  terminal  portion 
of  the  ileum  and  its  mesentery  in  front  and  to  the  left.  In  many  of  these 
cases  the  limitation  is 'perfect,  and  post  mortem  records  show  that  complete 
healing  may  take  place  with  the  obliteration  of  the  appendix  in  a  mass  of 
firm  scar  tissue. 

Pelvic  Peritonitis. — The  most  frequent  cause  is  inflammation  about  the 
uterus  and  Fallopian  tubes.  Puerperal  septicaemia,  gonorrhoea,  and  tubercu- 
losis are  the  usual  causes.  The  tubes  are  the  starting-point  in  a  majority 
of  the  cases.  The  fimbriae  become  adherent  and  closely  matted  to  the  ovary, 
and  there  is  gradually  produced  a  condition  of  thickening  of  the  parts,  in 
which  the  individual  organs  are  scarcely  recognizable.  The  tubes  are  dilated 
and  filled  with  cheesy  matter  or  pus,  and  there  may  be  small  abscess  cavities 
in  the  broad  ligaments.  Rupture  of  one  of  these  may  cause  general  perito- 
nitis, or  the  membrane  may  be  involved  by  extension,  as  in  tuberculosis  of 
these  parts. 


GOG  DISEASES    OF    THE    DIGESTIVE    SYSTEM 


IV.    CHRONIC   PERITONITIS 

The  following  varieties  may  be  recognized : 

Local  adhesive  peritonitis,  a  very  common  condition,  which  occurs  par- 
ticularly about  the  spleen,  forming  adhesions  between  the  capsule  and  the 
diaphragm,  about  the  liver,  less  frequently  about  the  intestines  and  mesentery. 
Points  of  thickening  or  puckering  on  the  peritoneum  occur  sometimes  with 
union  of  the  coils  or  with  fibrous  bands.  In  a  majority  of  such  cases  the  con- 
dition is  met  accidentally  post  mortem.  Two  sets  of  symptoms  may,  however, 
be  caused  by  these  adhesions.  When  a  fibrous  band  is  attached  in  such  a  way 
as  to  form  a  loop  or  snare,  a  coil  of  intestine  may  pass  through  it.  Thus,  of 
the  295  cases  of  intestinal  obstruction  analyzed  by  Fitz,  63  were  due  to  this 
cause.  The  second  group  is  less  serious  and  comprises  cases  with  persistent 
abdominal  pain  of  a  colicky  character,  sometimes  rendering  life  miserable. 

Diffuse  Adhesive  Peritonitis. — This  is  a  consequence  of  an  acute  inflam- 
mation, either  simple  or  tuberculous.  The  peritoneum  is  obliterated.  On 
cutting  through  the  abdominal  wall,  the  coils  of  intestines  are  uniformly 
matted  together  and  can  neither  be  separated  from  each  other  nor  can  the~ 
visceral  and  parietal  layers  be  distinguished.  There  may  be  thickening  of  the 
layers,  and  the  liver  and  spleen  are  usually  involved  in  the  adhesions. 

Proliferative  Peritonitis. — Apart  from  cancer  and  tubercle,  which  produce 
typical  lesions  of  chronic  peritonitis,  the  most  characteristic  form  is  that  which 
may  be  described  under  this  heading.  The  essential  anatomical  feature  is 
great  thickening  of  the  peritoneal  layers,  usually  without  much  adhesion. 
The  cases  are  sometimes  seen  with  sclerosis  of  the  stomach.  In  one  instance 
I  found  it  in  connection  with  a  sclerotic  condition  of  the  caecum  and  the  first 
part  of  the  colon.  It  is  not  uncommon  with  cirrhosis  of  the  liver.  In  the 
inspection  of  a  case  of  this  kind  there  is  usually  moderate  effusion,  more  rarely 
extensive  ascites.  The  peritoneum  is  opaque  white  -in  color,  and  everywhere 
thickened,  often  in  patches.  The  omentum  is  usually  rolled  and  forms  a 
thickened  mass  transversely  placed  between  the  stomach  and  the  colon.  The 
peritoneum  over  the  stomach,  intestines,  and  mesentery  is  sometimes  greatly 
thickened.  The  liver  and  spleen  may  simply  be  adherent,  or  there  is  a  con- 
dition of  chronic  perihepatitis  or  perisplenitis,  so  that  a  layer  of  firm,  almost 
gristly  connective  tissue  of  from  one-fourth  to  half  an  inch  in  thickness  encir- 
cles these  organs.  Usually  the  volume  of  the  liver  is  in  consequence  greatly 
reduced.  The  gastro-hepatic  omentum  may  be  constricted  by  this  new  growth 
and  the  calibre  of  the  portal  vein  much  narrowed.  A  serous  effusion  may  be 
present.  On  account  of  the  adhesions  which  form,  the  peritoneum  may  be 
divided  into  three  or  four  different  sacs,  as  is  more  fully  described  under  the 
tuberculous  peritonitis.  In  these  cases  the  intestines  are  usually  free,  though 
the  mesentery  is  greatly  shortened.  There  are  instances  of  chronic  peritonitis 
in  which  the  mesentery  is  so  shortened  by  this  proliferative  change  that  the 
intestines  form  a  ball  not  larger  than  a  cocoanut  situated  in  the  middle  line, 
and  after  the  removal  of  the  exudation  can  be  felt  as  a  solid  tumor.  The 
intestinal  wall  is  greatly  thickened  and  the  mucous  membrane  of  the  ileum 
is  thrown  into  folds  like  the  valvula?  conniventes.  This  proliferative  peri- 
tonitis is  found  frequently  in  the  subjects  of  chronic  alcoholism.  In  cases  of 


NEW    GROWTHS    IX    THE    PERITONEUM  607 

long-continued  ascites  the  serous  surfaces  generally  become  thickened  and  pre- 
sent an  opaque,  dead  white  color.  This  condition  is  observed  especially  in 
hepatic  cirrhosis,  but  attends  tumors,  chronic  passive  congestion,  etc. 

In  all  forms  of  chronic  peritonitis  a  friction  may  be  felt  usually  in  the 
upper  zone  of  the  abdomen.     Polyorrhomenitis,  polyserositis,  general  chronic 
inflammation  of  the  serous  membranes,  Concato's  disease  (as  the  Italians  call  . 
it)  may  occur  with  this  form  as  well  as  in  the  tuberculous  variety.    The  peri- 
cardium and  both  pleurae  may  be  involved. 

In  some  instances  of  chronic  peritonitis  the  membrane  presents  numerous 
nodular  thickenings,  which  may  be  mistaken  for  tubercles.  J.  F.  Payne  de- 
scribed a  case  of  this  sort  associated  with  disseminated  growths  throughout 
the  liver  which  were  not  cancerous.  It  has  been  suggested  that  some  of  the 
cases  of  tuberculous  peritonitis  cured  by  operation  have  been  of  this  nature, 
but  histological  examination  would,  as  a  rule,  readily  determine  between  the 
conditions.  Miura,  in  Japan,  has  reported  a  case  in  which  these  nodules  con- 
tained the  ova  of  a  parasite.  One  case  has  been  reported  in  which  the  exciting 
cause  was  regarded  as  cholesterin  plates,  which  were  contained  within  the 
granulomatous  nodules. 

Chronic  Haemorrhagic  Peritonitis. — Blood-stained  effusions  in  the  peri- 
toneum occur  particularly  in  cancerous  and  tuberculous  disease.  A  chronic 
inflammation  analogous  to  the  haemorrhagic  pachymeningitis  of  the  brain  was 
described  first  by  Virchow,  and  is  localized  most  commonly  in  the  pelvis. 
Layers  of  new  connective  tissue  form  on  the  surface  of  the  peritoneum  with 
large  wide  vessels  from  which  haemorrhage  occurs.  This  is  repeated  from 
time  to  time  with  the  formation  of  regular  layers  of  haemorrhagic  effusion. 
It  is  rarely  diffuse,  more  commonly  circumscribed.  Probably  the  spontaneous 
peritoneal  haemorrhage  with  the  features  of  an  "acute  abdomen"  (Church- 
man) may  represent  the  primary  form  of  this  rare  condition. 


V.    NEW   GROWTHS   IN   THE   PERITONEUM 

Tuberculous  Peritonitis. — This  has  already  been  considered. 

Cancer  of  the  Peritoneum. — Although,  as  a  rule,  secondary  to  disease  of 
the  stomach,  liver,  or  pelvic  organs,  cases  of  primary  cancer  have  been  de- 
scribed. It  is  probable  that  the  so-called  primary  cancers  of  the  serous  mem- 
branes are  endotheliomata  and  not  carcinomata.  Secondary  malignant  perito- 
nitis occurs  in  connection  with  all  forms  of  cancer.  It  is  usually  characterized 
by  a  number  of  round  tumors  scattered  over  the  entire  peritoneum,  sometimes 
small  and  miliary,  at  other  times  large  and  nodular,  with  puckered  centres. 
The  disease  most  commonly  starts  from  the  stomach  or  the  ovaries.  The 
omentum  is  indurated  and,  as  in  tuberculous  peritonitis,  forms  a  mass  which 
lies  transversely  across  the  upper  portion  of  the  abdomen.  Primary  malig- 
nant disease  of  the  peritoneum  is  extremely  rare.  Colloid  is  said  to  have' 
occurred,  forming  enormous  masses,  which  in  one  case  weighed  over  100 
pounds.  Cancer  of  this  membrane  spreads,  either  by  the  detachment  of  small 
particles  which  are  carried  in  the  lymph  currents  and  by  the  movements  to 
distant  parts,  or  by  contact  of  opposing  surfaces.  It  occurs  more  frequently  in 
women  than  in  men,  and  more  commonly  at  the  later  period  of  life. 


608  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

The  diagnosis  of  cancer  of  the  peritoneum  is  easy  with  a  history  of  a  local 
malignant  disease;  as  when  it  occurs  with  ovarian  tumor  or  with  cancer  of 
the  pylorus.  In  cases  in  which  there  is  no  evidence  of  a  primary  lesion  the 
diagnosis  may  be  doubtful.  The  clinical  picture  is  usually  that  of  chronic 
ascites  with  progressive  emaciation.  There  may  be  no  fever.  If  there  is 
much  effusion  nothing  definite  can  be  felt  on  examination.  After  tapping, 
irregular  nodules  or  the  curled  omentum  may  be  felt  lying  transversely  across 
the  upper  portion  of  the  abdomen.  Multiple  nodules,  if  large,  indicate  cancer, 
particularly  in  persons  above  middle  life.  Nodular  tuberculous  peritonitis  is 
most  frequent  in  children.  The  presence  about  the  navel  of  secondary  nodules 
and  indurated  masses  is  more  common  in  cancer.  Inflammation,  suppuration, 
and  the  discharge  of  pus  from  the  navel  rarely  occur  except  in  tuberculous 
disease.  Considerable  enlargement  of  the  inguinal  glands  may  be  present  in 
cancer.  The  nature  of  the  fluid  in  cancer  and  in  tubercle  may  be  much  alike. 
It  may  be  haemorrhagic  in  both;  more  often  in  the  latter.  The  histological 
examination  in  cancer  may  show  large  multinuclear  cells  or  groups  of  cells — 
the  sprouting  cell-groups  of  Foulis — which  are  extremely  suggestive.  The  col- 
loid cancer  may  produce  a  totally  different  picture ;  instead  of  ascitic  fluid,  the 
abdomen  is  occupied  by  the  semi-solid  gelatinous  substance,  and  is  firm,  not 
fluctuating. 

And,  lastly,  there  are  instances  of  echinococci  in  the  peritoneum  which 
may  simulate  cancer  very  closely. 


VI.    ASCITES 

(Hydro-peritoneum) 

Definition. — The  accumulation  of  serous  fluid  in-  the  peritoneal  cavity. 

Etiology. — LOCAL  CAUSES. —  (a)  Chronic  inflammation  of  the  peritoneum, 
either  simple,  cancerous,  or  tuberculous.  (&)  Portal  obstruction  in  the  ter- 
minal branches  within  the  liver,  as  in  cirrhosis  and  chronic  passive  congestion, 
or  by  compression  of  the  vein  in  the  gastro-hepatic  omentum,  either  by  pro- 
liferative  peritonitis,  by  new  growths,  or  by  aneurism,  (c)  Thrombosis  of  the 
portal  vein,  (d)  Tumors  of  the  abdomen.  The  solid  growths  of  the  ovaries 
may  cause  considerable  ascites,  which  may  completely  mask  the  true  condition. 
It  is  important  to  bear  in  mind  this  possibility  in  the  obscure  ascites  of 
women.  The  condition  is  not  infrequent,  as  I  saw  four  cases  due  to  this  cause 
in  1911.  The  enlarged  spleen  in  leukemia,  less  commonly  in  malaria,  may  be 
associated  with  recurring  ascites. 

GENERAL  CAUSES. — The  ascites  is  part  of  a  general  dropsy,  the  result  of 
mechanical  effects,  as  in  heart-disease,  chronic  emphysema,  and  sclerosis  of  the 
lung.  In  cardiac  lesions  the  effusion  is  sometimes  confined  to  the  peritoneum, 
in  which  case  it  is  due  to  secondary  changes  in  the  liver,  or  it  has  been  sug- 
gested to  be  connected  with  a  failure  of  the  suction  action  of  this  organ  by 
which  the  peritoneum  is  kept  dry.  Ascites  occurs  also  in  the  dropsy  of  Bright's 
disease,  and  in  hydraemic  states  of  the  blood. 

Symptoms. — A  gradual  uniform  enlargement  of  the  abdomen  is  the  char- 


ASCITES  609 

acteristic  symptom  of  ascites.  The  PHYSICAL  SIGNS  are  usually  distinctive, 
(a)  Inspection.— According  to  the  amount  of  fluid  the  abdomen  is  protuber- 
ant and  flattened  at  the  sides.  With  large  effusions,  the  skin  is  tense  and 
may  present  the  lines  albicantes.  Frequently  the  navel  itself  and  the  parts 
about  it  are  very  prominent.  In  many  cases  the  superficial  veins  are  enlarged 
and  a  plexus  joining  the  mammary  vessels  can  be  seen.  Sometimes  it  can  be 
determined  by  pressure  on  these  veins  that  the  current  is  from  below  upward. 
In  some  instances,  as  in  thrombosis  or  obliteration  of  the  portal  vein,  these 
superficial  abdominal  vessels  may  be  extensively  varicose.  About  the  navel 
in  cases  of  cirrhosis  there  is  occasionally  a  large  bunch  of  distended  veins,  the 
so-called  caput  Medusae.  The  heart  may  be  displaced  upward. 

(&)  Palpation. — Fluctuation  is  obtained  by  placing  the  fingers  of  one 
hand  upon  one  side  of  the  abdomen  and  by  giving  a  sharp  tap  on  the  opposite 
side  with  the  other  hand,  when  a  wave  is  felt  to  strike  as  a  definite  shock 
against  the  applied  fingers.  Even  comparatively  small  quantities  of  fluid 
may  give  this  fluctuation  shock.  When  the  abdominal  walls  are  thick  or  very 
fat,  an  assistant  may  place  the  edge  of  the  hand  or  a  piece  of  cardboard  in 
front  of  the  abdomen.  A  different  procedure  is  adopted  in  palpating  for  the 
solid  organs  in.  case  of  ascites.  Instead  of  placing  the  hand  flat  upon  the 
abdomen,  as  in  the  ordinary  method,  the  pads  of  the  fingers  only  are  placed 
lightly  upon  the  skin,  and  then  by  a  sudden  depression  of  the  fingers  the  fluid 
is  displaced  and  the  solid  organ  or  tumor  may  be  felt.  By  this  method  of 
"dipping"  or  displacement,  as  it  is  called,  the  liver  may  be  felt  below  the 
costal  margin,  or  the  spleen,  or  sometimes  solid  tumors  of  the  omentum  or 
intestine. 

(c)  Percussion. — In  the  dorsal  position  with  a  moderate  quantity  of  fluid 
in  the  peritoneum  the  flanks  are  dull,  while  the  umbilical  and  epigastric 
regions,  in  which  the  intestines  float,  are  tympanitic.  This  area  of  clear 
resonance  may  have  an  oval  outline.  Having  obtained  the  lateral  limit  of  the 
dulness  on  one  side,  if  the  patient  turns  on  the  opposite  side,  the  fluid  gravi- 
tates to  the  dependent  part  and  the  uppermost  flank  is  now  tympanitic.  In 
moderate  effusions  this  movable  dulness  changes  greatly  in  the  different  pos- 
tures. Small  amounts  of  fluid,  probably  under  a  litre,  would  scarcely  give 
movable  dulness,  as  the  pelvis  and  the  renal  regions  hold  a  considerable  quan- 
tity. In  such  cases  it  is  best  to  place  the  patient  in  the  knee-elbow  position, 
when  a  dull  note  will  be  determined  at  the  most  dependent  portion.  By  care- 
ful attention  to  these  details  mistakes  are  usually  avoided. 

Differential  Diagnosis. — The  following  are  among  the  conditions  which 
may  be  mistaken  for  dropsy :  Ovarian  tumor,  in  which  the  sac  develops,  as  a 
rule,  unilaterally,  though  when  large  it  is  centrally  placed.  The  dulness  is 
anterior  and  the  resonance  is  in  the  flanks,  into  which  the  intestines  are 
pushed  by  the  cyst.  Examination  per  vaginam  may  give  important  indica- 
tions. In  those  rare  instances  in  which  gas  develops  in  the  cyst  the  diagnosis 
may  be  very  difficult.  Succussion  has  been  obtained  in  such  cases.  A  distended 
bladder  may  reach  above  the  umbilicus.  In  such  instances  some  urine  dribbles 
away,  and  suspicion  of  ascites  or  a  cyst  is  occasionally  entertained.  I  once 
saw  a  trocar  thrust  into  a  distended  bladder,  which  was  supposed  to  be  an 
ovarian  cyst,  and  it  is  stated  that  John  Hunter  tapped  a  bladder,  supposing  it 
to  be  ascites.  Such  a  mistake  should  be  avoided  by  careful  catheterization 


610  DISEASES    OF    THE    DIGESTIVE    SYSTEM 

prior  to  any  operative  procedures.  And  lastly,  there  are  large  pancreatic  or 
hydatid  cysts  in  the  abdomen  which  may  simulate  ascites. 

Nature  of  the  Ascitic  Fluid. — Usually  this  is  a  clear  serum,  light  yellow 
in  the  ascites  of  anaemia  and  Bright's  disease,  often  darker  in  color  in  cirrho- 
sis of  the  liver.  The  specific  gravity  is  low,  seldom  more  than  1.010  or  1.015, 
whereas  in  the  fluid  of  ovarian  cysts  or  chronic  peritonitis  the  specific  gravity 
is  over  1.015.  It  is  albuminous  and  sometimes  coagulates  spontaneously. 
Dock  has  called  attention  to  the  importance  of  the  study  of  the  cells  in  the 
exudate.  In  cancer  very  characteristic  forms,  with  nuclear  figures,  may  be 
found.  Haemorrhagic  effusion  usually  occurs  in  cancer  and  tuberculosis,  and 
occasionally  in  cirrhosis.  I  have  already  referred  to  the  instances  of  haam- 
orrhagic  effusion  in  connection  with  ruptured  tubal  pregnancy. 

CHYLOUS  ASCITES. — Of  the  cases  tabulated  by  MacKenzie,  Wallis,  and 
Scholberg,  81  were  in  association  with  tumors,  46  with  the  infections,  chiefly 
tuberculosis,  37  in  association  with  affections  of  the  thoracic  duct  and  lym- 
phatic system,  and  78  in  connection  with  general  diseases  such  as  cirrhosis 
of  the  liver,  cardiac  disease,  nephritis,  amyloid  disease,  and  thrombosis  of  the 
blood-vessels.  In  a  certain  number  of  cases  the  cause  of  the  condition  is 
unknown.  Quincke  recognized  that  there  were  two  types,  one  in  which  there 
was  a  true  milky  or  fatty  fluid,  the  other  in  which  the  turbidity  is  due  to 
fatty  degeneration  of  cells  or  to  chemical  substances  of  a  non-fatty  nature. 
The  fluid  of  the  true  chylous  ascites  is  yellowish-white  in  color,  contains  fine 
fat  globules,  a  creamy  layer  collects  on  standing,  the  specific  gravity  generally 
exceeds  1.012,  and  the  fat  content  is  high.  As  a  rule,  it  tends  to  accumulate 
rapidly  and  large  amounts  may  be  removed.  The  fluid  of  pseudo-chylous 
ascites  is  milky  white,  the  opacity  often  may  vary  at  different  tappings. 
Microscopically  there  are  many  fine  refractile  granules,  but  they  do  not  give 
reactions  for  fat,  the  cellular  elements  may  be  numerous,  and  a  creamy  layer 
rarely  forms.  The  specific  gravity  is  less  than  1.012,  and  the  total  solids 
rarely  exceed  2  per  cent.  The  fat  content  is  low.  Lecithin  combined  with 
globulin  appears  to  be  the  cause  of  the  opalescence.  The  authors  from  whom 
I  have  quoted  conclude  that  milky  ascites  is  characteristic  of  no  specific  mor- 
bid lesion.  The  prognosis  is  usually  grave. 

Treatment  of  the  Previous  Conditions. — (a)  ACUTE  PERITONITIS. — Rest 
is  enjoined  upon  the  patient  by  the  severe  pain  which  follows  the  slightest 
movement,  and  he  should  be  propped  in  the  position  which  gives  him  greatest 
relief.  Whether  morphia  should  be  given  will  depend  upon  the  cause.  In 
the  pain  of  appendicitis  and  of  perforation  in  typhoid  fever  it  is  best  to  use 
an  ice-bag  and  withhold  the  drug.  Late  in  the  disease  and  in  hopeless  condi- 
tions it  may  be  given  freely.  The  opium  treatment  so  strongly  advocated  by 
the  late  Alonzo  Clark  has  gone  out  of  vogue. 

Local  applications — the  ice-bag,  hot  turpentine  stupes,  or  cloths  wrung 
out  of  ice-water — may  be  laid  upon  the  abdomen. 

The  question  of  the  use  of  purgatives  in  peritonitis  has  of  late  been  warmly 
discussed.  Theoretically  it  appears  correct  to  give  salines  in  concentrated 
form,  which  cause  a  rapid  and  profuse  exosmosis  of  serum  from  the  intestinal 
vessels,  relieving  the  congestion  and  reducing  the  oedema,  which  is  one  impor- 
tant factor  in  causing  the  meteorism.  It  is  also  urged  that  the  increased 
peristalsis  prevents  the  formation  of  adhesions.  In  reading  the  reports  of 


ASCITES  611 

these  successful  cases,  one  is  not  always  convinced,  however,  that  peritonitis 
actually  existed.  Still,  in  cases  of  acute  peritonitis  due  to  extension  or  follow- 
ing operation  or  in  septic  conditions  the  judgment  of  many  careful  men  is 
decidedly  in  favor  of  the  use  of  salines.  The  majority  of  cases  of  peritonitis 
which  come  under  the  care  of  the  physician  follow  lesions  of  the  abdominal 
viscera  or  are  due  to  perforation  of  ulcer  of  the  stomach,  the  ileum,  or  the 
appendix.  In  such  cases,  particularly  in  the  large  group  of  appendix  cases,  to 
give  saline  purgatives  is,  to  say  the  least,  most  injudicious  treatment.  In 
these  instances  rectal  injections  should  be  employed  to  relieve  the  large  bowel. 
No  symptom  in  acute  peritonitis  is  more  serious  than  the  tympanites,  and 
none  is  more  difficult  to  meet.  The  use  of  the  long  tube  and  injections  con- 
taining turpentine  may  be  tried.  Drugs  by  the  mouth  can  not  be  retained. 

For  the  vomiting,  ice  and  small  quantities  of  soda  water  may  be  employed. 
The  patient  should  be  fed  on  milk,  but  if  the  vomiting  is  distressing  it  is  best 
not  to  attempt  to  give  food  by  the  mouth,  but  to  use  small  nutrient  enemata. 
In  all  cases  it  is  best  to  have  a  surgeon  in  consultation  early  in  the  disease, 
as  the  question  of  operation  may  come  up  at  any  moment.  In  the  acute  forma 
of  tuberculous  peritonitis  operative  measures  appear  to  be  more  hopeful,  but 
they  are  not  always  successful. 

(6)  CHRONIC  PERITONITIS. — For  the  cases  of  chronic  proliferative  perito- 
nitis very  little  can  be  done.  The  treatment  is  practically  that  of  ascites.  In 
all  these  forms,  when  the  distention  becomes  extreme,  tapping  is  indicated. 
The  treatment  of  tuberculous  peritonitis  has  fallen  largely  into  the  hands  of 
the  surgeons,  but  the  results  depend  on  the  stage  at  which  the  operation  is 
performed  and  the  variety  of  the  disease.  "With  ascites  the  outlook  is  good; 
but  when  there  are  tuberculous  tumors  and  many  adhesions  the  results  are 
not  very  satisfactory.  Maurice  Kichardson,  in  a  child  aged  five,  with  a  sus- 
pected appendicitis  (tumor,  etc.),  found  the  symptoms  to  be  due  to  enlarged, 
tuberculous  mesenteric  glands,  which  were  removed,  and  the  boy  remained 
well  five  years  after  the  operation. 

(c)  ASCITES. — The  treatment  depends  somewhat  on  the  nature  of  the  case. 
In  cirrhosis  early  and  repeated  tapping  may  give  time  for  the  establishment 
of  the  collateral  circulation,  and  temporary  cures  have  followed  this  procedure. 
Permanent  drainage  with  Southey's  tube,  incision,  and  washing  out  the  peri- 
toneum have  also  been  practiced.  In  the  ascites  of  cardiac  and  renal  disease 
the  cathartics  are  most  satisfactory,  particularly  the  bitartrate  of  potash,  given 
alone  or  with  jalap,  and  the  large  doses  of  salts  given  an  hour  before  break- 
fast with  as  little  water  as  possible.  These  sometimes  cause  rapid  disappear- 
ance of  the  effusion,  but  they  are  not  so  successful  in  ascites  as  in  pleurisy  with 
effusion.  The  stronger  cathartics  may  sometimes  be  necessary.  The  ascites 
forming  part  of  the  general  anasarca  of  Bright's  disease  will  receive  consider- 
ation under  another  section. 


SECTION   VI 

DISEASES  OF  THE  KESPIRATORY  SYSTEM 

A.    DISEASES  OF  THE  NOSE 
I.    AUTUMNAL  CATARRH 

(Hay  Fever) 

Definition. — An  affection  of  the  upper  air-passages,  often  associated  with 
asthmatic  attacks,  due  to  the  action  of  the  pollen  of  certain  grasses  and  plants 
upon  a  hypersensitive  mucous  membrane. 

Etiology. — This  affection  was  first  described  in  1819  by  Bostock,  who 
called  it  catarrhus  cestivus.  Morrill  Wyman,  of  Cambridge,  Mass.,  wrote  a 
monograph  on  the  subject,  and  described  two  forms,  the  "June  cold,"  or  "rose 
cold/'  which  comes  on  in  the  spring,  and  the  autumnal  form,  which,  in  the 
United  States,  comes  on  in  August  and  September,  and  never  persists  after  a 
severe  frost.  In  the  Southern  States  cases  occur  all  through  the  year.  It  is 
more  common  in  America  and  in  Great  Britain  than  on  the  Continent.  The 
disposition  to  the  disease  is  hereditary.  Women  are  more  subject  to  it  than 
men.  Young  and  middle-aged  persons  are  most  often  attacked.  The  ten- 
dency lessens  as  age  advances.  Dwellers  in  cities  are  chiefly  attacked.  The 
educated  and  highly  nervous  are  most  susceptible.  The  disease  affects  certain 
families,  and  Beard  found  an  hereditary  factor  in  33  per  cent,  of  his  cases. 
A  morbid  sensitiveness  of  the  nasal  mucosa  is  present  in  many  cases. 

The  disease  must  be  differentiated  from  nervous  coryza  (which  has  been 
induced  by  suggestion)  and  from  the  attacks  of  irritation  of  the  nasal,  con- 
junctival,  and  bronchial  mucous  membranes  excited  by  the  odor  of  a  horse, 
or  of  the  "harmless  necessary  cat." 

Dunbar's  researches  have  placed  the  etiology  of  the  disease  on  a  scientific 
basis.  He  has  shown  that  there  is  but  one  cause,  the  pollen  of  grasses  and 
certain  plants.  The  pollen  of  about  130  different  plants  has  now  been  exam- 
ined, of  which  that  of  25  grasses  and  of  only  7  other  kinds  of  plants  exert  a 
definite  action.  The  pollen  of  rye  is  the  most  active.  Dunbar  and  his  stu- 
dents have  found  that  the  severity  of  hay-fever  attacks  is  in  direct  proportion 
to  the  quantity  of  pollen  present  in  the  atmosphere.  In  persons  predisposed 
to  the  disease  the  pollen  applied  to  the  ^conjunctivas  or  nasal  mucosa  excites 
characteristic  attacks.  He  has  isolated  a  peculiar  poison  of  an  albuminous 
nature  from  the  pollen.  It  is  so-  powerful  that  .000025  milligram  excites 
irritation  in  the  conjunctiva  of  a  susceptible  subject.  This  is  the  amount  of 
toxin  which  corresponds  to  two  or  three  pollen  grains.  It  is  entirely  without 

612 


EPISTAXIS  613 

influence  on  normal  persons.  In  larger  doses  severer  attacks  are  caused,  and, 
injected  subcutaneously,  it  has  been  followed  by  very  unpleasant  symptoms. 
He  has  succeeded  in  obtaining  an  antitoxin  by  injecting  the  poison  into  ani- 
mals. It  is  capable  of  cutting  short  attacks  of  ordinary  hay  fever. 

Symptoms. — These  are,  in  a  majority  of  the  cases,  very  like  those  of  ordi- 
nary coryza.  There  may,  however,  be  much  more  headache  and  distress,  and 
some  patients  become  very  low-spirited.  At  the  outset,  or  even  daily  through- 
out the  attack,  sneezing  may  be  frequent.  Cough  is  a  common  symptom  and 
may  be  very  distressing.  Paroxysms  of  asthma  may  occur  indistinguishable 
from  the  ordinary  bronchial  form.  The  two  conditions  may  indeed  alternate, 
the  patient  having  at  one  time  an  attack  of  common  hay  fever  and  at  another, 
under  similar  circumstances,  an  attack  of  bronchial  asthma. 

Treatment. — This  may  be  comprised  under  four  heads:  First,  remedies 
may  be  given  to  improve  the  stability  of  the  nervous  system — such  as  arsenic, 
phosphorus,  and  strychnia.  Secondly,  climatic.  Dwellers  in  the  cities  of  the 
Atlantic  seaboard  and  of  the  Central  States  enjoy  complete  immunity  in  the 
Adirondacks  and  White  Mountains.  As  a  rule  the  disease  is  aggravated  by 
residence  in  agricultural  districts.  The  dry  mountain  air  is  unquestionably 
the  best;  there  is  no  general  rule,  and  there  are  cases  which  do  well  at  the 
seaside.  Thirdly,  the  thorough  local  treatment  of  the  nose,  particularly  the 
destruction  of  the  vessels  and  sinuses  over  the  sensitive  areas.  Fourthly,  the 
antitoxin  treatment  of  Dunbar  in  suitable  cases  gives  excellent  results  when 
used  as  a  prophylactic.  Owing  to  the  peculiar  nature  of  the  disease  and  the 
constant  reinfection  of  the  mucous  membranes  by  pollen  on  exposure  to  the 
outside  air,  it  is  advised  to  sleep  with  the  windows  closed  and  to  apply  the 
serum  in  the  morning  before  rising  both  to  eyes  and  nose,  and  again  during 
the  day  if  irritation  is  felt  in  the  conjunctivas  or  nasal  mucous  membranes. 
Active  immunization  by  pollen  extracts  is  sometimes  helpful. 


n.  EPISTAXIS 

Etiology. — Bleeding  from  the  nose  may  result  from  local  or  constitutional 
conditions.  Among  local  causes  may  be  mentioned  traumatism,  small  ulcers, 
picking  or  scratching  the  nose,  new  growths,  and  the  presence  of  foreign 
bodies.  In  chronic  nasal  catarrh  bleeding  is  not  infrequent.  The  blood  may 
come  from  one  or  both  nostrils.  The  flow  may  be  profuse  after  an  injury. 

Among  general  conditions  with  which  nose-bleeding  is  associated,  the  fol- 
lowing are  the  most  important :  It  occurs  in  growing  children,  particularly 
about  the  age  of  puberty;  more  frequently  in  the  delicate  than  in  the  strong 
and  vigorous.  There  is  a  family  form  in  which  many  members  in  several 
generations  are  affected.  I  have  described  a  remarkable  hereditary  multiple 
telangiectasis,  a  special  feature  of  which  is  recurring  epistaxis.  The  disease 
has  nothing  to  do  with  hemophilia,  with  which  it  has  been  confounded.  The 
bleeding  occurs  from  the  telangiectasis  in  the  nasal  mucosa,  and  from  those 
in  the  lips,  tongue,  and  skin.  A  severe  anamia  may  be  caused  by  the  loss 
of  blood. 

Epistaxis  is  a  very  common  event  in  persons  of  so-called  plethoric  habit. 
It  is  stated  sometimes  to  precede,  or  to  indicate  a  liability  to,  apoplexy.  In 


614  DISEASES    OF   THE   RESPIRATORY    SYSTEM 

venous  engorgement  epistaxis  is  not  common  and  there  may  be  a  most  extreme 
grade  of  cyanosis  without  its  occurrence.  It  is  frequent  in  cirrhosis  hepatis. 
In  balloon  and  mountain  ascensions,  in  the  very  rarefied  atmosphere,  haemor- 
rhage from  the  nose  is  a  common  event.  In  haemophilia  the  nose  ranks  first 
of  the  mucous  membranes  from  which  bleeding  arises.  It  occurs  in  all  forms 
of  chronic  anaemias,  in  chronic  interstitial  nephritis,  and  in  cirrhosis  of  the 
liver.  It  precedes  the  onset  of  certain  fevers,  more  particularly  typhoid,  with 
which  it  seems  associated  in  a  special  manner.  Vicarious  epistaxis  has  been 
described  in  cases  of  suppression  of  the  menses.  Lastly,  it  is  said  to  be  brought 
on  by  certain  psychical  impressions,  but  the  observations  on  this  point  are  not 
trustworthy.  The  blood  in  epistaxis  results  from  capillary  oozing  or  diapedesis. 
The  mucous  membrane  is  deeply  congested  and  there  are  often  capillary  angi- 
omata  situated  usually  in  the  respiratory  portion  of  the  nostril  and  upon  the 
cartilaginous  septum. 

Symptoms. — Slight  haemorrhage  is  not  associated  with  any  special  features. 
When  the  bleeding  is  protracted  the  patients  have  the  more  serious  manifesta- 
tions of  loss  of  blood.  In  the  slow  dripping  which  takes  place  in  some  in- 
stances of  haemophilia,  there  may  be  formed  a  remarkable  blood  tumor  pro- 
jecting from  one  nostril  and  extending  even  below  the  mouth. 

Death  from  ordinary  epistaxis  is  very  rare.  The  more  blood  is  lost  the 
greater  is  the  tendency  to  clotting  with  spontaneous  cessation  of  the  bleeding. 

Diagnosis. — The  diagnosis  is  usually  easy.  One  point  only  need  be  men- 
tioned; namely,  that  bleeding  from  the  posterior  nares  occasionally  occurs 
during  sleep  and  the  blood  trickles  into  the  pharynx  and  may  be  swallowed.  If 
vomited,  it  may  be  confounded  with  haematemesis ;  or,  if  coughed  up,  with 
haemoptysis. 

Treatment. — In  a  majority  of  the  cases  the  bleeding  ceases  of  itself.  Vari- 
ous simple  measures  may  be  employed,  such  as  holding  the  arms  above  the 
head,  the  application  of  ice  to  the  nose,  or  the  injection  of  cold  or  hot  water 
into  the  nostrils.  Astringents,  such  as  zinc,  alum,  -or  tannin,  may  be  used ; 
and  the  tincture  of  the  perchloride  of  iron,  diluted  with  ice-water,  may  be 
introduced  into  the  nostrils.  If  the  bleeding  comes  from  an  ulcerated  surface, 
an  attempt  should  be  made  to  apply  chromic  acid  or  the  cautery.  If  the  bleed- 
ing is  at  all  severe  and  obstinate,  the  posterior  nares  should  be  plugged.  One 
of  the  patients  with  epistaxis  and  spider  angiomata  of  the  skin  and  mucous 
membranes  used  a  finger  of  a  rubber  glove  with  a  small  rubber  tube  and  stop- 
cock by  which  he  could  dilate  the  glove  finger,  inserted  into  the  nostril,  and 
so  effectually  control  the  bleeding.  The  inhalation  of  carbonic-acid  gas  may  be 
tried  or  a  solution  of  gelatine  or  of  adrenalin  injected  into  the  nostril. 


B.    DISEASES  OF  THE  LARYNX 
I.    ACUTE    CATARRHAL    LARYNGITIS 

This  may  come  on  as  an  independent  affection  or  in  association  with  gen- 
eral catarrh  of  the  upper  respiratory  passages. 

Etiology. — Many  cases  are  due  to  catching  cold  or  to  overuse  of  the  voice ; 


CHKOiNIC    LAKYiN'GlTiS  615 

others  come  on  in  consequence  of  the  inhalation  of  irritating  gases.  It  may 
occur  in  the  general  catarrh  associated  with  influenza  and  measles.  Very 
severe  laryngitis  is  excited  by  traumatism,  either  injuries  from  without  or  the 
lodgment  of  foreign  bodies.  It  may  be  caused  by  the  action  of  very  hot  liquids 
or  corrosive  poisons. 

Symptoms. — There  is  a  sense  of  tickling  referred  to  the  larynx;  the  cold 
air  irritates  and,  owing  to  the  increased  sensibility  of  the  mucous  membrane, 
the  act  of  inspiration  may  be  painful.  There  is  a  dry  cough,  and  the  voice  is 
altered.  At  first  it  is  simply  husky,  but  soon  phonation  becomes  painful,  and 
finally  the  voice  may  be  completely  lost.  In  adults  the  respirations  are  not 
increased  in  frequency,  but  in  children  dyspnoea  is  not  uncommon  and  may 
occur  in  spasmodic  attacks  and  become  urgent  if  there  is  much  oedema  with 
the  inflammatory  swelling. 

The  laryngoscope  shows  a  swollen  mucous  membrane  of  the  larynx,  par- 
ticularly the  ary-epiglottidean  folds.  The  vocal  cords  have  lost  their  smooth 
and  shining  appearance  and  are  reddened  and  swollen.  Their  mobility  also 
is  greatly  impaired,  owing  to  the  infiltration  of  the  adjoining  mucous  mem- 
brane and  of  the  muscles.  A  slight  mucoid  exudation  covers  the  parts.  The 
constitutional  symptoms  are  not  severe.  There  is  rarely  much  fever,  and  in 
many  cases  the  patient  is  not  seriously  ill.  Occasionally  cases  come  on  with 
greater  intensity,  the  cough  is  very  distressing,  deglutition  is  painful,  and  there 
may  be  urgent  dyspnoea. 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  nature  of  a 
case  if  a  satisfactory  laryngoscopic  examination  can  be  made.  The  severer 
forms  may  simulate  oedema  of  the  glottis.  When  the  loss  of  voice  is  marked, 
the  case  may  be  mistaken  for  one  of  nervous  aphonia,  but  the  laryngoscope 
would  decide  the  question  at  once.  Much  more  difficult  is  the  diagnosis  of 
acute  laryngitis  in  children,  particularly  in  the  very  young,  in  whom  it  is  so 
hard  to  make  a  proper  examination.-  From  ordinary  laryngismus  it  is  to  be 
distinguished  by  the  presence  of  fever,  the  mode  of  onset,  and  particularly  the 
coryza  and  the  previous  symptoms  of  hoarseness  or  loss  of  voice.  Membranous 
laryngitis  may  at  first  be  quite  impossible  to  differentiate,  but  in  a  majority 
of  cases  of  this  affection  there  are  patches  on  the  pharynx  and  early  swelling 
of  the  cervical  glands.  The  symptoms,  too,  are  much  more  severe. 

Treatment. — Eest  of  the  larynx  should  be  enjoined,  so  far  as  phonation  is 
concerned ;  smoking  should  be  forbidden.  In  cases  of  any  severity  the  patient 
should  be  kept  in  bed.  The  room  should  be  at  an  even  temperature  and  the 
air  saturated  with  moisture.  Early  in  the  disease,  if  there  is  much  fever, 
aconite  and  citrate  of  potash  may  be  given,  and  for  the  irritating  painful 
cough  a  full  dose  of  Dover's  powder  at  night.  An  ice-bag  externally  often 
gives  great  relief. 

H.    CHRONIC    LARYNGITIS 

Etiology. — The  cases  usually  follow  repeated  acute  attacks.  The  most 
common  cause  is  overuse  of  the  voice,  particularly  in  persons  whose  occupa- 
tion necessitates  shouting  in  the  open  air.  The  constant  inhalation  of  irritat- 
ing substances,  as  tobacco-smoke,  may  also  cause  it. 

Symptoms. — The  voice  is  usually  hoarse  and  rough  and  in  severe  cases  may 


616  DISEASES    OF    THE    EESPIRATORY    SYSTEM 

be  almost  lost.  There  is  usually  very  little  pain ;  only  the  unpleasant  sense  of 
tickling  in  the  larynx,  which  causes  a  frequent  desire  to  cough.  With  the 
laryngoscope  the  mucous  membrane  looks  swollen,  but  much  less  red  than  in 
the  acute  condition.  In  association  with  the  granular  pharyngitis,  the  mucous 
glands  of  the  epiglottis  and  of  the  ventricles  may  be  involved. 

Treatment. — The  nostrils  should  be  carefully  examined,  since  in  some 
instances  chronic  laryngitis  is  associated  with  and  even  dependent  upon  ob- 
struction to  the  free  passage  of  air  through  the  nose.  Local  application  must 
be  made  directly  to  the  larynx,  either  with  a  brush  or  by  means  of  a  spray. 
Among  the  remedies  most  recommended  are  the  solutions  of  nitrate  of  silver, 
chlorate  of  potash,  perchloride  of  zinc,  and  tannic  acid.  Insufflations  of  bis- 
muth are  sometimes  useful. 

Among  directions  to  be  given  are  the  avoidance  of  heated  rooms  and  loud 
speaking,  and  abstinence  from  tobacco  and  alcohol.  The  throat  should  not  be 
too  much  muffled,  and  morning  and  evening  the  neck  should  be  sponged  with 
cold  water. 

III.     (EDEMATOUS  LARYNGITIS 

Etiology. — (Edema  of  the  glottis,  or,  more  correctly,  of  the  structures 
which  form  the  glottis,  a  very  serious  affection,  is  met  with  (a)  as  a  rare 
sequence  of  ordinary  acute  laryngitis;  (&)  in  chronic  diseases  of  the  larynx, 
as  syphilis  or  tubercle;  (c)  in  severe  inflammatory  diseases  like  diphtheria, 
in  erysipelas  of  the  neck,  and  in  various  forms  of  cellulitis;  (d)  occasionally 
in  the  acute  infectious  diseases — scarlet  fever,  typhus,  or  typhoid ;  in  Bright's 
disease,  either  acute  or  chronic,  there  may  be  a  rapidly  developing  oedema; 
(e)  in  angio-neurotic  oedema. 

Symptoms. — There  is  dyspnoea,  increasing  in  intensity,  so  that  within  an 
hour  or  two  the  condition  becomes  very  critical.  There  is  sometimes  marked 
stridor  in  respiration.  The  voice  becomes  husky  and  disappears.  The  laryn- 
goscope shows  enormous  swelling  of  the  epiglottis,  which  can  sometimes  be 
felt  with  the  finger  or  even  seen  when  the  tongue  is  strongly  depressed  with  a 
spatula.  The  ary-epiglottidean  folds  are  the  seat  of  the  chief  swelling  and 
may  almost  meet  in  the  middle  line.  Occasionally  the  oedema  is  below  the 
true  cords. 

The  diagnosis  is  rarely  difficult,  inasmuch  as  even  without  the  laryngo- 
scope the  swollen  epiglottis  can  be  seen  or  felt  with  the  finger.  The  condition 
is  very  often  fatal. 

Treatment. — An  ice-bag  should  be  placed  on  the  larynx,  and  the  patient 
given  ice  to  suck.  The  air  of  the  room  should  be  moist.  If  the  symptoms 
are  urgent,  the  throat  should  be  sprayed  with  a  strong  solution  of  cocaine  or 
adrenalin  and  the  swollen  epiglottis  scarified.  If  relief  does  not  follow, 
tracheotomy  should  immediately  be  performed.  The  high  rate  of  mortality 
is  due  to  the  fact  that  this  operation  is,  as  a  rule,  too  long  delayed. 


SPASMODIC    LARYNGITIS  617 

IV.     SPASMODIC    LARYNGITIS 

(Laryngismus  stridulus) 

Spasm  of  the  glottis  is  met  with  in  many  affections  of  the  larynx,  but 
there  is  a  special  disease  in  children  which  has  received  the  above-mentioned 
and  other  names. 

Etiology. — A  purely  nervous  affection,  without  any  inflammatory  condi- 
tion of  the  larynx,  it  occurs  in  children  between  the  ages  of  six  months  and 
three  years,  and  is  most  commonly  seen  in  connection  with  rickets.  As 
Escherich  has  shown,  the  disease  has  close  relations  with  tetany  and  may  dis- 
play many  of  the  accessory  phenomena  of  this  disease.  Often  the  attack  comes 
on  when  the  child  has  been  crossed  or  scolded.  Mothers  sometimes  call  the 
attacks  "passion  fits"  or  attacks  of  "holding  the  breath."  It  was  supposed  at 
one  time  that  they  were  associated  with  enlargement  of  the  thymus,  and  the 
condition  therefore  received  the  name  of  ihymic  asthma. 

The  actual  state  of  the  larynx  during  a  paroxysm  is  a  spasm  of  the 
adductors,  but  the  precise  nature  of  the  influences  causing  it  is  not  yet  known, 
whether  centric  or  reflex  from  peripheral  irritation.  The  disease  is  not  so 
common  in  America  as  in  England. 

Symptoms. — The  attacks  may  come  on  either  in  the  night  or  in  the  day; 
often  just  as  the  child  awakes.  There  is  no  cough,  no  hoarseness,  but  the 
respiration  is  arrested  and  the  child  struggles  for  breath,  the  face  gets  con- 
gested, and  then,  with  a  sudden  relaxation  of  the  spasm,  the  air  is  drawn  into 
the  lungs  with  a  high-pitched  crowing  sound,  which  has  given  to  the  affection 
the  name  of  "child-crowing."  Convulsions  may  occur  during  an  attack  or 
there  may  be  carpo-pedal  spasms.  Death  may,  but  rarely  does,  occur  during 
the  attack.  With  the  cyanosis  the  spasm  relaxes  and  respiration  begins.  The 
attacks  may  recur  with  great  frequency  throughout  the  day. 

Treatment. — The  gums  should  be  carefully  examined  and,  if  swollen  and 
hot.  freely  lanced.  The  bowels  should  be  carefully  regulated  and,  as  these 
children  are  usually  delicate  or  rickety,  nourishing  diet  and  cod-liver  oil 
should  be  given.  By  far  the  most  satisfactory  method  of  treatment  is  the  cold 
sponging.  In  severe  cases,  two  or  three  times  a  day  the  child  should  be  placed 
in  a  warm  bath,  and  the  back  and  chest  thoroughly  sponged  for  a  minute  or 
two  with  cold  water.  Since  learning  this  practice  from  Ringer,  at  the  Uni- 
versity Hospital,  London,  I  have  seen  many  cases  in  which  it  proved  success- 
ful. It  may  be  employed  when  the  child  is  in  a  paroxysm,  though  if  the 
attack  is  severe  and  the  lividity  is  great  it  is  much  better  to  dash  cold  water 
into  the  face.  Sometimes  the  introduction  of  the  finger  far  back  into  the 
throat  will  relieve  the  spasm. 

Spasmodic  croup,  believed  to  be  a  functional  spasm  of  the  muscles  of  the 
larynx,  is  an  affection  seen  most  commonly  between  the  ages  of  two  and  five 
years.  According  to  Trousseau's  description,  the  child  goes  to  bed  well,  and 
about  midnight  or  in  the  early  morning  hours  awakes  with  oppressed  breath- 
ing, harsh,  croupy  cough,  and  perhaps  some  huskiness  of  voice.  The  oppres- 
sion and  distress  for  a  time  are  very  serious,  the  face  is  congested,  and  there 
are  signs  of  approaching  cyanosis.  The  attack  passes  off  abruptly,  the  child 
41 


618  DISEASES    OF    THE    EESPIKATORY    SYSTEM 

falls  asleep  and  awakes  the  next  morning  feeling  perfectly  well.  These  attacks 
may  be  repeated  for  several  nights  in  succession,  and  usually  cause  great  alarm 
to  the  parents.  Whether  this  is  entirely  a  functional  spasm  is,  I  think,  doubt- 
ful. There  are  instances  in  which  the  child  is  somewhat  hoarse  throughout 
the  day,  and  has  slight  catarrhal  symptoms  and  a  brazen,  croupy  cough.  There 
is  probably  slight  catarrhal  laryngitis  with  it.  These  cases  are  not  infrequently 
mistaken  for  true  croup,  and  parents  are  sometimes  unnecessarily  disturbed 
by  the  serious  view  which  the  physician  takes  of  the  case.  Too  often  the  poor 
child,  deluged  with  drugs,  is  longer  in  recovering  from  the  treatment  than  he 
would  be  from  the  disease.  To  allay  the  spasm  a  whiff  of  chloroform  may  be 
administered,  which  will  in  a  few  moments  give  relief,  or  the  child  may  be 
placed  in  a  hot  bath.  A  prompt  emetic,  such  as  wine  of  ipecac,  will  usually 
relieve  the  spasm,  and  is  specially  indicated  if  the  child  has  overloaded  the 
stomach  through  the  day. 


V.     TUBERCULOUS  LARYNGITIS 

Etiology. — Tubercles  may  arise  primarily  in  the  laryngeal  mucosa,  but  in 
the  great  majority  of  cases  the  affection  is  secondary  to  pulmonary  tubercu- 
losis, in  which  it  is  met  with  in  a  variable  proportion  of  from  18  to  30  per 
cent.  Laryngitis  may  occur  very  early  in  pulmonary  tuberculosis.  There 
may  be  well-marked  involvement  of  the  larynx  with  signs  of  very  limited 
trouble  at  one  apex.  These  are  cases  which,  in  my  experience,  run  a  very 
unfavorable  course. 

Morbid  Anatomy. — The  mucosa  is  at  first  swollen  and  presents  scattered 
tubercles,  which  seem  to  begin  in  the  neighborhood  of  the  blood-vessels.  By 
their  fusion  small  tuberculous  masses  arise,  which  caseate  and  finally  ulcerate, 
leaving  shallow  irregular  losses  of  substance.  -The  ulcers  are  usually  covered 
with  a  grayish  exudation,  and  there  is  a  general  thickening  of  the  mucosa 
about  them,  which  is  particularly  marked  upon  the  arytenoids.  The  ulcers 
may  erode  the  true  cords  and  finally  destroy  them,  and  passing  deeply  may 
cause  perichondritis  with  necrosis  and -occasionally  exfoliation  of  the  carti- 
lages. The  disease  may  extend  laterally  and  involve  the  pharynx,  and  down- 
ward over  the  mucous  membrane,  covering  the  cricoid  cartilage  toward  the 
oesophagus.  Above,  it  may  reach  the  posterior  wall  of  the  pharynx,  and  in 
rare  cases  extend  to  the  fauces  and  tonsils.  The  epiglottis  may  be  entirely 
destroyed.  There  are  rare  instances  in  which  cicatricial  changes  go  on  to  such 
a  degree  that  stenosis  of  the  larynx  is  induced. 

Symptoms. — The  first  indication  is  slight  huskiness  of  the  voice,  which 
finally  deepens  to  hoarseness,  and  in  advanced  stages  there  may  bo  complete 
loss  of  voice.  There  is  something  very  suggestive  in  the  early  hoarseness  of 
tuberculous  laryngitis.  The  attention  may  be  directed  to  the  lungs  simply  by 
the  quality  of  the  voice. 

The  cough  is  in  part  due  to  involvement  of  the  larynx.  Early  in  the 
disease  it  is  not  very  troublesome,  but  when  the  ulceration  is  extensive  it 
becomes  husky  and  ineffectual.  Of  the  symptoms,  none  is  more  aggravating 
than  the  dysphagia,  which  is  met  with  particularly  when  the  epiglottis  is 
involved,  and  when  the  ulceration  has  extended  to  the  pharynx.  There  is  no 


SYPHILITIC    LARYNGITIS  019 

more  distressing  or  painful  complication  in  phthisis.  In  instances  in  which 
the  epiglottis  is  in  great  part  destroyed  with  each  attempt  to  take  food  there 
are  distressing  paroxysms  of  cough,  and  even  of  suffocation. 

With  the  laryngoscope  there  is  seen  early  in  the  disease  a  pallor  of  the 
mucous  membrane,  which  also  looks  thickened  and  infiltrated,  particularly 
that  covering  the  arytenoid  cartilages.  The  ulcers  are  very  characteristic. 
They  are  broad  and  shallow,  with  gray  bases  and  ill-defined  outlines.  The 
vocal  cords  are  infiltrated  and  thickened,  and  ulceration  is  very  common. 

The  diagnosis  is  rarely  difficult,  as  it  is  usually  associated  with  well-marked 
pulmonary  disease.  In  case  of  doubt  the  secretion  from  the  base  of  an  ulcer 
should  be  examined  for  bacilli. 

Treatment. — The  voice  should  not  be  used.  In  the  early  stages  no  method 
of  treatment  is  more  effectual.  The  ulcers  should  be  sprayed  and  kept  thor- 
oughly cleansed  with  a  solution  of  tannic  acid,  nitrate  of  silver,  or  sulphate 
of  zinc.  The  insufflation,  three  times  a  day,  of  a  powder  of  iodoform  with 
morphia,  after  cleansing  the  ulcers  With  a  spray,  relieves  the  pain  in  a  majority 
of  the  cases.  Cocaine  (4-per-cent.  solution)  applied  with  the  atomizer  will 
often  enable  the  patient  to  swallow  his  food  comfortably.  There  are,  however, 
distressing  cases  of  extensive  laryngeal  and  pharyngeal  ulceration  in  which 
even  cocaine  loses  its  good  effects.  When  the  epiglottis  is  lost  the  difficulty 
in  swallowing  becomes  very  great.  Wolfenden  states  that  this  may  be  obviated 
if  the  patient  hangs  his  head  over  the  side  of  the  bed  and  sucks  milk  through 
a  rubber  tube  from  a  mug  placed  on  the  floor. 


VI.    SYPHILITIC   LARYNGITIS 

Syphilis  attacks  the  larynx  with  great  frequency.  It  may  result  from  the 
inherited  disease  or  be  a  secondary  or  tertiary  manifestation  of  the  acquired 
form. 

Symptoms. — In  secondary  syphilis  there  is  occasionally  erythema  of  the 
larynx,  which  may  go  on  to  definite  catarrh,  but  has  nothing  characteristic. 
The  process  may  proceed  to  the  formation  of  superficial  whitish  ulcers,  usually 
symmetrically  placed  on  the  cords  or  ventricular  bands.  Mucous  patches  and 
condylomata  are  rarely  seen.  The  symptoms  are  practically  those  of  slight 
loss  of  voice  with  laryngeal  irritation,  as  in  the  simple  catarrhal  form. 

The  tertiary  laryngeal  lesions  are  numerous  and  very  serious.  True  gum- 
mata,  varying  in  size  from  the  head  of  a  pin  to  a  small  nut,  arise  in'the  sub- 
mucous  tissue,  most  commonly  at  the  base  of  the  epiglottis.  They  go  through 
the  changes  characteristic  of  these  structures  and  may  either  break  down,  pro- 
ducing extensive  and  deep  ulceration,  or — and  this  is  more  characteristic  of 
syphilitic  laryngitis — in  their  healing  form  a  fibrous  tissue  which  shrinks  and 
produces  stenosis.  The  ulceration  is  apt  to  extend  deeply  and  involve  the  car- 
tilage, inducing  necrosis  and  exfoliation,  and  even  haemorrhage  from  erosion 
of  the'  arteries.  (Edema  may  suddenly  prove  fatal.  The  cicatrices  which  fol- 
low the  sclerosis  of  the  gummata  or  the  healing  of  the  ulcers  produce  great 
deformity.  The  epiglottis,  for  instance,  may  be  tied  down  to  the  pharyngeal 
wall  or  to  the  epiglottic  folds,  or  even  to  the  tongue;  and  eventually  a  stenosis 
results,  which  may  necessitate  tracheotomy. 


620  DISEASES    OF   THE   RESPIRATORY    SYSTEM 

The  laryngeal  symptoms  of  inherited  syphilis  have  the  usual  course  of 
these  lesions  and  appear  either  early,  within  the  first  five  or  six  months,  or 
after  puberty;  most  commonly  in  the  former  period.  The  gummatous  infil- 
tration leads  to  ulceration,  most  commonly  of  the  epiglottis  and  in  the  ven- 
tricles, and  the  process  may  extend  deeply  and  involve  the  cartilage.  Cica- 
tricial  contraction  may  also  occur. 

The  diagnosis  of  syphilis  of  the  larynx  is  rarely  difficult,  since  it  occurs 
most  commonly  in  connection  with  other  symptoms  of  the  disease. 

Treatment. — The  administration  of  constitutional  remedies  is  the  most 
important,  and  under  mercury  and  iodide  of  potassium  the  local  symptoms 
may  rapidly  be  relieved.  The  tertiary  laryngeal  manifestations  are  always 
serious  and  difficult  to  treat.  The  deep  ulceration  is  specially  hard  to  combat, 
and  the  cicatrization  may  necessitate  tracheotomy,  or  gradual  dilatation,  as 
practiced  by  Schroetter. 


C.     DISEASES  OF  THE  BEONCHI 
I.    ACUTE   BRONCHITIS 

Acute  catarrhal  inflammation  of  the  bronchial  mucous  membrane  is  a  very 
common  disease,  rarely  serious  in  healthy  adults,  but  very  fatal  in  the  old  and 
in  the  young,  owing  to  associated  pulmonary  complications.  It  is  bilateral 
and  affects  either  the  larger  and  medium  sized  tubes  or  the  smaller  bronchi, 
in  which  case  it  is  known  as  capillary  bronchitis. 

We  shall  speak  only  of  the  former,  as  the  latter  is  part  and  parcel  of 
broncho-pneumonia. 

Etiology. — Acute  bronchitis  is  a  common  sequel  of  catching  cold,  and  is 
often  nothing  more  than  the  extension  downward  of  an  ordinary  coryza.  It 
occurs  most  frequently  in  the  changeable  weather  of,  early  spring  and  late 
autumn.  The  pneumococcus  and  influenza  bacillus  are  the  most  common 
causal  organisms.  It  may  prevail  as  an  epidemic  apart  from  influenza,  of 
which  it  is  an  important  feature.  / 

Acute  bronchitis  is  associated  with  many  other  affections,  notably  measles. 
It  is  by  no  means  rare  at  the  onset  of  typhoid  fever  and  malaria.  It  is  pres- 
ent also  in  asthma  and  whooping-cough.  The  subjects  of  spinal  curvature  are 
specially  liable  to  the  disease.  The  bronchitis  of  Bright's  disease,  gout,  and 
heart-disease  is  usually  a  chronic  form.  It  attacks  persons  of  all  ages,  but 
most  frequently  the  young  and  the  old.  There  are  individuals  who  have  a 
special  disposition  to  bronchial  catarrh,  and  the  slightest  exposure  is  apt  to 
bring  on  an  attack.  Persons  who  live  an  out-of-door  life  are  usually  less  sub- 
ject to  the  disease  than  those  who  follow  sedentary  occupations. 

Bacteriology. — The  pneiimococcus  is  responsible  for  many  cases  both  in 
young  and  old.  The  infection  may  follow  pneumonia,  and  bronchitis  may 
recur  winter  after  winter,  with  the  sputum  showing  an  almost  pure  culture 
of  the  pneumococcus.  In  one  patient  these  germs  have  persisted  in  the 
sputum  for  seven  years,  with  an  almost  daily  cough,  aggravated  in  the  winter. 
The  influenza  bacillus  is  very  common  and  may  be  found  alone  or  with  strep- 
tococci. The  Micrococcus  catarrh  alls  is  present  in  a  number  of  the  ordinary 


ACUTE    BKONCHITIS  621 

cases,  very  often  in  combination  with  other  organisms.  Less  frequently  the 
staphylococci,  colon  bacillus,  and  typhoid  bacilli  have  been  found. 

Morbid  Anatomy.— The  mucous  membrane  of  the  trachea  and  bronchi  is 
reddened,  congested,  and  covered  with  mucus  and  muco-pus,  which  may  be 
seen  oozing  from  the  smaller  bronchi,  some  of  which  are  dilated.  The  finer 
changes  in  the  mucosa  consist  in  desquamation  of  the  ciliated  epithelium, 
swelling  and  oedema  of  the  submucosa,  and  infiltration  of  the  tissue  with  leu- 
cocytes. The  mucous  glands  are  much  swollen. 

Symptoms. — GENERAL. — The  symptoms  of  an  ordinary  "cold"  accompany 
the  onset  of  an  acute  bronchitis.  The  coryza  extends  to  the  tubes,  and  may 
also  affect  the  larynx,  producing  hoarseness,  which  in  many  cases  is  marked. 
A  chill  is  rare, -but  there  is  invariably  a  sense  of  oppression,  with  heaviness 
and  languor  and  pains  in  the  bones  and  back.  In  mild  cases  there  is  scarcely 
any  fever,  but  in  severer  forms  the  range  is  from  101°  to  103°  F.  The 
bronchial  symptoms  set  in  with  a  feeling  of  tightness  and  rawness  beneath  the 
sternum  and  a  sensation  of  oppression  in  the  chest.  The  cough  is  rough  at 
first,  and  often  of  a  ringing  character.  It  comes  on  in  paroxysms  which  rack 
and  distress  the  patient  extremely.  During  the  severe  spells  the  pain  may 
be  very  intense  beneath  the  sternum  and  along  the  attachments  of  the  dia- 
phragm. At  first  the  cough  is  dry  and  the  expectoration  scanty  and  viscid, 
but  in  a  few  days  the  secretion  becomes  muco-purulent  and  abundant,  and 
finally  purulent.  With  the  loosening  of  the  cough  great  relief  is  experienced. 
The  sputum  is  made  up  largely  of  pus-cells,  with  a  variable  number  of  the 
large  round  alveolar  cells,  many  of  which  contain  carbon  grains,  while  others 
have  undergone  the  myelin  degeneration. 

PHYSICAL  SIGNS. — The  respiratory  movements  are  not  greatly  increased 
in  frequency  unless  the  fever  is  high.  There  are  instances,  however,  in  which 
the  breathing  is  rapid  and  when  the  smaller  tubes  are  involved  there  is  dys- 
pnoea. On  palpation  the  bronchial  fremitus  may  often  be  felt.  On  auscultation 
in  the  early  stage,  piping  sibilant  rales  are  everywhere  to  be  heard.  They  are 
very  changeable,  and  appear  and  disappear  with  coughing.  With  the  relaxa- 
tion of  the  bronchial  membranes  and  the  greater  abundance  of  the  secretion, 
the  rales  change  and  become  mucous  and  bubbling  in  quality.  The  bases  of 
the  lungs  should  be  carefully  examined  each  day,  particularly  in  children  and 
the  aged. 

Course.  — The  course  of  the  disease  depends  on  the  conditions  under  which 
it  arises.  In  healthy  adults,  by  the  end  of  a  week  the  fever  subsides  and  the 
cough  loosens.  In  another  week  or  ten  days  convalescence  is  fully  established. 
In  young  children  the  chief  risk  is  in  the  extension  of  the  process  downward. 
In  measles  and  whooping-cough  the  ordinary  bronchial  catarrh  is  very  apt  to 
descend  to  the  finer  tubes,  which  become  dilated  and  plugged  with  muco-pus, 
inducing  areas  of  collapse,  and  finally  broncho-pneumonia.  This  extension 
is  indicated  by  changes  in  the  physical  signs.  Usually  at  the  base  the  rales  are 
subcrepitant  and  numerous  and  there  may  be  areas  of  defective  resonance  and 
of  feeble  or  distant  tubular  breathing.  In  the  aged  and  debilitated  there 
are  similar  dangers  if  the  process  extends  from  the  larger  to  the  smaller  tubes. 
In  old  age  the  bronchial  mucosa  is  less  capable  of  expelling  the  mucus,  which 
is  more  apt  to  sag  to  the  dependent  parts  and  induce  dilatation  of  the  tubes 
with  extension  of  the  inflammation  to  the  contiguous  air-cells. 


622  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

Diagnosis. — The  diagnosis  of  acute  bronchitis  is  rarely  difficult.  Although 
the  mode  of  onset  may  be  brusque  and  perhaps  simulate  pneumonia,  yet  the 
absence  of  dulness  and  blowing  breathing,  and  the  general  character  of  the 
bronchial  inflammation,  render  the  diagnosis  easy.  The  complication  of 
broncho-pneumonia  is  indicated  by  the  greater  severity  of  the  symptoms,  par- 
ticularly the  dyspnoea,  the  changed  color,  and  the  physical  signs. 

Treatment. — In  mild  cases  household  measures  suffice.  The  hot  foot- 
bath, or  the  warm  bath,  a  drink  of  hot  lemonade,  and  a  mustard  plaster  on  the 
chest  will  often  give  relief.  In  severe  cases  the  patient  should  be  in  bed; 
liquids  should  be  taken  freely.  For  the  dry,  racking  cough,  the  symptom  most 
complained  of  by  the  patient,  Dover's  powder  is  the  best  remedy.  It  is  a 
popular  belief  that  quinine,  in  full  doses,  will  check  an  oncoming  cold  on  the 
chest,  but  this  is  doubtful.  It  is  a  common  custom  when  persons  feel  the 
approach  of  a  cold  to  take  a  Turkish  bath,  and  though  the  tightness  and 
oppression  may  be  relieved  by  it,  there  is  in  a  majority  of  the  cases  great  risk. 
Some  of  the  severest  cases  of  bronchitis  which  I  have  seen  have  followed  this 
initial  Turkish  bath.  No  doubt,  if  the  person  could  go  to  bed  directly  from 
the  bath,  its  action  would  be  beneficial,  but  there  is  great  risk  of  catching 
"cold"  in  going  home  from  the  bath.  Hydrotherapy  is  most  useful  in  the  form 
of  compresses  to  the  thorax  or  a  wet  pack.  Relief  is  obtained  from  the  un- 
pleasant sense  of  rawness  by  keeping  the  air  of  the  room  saturated  with  mois- 
ture, and  in  this  dry  stage  the  old-fashioned  mixture  of  the  wines  of  antimony 
and  ipecacuanha  with  liquor  ammonii  acetatis  and  nitrous  ether  is  useful.  If 
the  pulse  is  very  rapid,  tincture  of  aconite  may  be  given,  particularly  in  the 
case  of  children.  The  use  of  inhalations,  such  as  the  compound  tincture  of 
benzoin,  often  gives  relief.  For  the  cough,  when  dry  and  irritating,  opium 
should  be  freely  used  in  the  form  of  Dover's  powder  or  paregoric.  Of  course, 
in  the  very  young  and  the  aged  care  must  be  exercised  in  the  use  of  opium, 
particularly  if  the  secretions  are  free ;  but  for  the  distressing,  irritative  cough, 
which  keeps  the  patient  awake,  opium  in  some  for,m  gives  the  only  relief. 
Heroin  is  often  helpful  for  this.  As  the  cough  loosens  and  the  expectoration 
is  more  abundant,  the  patient  becomes  more  comfortable.  In  this  stage  it  is 
customary  to  ply  him  with  expectorants  of  various  sorts.  Though  useful 
occasionally,  they  should  not  be  given  as  a  matter  of  routine.  A  mixture  of 
squill,  ammonia,  and  senega  is  a  favorite  one  with  many  practitioners  at  this 
etage.  Vaccine  treatment  is  not  very  successful,  even  when  a  single  organism 
has  been  recovered. 

In  the  acute  bronchitis  of  children,  if  the  amount  of  secretion  is  large 
and  difficult  to  expectorate,  or  if  there  is  dyspnoea  and  the  color  begins  to  get 
dusky,  an  emetic  (a  tablespoonful  of  ipecac  wine)  should  be  given  at  once 
and  repeated  if  necessary. 


H.    CHRONIC   BRONCHITIS 

Etiology. — This  affection  may  follow  repeated  attacks  of  acute  bronchitis, 
but  it  is  most  commonly  met  with  in  chronic  lung  affections,  heart-disease, 
aneurism  of  the  aorta,  gout,  and  renal  disease.  It  is  frequent  in  the  aged: 
the  young  rarely  are  affected.  Climate  and  season  have  an  important  influ- 


CHRONIC    BRONCHITIS  623 

ence.  It  is  the  cause  of  the  winter  cough  of  the  aged,  which  recurs  with  regu- 
larity as  the  weather  gets  cold  and  changeable.  Owing  to  the  more  uniform 
heating  of  the  houses,  it  is  much  less  common  in  Canada  and  in  the  United 
States  than  in  England. 

Morbid  Anatomy. — The  bronchial  mucosa  presents  a  great  variety  of 
changes,  depending  somewhat  upon  the  disease  with  which  chronic  bronchitis 
is  associated.  In  some  cases  the  mucous  membrane  is  very  thin,  so  that  the 
longitudinal  bands  of  elastic  tissue  stand  out  prominently.  The  tubes  are 
dilated,  the  muscular  and  glandular  tissues  are  atrophied,  and  the  epithelium 
is  in  great  part  shed. 

In  other  instances  the  mucosa  is  thickened,  granular,  and  infiltrated.  There 
may  be  ulceration,  particularly  of  the  mucous  follicles.  Bronchial  dilatations 
are  not  uncommon  and  emphysema  is  a  constant  accompaniment. 

Symptoms. — In  the  form  met  with  in  old  men,  associated  with  emphysema, 
gout,  or  heart-disease,  the  chief  symptoms  are  as  follows :  Shortness  of  breath, 
which  may  not  be  noticeable  except  on  exertion.  The  patients  "puff  and  blow" 
on  going  up  hill  or  up  a  flight  of  stairs.  This  is  due  not  so  much  to  the 
chronic  bronchitis  itself  as  to  associated  emphysema  or  even  to  cardiac  weak- 
ness. They  complain  of  no  pain.  The  cough  is  variable,  changing  with  the 
weather  and  with  the  season.  During  the  summer  they  may  remain  free,  but 
each  succeeding  winter  the  cough  comes  on  with  severity  and  persists.  There  . 
may  be  only  a  spell  in  the  morning,  or  the  chief  distress  is  at  night.  The 
sputum  in  chronic  bronchitis  is  very  variable.  In  cases  of  the  so-called  dry 
catarrh  there  is  no  expectoration.  Usually,  however,  it  is  abundant,  muco- 
purulent,  or  distinctly  purulent  in  character.  There  are  instances  in  which 
the  patient  coughs  up  for  years  a  thin  fluid  sputum.  There  is  rarely  fever. 
The  general  health  may  be  good  and  the  disease  may  present  no  serious  fea- 
tures apart  from  the  liability  to  induce  emphysema  and  bronchiectasis.  In 
many  cases  it  is  an  incurable  affection.  Patients  improve  and  the  cough  dis- 
appears in  the  summer  time  only  to  return  during  the  winter  months. 

PHYSICAL  SIGNS. — The  chest  is  usually  distended,  the  movements  are 
limited,  and  the  condition  is  often  that  which  we  see  in  emphysema.  The 
percussion  note  is  clear  or  hyperresonant.  On  auscultation,  expiration  is  pro- 
longed and  wheezy  and  rhonchi  of  various  sorts  are  heard — some  high-pitched 
and  piping,  others  deep-toned  and  snoring.  Crepitant  rales  are  common  at 
the  bases. 

Clinical  Varieties. — The  description  just  given  is  of  the  ordinary  chronic 
bronchitis  which  occurs  in  connection  with  emphysema  and  heart-disease  and 
in  many  elderly  men.  There  are  certain  forms  which  merit  special  descrip- 
tion: (a)  There  is  a  form  of  CHRONIC  BRONCHITIS  in  women,  which  comes 
on  between-  the  ages  of  twenty  and  thirty  and  may  continue  indefinitely  with- 
out serious  impairment  of  the  health.  In  several  cases  the  cough  followed 
influenza,  and  there  may  be  slight  bronchiectasis.  v 

(&)  BRONCHORRHCEA. — Excessive  bronchial  secretion  is  met  with  under 
several  conditions.  It  must  not  be  mistaken  for  the  profuse  expectoration  of 
bronchiectasis.  The  secretion  may  be  very  liquid  and  watery— bronchorrhcea 
serosa — and  in  extraordinary  amount.  More  commonly,  it  is  purulent  though 
thin,  and  with  greenish  or  yellow-green  masses.  It  may  be  thick  and  uniform. 
This  profuse  bronchial  secretion  is  usually  a  manifestation  of  chronic^bron- 


624  DISEASES   OF   THE   RESPIRATORY   SYSTEM 

chitis,  and  may  lead  to  dilatation  of  the  tubes  and  ultimately  to  fetid  bron- 
chitis. In  the  young  the  condition  may  persist  for  years  without  impairment 
of  health  and  without  apparently  damaging  the  lungs. 

(c)  PUTRID  BRONCHITIS. — Fetid  expectoration  is  met  with  in  connection 
with  bronchiectasis,  gangrene,  abscess,  or  with   decomposition  of  secretions 
within  phthisical  cavities  and  in  an  empyema  which  has  perforated  the  lung. 
There  are  instances  in  which,  apart  from  any  of  these  states,  the  expectora- 
tion has  a  fetid  character.     The  sputa  are  abundant,  usually  thin,  grayish- 
white  in  color,  and  they  separate  into  an  upper  fluid  layer  capped  with  frothy 
mucus  and  a  thick  sediment  in  which  may  sometimes  be  found  dirty  yellow 
masses  the  size  of  peas  or  beans — the  so-called  Dittrich's  plugs.    The  affection 
is  very  rare  apart  from  the  above-mentioned  conditions.     In  severe  cases  it 
leads  to  changes  in  the  bronchial  walls,  pneumonia,  and  often  to  abscess  or 
gangrene.    Metastatic  brain  abscess  has  followed  putrid  bronchitis  in  a  certain 
number  of  cases. 

(d)  DRY  CATARRH. — The  catarrhe  sec  of  Laennec,  a  not  uncommon  form, 
is  characterized  by  paroxysms  of  coughing  of  great  intensity,  with  little  or 
no  expectoration.    It  is  usually  met  with  in  elderly  persons  with  emphysema, 
and  is  one  of  the  most  obstinate  of  all  varieties  of  bronchitis. 

Treatment. — Removal  to  a  southern  latitude  may  prevent  the  onset.  In 
England  the  milder  climate  of  Falmouth,  Torquay,  and  Bournemouth  is  suit- 
able for  those  who  cannot  go  elsewhere.  Egypt,  southern  France,  southern 
California,  and  Florida  furnish  winter  climates  in  which  the  subjects  of 
chronic  bronchitis  live  with  the  greatest  comfort.  With  care  chronic  bron- 
chitis may  prove  to  be  the  slight  ailment  that,  as  Oliver  Wendell  Holmes  says, 
promotes  longevity. 

The  first  endeavor  is  to  ascertain,  if  possible,  whether  there  are  constitu- 
tional or  local  affections  with  which  it  is  associated.  In  many  instances  the 
urine  is  found  to  be  highly  acid,  perhaps  slightly  albuminous,  and  the  arteries 
are  stiff.  In  the  form  associated  with  this  condition,  sometimes  called  gouty 
bronchitis,  the  attacks  seem  related  to  the  defective  renal  elimination,  and  to 
this  condition  the  treatment  should  be  first  directed.  In  other  instances  there 
are  heart-disease  and  emphysema.  In  the  form  occurring  in  old  men  much 
may  be  done  in  the  way  of  prophylaxis.  There  is  no  doubt  that  with  pru- 
dence even  in  the  most  changeable  winter  weather  much  may  be  done  to  pre- 
vent the  onset  of  chronic  bronchitis.  Woollen  undergarments  should  be  used 
and  especial  care  should  be  taken  in  the  spring  months  not  to  change  them 
for  lighter  ones  before  the  warm  weather  is  established. 

Cure  is  seldom  effected  by  medicinal  remedies.  There  are  instances  in 
which  iodide  of  potassium  acts  with  remarkable  benefit,  and  it  should  always 
be  given  a  trial  in  cases  of  paroxysmal  bronchitis  of  obscure  origin.  For  the 
morning  cough,  bicarbonate  of  sodium  (gr.  xv,  1  gm.),  chloride  of  sodium 
(gr.  v,  0.3  gm.),  spirits  of  chloroform  (Tl[  v,  0.3  e.  .c)  in  anise  water  and 
taken  with  an  equal  amount  of  warm  water  will  be  found  useful  (Fowler). 
When  there  is  much  sense  of  tightness  and  fullness  of  the  chest,  the  portable 
Turkish  bath  may  be  tried.  When  the  secretion  is  excessive  muriate  of  ammo- 
nia and  senega  are  useful.  Stimulating  expectorants  are  contraindicated. 
When  the  heart  is  feeble,  the  combination  of  digitalis  and  strychnia  is  very 
beneficial.  Turpentine,  the  old-fashioned  remedy  so  warmly  recommended  by 


BROXCHIECTASIS  625 

the  Dublin  physicians,  has  in  many  quarters  fallen  undeservedly  into  disuse. 
Preparations  of  tar,  creosote,  and  terebene  are  sometimes  useful.  Of  other 
balsamic  remedies,  sandal-wood,  the  compound  tincture  of  benzoin,  copaiba, 
balsam  of  Peru  or  tolu  may  be  used.  Inhalations  of  eucalyptus  and  of  the 
spray  of  ipecacuanha  wine  are  often  very  useful.  If  fetor  be  present,  carbolic 
acid  in  the  form  of  spray  (1  to  2  per  cent,  solution)  will  lessen  the  odor, 
or  thymol  (1  to  1,000),  but  the  intratracheal  medication  is  the  most  efficient. 
After  the  larynx  is  anaesthetized  with  a  4  per  cent,  cocaine  solution,  inject 
with  suitable  syringe  about  two  drachms  (8  c.  c.)  of  olive  oil,  with  gr.  i/2 
(0.032  gm.)  of  iodoform,  and  gr.  i/8  (0.008  gm.)  of  morphia  if  there  is 
irritating  cough.  For  urgent  dyspnoea  with  cyanosis,  bleeding  from  the  arm 
gives  most  relief. 

m.    BRONCHIECTASIS 

Etiology. — The  following  excellent  classification  is  given  by  Barty  King: 

I.     BronchiolectasisJ Acute 
I  Chronic 

1.  Chronic  bronchitis 

2.  Broncho-pneumonic 

A.  Pure  J  3.    Chronic  pneumonic 

4.  Pneumonic 

5.  Pleuritic 

B.  Tuberculous 

{1.    Aneurism 
2.    Tumor 
3.    Foreign  body 
4.    Syphilis 

In  addition  there  is  a  congenital  defect  which  Grawitz  has  described  as  Iron- 
chiectasis  universalis. 

Unquestionably  the  weakening  of  the  bronchial  wall  is  the  most  impor- 
tant, probably  the  essential,  factor  in  inducing  bronchiectasis,  since  the  wall 
is  then  not  able  to  resist  the  pressure  of  air  in  severe  spells  of  coughing  and 
in  straining.  In  some  instances  the  mere  weight  of  the  accumulated  secretion 
may  be  sufficient  to  distend  the  terminal  tubules,  as  is  seen  in  compression  of 
a  bronchus  by  aneurism.  Barty  King  lays  great  stress  on  pleural  adherency 
as  a  factor  in  the  initial  dilatation  of  the  tubes.  The  disease  seems  to  have 
increased  in  frequency  since  the  influenza  epidemics  of  the  past  fifteen  years. 
Of  six  consecutive  cases  in  my  wards  in  the  session  of  1904-05  from  every 
one  Boggs  isolated  the  influenza  bacillus. 

Morbid  Anatomy.— Two  chief  forms  of  bronchiectasis  are  recognized — the 
cylindrical  and  the  saccular — which  may  exist  together  in  the  same  lung.  The 
condition  may  be  general  or  partial.  Universal  bronchiectasis  is  always  uni- 
lateral. It  occurs  in  rare  congenital  cases  and  is  occasionally  seen  as  a 
sequence  of  interstitial  pneumonia.  The  entire  bronchial  tree  is  represented 
by  a  series  of  sacculi  opening  one  into  the  other.  The  walls  are  smooth  and 


II.     Bronchiectasis- 


626  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

possibh  without  ulceration  or  erosion  except  in  the  dependent  parts.  The 
lining  membrane  of  the  sacculi  is  usually  smooth  and  glistening.  The  dila- 
tations may  form  large  cysts  immediately  beneath  the  pleura.  Intervening 
between  the  sacculi  is  a  dense  cirrhotic  lung  tissue.  The  partial  dilatations — 
the  saccular  and  cylindrical — are  common  in  chronic  phthisis,  particularly  at 
the  apex,  in  chronic  pleurisy  at  the  base,  and  in  emphysema.  Here  the  dila- 
tation is  more  commonly  cylindrical,  sometimes  fusiform.  The  bronchial 
mucous  membrane  is  much  involved  and  sometimes  there  is  a  narrowing  of 
the  lumen.  Occasionally  one  meets  with  a  single  saccular  bronchiectasis  in 
connection  with  chronic  bronchitis  or  emphysema.  Some  of  these  look  like 
simple  cysts,  with  smooth  walls,  without  fluid  contents.  Bronchiolectasis  as 
an  acute  condition  may  follow  the  infectious  diseases,  as  in  the  cases  described 
by  Sharkey,  Carr,  and  others.  The  chronic  variety  is  a  sequel  of  bronchitis  in 
old  subjects. 

Histologically  the  bronchi  which  are  the  seat  of  dilatation  show  important 
changes.  In  the  large,  smooth  dilatations  the  cylindrical  is  replaced  by  a 
pavement  epithelium.  The  muscular  layer  is  stretched,  atrophied,  and  the 
fibres  separated;  the  elastic  tissue  is  also  much  stretched  and  separated.  In. 
the  large  saccular  bronchiectases  and  in  some  of  the  cylindrical  forms,  due  to 
retained  secretions,  the  lining  membrane  is  ulcerated.  The  contents  of  some 
of  the  larger  bronchiectatic  cavities  are  horribly  fetid. 

Symptoms. — There  are  acute  cases,  usually  the  bronchiolectasis  of  chil- 
dren; but  a  case  in  my  wards  of  the  broncho-pneumonic  form  died  in  six 
weeks  from  the  onset.  The  bronchi  of  the  lower  lobes  were  dilated;  there 
were  areas  of  broncho-pneumonia  and  one  or  two  spots  of  gangrene.  The 
patient  became  hemiplegic,  probably  from  abscess  of  the  brain.  In  the  lim- 
ited dilatations  of  phthisis,  emphysema,  and  chronic  bronchitis  the  symptoms 
are  in  great  part  those  of  the  original  disease,  and  the  condition  often 
is  not  suspected  during  life. 

In  extensive  saccular  bronchiectasis  the  characters  of  the  cough  and  expec- 
toration are  distinctive.  T^e  patient  will  pass  the'  greater  part  of  the  day 
without  any  cough  and  then  in  a  severe  paroxysm  will  bring  up  a  large  quan- 
tity of  sputum.  Ten  of  my  cases  showed  this  symptom.  Of  23  of  my  cases 
the  amount  for  twenty-four  hours  was  in  2  less  than  100  c.  c.,  in  11  from 
100-300  c.  c.,  in  2  almost  500  c.  c.,  in  7  over  600  c.  c.  In  one  case  with  over 
one  litre  per  day  the  cavities  found  were  very  small.  Sometimes  change  of 
position  will  bring  on  a  violent  attack,  probably  due  to  the  fact  that  some  of 
the  secretion  flows  from  the  dilatation  to  a  normal  tube.  The  daily  spell  of 
coughing  is  usually  in  the  morning.  The  expectoration  is  in  many  instances 
very  characteristic.  It  is  grayish  or  grayish  brown  in  color,  fluid,  purulent, 
with  a  peculiar  acid,  sometimes  fetid,  odor.  Placed  in  a  conical  glass,  it  sepa- 
rates into  a  thick  granular  layer  below  and  a  thin  mucoid  intervening  layer 
above,  which  is  capped  by  a  brownish  froth.  Microscopically  it  consists  of 
pus-corpuscles,  often  large  crystals  of  fatty  acids,  which  are  sometimes  in 
enormous  numbers  over'  the  field  and.  arranged  in  bunches.  Hasmatoidin 
crystals  are  sometimes  present.  Elastic  fibres  are  seldom  found  except  when 
there  is  ulceration  of  the  bronchial  walls.  Tubercle  bacilli  are  not  present. 
In  some  cases,  as  in  10  of  my  series,  the  expectoration  is  very  fetid  and  has  all 
the  characters  of  that  described  und^r  fetid  bronchitis,  ^ummular  exoectora- 


BRONCHIAL   ASTHMA  627 

tion,  such  as  comes  from  phthisical  cavities,  is  not  common.  Haemorrhage 
occurred  in  14  out  of  35  cases  analyzed  by  Fowler,  in  17  of  my  24  cases, 
slight  in  8,  and  extreme  in  3.  Arthritis  may  occur,  and  it  is  one  of  the  con- 
ditions with  which  the  pulmonary  osteo-arthropathy  is  commonly  associated. 
There  is  a  remarkable  association  of  bronchiectasis  with  abscess  of  the  brain. 
Among  13,700  autopsies  at  the  London  Hospital  and  the  Brompton  Hospital 
there  were  19  instances  of  cerebral  abscess  with  pulmonary  disease,  usually 
bronchiectasis  ( Schorstein ) . 

Diagnosis. — In  the  extensive  sacculated  forms,  unilateral  and  associated 
with  interstitial  pneumonia  or  chronic  pleurisy,  the  diagnosis  is  easy.  There  is 
contraction  of  the  side,  which  in  some  instances  is  not  at  all  extreme.  The 
cavernous  signs  may  be  chiefly  at  the  base  and  may  vary  according  to  the 
condition  of  the  cavity,  whether  full  or  empty.  There  may  be  the  most  ex- 
quisite amphoric  phenomena  and  loud  resonant  rales.  The  condition  persists 
for  years  and  is  not  inconsistent  with  a  tolerably  active  life.  The  patients 
frequently  show  signs  of  marked  embarrassment  of  the  pulmonary  circulation. 
There  is  a  cyanosis  on  exertion,  the  finger-tips  are  clubbed,  and  the  nails 
incurved.  A  condition  very  difficult  to  distinguish  from  bronchiectasis  is  a 
limited  pleural  cavity  communicating  with  a  bronchus.  The  X-ray  examina- 
tion is  an  important  aid  in  diagnosis. 

Treatment. — Medical  treatment  is  not  satisfactory,  since  it  is  impossible 
to  heal  the  cavities.  Postural  treatment  is  important,  and  the  most  favorable 
position  should  be  studied  for  each  patient.  Sleeping  with  the  head  low 
favors  "drainage."  I  have  practiced  the  injection  of  antiseptic  fluids  in  some 
instances  with  benefit.  Intratracheal  injections  have  been  recommended  of 
late.  With  a  suitable  syringe  a  drachm  may  be  injected  twice  a  day  of  the 
following  solution:  Menthol  10  parts,  guaiacol  2  parts,  olive  oil  88  parts. 
Or  better  still  when  the  odor  is  very  offensive  iodoform  in  olive  oil.  The 
creosote  vapor  bath  may  be  given  in  a  small  room.  The  patient's  eyes  must  be 
protected  with  well-fitting  goggles,  and  the  nostrils  stuffed  with  cotton-wool. 
Twenty  to  thirty  drops  of  creosote  are  poured  upon  water  in  a  saucer  and 
vaporized  by  placing  the  saucer  over  a  spirit  lamp.  At  first  the  vapor  is  very 
irritating  and  disagreeable,  but  the  patient  gets  used  to  it.  The  bath  should 
be  taken  at  first  every  other  day  for  fifteen  minutes,  then  gradually  increased 
to  an  hour  daily.  The  treatment  should  be  continued  for  three  months.  I 
can  recommend  it  as  a  most  satisfactory  method.  In  suitable  cases,  as  when 
there  is  a  single  large  cavity,  drainage  of  the  cavities  may  be  attempted,  par- 
ticularly if  the  patient  is  in  fairly  good  condition.  Eesection  of  the  overlying 
ribs  has  been  employed.  For  the  fetid  secretion  turpentine  may  be  given,  or 
terebene,  and  inhalations  of  carbolic  acid  or  thymol  used. 

IV.    BRONCHIAL   ASTHMA 

Asthma  is  a  term  which  has  been  applied  to  various  conditions  associated 
with  dyspnoea— hence  the  names  cardiac  and  renal  asthma— but  its  use  should 
be  limited  to  the  affection  known  as  bronchial  or  spasmodic  asthma. 

Etiology. All  writers  agree  that  there  is  in  a  majority  of  cases  of  bron- 
chial asthma  a  strong  neurotic  element.  Many  regard  it  as  a  neurosis  in 


C.Sfi  DISEASES    OF    TTTE    TiESPTTUTOttY    SYSTEM 

which,  according  to  one  view,  spasm  of  the  bronchial  muscles,  according  to  the 
other  turgescence  of  the  mucosa,  results  from  disturbed  innervation,  pneumo- 
gastric  or  vaso-motor.  Of  the  numerous  theories  the  following  are  the  most 
important : 

(1)  That  it  is  due  to  spasm  of  the  bronchial  muscles,  a  theory  which  has 
perhaps  the  largest  number  of  adherents.     The  original  experiments  of  C.  J. 
B.  Williams,  upon  which  it  is  largely  based,  have  been  confirmed  by  Brodie. 

(2)  That  the  attack  is  due  to  swelling  of  the  bronchial  mucous  membrane 
— fluctionary  hypersemia  (Traube),  vaso-motor  turgescence  (Weber),  diffuse 
hyperaemic  swelling  (Clark). 

(3)  That  in  many  cases  it  is  a  special  form  of  inflammation  of  the  smaller 
bronchioles — bronchiolitis  exudativa    (Curschmann).      Other   theories   which 
may  be  mentioned  are  that  the  attack  depends  on  spasm  of  the  diaphragm,  on 
reflex  spasm  of  all  the  inspiratory  muscles,  or  on  protein  sensitization. 

As  already  mentioned,  the  so-called  hay  fever  is  an  affection  which  has 
many  resemblances  to  bronchial  asthma,  with  which  the  attacks  may  alternate. 
In  the  suddenness  of  onset  and  in  many  of  their  features  these  diseases  have 
a  great  similarity  and  differ  only  in  site,  as  suggested  by  Sir  Andrew  Clark 
and  generally  acknowledged  by  specialists.  Making  due  allowance  for  ana- 
tomical differences,  if  the  structural  changes  occurring  in  the  nasal  mucous 
membrane  during  an  attack  of  hay  fever  were  to  occur  also  in  various  parts 
of  the  bronchial  mucosa,  their  presence  there  would  afford  a  complete  and 
adequate  explanation  of  the  facts  observed  during  a  paroxysm  of  bronchial 
asthma  (Clark).  With  this  statement  I  fully  agree,  but  the  observations  of 
Curschmann  have  directed  attention  to  a  feature  in  asthma  which  has  been 
neglected;  namely,  that  in  a  majority,  of  the  cases  it  is  associated  with  an 
exudation,  such  as  might  be  supposed  to  come  from  a  turgescent  mucosa  and 
which  is  of  a  very  characteristic  and  peculiar  character.  The  hyperaemia  and 
swelling  of  the  mucosa  and  the  extremely  viscid,  tenacious  mucus  explain  well 
the  hindrance  to  inspiration  and  expiration  and  also  the  quality  of  the  rales. 
An  oedema  of  the  angio-neurotic  type  has  been  described  in  the  hands  and 
arms  in  asthma. 

Some  general  facts  with  reference  to  etiology  may  be  mentioned.  The 
affection  sometimes  runs  in  families,  particularly  those  with  irritable  and 
unstable  nervous  systems.  The  attack  may  be  associated  with  neuralgia  or, 
as  Salter  mentions,  even  alternate  with  epilepsy.  Men  are  more  frequently 
affected  than  women.  The  disease  often  begins  in  childhood  and  sometimes 
lasts  until  old  age.  For  years  asthmatic  attacks  may  follow  whooping-cough. 
One  of  its  most  striking  peculiarities  is  the  bizarre  and  extraordinary  variety 
of  circumstances  which  at  times  induce  a  paroxysm.  Among  these  local  con- 
ditions climate  or  atmosphere  is  most  important.  A  person  may  be  free  in 
the  city  and  invariably  suffer  from  an  attack  when  he  goes  into  the  country, 
or  into  one  special  part  of  the  country.  Such  cases  are  by  no  means  uncom- 
mon. Breathing  the  air  of  a  particular  room  or  a  dusty  atmosphere  may 
bring  on  an  attack.  Odors,  particularly  of  flowers  and  of  hay,  or  emanations 
from  animals,  as  the  horse,  dog,  or  cat,  may  at  once  cause  an  outbreak.  Fright 
or  violent  emotion  of  any  sort  may  bring  on  a  paroxysm.  Uterine  and  ovarian 
troubles  were  formerly  thought  to  induce  attacks  and  may  do  so  in  rare  in- 
stances. Diet,  too,  has  an  important  influence,  and  in  persons  subject  to  the 


BRONCHIAL   ASTHMA  629 

disease  severe  paroxysms  may  be  induced  by  overloading  the  stomach,  or  by 
taking  certain  articles  of  food.  Chronic  cases,  in  which  the  attacks  recur  year 
after  year,  gradually  become  associated  with  emphysema,  and  every  fresh 
"cold"  induces  a  paroxysm.  And,  lastly,  many  cases  of  bronchial  asthma  are 
associated  with  affections  of  the  nose,  particularly  with  hypertrophic  rhinitis 
and  nasal  polypi. 

Briefly  stated,  then,  bronchial  asthma  is  a  neurotic  affection,  characterized 
by  hyperaemia  and  turgescence  of  the  mucosa  of  the  smaller  bronchial  tubes 
and  a  peculiar  exudate  of  mucin.  The  attacks  may  be  due  to  direct  irritation 
of  the  bronchial  mucosa  or  may  be  induced,  reflexly,  by  irritation  of  the  nasal 
mucosa,  and  indirectly,  too,  by  reflex  influences,  from  stomach,  intestines,  or 
genital  organs.  It  is  important  to  remember  that  in  the  subjects  of  asthma 
to  whom  injections  of  diphtheria  or  other  antitoxins  are  given  anaphylaxis 
may  be  induced  with  a  rapidly  fatal  termination. 

Symptoms. — Premonitory  sensations  precede  some  attacks,  such  as  chilly 
feelings,  a  sense  of  tightness  in  the  chest,  flatulence,  the  passage  of  a  large 
quantity  of  urine,  or  great  depression  of  spirits.  Nocturnal  attacks  are  com- 
mon. After  a  few  hours'  sleep,  the  patient  is  aroused  with  a  distressing  sense 
of  want  of  breath  and  a  feeling  of  great  oppression  in  the  chest.  Soon  the 
respiratory  efforts  become  violent,  all  the  accessory  muscles  are  brought  into 
play,  and  in  a  few  minutes  the  patient  is  in  a  paroxysm  of  the  most  intense 
dyspnoea.  The  face  is  pale,  the  expression  anxious,  speech  is  impossible,  and 
in  spite  of  the  most  strenuous  inspiratory  efforts  very  little  air  enters  the 
lungs.  Expiration  is  prolonged  and  also  wheezy.  The  number  of  respirations, 
however,  is  not  much  increased.  The  asthmatic  fit  may  last  from  a  few  min- 
utes to  several  hours.  When  severe,  the  signs  of  defective  aeration  soon 
appear,  the  face  becomes  bedewed  with  sweat,  the  pulse  is  small  and  quick, 
the  extremities  get  cold,  and  just  as  the  patient  seems  to  be  at  his  worst  the 
breathing  begins  to  get  easier,  and  often  with  a  paroxysm  of  coughing  relief 
is  obtained  and  he  sinks  exhausted  to  sleep.  The  relief  may  be  but  temporary 
and  a  second  attack  may  soon  come  on.  In  a  majority  of  the  cases  even  in 
the  intervals  between  the  asthmatic  fits  the  respiration  is  somewhat  embar- 
rassed. The  cough  is  at  first  very  tight  and  dry  and  the  expectoration  is 
tenacious.  Emphysema  of  the  neck  may  occur  during  the  violent  coughing 
spells.  Urticaria  may  break  out  over  the  whole  body  during  an  attack,  or, 
as  in  one  patient,  may  be  confined  to  the  skin  of  the  interscapular  regions. 

The  PHYSICAL  SIGNS  during  an  attack  are  very  characteristic.  On  inspec- 
tion the  thorax  looks  enlarged,  barrel-shaped,  and  is  fixed,  the  amount  of 
expansion  being  altogether  disproportionate  to  the  intensity  of  the  inspiratory 
movements.  The  diaphragm  is  lowered  and  moves  but  slightly.  Inspiration  is 
short  and  quick,  expiration  prolonged.  Percussion  may  not  reveal  any  special 
difference,  but  there  is  sometimes  marked  hyperresonance,  particularly  in 
patients  who  have  had  repeated  attacks. 

On  auscultation,  with  inspiration  and  expiration,  there  are  innumerable 
sibilant  and  sonorous  rales  of  all  varieties,  piping  and  high-pitched,  low- 
pitched  and  grave.  Later  in  the  attack  there  are  moist  rales. 

The  sputum  is  quite  distinctive,  unlike  that  which  occurs  in  any  other 
affection.  Early  in  the  attack  it  is  brought  up  with  great  difficulty  and  is  in 
the  form  of  rounded  gelatinous  masses,  the  so-called  "perks"  of  Laennec. 


630  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

Though  ball-like,  they  can  be  unfolded  and  really  represent  moulds  in  mucus 
of  the  smaller  tubes.  The  entire  expectoration  may  be  made  up  of  these 
somewhat  translucent-looking  pellets,  floating  in  a  small  quantity  of  thin 
mucus.  Some  of  them  are  opaque.  Often  with  the  naked  eye  a  twisted  spiral 
character  can  be  seen,  particularly  if  the  sputum  is  spread  on  a  glass  with  a 
black  background.  Microscopically,  many  of  these  pellets  have  a  spiral  struc- 
ture, which  renders  them  among  the  most  remarkable  bodies  met  with  in 
sputum.  It  is  not  a  little  curious  that  they  should  have  been  practically 
overlooked  until  described  by  von  Curschmann.  Under  the  microscope  the 
spirals  are  of  two  forms.  In  one  there  is  simply  a  twisted,  spirally  arranged 
filament  of  mucin,  in  which  are  entangled  leucocytes,  the  majority  of  which 
are  eosinophiles.  The  twist  may  be  loose  or  tight.  The  second  form  is  much 
more  peculiar.  In  the  centre  of  a  tightly  coiled  skein  of  mucin  fibrils  with  a 
few  scattered  cells  is  a  filament  of  extraordinary  clearness  and  translucency, 
probably  composed  of  transformed  mucin.  These  spirals  are  doubtless  formed 
in  the  finer  bronchioles  and  constitute  the  product  of  an  acute  bronchiolitis. 
It  is  difficult  to  explain  their  spiral  nature.  I  do  not  know  of  any  observa- 
tions upon  the  course  of  the  currents  produced  by  the  ciliated  epithelium  in 
the  bronchi,  but  it  is  quite  possible  that  their  action  may  be  rotatory,  in  which 
case,  particularly  when  combined  with  spasm  of  the  bronchial  muscles,  it  is 
possible  to  conceive  that  the  mucus  formed  in  the  tube  might  be  compelled 
to  assume  a  spiral  form.  Within  two  or  three  days  the  sputum  changes  en- 
tirely in  character;  it  becomes  muco-purulent  and  von  Curschmann's  spirals 
are  no  longer  to  be  found.  They  occur  in  all  instances  of  true  bronchial 
asthma  in  the  early  period  of  the  attack.  I  have  never  seen  the  true  spirals 
either  in  bronchitis  or  pneumonia.  There  are,  in  addition,  in  many  cases,  the 
pointed,  octahedral  crystals  described  by  Leyden  and  sometimes  called  asthma 
crystals.  They  are  identical  with  the  crystals  found  in  the  semen  and  in  the 
blood  in  leukasmia.  At  one  time  they  were  supposed,  by  their  irritating  char- 
acter, to  induce  the  paroxysms.  Eosinophiles  in  the  blood  are  enormously 
increased  in  asthma — to  25  or  35  per  cent,  of  the  leucocytes,  or  even  to  53.6 
per  cent,  in  one  case. 

Course. — This  is  very  variable.  In  severe  attacks  the  paroxysms  recur  for 
three  or  four  nights  or  even  more,  and  in  the  intervals  and  during  the  day 
there  may  be  wheezing  and  cough.  Early  in  the  disease  the  patient  may  be 
free  in  the  morning,  without  cough  or  much  distress,  and  the  attacks  may 
appear  at  first  to  be  of  a  purely  nervous  character.  In  the  long-standing  cases 
emphysema  almost  invariably  develops  and,  while  the  pure  asthmatic  fits 
diminish  in  frequency  the  chronic  bronchitis  and  shortness  of  breath  become 
aggravated. 

We  have  no  knowledge  of  the  morbid  anatomy  of  true  asthma.  Death 
during  the  attack  is  unknown.  In  long-standing  cases  the  lesions  are  those  of 
chronic  bronchitis  and  emphysema. 

Treatment. — The  asthmatic  attack  usually  demands  immediate  and  prompt 
treatment,  and  remedies  should  be  administered  which  experience  has  shown 
are  capable  of  relieving  the  condition  of  the  bronchial  mucosa.  A  few  whiffs 
of  chloroform  will  produce  prompt  though  temporary  relaxation.  In  a  child 
with  very  severe  attacks,  resisting  all  the  usual  remedies,  the  treatment  by 
chloroform  gave  immediate  and  finally  permanent  relief.  Hypodermic  injec- 


FIBRINOUS    BRONCHITIS  631 

tions  of  pilocarpin  (gr.  %,  0.008  gm.)  will  sometimes  relax  the  mucosa  in  the 
profuse  sweating.  Perles  of  nitrite  of  amyl  may  be  broken  on  the  handker- 
chief or  from  two  to  five  drops  of  the  solution  may  be  placed  upon  cotton-wool 
and  inhaled.  Strong  stimulants  given  hot  or  a  dose  of  spirit  of  chloroform  in 
hot  whisky  will  sometimes  induce  relaxation.  More  permanent  relief  is  given 
by  the  hypodermic  injection  of  morphia  or  of  morphia  and  strychnine  com- 
bined. In  obstinate  and  repeatedly  recurring  attacks  this  has  proved  a  very 
satisfactory  plan.  The  sedative  antispasmodics,  such  as  belladonna,  henbane, 
stramonium,  and  lobelia,  may  be  given  ir.  solution  or  used  in  the  form  of 
cigarettes.  Nearly  all  the  popular  remedies  either  in  this  form  or  in  pastilles 
contain  some  plant  of  the  order  solanacece,  with  nitrate  or  chlorate  of  potash. 
Excellent  cigarettes  are  now  manufactured  and  asthmatics  try  various  sorts, 
since  one  form  benefits  one  patient,  another  form  another  patient.  Nitra 
paper  made  with  a  strong  solution  of  nitrate  of  potash  is  very  serviceable. 
Filling  the  room  with  the  fumes  of  this  paper  prior  to  retiring  will  some- 
times ward  off  a  nocturnal  attack.  I  have  known  several  patients  to  whom 
tobacco  smoke  inhaled  was  quite  as  pctent  as  the  prepared  cigarettes. 

Cauterization  of  the  mucous  membrane  of  the  nose  has  given  great  relief, 
particularly  in  cases  with  swelling  and  irritation.  The  use  of  compressed 
air  in  the  pneumatic  cabinet  is  very  beneficial;  oxygen  inhalations  may  also 
be  tried.  In  preventing  the  recurrence  of  the  attacks  there  is  no  remedy  so 
useful  as  iodide  of  potassium,  which  sometimes  acts  like  a  specific.  From 
10  to  20  grains  (0.6  to  1.3  gm.)  three  times  a  day  is  usually  sufficient.  Per- 
sistent hydrotherapy  is  often  of  value. 

Particular  attention  should  be  paid  to  the  diet  of  asthmatic  patients.  A 
rule  which  experience  generally  compels  them  to  make  is  to  take  the  heavy 
meals  in  the  early  part  of  the  day  and  not  retire  to  bed  before  gastric  diges- 
tion is  completed.  As  the  attacks  are  often  induced  by  flatulency,  the  carbo- 
hydrates should  be  restricted.  Coffee  is  a  more  suitable  drink  than  tea.  In 
respect  to  climate  it  is  very  difficult  to  lay  down  rules  for  asthmatics.  The 
patients  are  often  much  better  in  the  city  than  in  the  country.  The  high  and 
dry  altitudes  are  certainly  more  beneficial  than  the  sea-shore ;  but  in  the  pro- 
tracted cases,  with  emphysema  as  a  secondary  complication,  the  rarefied  air  of 
high  altitudes  is  not  advantageous.  In  young  persons  I  have  known  a  resi- 
dence for  six  months  in  Florida  or  southern  California  to  be  followed  by 
prolonged  freedom  from  attacks.  Egypt  is  a  peculiarly  satisfactory  winter 
slimate. 

V.    FIBRINOUS   BRONCHITIS 

(Plastic  or  Croupous  Bronchitis] 

Definition.  — An  acute  or  chronic  affection,  characterized  by  the  formation 
in  certain  of  the  bronchial  tubes  of  fibrinous  casts,  which  are  expelled  in 
paroxysms  of  dyspnoea  and  cough. 

In  several  diseases  fibrinous  moulds  of  the  bronchi  are  formed,  as  in  diph- 
theria (with  extension  into  the  trachea  and  bronchi),  in  pneumonia,  and 
occasionally  in  phthisis — conditions  Jrhich,  however,  have  nothing  to  do  with 
true  fibrinous  bronchitis.  These  casts  are  not  to  be  confounded  with  th? 
blood-casts  which  occur  occasionally  in  hemoptysis. 


632  DISEASES    OF   THE    RESPIRATORY    SYSTEM 

Clinical  Description. — Bettman,  in  reporting  a  case  which  occurred  in 
Whitriclge  Williams's  obstetrical  clinic  at  the  Johns  Hopkins  Hospital, 
analyzed  all  the  cases  from  the  literature  since  1869,  grouping  them  into  dif- 
ferent classes.  The  first  and  most  important  is  chronic  idiopathic  fibrinous 
bronchitis.  It  is  a  rare  affection.  Of  27  cases,  15  were  in  males.  It  is  most 
common  at  the  middle  period  of  life.  The  attacks  may  occur  at  definite  inter- 
vals for  months  or  years.  The  form  and  size  of  the  casts  may  be  identical  at 
each  attack  as  though  each  time  precisely  the  same  bronchial  area  was  in- 
volved. The  expectoration  of  the  casts  is  associated  with  paroxysms  of  dysp- 
noea and  coughing,  which  occur  at  longer  or  shorter  intervals.  Fever  and 
haemoptysis  may  be  present  during  the  attack.  Physical  signs  usually  indicate 
the  portion  of  the  lung  affected,  as  there  are  suppressed  breath  sounds  and 
numerous  rales  on  coughing.  A  very  dry  rale,  called  the  "bruit  de  drapeau," 
has  been  described,  caused  by  the  vibration  of  a  loosened  portion  of  the  cast. 

In  five  cases  there  were  skin  lesions.  Tuberculosis  is  sometimes  present. 
The  casts  are  usually  rolled  up  and  mixed  with  mucus  and  blood.  When 
unrolled  they  are  large  white  branching  structures.  The  main  stem  may  be 
as  thick  as  the  little  finger.  From  the  consistency  and  appearance  they  have 
been  described  as  fibrinous,  but  they  consist  mainly  of  mucin.  On  cross- 
section  they  show  a  concentrically  stratified  structure,  with  leucocytes  and 
alveolar  epithelium.  Leyden's  crystals  and  von  Curschmann's  spirals  are 
sometimes  found,  and  in  Bettman's  case  there  were  protozoan-like  bodies. 
Death  occurred  in  only  one  case  of  the  series. 

There  is  a  very  remarkable  acute  form,  of  which  Bettman  collected  15 
cases.  It  comes  on  most  frequently  during  some  fever,  as  typhoid,  pneumonia, 
or  the  eruptive  fevers.  After  a  preliminary  bronchitis  the  dyspnoea  increases, 
and  then  the  casts  are  coughed  up.  Chills  and  fever  have  been  present.  Four 
of  the  15  cases  proved  fatal,  and  the  casts  were  found  in  situ.  It  is  much 
more  serious  than  the  chronic  form.  There  may  be  casts  expectorated  which 
have  not  the  arborescent  structure  of  the  true  fibrinous  moulds,  but  which 
come  from  a  single  tube  or  its  bifurcation.  Sometimes  they  are  very  small 
and  "tail  off"  into  true  spirals. 

Fibrinous  casts  are  expectorated  in  connection  with  chronic  heart-disease 
(10  cases)  and  in  pulmonary  tuberculosis  (14  cases),  in  the  latter  disease 
usually  late  in  the  course  and  of  unfavorable  moment.  In  the  albuminous 
expectoration  following  tapping  of  a  pleural  exudate  fibrinous  casts  have  been 
coughed  up. 

In  haemoptysis  blood-casts  may  be  expectorated,  and  they  are  not  to  be 
confounded  with  the  casts  of  true  fibrinous  bronchitis  which,  may  be  coughed 
up  with  profuse  haemorrhage. 

In  pneumonia  small  fibrinous  plugs  are  not  uncommon  in  the  sputum,  and 
in  a  few  rare  instances  quite  large  moulds  of  the  tubes  may  be  coughed  up. 

The  mycelium  of  Aspergillus  fumigatus  may  form  membranous  casts  in 
the  bronchi.  I  reported  an  instance  of  the  kind  in  which  a  small  partial 
mould  of  this  kind  was  expectorated,  and  there  is  on  record  a  case  in  which 
for  long  periods  membranes  composed  of  this  fungus  were  coughed  up  in 
attacks  of  dyspnoea. 

Pathology. — The  pathology  of  the  disease  is  obscure.  The  membrane  is 
identical  with  that  to  which  the  term  crouppus  is  applied,  and  the  obscurity 


CIRCULATORY    DISTURBANCES    IN    THE    LUNGS         633 

relates  not  so  much  to  the  mechanism  of  the  production,  which  is  probably 
the  same  as  in  other  mucous  surfaces,  as  to  the  curious  limitation  of  the  affec- 
tion to  certain  bronchial  territories  and  in  the  chronic  form  to  the  remarkable 
recurrence  at  stated  or  irregular  intervals  throughout  a  period  of  many  years. 

In  the  fatal  cases  the  bronchial  mucous  membrane  may  be  found  injected 
or  pale.  In  Biermer's  case  the  epithelial  lining  was  intact  beneath  the  cast, 
but  in  that  of  Kretschy  the  bronchi  were  denuded  of  their  epithelium.  Em- 
physema is  almost  invariably  present.  Evidences  of  recent  or  antecedent  pleu- 
risy are  sometimes  found.  Model,  in  an  article  published  from  Baumler's 
clinic,  states  that  tuberculosis  was  present  in  10  out  of  21  autopsies. 

Treatment. — In  the  acute  cases  the  treatment  should  be  that  of  ordinary 
acute  bronchitis.  We  know  of  nothing  which  can  prevent  the  recurrence  of  the 
attacks  in  the  chronic  form.  In  the  uncomplicated  cases  there  is  rarely  any 
danger  during  the  paroxysm,  even  though  the  symptoms  may  be  most  distress- 
ing and  the  dyspnoea  and  cough  very  severe.  Inhalations  of  ether,  steam,  or 
atomized  lime-water  aid  in  the  separation  of  the  membranes.  Waldenberg 
employed  the  last  remedy  with  success  in  one  case.  Ewart  recommends  intra- 
tracheal  injections  of  olive  oil.  Pilocarpine  might  be  useful,  as  in  some  in- 
stances it  increases  the  bronchial  secretion.  The  employment  of  emetics  may 
be  necessary,  and  in  some  cases  they  are  effective  in  promoting  the  removal  of 
the  casts. 

D.    DISEASES   OF   THE   LUNGS 
I.     CIRCULATORY   DISTURBANCES   IN   THE   LUNGS 

Congestion. — There  are  two  forms  of  congestion  of  the  lungs — active  and 
passive. 

1.  ACTIVE  CONGESTION  OF  THE  LUNGS. — Much  doubt  and  confusion  still 
exist  on  this  subject.  French  writers,  following  Woillez,  regard  it  as  an  inde- 
pendent primary  affection  (maladie  de  Woillez),  and  in  their  dictionaries  and 
text-books  allot  much  space  to  it.  English  and  American  authors  more  cor- 
rectly regard  it  as  a  symptomatic  affection.  Active  fluxion  to  the  lungs  occurs 
with  increased  action  of  the  heart,  and  when  very  hot  air  or  irritating  sub- 
stances are  inhaled.  In  diseases  which  interfere  locally  with  the  circulation 
the  capillaries  in  the  adjacent  unaffected  portions  may  be  greatly  distended. 
The  importance,  however,  of  this  collateral  fluxion,  as  it  is  called,  is  probably 
exaggerated.  In  a  whole  series  of  pulmonary  affections  there  is  this  asso- 
ciated congestion — in  pneumonia,  bronchitis,  pleurisy,  and  tuberculosis. 

The  symptoms  of  active  congestion  of  the  lungs  are  by  no  means  definite. 
The  description  given  by  Woillez  and  by  other  French  writers  is  of  an  affec- 
tion which  is  difficult  to  recognize  from  anomalous  or  larval  forms  of  pneu- 
monia. The  chief  symptoms  described  ar3  initial  chill,  pain  in  the  side,  dysp- 
noea, moderate  cough,  and  temperature  from  101°  to  103°  F.  The  physical 
signs  are  defective  resonance,  feeble  breathing,  sometimes  bronchial  in  charac- 
ter, and  fine  rales.  A  majority  of  clinical  physicians  would  undoubtedly  class 
such  cases  under  inflammation  of  the  lung.  In  many  epidemics  the  abnormal 
and  larval  forms  are  specially  prevalent 
42 


634 

The  occurrence  of  an  intense  and  rapidly  fatal  congestion  of  the  lung,  fol- 
lowing extreme  heat  or  cold  or  sometimes  violent  exertion,  is  recognized  by 
some  authors.  Eenforth,  the  oarsman,  is  said  to  have  died  from  this  cause 
during  a  race  at  Halifax.  Leuf  has  described  cases  in  which,  .in  association 
with  drunkenness,  exposure,  and  cold,  death  occurred  suddenly,  or  within 
twenty-four  hours,  the  only  lesion  found  being  an  extreme,  almost  haemor- 
rhagic,  congestion  of  the  lungs.  'It  is  by  no  means  certain  that  in  these  cases 
death  really  occurs  from  pulmonary  congestion  in  the  absence  of  specific  state- 
ments with  reference  to  the  coronary  arteries  and  the  heart. 

2.  PASSIVE  CONGESTION. — Two  forms  of  this  may  be  recognized,  the  me- 
chanical and  the  hypostatic. 

(a)  Mechanical  congestion  occurs  whenever  there  is  an  obstacle  to  the 
return  of  the  blood  to  the  heart.  It  is  a  common  event  in  many  affections 
of  the  left  heart.  The  lungs  are  voluminous,  russet  brown  in  color,  cutting 
and  tearing  with  great  resistance.  On  section  they  show  at  first  a  brownish 
red  tinge,  and  then  the  cut  surface,  exposed  to  the  air,  becomes  rapidly  of  a 
vivid  red  color  from  oxidation  of  the  abundant  haemoglobin.  This  is  the  con- 
dition known  as  brown  induration  of  the  lung.  Histologically  it  is  charac- 
terized by  (i)  great  distention  of  the  alveolar  capillaries;  (ii)  increase  in 
the  connective-tissue  elements  of  the  lung;  (m)  the  presence  in  the  alveolar 
walls  of  many  cells  containing  altered  blood-pigment;  (iv)  in  the  alveoli 
numerous  epithelial  cells  containing  blood-pigment  in  all  stages  of  alteration, 
which  are  also  found  in  great  numbers  in  the  sputum. 

It  occasionally  happens  that  this  mechanical  hyperaemia  of  the  lung  results 
from  pressure  by  tumors.  So  long  as  compensation  is  maintained  the  mechan- 
ical congestion  of  the  lung  in  heart  disease  does  not  produce  any  symptoms, 
but  with  enfeebled  heart  action  the  engorgement  becomes  marked  and 
there  are  dyspnoea,  cough,  and  expectoration,  with  the  characteristic  alveolar 
cells. 

(6)  Hypostatic  Congestion. — In  fevers  and  adynamic  states  generally  it  is 
very  common  to  find  the  bases  of  the  lungs  deeply  'congested,  a  condition  in- 
duced partly  by  the  effect  of  gravity,  the  patient  lying  recumbent  in  one  pos- 
ture for  a  long  time,  but  chiefly  by  weakened  heart  action.  That  it  is  not  an 
effect  of  gravity  alone  is  shown  by  the  fact  that  a  healthy  person  may  remain 
in  bed  an  indefinite  time  without  its  occurrence.  The  posterior  parts  of  the 
lung  are  dark  in  color  and  engorged  with  blood  and  serum ;  in  some  instances 
to  such  a  degree  that  the  alveoli  no  longer  contain  air  and  portions  of  the  lung 
sink  in  water.  The  terms  splenization  and  hypostatic  pneumonia  have  been 
given  to  these  advanced  grades.  It  is  a  common  affection  in  protracted  cases 
of  typhoid  fever  and  in  long  debilitating  illness.  In  ascites,  meteorism,  and 
abdominal  tumors  the  bases  of  the  lungs  may  be  compressed  and  congested.  In 
this  connection  must  be  mentioned  the  form  of  passive  congestion  met  with 
in  injury  to,  and  organic  disease  of,  the  brain.  In  cerebral  apoplexy  the  bases 
•of  the  lungs  are  deeply  engorged,  not  quite  airless,  but  heavy,  and  on  section 
drip  with  blood  and  serum.  I  have  twice  seen  this  condition  in  an  extreme 
grade  throughout  the  lungs  in  death  from  morphia  poisoning.  In  some  in- 
stances the  lung  tissue  has  a  blackish,  gelatinous,  infiltrated  appearance,  almost 
)ike  diffuse  pulmonary  apoplexy.  Occasionally  this  congestion  is  most  marked 
in,  and  even  confined  to,  the  hemiplegic  side.  In  prolonged  coma  the  hypo- 


CIRCULATORY  DISTURBANCES  IN  THE  LUNGS    635 

static  congestion  may  be  associated  with  patches  of  consolidation,  due  to  the 
aspiration  of  portions  of  food  into  the  air-passages. 

The  symptoms  of  hypostatic  congestion  are  not  at  all  characteristic,  and 
the  condition  has  to  he  sought  for  by  careful  examination  of  the  bases  of  the 
lungs,  when  slight  dulness,  feeble,  sometimes  blowing,  breathing  and  liquid 
rales  can  be  detected. 

TREATMENT. — The  treatment  of  congestion  of  the  lungs  is  usually  that 
of  the  condition  with  which  it  is  associated.  In  the  intense  pulmonary  en- 
gorgement, which  may  possibly  occur  primarily,  and  which  is  met  with  in 
heart  disease  and  emphysema,  free  bleeding  should  be  practiced.  From  20  to 
30  ounces  of  blood  should  be  taken  from  the  arm,  and  if  the  blood  does  not 
flow  freely  and  the  condition  of  the  patient  is  desperate  aspiration  of  the 
right  auricle  may  be  performed. 

(Edema. — In  all  forms  of  intense  congestion  of  the  lungs  there  is  a  transu- 
dation  of  serum  from  the  engorged  capillaries  chiefly  into  the  air-cells,  but 
also  into  the  alveolar  walls.  Not  only  is  it  very  frequent  in  congestion,  but 
also  with  inflammation,  with  new  growths,  infarcts,  and  tubercles.  When 
limited  to  the  neighborhood  of  an  affected  part,  the  name  collateral  oedema 
is  sometimes  applied  to  it. 

Acute  oedema  is  met  with:  (1)  in  the  infections;  (2)  in  Bright's  disease; 
(3)  in  heart  disease,  particularly  angina  pectoris,  myocarditis,  and  valve 
lesions;  (4)  in  arterio-sclerosis ;  (5)  pregnancy;  (6)  angio-neurotic  oedema, 
and  (7)  as  a  complication  of  the  epileptic  fit.  The  theory  most  generally 
accepted  is  that  of  Welch,  whose  experiments  seemed  to  indicate  that  pul- 
monary oedema  is  due  to  a  disproportionate  weakness  of  the  left  ventricle,  so 
that  the  blood  accumulates  in  the  lung  capillaries  until  transudation  occurs. 
Such  weakness  may  be  brought  about  by  paralysis  or  by  spasm  of  the  left 
ventricle.  Others  regard  it  as  an  effect  of  disturbance  in  the  vasomotor 
mechanism  of  the  lungs.  In  some  cases  there  are  recurring  attacks  of  acute 
oedema. 

Anatomically  the  lung  is  anaemic,  heavy,  sodden,  pits  on  pressure,  and  on 
section  a  large  quantity  of  clear  or  blood-tinged  serum  flows  out.  It  may 
have  in  places  a  gelatinous  aspect. 

SYMPTOMS. — The  onset  is  sudden  with  a  feeling  of  oppression  and  pain 
in  the  chest  and  rapid  breathing  which  soon  becomes  dyspnceic  or  orthopnoeic. 
There  may  be  an  incessant  short  cough  and  a  copious  frothy,  sometimes  blood- 
tinged,  expectoration,  which  may  be  expelled  in  a  gush  from  the  mouth  and 
nose.  The  face  is  pale  and  covered  with  a  cold  sweat ;  the  pulse  is  feeble  and 
the  heart's  action  weak.  Over  the  entire  chest  may  be  heard  piping  and 
bubbling  rales.  The  attack  may  be  fatal  in  a  few  hours  or  it  may  persist 
for  twelve  or  twenty-four  hours  and  then  pass  off.  Steven,  of  Glasgow,  has 
reported  a  case  with  72  attacks  in  two  and  a  half  years.  I  have  seen  this 
recurrent  form  in  angina  pectoris,  each  paroxysm  of  which  was  associated  with 
intense  dyspnoea  and  all  the  features  of  acute  oedema  of  the  lungs. 

Bleeding  should  be  practiced  at  once  and  is  often  most  helpful.  Dry 
cupping  may  be  tried.  One  of  my  patients  had  great  relief  from  inhalations 
of  chloroform.  Oxygen  may  be  used.  Atropine  hypodermically  (gr.  1/100, 
0.00065  gm.)  is  sometimes  of  value.  If  there  is  much  agitation  and  sense 
of  impending  death,  morphia  may  be  given  hypodermically. 


636  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

Pulmonary  Haemorrhage. — This  occurs  in  two  forms — broncho-pulmonary 
hemorrhage,  sometimes  called  bronchorrhagia,  in  which  the  blood  is  poured 
out  into  the  bronchi  and  is  expectorated,  and  pulmonary  apoplexy  or  pneumor- 
rhagia,  in  which  the  haemorrhage  takes  place  into  the  air-cells  and  the  lung 
tissue. 

1.  BRONCHO-PULMONARY  HEMORRHAGE;  HAEMOPTYSIS. — Spitting  of 
blood,  to  which  the  term  haemoptysis  should  be  restricted,  results  from  a 
variety  of  conditions,  among  which  the  following  are  the  most  important :  (a) 
In  young  healthy  persons  haemoptysis  may  occur  without  warning,  and  after 
continuing  for  a  few  days  disappear  and  leave  no  ill  traces.  There  may  be  at 
the  time  of  the  attack  no  physical  signs  indicating  pulmonary  disease.  In 
such  cases  good  health  may  be  preserved  for  years  and  no  further  trouble 
occur.  These  cases  are  not  very  uncommon,  but  in  spite  of  the  good  health 
tuberculosis  may  be  suspected.  In  Ware's  important  contribution  to  this  sub- 
ject, of  386  cases  of  haemoptysis  noted  in  private  practice  62  recovered  and 
pulmonary  disease  did  not  subsequently  develop  in  them.  (&)  Hemoptysis 
in  pulmonary  tuberculosis,  which  is  considered  on  page  194.  (c)  In  con- 
nection with  certain  diseases  of  the  lung,  as  pneumonia  (in  the  initial  stage) 
and  cancer,  occasionally  in  gangrene,  abscess,  and  bronchiectasis.  (d)  In 
many  heart  affections,  particularly  mitral  lesions.  It  may  be  profuse  and 
recur  at  intervals  for  years,  (e)  In  ulcerative  affections  of  the  larynx, 
trachea,  or  bronchi.  Sometimes  the  haemorrhage  is  profuse  and  rapidly  fatal, 
as  when  the  ulcer  erodes  a  large  branch  of  the  pulmonary  artery,  an  accident 
which  I  have  known  to  happen  in  a  case  of  chronic  bronchitis  with  emphy- 
sema, (f)  Aneurism  is  an  occasional  cause  of  haemoptysis.  It  may  be  sudden 
and  rapidly  fatal  when  the  sac  bursts  into  the  air-passages.  Slight  bleeding 
may  continue  for  weeks  or  months,  due  to  pressure  on  the  mucous  membrane 
or  erosion  of  the  lung;  or  in  some  cases  the  sac  "weeps"  through  the  exposed 
laminae  of  fibrin.  (g}  Vicarious  hemorrhage,  which  occurs  in  rare  instances 
in  cases  of  interrupted  menstruation.  The  instances  are  well  authenticated. 
Flint  mentions  a  case  which  he  had  had  under  observation  for  four  years,  and 
Hippocrates  refers  to  it  in  the  aphorism,  "Haemoptysis  in  a  woman  is  removed 
by  an  eruption  of  the  menses."  Periodical  haemoptysis  has  also  been  met  with 
after  the  removal  of  both  ovaries.  Even  fatal  haemorrhage  has  occurred  from 
the  lung  during  menstruation  when  no  lesion  was  found  to  account  for  it. 
(h)  There  is  a  form  of  recurring  hemoptysis  in  arthritic  subjects  to  which 
Sir  Andrew  Clark  has  called  special  attention  and  which  also  is  described  by 
French  writers.  The  cases  occur  in  persons  over  fifty  years  of  age  who  usu- 
ally present  signs  of  the  arthritic  diathesis.  It  rarely  leads  to  fatal  issue  and 
subsides  without  inducing  pulmonary  changes,  (i)  Haemoptysis  occurs  some- 
times in  malignant  fevers  and  in  purpura  hemorrhagica.  Lastly,  there  is 
endemic  haemoptysis,  due  to  the  bronchial  fluke,  an  affection  which  is  confined 
to  parts  of  China  and  Japan. 

Symptoms. — Haemoptysis  sets  in,  as  a  rule,  suddenly.  Often  without  warn- 
ing the  patient  experiences  a  warm,  saltish  taste  as  the  mouth  fills  with  blood. 
Coughing  is  usually  induced.  There  may  be  only  an  ounce  or  so  brought  up 
before  the  haemorrhage  stops,  or  the  bleeding  may  continue  for  days,  the 
patient  bringing  up  small  quantities.  In  other  instances,  particularly  when 
a  large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount  is  large,  and  the 


CIRCULATORY    DISTURBANCES    IN    THE   LUNGS         637 

patient,  after  a  few  attempts  at  coughing,  shows  signs  of  suffocation  and  death 
is  produced  by  inundation  of  the  bronchial  system.  Fatal  hemorrhage  even 
may  occur  into  a  large  cavity  in  a  patient  debilitated  by  phthisis  without  the 
production  of  haemoptysis.  I  dissected  a  case  of  this  kind  at  the  Philadelphia 
Hospital.  The  blood  from  the  lungs  generally  has  characters  which  render 
it  readily  distinguishable  from  the  blood  which  is  vomited.  It  is  alkaline 
in  reaction,  frothy,  and  mixed  with  mucus,  and  when  coagulation  occurs  air- 
bubbles  are  present  in  the  clot.  Blood-moulds  of  the  smaller  bronchi  are 
sometimes  seen.  Patients  can  usually  tell  whether  the  blood  has  been  brought 
up  by  coughing  or  by  vomiting,  and  in  a  majority  of  cases  the  history  gives 
important  indications.  In  paroxysmal  hemoptysis  connected  with  menstrual 
disturbances  the  practitioner  should  see  that  the  blood  is  actually  coughed 
up,  since  deception  may  be  practiced.  The  spurious  hemoptysis  of  hysteria  is 
considered  with  that  disease.  Naturally,  the  patient  is  at  first  alarmed  at  the 
occurrence  of  bleeding,  but,  unless  very  profuse,  as  when  due  to  rupture  of 
an  aortic  aneurism  in  a  pulmonary  cavity,  the  danger  is  rarely  immediate. 
The  attacks,  however,  are  apt  to  recur  for  a  few  days  and  the  sputum 
may  remain  blood-tinged  for  a  longer  period.  In  the  great  majority  of  cases 
the  haemorrhage  ceases  spontaneously.  It  should  be  remembered  that  some 
of  the  blood  may  be  swallowed  and  produce  vomiting,  and,  after  a  day  or 
two,  the  stools  may  be  dark  in  color.  It  is  not  advisable  to  examine  the  chest 
during  an  attack  of  haemoptysis. 

2.  PULMONARY  APOPLEXY;  H^EMORRHAGIC  INFARCT. — In  this  condition 
the  blood  is  effused  into  the  air-cells  and  interstitial  tissue.  It  is  usually 
diffuse,  the  parenchyma  not  being  broken,  as  is  the  brain  tissue  in  cerebral 
apoplexy.  .  Sometimes,  in  disease  of  the  brain,  in  septic  conditions,  and  in 
the  malignant  forms  of  fevers,  the  lung  tissue  is  uniformly  infiltrated  with 
blood  and  has,  on  section,  a  black,  gelatinous  appearance. 

As  a  rule,  the  hemorrhage  is  limited  and  results  from  the  blocking  of 
a  branch  of  the  pulmonary  artery  either  by  a  thrombus  or  an  embolus.  The 
condition  is  most  common  in  chronic  heart-disease.  Although  the  pulmonary 
arteries  are  terminal  ones,  blocking  is  not  always  followed  by  infarction; 
partly  because  the  wide  capillaries  furnish  sufficient  anastomosis,  and  partly 
because  the  bronchial  vessels  may  keep  up  the  circulation.  The  infarctions 
are  chiefly  at  the  periphery  of  the  lung,  usually  wedge-shaped,  with  the  base 
of  the  wedge  toward  the  surface.  When  recent,  they  are  dark  in  color,  hard 
and  firm,  and  look  on  section  like  an  ordinary  blood-clot.  Gradual  changes 
go  on,  and  the  color  becomes  a  reddish  brown.  The  pleura  over  an  infarct 
is  usually  inflamed.  A  microscopic  section  shows  the  air-cells  to  be  distended 
with  red  blood  corpuscles,  which  may  also  be  in  the  alveolar  walls.  The 
infarcts  are  usually  multiple  and  vary  in  size  from  a  walnut  to  an  orange. 
Very  large  ones  may  involve  the  greater  part  of  a  lobe.  In  the  artery  passing 
to  the  affected  territory  a  thrombus  or  an  embolus  is  found.  The  globular 
thrombi,  formed  in  the  right  auricular  appendix,  play  an  important  part  in 
the  production  of  haemorrhagic  infarction.  In  many  cases  the  source  of  the 
embolus  can  not  be  discovered,  and  the  infarct  may  have  resulted  from 
thrombosis  in  the  pulmonary  artery,  but,  as  before  mentioned,  it  is  not  infre- 
quent to  find  total  obstruction  of  a  large  branch  of  a  pulmonary  artery  with- 
out hemorrhage  into  the  corresponding  lung  area.  The  further  history  of  an 


638  DISEASES    OF   THE   RESPIRATORY    SYSTEM 

infarction  is  variable.  It  is  possible  that  in  some  instances  the  circulation  is 
re-established  and  the  blood  removed.  More  commonly,  if  the  patient  lives, 
the  usual  changes  go  on  in  the  extravasated  blood  and  ultimately  a  pigmented, 
puckered,  fibroid  patch  results.  Sloughing  may  occur  with  the  formation  of  a 
cavity.  Occasionally  gangrene  results.  In  a  case  at  the  University  Hospital, 
Philadelphia,  a  gangrenous  infarct  ruptured  and  produced  fatal  pneumo- 
thorax. 

The  symptoms  of  pulmonary  apoplexy  are  by  no  means  definite.  The 
condition  may  be  suspected  in  chronic  heart-disease  when  hemoptysis  occurs, 
particularly  in  mitral  stenosis,  but  the  bleeding  may  be  due  to  the  extreme 
engorgement.  When  the  infarcts  are  very  large,  and  particularly  in  the  lower 
lobe,  in  which  they  most  commonly  occur,  there  may  be  signs  of  consolidation 
with  blowing  breathing  and  a  pleuritic  friction. 

TREATMENT  OF  PULMONARY  HAEMORRHAGE. — The  pressure  within  the 
pulmonary  artery  is  considerably  less  than  that  in  the  aortic  system.  The 
system  is  under  vaso-motor  control,  but  our  knowledge  of  the  mutual  rela- 
tions of  pressure  in  the  aorta  and  in  the  pulmonary  artery,  under  varying 
conditions,  is  still  very  imperfect  (Bradford).  There  may  be  an  influence 
on  the  systemic  blood-pressure  without  any  on  the  pulmonary,  and  the  pres- 
sure in  the  one  may  rise  while  it  falls  in  the  other,  or  it  may  rise  and  fall  in 
both  together.  The  researches  of  Brodie  and  Dixon  indicate  that  drugs  which 
raise  the  peripheral  blood  pressure  by  vaso-constriction  increase  the  total  blood 
in  the  lung.  Thus  ergot,  the  remedy  perhaps  most  commonly  used,  cause?  a 
distinct  rise  in  the  pulmonary  blood-pressure,  while  aconite  produces  a  definite 
fall. 

The  question  is  beset  with  difficulties,  and  experimental  work  is  by  no 
means  in  accord.  In  a  recent  study  Wiggers  concludes  that  in  the  early  stages 
of  haemoptysis,  when  the  breathing  is  not  altered,  lowering  of  the  blood  pres- 
sure within  the  pulmonary  circuit  can  not  be  accomplished  by  the  nitrites,  but 
this  can  only  be  done  with  the  cardiac  depressants,  such  as  chloroform  and 
the  pituitary  extracts;  and  in  the  later  stages  of 'an  attack,  when  the  heart 
is  very  rapid,  pituitary  extract  is  the  only  drug  that  raises  systemic  pressure 
while  simultaneously  lowering  that  in  the  pulmonary  circuit. 

The  anatomical  condition  in  haemoptysis  is  either  hyperaemia  of  the  bron- 
chial mucosa  (or  of  the  lung  tissue)  or  a  perforated  vessel.  In  the  latter  case 
the  patient  often  passes  rapidly  beyond  treatment,  though  there  are  instances 
of  the  most  profuse  haemorrhage,  which  must  have  come  from  a  perforated 
artery  or  a  ruptured  aneurism,  in  which  recovery  has  occurred.  Practically, 
for  treatment,  we  should  separate  these  cases,  as  the  remedies  which  would  be 
applicable  in  the  case  of  congested  and  bleeding  mucosa  would  be  as  much 
out  of  place  in  a  case  of  haemorrhage  from  ruptured  aneurism  as  in  a  cut 
radial  artery.  When  the  blood  is  brought  up  in  large  quantities,  it  is  almost 
certain  either  that  an  aneurism  has  ruptured  or  a  vessel  has  been  eroded.  In 
the  instances  in  which  the  sputum  is  blood  tinged  or  when  the  blood  is  in 
smaller  quantities,  bleeding  comes  by  diapedesis  from  hyperaemic  vessels.  In 
such  cases  the  haemorrhage  may  be  beneficial  in  relieving  the  congested  blood- 
vessels. 

The  indications  are  to  reduce  the  frequency  of  the  heart-beats  and  to  lower 
the  blood-pressure.  The  truth,  Das  Blut  ist  ein  ganz  besonderer  Saft,  is 


CHRONIC    INTERSTITIAL   PNEUMONIA  639 

strikingly  emphasized  by  the  frightened  state  of  the  patient.  Rest  of  the 
body  and  peace  of  the  mind — "quies,  securitas,  silentium"  of  Celsus — should 
be  secured.  If  there  is  marked  restlessness,  morphia  hypodermically  (gr. 
VQ,  0.011  gm.)  is  advisable.  Turn  the  patient  on  the  affected  side,  if  known, 
as  the  regurgitation  is  less  apt  to  occur  into  the  bronchi  of  the  sound  lung.  As 
Aretseus  remarks,  in  haemoptysis  the  patient  despairs  from  the  first,  and  needs 
to  be  strongly  reassured.  Death  is  rarely  due  directly  to  haemoptysis ;  patients 
die  after,  not  of  it  (S.  West).  In  the  majority  of  cases  of  mild  haemoptysis 
this  is  sufficient.  Even  when  the  patient  insists  upon  going  about,  the  bleeding 
may  stop  spontaneously.  The  diet  should  be  light  and  unstimulating.  Alcohol 
should  not  be  used.  The  patient  may,  if  he  wishes,  have  ice  to  suck.  Small 
doses  of  aromatic  sulphuric  acid  may  be  given,  but  unless  the  bleeding  is 
protracted  styptic  and  astringent  medicines  are  not  indicated.  For  cough, 
which  is  always  present  and  disturbing,  opium  should  be  freely  given,  and 
is  of  all  medicines  most  serviceable  in  haemoptysis.  Digitalis  should  not  be 
used,  as  it  raises  the  blood-pressure  in  the  pulmonary  artery.  Aconite,  as  it 
lowers  the  pressure,  may  be  used  when  there  is  much  vascular  excitement. 
Ergot,  tannic  acid,  and  lead,  which  are  so  much  employed,  have  little  or  no 
influence  in  haemoptysis;  ergot  probably  does  harm.  One  of  the  most  satis- 
factory means  of  lowering  the  blood-pressure  is  purgation,  and  when  the  bleed- 
ing is  protracted  salts  may  be  freely  given.  In  profuse  haemoptysis,  such  as 
comes  from  erosion  of  an  artery  or  the  rupture  of  an  aneurism,  a  fatal  result 
is  common,  and  yet  post  mortem  evidence  shows  that  thrombosis  may  occur 
with  healing  in  a  rupture  of  considerable  size.  The  fainting  induced  by  the 
loss  of  blood  is  probably  the  most  efficient  means  of  promoting  thrombosis, 
and  it  was  on  this  principle  that  formerly  patients  were  bled  from  the  arm, 
or  from  both  arms,  as  in  the  case  of  Laurence  Sterne.  Ligatures,  or 
Esmarch's  bandages,  placed  around  the  legs  may  serve  temporarily  to  check 
the  bleeding.  The  ice-bag  on  the  sternum  is  of  doubtful  utility.  In  pro- 
tracted cases  pneumothorax  has  been  induced,  sometimes  with  success. 

Briefly,  then,  we  may  say  that  haemorrhage  from  rupture  of  aneurism  or 
erosion  of  a  blood-vessel  usually  proves  fatal.  The  fainting  induced  by  the 
loss  of  blood  is  beneficial,  and,  if  the  patient  can  be  kept  alive  for  twenty-four 
hours,  a  thrombus  of  sufficient  strength  to  prevent  further  bleeding  may  form. 
The  chief  danger  is  the  inundation  of  the  bronchial  system  with  the  blood,  so 
that  while  the  haemorrhage  is  profuse  the  cough  should  be  encouraged.  Opium 
should  not  then  be  used,  and  stimulants  should  be  given  with  caution. 

In  the  other  group,  in  which  the  haemorrhage  comes  from  a  congested 
area  and  is  limited,  the  patient  gets  well  if  kept  absolutely  quiet,  and  fatal 
haemorrhage  probably  never  occurs  from  this  source.  Rest,  reduction  of  the 
blood-pressure  by  minimum  diet,  purging,  if  necessary,  and  the  administration 
of  opium  to  allay  the  cough  are  the  main  indications. 

II.     CHRONIC    INTERSTITIAL   PNEUMONIA 

(Cirrhosis  of  the  Lung— Fibroid  Phthisis) 

A  fibroid  change  may  have  its  starting  point  in  the  tissue  about  the 
bronchi  and  blood-vessels,  the  interlobular  septa,  the  alveolar  walls,  or  in  the 


640  DISEASES    OF   THE   RESPIRATORY   SYSTEM 

pleura.  So  diverse  are  the  forms  and  so  varied  the  conditions  under  which 
this  change  occurs  that  a  proper  classification  is  extremely  difficult.  We 
may  recognize,  however,  two  chief  forms — the  local,  involving  only  a  limited 
area  of  the  lung  substance,  and  the  diffuse,  invading  either  both  lungs  or  an 
entire  organ. 

Etiology. —  (a)  LOCAL  fibroid  change  in  the  lungs  is  common.  It  is  a 
constant  accompaniment  of  tubercle,  in  the  evolution  of  which  interstitial 
changes  play  a  very  important  role.  In  tumors,  abscess,  gummata,  hydatids, 
and  emphysema  it  also  occurs.  Fibroid  processes  are  frequently  met  with  at 
the  apices  of  the  lung  and  may  be  due  either  to  a  limited  healed  tuberculosis, 
to  fibroid  induration  in  consequence  of  pigment,  or,  in  a  few  instances,  may 
result  from  thickening  of  the  pleura. 

(&)  DIFFUSE  INTERSTITIAL  PNEUMONIA  is  met  with:  (1)  As  a  sequence 
of  acute  fibrinous  pneumonia.  Although  extremely  rare,  this  is  recognized  as 
a  possible  termination.  From  unknown  causes  resolution  fails  to  take  place. 
Organization  goes  on  in  the  fibrinous  plugs  within  the  air-cells  and  the  alveo- 
lar walls  become  greatly  thickened  by  a  new  growth,  first  of  nuclear  and  subse- 
quently of  fibrillated  connective  tissue.  Macroscopically  there  is  produced  a 
smooth,  grayish,  homogeneous  tissue  which  has  the  peculiar  translucency  of  all 
new-formed  connective  tissue.  This  has  been  called  gray  induration.  A 
majority  of  the  cases  terminate  within  a  few  months,  but  instances  which 
have  been  followed  from  the  outset  are  very  rare. 

(2)  Chronic  Broncho-pneumonia. — The  relation  of  broncho-pneumonia  to 
cirrhosis  of.  the  lung  has  been  specially  studied  by  Charcot,  who  states  that  it 
may  follow  the  acute  or  subacute  form  of  this  disease,  particularly  in  children. 
The  fibrosis  extends  from  the  bronchi,  which  are  usually  found  dilated.  Bron- 
chiectasis  itself  may  be  followed  by  fibrosis  of  the  lung.     The  alveolar  walls 
are  thickened  and  the  lobules  converted  into  firm  grayish  masses,  in  which 
there  is  no  trace  of  normal  lung  tissue.    This  process  may  go  on  and  involve 
an  entire  lobe  or  even  the  whole  lung.     Many  of  these  cases  are  tuberculous 
from  the  outset. 

(3)  Pleurogenous  Interstitial  Pneumonia. — Charcot  applies  this  term  to 
that  form  of  cirrhosis  of  the  lung  which  follows  invasion  from  the  pleura. 
Doubt  has  been  expressed  by  some  writers  whether  this  really  occurs.     While 
Wilson  Fox  was  probably  correct  in  questioning  whether  an  entire  lung  can 
become  cirrhosed  by  the  gradual  invasion  from  the  pleura,  there  can  be  no 
doubt  that  there  are  instances  of  primitive  dry  pleurisy,  which,  as  Sir  Andrew 
Clark  has  pointed  out,  gradually  compresses  the  lung  and  at  the  same  time 
leads  to  interstitial  cirrhosis.    This  may  be  due  in  part  to  the  fibroid  change 
which  follows  prolonged  compression.    In  some  cases  there  seems  to  be  a  dis- 
tinct connection  between  the  greatly  thickened  pleura  and  the  dense  strands 
of 'fibrous  tissue  passing  from  it  into  the  lung  substance.     Instances  occur  in 
which  one  lobe  or  the  greater  part  of  it  presents,  on  section,  a  mottled  appear- 
ance, owing  to  the  increased  thickness  of  the  interlobar  septa — a  condition 
which  may  exist  without  a  trace  of  involvement  of  the  pleura.    In  many  other 
cases,  however,  the  extension  seems  to  be  so  definitely  associated  with  pleurisy 
that  there  is  no  doubt  as  to  the  causal  connection  between  the  two  processes. 
In  these  instances  the  lung  is  removed  with  great  difficulty,  owing  to  the 
thickness  and  close  adhesion  of  the  pleura  to  the  chest  wall. 


CHRONIC    INTERSTITIAL   PNEUMONIA  641 

(4)  Chronic  interstitial  pneumonia,  due  to  inhalation  of  dust,  which  is 
considered  in  a  separate  section. 

(5)  Syphilis  of  the  lung  may  present  the  features  of  a  chronic  fibrosis. 

(6)  Indurative  changes  in  the  lung  may  follow  the  compression  by  aneur- 
ism or  new  growth  or  the  irritation  of  a  foreign  body  in  a  bronchus. 

Morbid  Anatomy. — There  are  two  chief  forms,  the  massive  or  lobar  and 
the  insular  or  broncho-pneumonic  form.  In  the  massive  type  the  disease  is 
unilateral ;  the  chest  of  the  affected  side  is  sunken,  deformed,  and  the  shoulder 
much  depressed.  On  opening  the  thorax  the  heart  is  seen  drawn  far  over 
to  the  affected  side.  The  unaffected  lung  is  emphysematous  and  covers  the 
greater  portion  of  the  mediastinum.  It  is  scarcely  credible  in  how  small  a 
space,  close  to  the  spine,  the  cirrhosed  lung  may  lie.  The  adhesions  between 
the  pleural  membranes  may  be  extremely  dense  and  thick,  particularly  in 
the  pleurogenous  cases;  but  when  the  disease  has  originated  in  the  lung 
there  may  be  little  thickening  of  the  pleura.  The  organ  is  airless,  firm, 
and  hard.  It  strongly  resists  cutting,  and  on  section  shows  a  grayish 
fibroid  tissue  of  variable  amount,  through  which  pass  the  blood-vessels  and 
bronchi.  The  latter  may  be  either  slightly  or  enormously  dilated.  There 
are  instances  in  which  the  entire  lung  is  converted  into  a  series  of  bron- 
chiectatic  cavities  and  the  cirrhosis  is  apparent  only  in  certain  areas  or 
at  the  root.  The  tuberculous  cases  can  usually  be  differentiated  by  the 
presence  of  an  apical  cavity,  not  bronchiectatic,  often  large,  and  the  other 
lung  almost  invariably  shows  tuberculous  lesions.  Aneurisms  of  the  pul- 
monary artery  are  not  infrequent  in  the  cavities.  The  other  lung  is  always 
greatly  enlarged  and  emphysematous.  The  heart  is  hypertrophied,  par- 
ticularly the  right  ventricle,  and  there  may  be  marked  atheromatous 
changes  in  the  vessels.  An  amyloid  condition  of  the  viscera  is  found  in  some 
cases. 

In  the  broncho-pneumonic  form  the  areas  are  smaller,  often  centrally 
placed,  and  most  frequently  in  the  lower  lobes.  They  are  deeply  pigmented, 
show  dilated  bronchi,  and  when  multiple  are  separated  by  emphysematous 
lung  tissue. 

A  reticular  form  of  fibrosis  of  the  lung  has  been  described  by  Percy  Kidd 
and  W.  McCollum,  in  which  the  lungs  are  intersected  by  grayish  fibroid 
strands  following  the  lines  of  the  interlobular  septa. 

Symptoms  and  Course. — The  disease  is  essentially  chronic,  extending  over 
a  period  of  many  years,  and  when  once  the  condition  is  established  the  health 
may  be  fairly  good.  In  a  well  marked  case  the  patient  complains  only  of  his 
chronic  cough,  perhaps  a  slight  shortness  of  breath.  In  other  respects  he  is 
quite  well,  and  is  usually  able  to  do  light  work.  The  cases  are  commonly 
regarded  as  phthisical,  though  there  may  be  scarcely  a  symptom  of  that  affec- 
iton  except  the  cough.  There  are  instances,  however,  of  fibroid  phthisis  which 
can  not  be  distinguished  from  cirrhosis  of  the  lung  except  by  the  presence  of 
tubercle  bacilli  in  the  expectoration.  As  the  bronchi  are  usually  dilated,  the 
symptoms  and  physical  signs  may  be  those  of  bronchiectasis.  The  cough  is 
paroxysmal  and  the  expectoration  is  generally  copious  and  of  a  muco-purulent 
or  sero-purulent  nature.  It  is  sometimes  fetid.  Hemorrhage  is  by  no  means 
infrequent,  and  occurred  in  more  than  one-half  of  the  cases  analyzed  by 
Bastian.  Walking  on  the  level  and  in  the  ordinary  affairs  of  life,  the  patient 


642  DISEASES   OP   THE   RESPIRATORY   SYSTEM 

may  show  no  shortness  of  breath,  but  in  the  ascent  of  stairs  and  on  exertion 
there  may  be  dyspnoea. 

PHYSICAL  SIGNS. — Inspection. — The  affected  side  of  the  chest  is  immo- 
bile, retracted,  and  shrunken,  and  contrasts  in  a  striking  way  with  the  volu- 
minous healthy  one.  The  intercostal  spaces  are  obliterated  and  the  ribs  may 
even  overlap.  The  shoulder  is  drawn  down  and  from  behind  it  is  seen  that 
the  spine  is  bowed.  The  muscles  of  the  shoulder-girdle  are  wasted.  The  heart 
is  greatly  displaced,  being  drawn  over  by  the  shrinkage  of  the  lung  to  the 
affected  side.  When  the  left  lung  is  affected  there  may  be  a  large  area  of 
visible  impulse  in  the  second,  third,  and  fourth  interspaces.  Mensuration 
shows  a  great  diminution  in  the  affected  side,  and  with  the  saddle-tape  the 
expansion  niay  be  seen  to  be  negative.  The  percussion  note  varies  with  the 
condition  of  the  bronchi.  It  may  be  absolutely  flat,  particularly  at  the  base 
or  at  the  apex.  In  the  axilla  there  may  be  a  flat  tympany  or  even  an  am- 
phoric note  over  a  large  sacculated  bronchus.  On  the  opposite  side  the  per- 
cussion note  is  usually  hyperresonant.  On  auscultation  the  breath-sounds  have 
either  a  cavernous  or  amphoric  quality  at  the  apex,  and  at  the  base  are  feeble, 
with  mucous,  bubbling  rales.  The  voice-sounds  are  usually  exaggerated. 
Cardiac  murmurs  are  not  uncommon,  particularly  late  in  the  disease,  when 
the  right  heart  fails.  These  are,  of  course,  the  physical  signs  of  the  disease 
when  it  is  well  established.  They  naturally  vary  considerably,  according  to 
the  stage  of  the  process.  The  disease  is  essentially  chronic,  and  may  persist 
for  fifteen  or  twenty  years.  Death  occurs  sometimes  from  hemorrhage,  more 
commonly  from  gradual  failure  of  the  right  heart  with  dropsy,  and  occasion- 
ally from  amyloid  degeneration  of  the  organs. 

Diagnosis. — The  diagnosis  is  never  difficult.  It  may  be  impossible  to  say, 
without  a  clear  history,  whether  the  origin  is  pleuritic  or  pneumonic.  Between 
cases  of  this  kind  and  fibroid  phthisis  it  is  not  always  easy  to  discriminate,  as 
the  conditions  may  be  almost  identical.  When  tuberculosis  is  present,  how- 
ever, even  in  long-standing  cases,  bacilli  are  usually  present  in  the  sputum, 
and  there  may  be  signs  of  disease  in  the  other  lung/ 

Treatment. — It  is  only  for  an  intercurrent  affection  or  for  an  aggravation 
of  the  cough  that  the  patient  seeks  relief.  Nothing  can  be  done  for  the  con- 
dition itself.  When  possible  the  patient  should  live  in  a  mild  climate,  and 
avoid  exposure  to  cold  and  damp.  A  distressing  feature  in  some  cases  is  the 
putrefaction  of  the  contents  of  the  dilated  tubes,  for  which  the  same  measures 
may  be  used  as  in  fetid  bronchitis. 


III.    PNEUMONOKONIOSIS 

Definition. — Under  this  term,  introduced  by  Zenker,  are  embraced  those 
forms  of  fibrosis  of  the  lung  due  to  the  inhalation  of  dusts  in  various  occupa- 
tions. They  have  received  various  names,  according  to  the  nature  of  the  in- 
haled particles — anihracosis,  or  coal-miner's  disease;  siderosis,  due  to  the 
inhalation  of  metallic  dusts,  particularly  iron;  chalicosis  and  silicosis,  due  to 
the  inhalation  of  mineral  dusts,  producing  the  so-called  stone-cutter's  phthisis, 
or  the  "grinder's  rot"  of  the  Sheffield  workers. 

Etiology. — The  dust  particles  inhaled  into  the  lungs  are  dealt  with  exten- 


PNEUMONOKOXIOSIS  643 

Sively  by  the  ciliated  epithelium  and  by  the  phagocytes,  which  exist  normally 
in  the  respiratory  organs.  The  ordinary  mucous  corpuscles  take  in  a  large 
number  of  the  particles,  which  fall  upon  the  trachea  and  main  bronchi.  The 
cilia  sweep  the  mucus  out  to  a  point  from  which  it  can  be  expelled  by  cough- 
ing. It  is  doubtful  if  the  particles  ever  reach  the  air-cells,  but  the  swollen 
alveolar  cells  (in  which  they  are  in  numbers)  probably  pick  them  up  on  the 
way.  The  mucous  and  the  alveolar  cells  are  the  normal  respiratory  scavengers. 
In  dwellers  in  the  country,  in  which  the  air  is  pure,  they  are  able  to  prevent 
the  access  of  dust  particles  to  the  lung  tissue,  so  that  even  in  adults  these 
organs  present  a  rosy  tint,  very  different  from  the  dark,  carbonized  appear- 
ance of  the  lungs  of  dwellers  in  cities.  When  the  impurities  in  the  air  are 
very  abundant,  a  certain  proportion  of  the  dust  particles  escapes  these  cells 
and  penetrates  the  mucosa,  reaching  the  lymph  spaces,  where  they  are  attacked 
at  once  by  the  cells  of  the  connective-tissue  stroma,  which  are  capable  of 
ingesting  and  retaining  a  large  quantity.  In  coal-miners,  coal-heavers,  and 
others  whose  occupations  necessitate  the  constant  breathing  of  a  very  dusty 
atmosphere  even  these  forces  are  insufficient.  Vansteenberghe  and  Grysez 
have  demonstrated  that  pulmonary  anthracosis  may  be  induced  by  passing 
an  emulsion  of  china  ink  into  the  stomach  of  an  animal  through  a  catheter. 
From  a  long  series  of  experiments  they  conclude  that  anthracosis  is  due  to 
the  intestinal  absorption  of  carbon  particles  arrested  in  the  nose  and  pharynx, 
and  then  swallowed.  Their  experiments  further  show  that  both  the  tracheal 
and  intestinal  routes  are  used — through  the  former  the  particles  reach  the 
bronchi  and  external  portions  of  the  alveoli,  through  the  latter  the  parenchyma 
of  the  lung.  Occasionally  in  anthracosis  the  carbon  grains  reach  the  general 
circulation,  and  the  coal  dust  is  found  in  the  liver  and  spleen.  As  Weigert 
has  shown,  this  occurs  when  the  densely  pigmented  bronchial  glands  closely 
adhere  to  the  pulmonary  veins,  through  the  walls  of  which  the  carbon  particles 
pass  to  the  general  circulation.  The  lung  tissue  has  a  remarkable  tolerance 
for  these  particles;  but  by  constant  exposure  a  limit  is  reached,  and  there  is 
brought  about  a  very  definite  pathological  condition,  an  interstitial  sclerosis. 
In  coal-miners  this  may  occur  in  patches,  even  before  the  lung  tissue  is  uni- 
formly infiltrated  with  the  dust.  In  others  it  appears  only  after  the  entire 
organs  have  become  so  laden  that  they  are  dark  in  color,  and  an  ink-like 
juice  flows  from  the  cut  surface.  The  lungs  of  a  miner  may  be  black  through- 
out and  yet  show  no  local  lesions  and  be  everywhere  crepitant. 

Morbid  Anatomy. — The  particles  of  carbon  are  found  deposited  in  large 
numbers  in  the  follicular  cords  of  the  tracheal  and  bronchial  glands  and 
of  the  peri-bronchial  and  peri-arterial  lymph  nodules,  and  in  these  they  finally 
excite  proliferation  of  the  connective  tissue  elements.  It  is  by  no  means  un- 
common to  find  in  persons  whose  lungs  are  only  moderately  carbonized  the 
bronchial  glands  sclerosed  and  hard.  In  anthracosis  the  fibroid  changes  usu- 
ally begin  in  the  peri-bronchial  lymph  tissue,  and  in  the  enrly  stage  of  the 
process  the  sclerosis  may  be  largely  confined  to  these  regions.  A  Nova  Scotian 
miner,  aged  thirty-six,  died  under  my  care,  at  the  Montreal  General  Hospital, 
of  black  small-pox,  after  an  illness  of  a  few  days.  In  his  lungs  (externally 
coal-black)  there  were  round  and  linear  patches  ranging  in  size  from  a  pea 
to  a  hazel-nut,  of  an  intensely  black  color,  airless  and  firm,  and  surrounded 
by  a  crepitant'tissue,  slate  gray  in  color.  In  the  centre  of  each  of  these  areas 


644  DISEASES    OF   THE    RESPIRATORY    SYSTEM 

was  a  small  bronchus.  Many  of  them  were  situated  just  beneath  the  pleura, 
and  formed  typical  examples  of  limited  fibroid  broncho-pneumonia.  In 
addition  there  is  usually  thickening  of  the  alveolar  walls,  particularly 
in  certain  areas.  By  the  gradual  coalescence  of  these  fibroid  patches 
large  portions  of  the  lung  may  be  converted  into  firm  areas  of  cirrho- 
sis, grayish  black  in  the  case  of  the  coal-miner,  steel  gray  in  the  case 
of  the  stone-worker.  In  the  case  of  a  Cornish  miner,  aged  sixty-three,  who 
died  under  my  care,  one  of  these  fibroid  areas  measured  18  by  6  cm.  and  4.5 
cm.  in  depth. 

A  second  important  factor  in  these  cases  is  chronic  bronchitis,  which  is 
present  in  a  large  proportion  and  really  causes  the  chief  symptoms.  A  third 
is  the  occurrence  of  emphysema,  which  is  almost  invariably  associated  with 
long-standing  cases  of  pneumonokoniosis.  With  the  changes  so  far  described, 
unless  the  cirrhotic  area  is  unusually  extensive,  the  case  may  present  the 
features  of  chronic  bronchitis  with  emphysema,  but  finally  another  element 
comes  into  play.  In  the  fibroid  areas  softening  occurs,  probably  a  process  of 
necrosis  similar  to  that  by  which  softening  is  produced  in  fibro-myomata  of 
the  uterus.  At  first  these  are  small  and  contain  a  dark  liquid.  Charcot  calls 
them  ulcer es  du  poumon.  They  rarely  attain  a  large  size  unless  a  communica- 
tion is  formed  with  the  bronchus,  in  which  case  they  may  become  converted 
into  suppurating  cavities. 

Anthracosis  and  Tuberculosis. — In  the  Pennsylvania  anthracite  district 
tuberculosis  is  relatively  less  common  among  the  miners,  the  figures  for 
ten  years  at  Scranton  for  male  adults  being  3.37  per  cent,  in  mine  workers, 
9.97  per  cent,  in  those  of  other  occupations  (Wainwright).  Goldman  in 
Germany,  Oliver  and  Trotter  in  England,  all  agree  upon  the  comparative 
rarity  of  tuberculosis  among  coal  miners.  Though  this  may  be  attributed  in 
part  to  the  improved  ventilation  of  the  mines,  it  has  also  probably  something 
to  do  with  the  less  favorable  soil  offered  to  the  bacilli  in  a  lung  infiltrated  with 
coal  dust. 

The  siderosis  induced  by  the  oxide  of  iron  causes'  an  interstitial  pneumonia 
similar  to  anthracosis.  Workers  in  brass  and  in  bronze  are  liable  to  a  like 
affection. 

Chalicosis  and  silicosis,  due  to  the  deposit  of  particles  of  silex  and 
alumina,  are  found  in  the  makers  of  mill-stones,  particularly  the  French  mill- 
stones, and  also  in  knife  and  axe  grinders  and  stone-cutters.  It  prevails 
extensively  among  the  Rand  miners  of  South  Africa  (gold-miners'  phthisis), 
and  in  the  workers  of  the  Australian  and  Tasmanian  mines.  Anatomically, 
this  form  is  characterized  by  the  production  of  nodules  of  various  sizes,  which 
are  cut  with  the  greatest  difficulty  and  sometimes  present  a  curious  grayish, 
even  glittering,  crystalloid  appearance. 

Workers  in  flax  and  in  cotton,  and  grain-shovellers  are  also  subject  to 
these  chronic  interstitial  changes  in  the  lungs. 

Symptoms.— The  symptoms  do  not  come  on  until  the  patient  has  worked 
for  a  variable  number  of  years  in  the  dusty  atmosphere.  As  a  rule  there  are 
cough  and  failing  health  for  a  prolonged  period  of  time  before-  complete  disa- 
bility. The  coincident  emphysema  is  responsible  in  great  part  for  the  short- 
ness of  breath  and  wheezy  condition  of  these  patients.  The  expectoration  is 
usually  muco-purulent,  often  profuse,  and  in  anthracosis  very  dark  in  color — 


EMPHYSEMA  645 

the  so-called  "black  spit,"  while  in  chalicosis  there  may  be  seen  under  the 
microscope  the  bright  angular  particles  of  silica. 

Even  when  there  are  physical  signs  of  cavity,  tubercle  bacilli  are  not  neces- 
sarily, and  indeed  in  my  experience  are  not  usually  present.  It  is  remarkable 
for  how  long  a  time  a  coal-miner  may  continue  to  bring  up  sputum  laden  with 
coal  particles  even  when  there  are  signs  only  of  a  chronic  bronchitis.  Many 
of  the  particles  are  contained  in  the  cells  of  the  alveolar  epithelium.  In  these 
instances  it  appears  that  an  attempt  is  made  by  the  leucocytes  to  rid  the  lungs 
of  some  of  the  carbon  grains. 

Diagnosis.— The  diagnosis  of  the  condition  is  rarely  difficult ;  the  expecto- 
ration is  usually  characteristic.  It  must  always  be  borne  in  mind  that  chronic 
bronchitis  and  emphysema  form  essential  parts  of  the  process  and  that  in  late 
stages  there  may  be  tuberculous  infection. 

Prophylaxis. — Much  has  been  done  to  reduce  the  prevalence  of  the  disease 
in  England  by  proper  ventilation  of  works  and  the  protection  of  the  men. 
The  conversion  of  dry  into  wet  mining  prevents  the  distribution  of  the  injuri- 
ous dust. 

Treatment. — The  treatment  of  the  condition  is  practically  that  of  chronic 
bronchitis  and  emphysema. 

IV.    EMPHYSEMA 

Definition. — The  condition  in  which  the  infundibular  passages  and  the 
alveoli  are  dilated  and  the  alveolar  walls  atrophied. 

Floyer  of  Litchfield  first  described  the  anatomical  condition  and  spoke 
of  the  disease  as  "fla'tulent  asthma"  (1698),  meaning  a  disorder  in  which 
the  lungs  were  blown  up  with  air. 

A  practical  division  may  be  made  into  compensatory,  hypertrophic,  and 
atrophic  forms,  the  acute  vesicular  emphysema,  and  the  interstitial  forms. 
The  last  two  do  not  in  reality  come  under  the  above  definition,  but  for  con- 
venience they  may  be  considered  here. 

1.    COMPENSATOBY   EMPHYSEMA 

Whenever  a  region  of  the  lung  does  not  expand  fully  in  inspiration,  either 
another  portion  of  the  lung  must  expand  or  the  chest  wall  sink  in  order  to 
occupy  the  space.  The  former  almost  invariably  occurs.  We  have  already 
mentioned  that  in  broncho-pneumonia  there  is  a  vicarious  distention  of  the 
air-vesicles  in  the  adjacent  healthy  lobules,  and  the  same  happens  in  the 
neighborhood  of  tuberculous  areas  and  cicatrices.  In  general  pleural  adhe- 
sions there  is  often  compensatory  emphysema,  particularly  at  the  anterior 
margins  of  the  lung.  The  most  advanced  example  of  this  form  is  seen  in 
cirrhosis,  when  the  unaffected  lung  increases  greatly  in  size,  owing  to  disten- 
tion of  the  air-vesicles.  A  similar  though  less  marked  condition  is  seen  in 
extensive  pleurisy  with  effusion  and  in  pneumothorax. 

At  first,  this  distention  of  the  air-vesicles  is  a  simple  physiological  process 
and  the  alveolar  walls  are  stretched  but  not  atrophied.  Ultimately,  however, 
in  many  cases  they  waste  and  the  contiguous  air-cells  fuse,  producing  true 
emphysema. 


C4C  DISEASES   OF   THE   RESPIRATORY   SYSTEM 

2.     HYPERTEOPHIC    EMPHYSEMA 

The  large-lunged  emphysema  of  Jenner,  also  known  as  substantive  or 
idiopathic  emphysema,  is  a  well-marked  clinical  affection,  characterized  by 
enlargement  of  the  lungs,  due  to  distention  of  the  air-cells  and  atrophy  of 
their  walls,  and  clinically  by  imperfect  aeration  of  the  blood  and  more  or  less 
marked  dyspnoea. 

Etiology. — Emphysema  is  the  result  of  persistently  high  intra-alveolar 
tension  acting  upon  a  congenitally  weak  lung  tissue.  Strongly  in  favor  of 
the  view  that  the  nutritive  change  in  the  air-cells  is  the  primary  factor  are  the 
markedly  hereditary  character  of  the  disease  and  the  frequency  with  which  it 
starts  early  in  life.  To  James  Jackson,  Jr.,  of  Boston,  we  owe  the  first 
observations  on  the  hereditary  character  of  emphysema.  "Working  under 
Louis'  direction,  he  found  that  in  18  out  of  28  cases  one  or  both  parents  were 
affected. 

In  childhood  it  may  follow  recurring  asthmatic  attacks  due  to  adenoid 
vegetations.  It  may  occur,  too,  in  several  members  of  the  same  family.  We 
are  still  ignorant  as  to  the  nature  of  this  congenital  pulmonary  weakness. 
Cohnheim  thinks  it  probably  due  to  a  defect  in  the  development  of  the  elastic- 
tissue  fibres — a  statement  which  is  borne  out  by  Eppinger's  observations. 

Heightened  pressure  within  the  air-cells  may  be  due  to  forcible  inspira- 
tion or  expiration.  Much  discussion  has  taken  place  as  to  the  part  played  by 
these  two  acts  in  the  production  of  the  disease.  The  inspiratory  theory  was 
advanced  by  Laennec  and  subsequently  modified  by  Gairdner,  who  held  that 
in  chronic  bronchitis  areas  of  collapse  were  induced,  and  compensatory  dis- 
tention took  place  in  the  adjacent  lobules.  This  unquestionably  does  occur 
in  the  vicarious  or  compensatory  emphysema,  hut  it  probably  is  not  a  factor 
of  much  moment  in  the  form  now  under  consideration.  The  expiratory  the- 
ory, which  was  supported  by  Mendelssohn  and  Jenner,  accounts  for  the  con- 
dition in  a  much  more  satisfactory  way.  In  all  straining  efforts  and  violent 
attacks  of  coughing  the  glottis  is  closed  and  the  '  chest  walls  are  strongly 
compressed  by  muscular  efforts,  so  that  the  strain  is  thrown  upon  those  parts 
of  the  lung  least  protected,  as  the  apices  and  the  anterior  margins,  in  which 
we  always  find  the  emphysema  most  advanced.  The  sternum  and  costal 
cartilages  gradually  yield  to  the  heightened  intrathoracic  pressure  and  are, 
in  advanced  cases,  pushed  forward,  giving  the  characteristic  rotundity  to  the 
thorax. 

FREUND'S  THEORY. — A  primary  disease  of  the  costal  cartilages — a  chronic 
hyperplasia  with  premature  ossification  is  believed  to  bring  about  gradually 
a  state  of  rigid  dilatation  of  the  chest,  to  which  the  emphysema  is  secondary. 
Recent  observations  make  it  probable  that  there  is  a  group  of  cases  in  which 
such  changes  occur  in  young  persons,  particularly  in  the  cartilages  of  the  first 
three  ribs.  Niemeyer  says  that  he  had  met  with  a  few  such  cases,  and  there 
have  been  reported  recently  instances  in  which  the  cartilages  increased  in  size 
and  stood  out  prominently.  For  such  a  condition  what  is  now  called  Freund's 
operation  (of  resection)  would  be  indicated.  . 

Of  other  etiological  factors  occupation  is  the  most  important.  The  dis- 
ease is  met  with  in  players  on  wind  instruments,  in  glass-blowers,  and  in 
occupations  necessitating  heavy  lifting  or-  straining.  Whooping-cough  and 


EMPHYSEMA  647 

bronchitis  play  an  important  role,  not  so  much  in  the  changes  which  they 
induce  in  the  bronchi  as  in  consequence  of  the  prolonged  attacks  of  coughing. 

Morbid  Anatomy.— The  thorax  is  capacious,  usually  barrel-shaped,  and  the 
cartilages  are  calcified.  On  removal  of  the  sternum,  the  anterior  medias- 
tinum is  found  completely  occupied  by  the  margins  of  the  lungs,  and  the 
pericardial  sac  may  not  be  visible.  The  organs  are  very  large  and  have  lost 
their  elasticity,  so  that  they  do  not  collapse  either  in  the  thorax  or  when  placed 
on  the  table.  The  pleura  is  pale  and  there  is  often  an  absence  of  pigment, 
sometimes  in  patches,  termed  by  Virchow  albinism  of  the  lung.  To  the  touch 
they  have  a  peculiar,  downy,  feathery  feel,  and  pit  readily  on  pressure.  This 
is  one  of  the  most  marked  features.  Beneath  the  pleura  greatly  enlarged  air- 
vesicles  may  be  readily  seen.  They  vary  in  size  from  .5  to  3  mm.,  and  irregu- 
lar bulls,  the  size  of  a  walnut  or  larger,  may  project  from  the  free  margins. 
The  best  idea  of  the  extreme  rarefaction  of  the  tissue  is  obtained  from  sec- 
tions of  a  lung  distended  and  dried.  At  the  anterior  margins  the  structure 
may  form  an  irregular  series  of  air-chambers,  resembling  the  frog's  lung.  On 
Careful  inspection  with  the  hand-lens,  remnants  of  the  interlobular  septa  or 
evt^  of  the  alveoli  may  be  seen  on  these  large  emphysematous  vesicles. 
Thou^  general,  the  distention  is  more  marked,  as  a  rule,  at  the  anterior 
margins,  cnA  is  often  specially  marked  at  the  inner  surface  of  the  lobe  near 
the  root,  wht'.'e  in  extreme  cases  air-spaces  as  large  as  a  hen's  egg  may  some- 
times be  found.  Microscopically  there  is  seen  atrophy  of  the  alveolar  walls, 
by  which  is  produced  a  coalescence  of  neighboring  air-cells.  In  this  process 
the  capillary  network  disappears  before  the  walls  are  completely  atrophied. 
The  loss  of  the  elastic  tissue  is  a  special  feature.  It  is  stated,  indeed,  that  in 
certain  cases  there  is  a  congenital  defect  in  the  development  of  this  tissue. 
The  epithelium  of  the  air-cells  undergoes  a  fatty  change,  but  the  large  dis- 
tended air-spaces  retain  a  pavement  layer. 

The  bronchi  show  important  changes.  In  the  larger  tubes  the  mucous 
membrane  may  be  rough  and  thickened  from  chronic  bronchitis;  often  the 
longitudinal  lines  of  submucous  elastic  tissue  stand  ouf  prominently.  In  the 
advanced  cases  many  of  the  smaller  tubes  are  dilated,  particularly  when, 
in  addition  to  emphysema,  there  are  peri-bronchial  fibvoid  changes.  Bron- 
chiectasis  is  not,  however,  an  invariable  accompaniment  of  emphysema,  but, 
as  Laennec  remarks,  it  is  difficult  to  understand  why  it  is  not  more  common. 
Of  associated  morbid  changes  the  most  important  are  found  in  the  heart. 
The  right  chambers  are  dilated  and  hypertrophied,  the  tricuspid  orifice  is 
large,  and  the  valve  segments  are  often  thickened  at  the  edges.  In  advanced 
cases  the  cardiac  hypertrophy  is  general.  The  pulmonary  artery  and  itp 
branches  may  be  wide  and  show  marked  atheromatous  changes. 

The  changes  in  the  other  organs  are  those  commonly  associated  with  pro- 
longed venous  congestion.  Pneumothorax  may  follow  the  rupture  of  an  em- 
physematous bleb. 

Symptoms. — The  disease  may  be  tolerably  advanced  before  any  special 
symptoms  occur.  A  child,  for  instance,  may  be  somewhat  short  of  breath  on 
going  up-stairs  or  may  be  unable  to  run  and  play  as  other  children  without 
great  discomfort ;  or,  perhaps,  has  attacks  of  slight  lividity.  Doubtless  much 
depends  upon  the  completeness  of  cardiac  compensation.  When  this  is  per- 
fect, there  may  be  no  special  interruption  of  the  pulmonary  circulation  and, 


648  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

except  with  violent  exertion,  there  is  no  interference  with  the  aeration  of  the 
blood.  In  well-marked  cases  the  following  are  the  most  important  symptoms : 
Dyspnaa,  which  may  be  felt  only  on  slight  exertion,  or  may  be  persistent,  and 
aggravated  by  intercurrent  attacks  of  bronchitis.  The  respirations  are  often 
harsh  and  wheezy,  and  expiration  is  distinctly  prolonged. 

Cyanosis  of  an  extreme  grade  is  more  common  in  emphysema  than  in 
other  affections  with  the  exception  of  congenital  heart-disease.  So  far  as  I 
know  it  is  the  only  disease  in  which  a  patient  may  be  able  to  go  about  and 
even  to  walk  into  the  hospital  or  consulting-room  with  a  lividity  of  startling 
intensity.  The  contrast  between  the  extreme  cyanosis  and  the  comparative 
comfort  of  the  patient  is  very  striking.  In  other  affections  of  the  heart  and 
lungs  associated  with  a  similar  degree  of  cyanosis  the  patient  is  invariably  in 
bed  and  usually  in  a  state  of  orthopncea.  One  condition  must  be  here  referred 
to,  viz.,  the  extraordinary  cyanosis  in  cases  of  poisoning  by  aniline  products, 
which  is  in  most  part  due  to  the  conversion  of  the  hemoglobin  into  methasmo- 
globin. 

Bronchitis  with  associated  cough  is  a  frequent  symptom  and  often  the 
direct  cause  of  the  pulmonary  distress.  The  contrast  between  emphysematous 
patients  in  the  winter  and  summer  is  marked  in  this  respect.  In  the  latter 
they  may  be  comfortable  and  able  to  attend  to  their  work,  but  with  the  cold 
and  changeable  weather  they  are  laid  up  with  attacks  of  bronchitis.  Finally, 
in  fact,  the  two  conditions  become  inseparable  and  the  patient  has  persistently 
more  or  less  cough.  The  acute  bronchitis  may  produce  attacks  not  unlike 
asthma.  In  some  instances  this  is  true  spasmodic  asthma,  with  which  emphy- 
sema is  frequently  associated. 

As  age  advances,  and  with  successive  attacks  of  bronchitis,  the  condition 
grows  slowly  worse.  In  hospital  practice  it  is  common  to  admit  patients  over 
sixty  with  well  marked  signs  of  advanced  emphysema.  The  affection  can 
generally  be  told  at  a  glance — the  rounded  shoulders,  barrel  chest,  the  thin 
yet  oftentimes  muscular  form,  and  sometimes,  I  think,  a  very  characteristic 
facial  expression. 

There  is  another  group  of  younger  patients  from  twenty-five  to  forty  years 
of  age  who,  winter  after  winter,  have  attacks  of  intense  cyanosis  in  conse- 
quence of  an  aggravated  bronchial  catarrh.  On  inquiry  we  find  that  these 
patients  have  been  short-breathed  from  infancy,  and  they  belong  to  a  category 
in  which  there  has  been  a  primary  defect  of  structure  in  the  lung  tissue. 

PHYSICAL  SIGNS. — Inspection. — The  thorax  is  markedly  altered  in  shape ; 
the  antero-posterior  diameter  is  increased  and  may  be  even  greater  than  trie- 
lateral,  so  that  the  chest  is  barrel-shaped.  The  appearance  is  somewhat  as  if 
the  chest  was  in  a  permanent  inspiratory  position.  The  sternum  and  costal 
cartilages  are  prominent.  The  lower  zone  of  the  thorax  looks  large  and  the 
intercostal  spaces  are  much  widened,  particularly  in  the  hypochondriac 
regions.  The  sternal  fossa  is  deep,  the  clavicles  stand  out  with  great  promi- 
nence, and  the  neck  looks  shortened  from  the  elevation  of  the  thorax  and  the 
sternum.  A  zone  of  dilated  venules  may  be  seen  along  the  line  of  attachment 
of  trie  diaphragm.  Though  this  is  common  in  emphysema,  it  is  by  no  means 
peculiar  to  it  or  indeed  to  any  special  affection. 

The  curve  of  the  spine  is  increased  and  the  back  is  remarkably  rounded, 
so  that  the  scapula  seem  to  be  almost  horizontal.  Mensuration  shows  the 


EMPHYSEMA  649 

rounded  form  of  the  chest  and  the  very  slight  expansion  on  deep  inspiration. 
The  respiratory  movements,  which  may  look  energetic  and  forcible,  exercise 
little  or  no  influence.  The  chest  does  not  expand,  but  there  is  a  general  ele- 
vation. The  inspiratory  effort  is  short  and  quick;  the  expiratory  movement 
is  prolonged.  There  may  be  retraction  instead  of  distention  in  the  upper 
abdominal  region  during  inspiration,  and  there  is  sometimes  seen  a  transverse 
curve  crossing  the  abdomen  at  the  level  of  the  twelfth  rib.  The  apex  beat  of 
the  heart  is  not  visible,  and  there  is  usually  marked  pulsation  in  the  epigastric 
region.  The  cervical  veins  stand  out  prominently  and  may  pulsate. 

Palpation. — The  vocal  fremitus  is  somewhat  enfeebled  but  not  lost.  The 
apex  beat  can  rarely  be  felt.  There  is  a  marked  shock  in  the  lower  sternal 
region  and  very  distinct  pulsation  in  the  epigastrium.  Percussion  gives 
greatly  increased  resonance,  full  and  drum-like — what  is  sometimes  called 
hyperresonance.  The  note  is  not  often  distinctly  tympanitic  in  quality.  The 
percussion  note  is  greatly  extended,  the  heart  dulness  may  be  obliterated,  the 
upper  limit  of  liver  dulness  is  greatly  lowered,  and  the  resonance  may  extend 
to  the  costal  margin.  Behind,  a  clear  percussion  note  extends  to  a  much  lower 
level  than  normal.  The  level  of  splenic  dulness,  too,  may  be  lowered. 

On  auscultation  the  breath-sounds  are  usually  enfeebled  and  may  be 
masked  by  bronchitic  rales.  The  most  characteristic  feature  is  the  prolonga- 
tion of  the  expiration,  and  the  normal  ratio  may  be  reversed — 4  to  1  instead  of 
1  to  4.  It  is  often  ^rheezy  and  harsh  and  associated  with  coarse  rales  and 
sibilant  rhonchi.  It  is  said  that  in  interstitial  emphysema  there  may  be  a 
friction  sound  heard,  not  unlike  that  of  pleurisy.  The  heart-sounds  are  usu- 
ally feeble  but  clear;  in  advanced  cases,  when  there  is  marked  cyanosis,  a 
tricuspid  regurgitant  murmur  may  be  heard.  Accentuation  of  the  pulmonary 
second  sound  may  be  present. 

Course. — The  course  of  the  disease  is  slow  but  progressive,  the  recurring- 
attacks  of  bronchitis  aggravating  the  condition.  Death  may  occur  from  inter- 
current  pneumonia,  either  lobar  or  lobular,  and  dropsy  may  supervene  from 
cardiac  failure.  Occasionally  death  results  from  overdistention  of  the  heart, 
with  extreme  cyanosis.  Duckworth  has  called  attention  to  the  occasional 
occurrence  of  fatal  hemorrhage  in  emphysema.  In  an  old  emphysematous 
patient  at  the  Montreal  General  Hospital  death  followed  the  erosion  of  a  main 
branch  of  the  pulmonary  artery  by  an  ulcer  near  the  bifurcation  of  the 

trachea. 

Treatment.— Practically,  the  measures  mentioned  in  connection  with 
bronchitis  should  be  employed.  In  children  with  asthma  and  emphysema  the 
nose  should  be  carefully  examined.  No  remedy  is  known  which  has  any  influ- 
ence over  the  progress  of  the  condition  itself.  Bronchitis  is  the  great  danger 
of  these  patients,  and  therefore  when  possible  they  should  live  in  an  equable 
climate  They  do  well  in  southern  California  and  in  Egypt.  In  consequence 
of  the  venous  engorgement  they  are  liable  to  gastric  and  intestinal  disturbance 
and  it  is  particularly  important  to  keep  the  bowels  regulated  and  to  avoid 
flatulency,  which  often  seriously  aggravates  the  dyspnoea.  Patients  who  come 
into  the  hospital  in  a  state  of  urgent  dyspnoea  and  lividity,  with  great  en- 
gorgement of  the  veins,  particularly  if  they  are  young  and  vigorous  should 
be  bled  freely.  Inhalation  of  oxygen  may  be  used.  Strychnine  will  be  found 
specially  useful,  and  breathing  exercises  are  sometimes  helpful.  Breathing 
43 


650  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

of  compressed  air  in  a  pneumatic  cabinet  gives  temporary  relief.  Resection 
of  the  first  costal  cartilage  or  of  the  first  three  cartilages  on  either  side  has 
been  practiced  (Freund's  operation).  It  is  not  likely  to  be  of  any  benefit  in 
the  aged  in  whom  the  condition  is  established,  but  in  a  special  group  in  the 
young  in  which  the  primary  trouble  appears  to  be  in  the  cartilages — what  has 
been  called  Freund's  Disease — the  operation  may  be  practiced  and  good  results 
have  followed. 

3.     ATEOPHIC    EMPHYSEMA 

A  senile  change,  called  by  Sir  William  Jenner  small-lunged  emphysema,  is 
really  a  primary  atrophy  of  the  lung,  coming  on  in  advanced  life,  and  scarcely 
constitutes  a  special  affection.  It  occurs  in  "withered-looking  old  persons" 
who  may  perhaps  have  had  a  winter  cough  and  shortness  of  breath  for  years. 
In  striking  contrast  to  the  essential  hypertrophic  emphysema,  the  chest  is 
small  and  the  ribs  obliquely  placed.  The  thoracic  muscles  are  usually  atro- 
phied. The  lung  presents  a  remarkable  appearance,  being  converted  into  a 
series  of  large  vesicles,  on  the  walls  of  which  the  remnants  of  air-cells  may 
be  seen. 

4.     ACUTE    VESICULAE   EMPHYSEMA 

When  death  occurs  from  bronchitis  of  the  smaller  tubes,  when  strong 
inspiratory  efforts  have  been  made,  the  lungs  are  large  in  volume  and  the  air- 
cells  are  much  distended.  Clinically,  this  condition  may  occur  rapidly  in 
cases  of  cardiac  asthma  and  angina  pectoris.  The  area  of  pulmonary  reso- 
nance is  much  increased,  and  on  auscultation  there  are  heard  everywhere 
piping  rales  and  prolonged  expiration.  A  similar  condition  may  follow  pres- 
sure on  the  vagi. 

5.     INTERSTITIAL    EMPHYSEMA 

Beads  of  air  are  seen  in  the  interlobular  and  subpleural  tissue,  sometimes 
forming  large  bullas  beneath  the  pleura.  A  rare  event  is  rupture  close  to  the 
root  of  the  lung,  and  the  passage  of  air  along  the  trachea  into  the  subcuta- 
neous tissues  of  the  neck.  After  tracheotomy  just  the  reverse  may  occur  and 
the  air  may  pass  from  the  tracheotomy  wound  along  the  windpipe  and  bronchi 
and  appear  beneath  the  surface  of  the  pleura.  From  this  interstitial  emphy- 
sema spontaneous  pneumothorax  may  arise  in  healthy  persons. 


V.     GANGRENE   OF   THE   LUNG 

Etiology. — Gangrene  of  the  lung  is  not  an  affection  per  se,  but  occurs  in 
a  variety  of  conditions  when  necrotic  areas  undergo  putrefaction.  It  is  not 
easy  to  say  why  sphacelus  should  occur  in  one  case  and  not  in  another,  as 
the  germs  of  putrefaction  are  always  in  the  air-passages,  and  yet  necrotic 
territories  rarely  become  gangrenous.  Total  obstruction  of  a  pulmonary 
artery,  as  a  rule,  causes  infarction,  and  the  area  shut  off  does  not  often,  though 
it  may,  sphacelate.  Another  factor  would  seem  to  be  necessary — probably  a 
lowered  tissue  resistance,  the  result  of  general  or  local  causes.  It  is  met 
with  (1)  as  a  sequence  of  lobar  pneumonia.  This  rarely  occurs  in  a  previously 


GANGBENE    OF   THE   LUNG  651 

healthy  person— more  commonly  in  the  debilitated  or  in  the  diabetic  subject. 
(2)  Gangrene  is  very  prone  to  follow  the  aspiration  pneumonia,  since  the 
foreign  particles  rapidly  undergo  putrefactive  changes.  Of  a  similar  nature 
are  the  cases  of  gangrene  due  to  perforation  of  cancer  of  the  oesophagus  into 
the  lung  or  into  the  bronchus.  (3)  The  putrid  contents  of  a  bronchiectatic, 
more  commonly  of  a  tuberculous,  cavity  may  excite  gangrene  in  the  neighbor- 
ing tissues.  The  pressure  bronchiectasis  following  aneurism  or  tumor  may 
lead  to  extensive  sloughing.  (4)  Gangrene  may  follow  simple  embolism  of 
the  pulmonary  artery.  More  commonly,  however,  the  embolus  is  derived  from 
a  part  which  is  mortified  or  comes  from  a  focus  of  bone  disease.  In  typhus 
and  in  typhoid  fever  gangrene  of  the  lung  may  follow  thrombosis  of  one  of 
the  larger  branches  of  the  pulmonary  artery.  A  case  occurred  in  my  wards 
in  October,  1897,  in  connection  with  a  typhoid  septicaemia.  Typhoid  bacilli 
were  isolated  from  the  lung.  Lastly,  gangrene  of  the  lung  may  occur  in  con- 
ditions of  debility  during  convalescence  from  protracted  fever — occasionally, 
indeed,  without  our  being  able  to  assign  any  reasonable  cause. 

Morbid  Anatomy. — Laennec,  who  first  accurately  described  pulmonary 
gangrene,  recognized  a  diffuse  and  a  circumscribed  form.  The  former,  though 
rare,  is  sometimes  seen  in  connection  with  pneumonia,  more  rarely  after 
obliteration  of  a  large  branch  of  the  pulmonary  artery.  It  may  involve  the 
greater  part  of  a  lobe,  and  the  lung  tissue  is  converted  into  a  horribly  offensive 
greenish-black  mass,  torn  and  ragged  in  the  centre.  In  the  circumscribed 
form  there  is  well-marked  limitation  between  the  gangrenous  area  and  the 
surrounding  tissue.  The  focus  may  be  single  or  there  may  be  two  or  more. 
The  lower  lobe  is  more  commonly  affected  than  the  upper,  and  the  peripheral 
more  than  the  central  portion  of  the  lung.  A  gangrenous  area  is  at  first 
uniformly  greenish  brown  in  color;  but  softening  rapidly  takes  place  with 
the  formation  of  a  cavity  with  shreddy,  irregular  walls  and  a  greenish, 
offensive  fluid.  The  lung  tissue  in  the  immediate  neighborhood  shows  a  zone 
of  deep  congestion,  often  consolidation,  and  outside  this  an  intense  oedema. 
In  the  embolic  cases  the  plugged  artery  can  sometimes  be  found.  When  rap- 
idly extending,  vessels  may  be  opened  and  a  copious  haemorrhage  ensue.  Per- 
foration of  the  pleura  is  not  uncommon.  The  irritating  decomposing  material 
usually  excites  the  most  intense  bronchitis.  Embolic  processes  are  not  infre- 
quent. There  is  a  remarkable  association  in  some  cases  between  circumscribed 
gangrene  of  the  lung  and  abscess  of  the  brain.  It  has  been  referred  to  under 
the  section  on  bronchiectasis. 

Symptoms  and  Course.— Usually  definite  symptoms  of  local  pulmonary 
disease  precede  the  characteristic  features  of  gangrene.  These,  of  course,  are 
very  varied,  depending  on  the  nature  of  the  trouble.  The  sputum  is  very  char- 
acteristic. It  is  intensely  fetid — usually  profuse — and,  if  expectorated  into 
a  conical  glass,  separates  into  three  layers— a  greenish  brown,  heavy  sediment; 
an  intervening  thin  liquid,  which  sometimes  has  a  greenish  or  a  brownish  tint ; 
and,  on  top,  a  thick,  frothy  layer.  Spread  on  a  glass  plate,  the  shreddy  debris 
of  lung  tissue  can  readily  be  picked  out.  Even  large  fragments  of  lung  may 
be  coughed  up.  Robertson,  of  Onancock,  Va.,  sent  me  one  several  centimetres 
in  length,  which  had  been  expectorated  by  a  lad  of  eighteen,  who  had  severe 
gangrene  and  recovered.  Microscopically,  elastic  fibres  are  found  m  abun- 
dance, with  granular  matter,  pigment  grains,  fatty  crystals,  bacteria,  and 


052  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

leptothrix.  It  is  stated  that  elastic  tissue  is  sometimes  absent,  but  I  have 
never  met  with  such  an  instance.  The  peculiar  plugs  of  sputum  which  occur 
in  bronchiectasis  are  not  found.  Blood  is  often  present,  and,  as  a  rule,  is 
much  altered.  The  sputum  has,  in  a  majority  of  the  cases,  an  intensely  fetid 
odor,  which  is  communicated  to  the  breath  and  may  permeate  the  entire  room. 
It  is  much  more  offensive  than  in  fetid  bronchitis  or  in  abscess  of  the  lung. 
The  fetor  is  particularly  marked  when  there  is  free  communication  between 
the  gangrenous  cavities  and  the  bronchi.  On  several  occasions  I  have  found, 
post  mortem,  localized  gangrene,  which  had  been  unsuspected  during  life, 
and  in  which  there  had  been  no  fetor  of  the  breath. 

The  physical  signs,  when  extensive  destruction  has  occurred,  are  those 
of  cavity,  but  the  limited  circumscribed  areas  may  be  difficult  to  detect. 
Bronchitis  is  always  present.  The  X-ray  examination  may  aid  in  diagnosis. 

Among  the  general  symptoms  may  be  mentioned  fever,  usually  of  moderate 
grade;  the  pulse  is  rapid,  and  very  often  the  constitutional  depression  is 
severe.  But  the  only  special  features  indicative  of  gangrene  are  the  sputum 
and  the  fetor  of  the  breath.  The  patient  generally  sinks  from  exhaustion. 
Fatal  haemorrhage  may  ensue. 

Treatment. — The  treatment  of  gangrene  is  very  unsatisfactory.  The  indi- 
cations, of  course,  are  to  disinfect  the  gangrenous  area,  but  this  is  often  impos- 
sible. An  antiseptic  spray  of  carbolic  acid  may  be  employed.  A  good  plan 
is  for  the  patient  to  use  over  the  mouth  and  nose  an  inhaler,  which  may  be 
charged  with  a  solution  of  carbolic  acid  or  with  guaiacol ;  the  latter  drug  has 
also  been  used  hypodermically,  with,  it  is  said,  happy  results  in  removing  the 
odor.  If  the  signs  of  cavity  are  distinct  an  attempt  should  be  made  to  cleanse 
it  by  direct  injections  of  an  antiseptic  solution.  If  the  patient's  condition  is 
good  and  the  gangrenous  region  can  be  localized,  surgical  interference  may  be 
indicated.  Successful  cases  have  been  reported.  The  general  condition  of 
the  patient  is  always  such  as  to  demand  the  greatest  care  in  the  matter  -of 
diet  and  nursing. 

VI.    ABSCESS    OF    THE    LUNG 

Etiology. — Suppuration  occurs  in  the  lung  under  the  following  condi- 
tions: (1)  As  a  sequence  of  inflammation,  either  lobar  or  lobular.  Apart 
from  the  purulent  infiltration  this  is  unquestionably  rare,  and  even  in  lobar 
pneumonia  the  abscesses  are  of  small  size  ,and  usually  involve,  as  Addison 
remarked,  several  points  at  the  same  time.  On  the  other  hand,  abscess  for- 
mation is  extremely  frequent  in  the  deglutition  and  aspiration  forms  of  lobular 
pneumonia.  After  wounds  of  the  neck  or  operations  upon  the  throat,  in  sup- 
purative  disease  of  the  nose  or  larynx,  occasionally  even  of  the  ear  (Volk- 
mann),  infective  particles  reach  the  bronchial  tubes  by  aspiration  and  excite 
an  intense  inflammation  which  often  ends  in  abscess.  Cancer  of  the  oesopha- 
gus, perforating  the  root  of  the  lung  or  into  the  bronchi,  may  produce 
extensive  suppuration.  The  abscesses  vary  in  size  from  a  walnut  to  an  orange, 
and  have  ragged  and  irregular  walls,  and  purulent,  sometimes  necrotic,  con- 
tents. 

(2)  Embolic,  so-called  metastatic,  abscesses,  the  result  of  infective  emboli, 
are  extremely  common  in  pyaemia.  They  may  be  numerous  and  present  very 


NEW   GKOWTHS    IN   THE    LUNGS  653 

definite  characters.  As  a  rule  they  are  superficial,  beneath  the  pleura,  and 
often  wedge-shaped.  At  first  firm,  grayish  red  in  color,  and  surrounded  by  a 
zone  of  intense  hyperamia,  suppuration  soon  follows  with  the  formation  of  a 
definite  abscess.  The  pleura  is  usually  covered  with  greenish  lymph,  and  per- 
foration sometimes  takes  place  with  the  production  of  pneumothorax. 

(3)  Perforation  of  the  lung  from  without,  lodgment  of  foreign  bodies, 
and,  in  the  right  lung,  perforation  from  abscess  of  the  liver  or  a  suppurating 
echinococcus  cyst  are  occasionally  causes  of  pulmonary  abscess. 

(4)  Suppurative  processes  play  an  important  part  in  chronic  pulmonary 
tuberculosis,  many  of  the  symptoms  of  which  are  due  to  them. 

Symptoms. — Abscess  following  pneumonia  is  easily  recognized  by  an  aggra- 
vation of  the  general  symptoms  and  by  the  physical  signs  of  cavity  and  the 
characters  of  the  expectoration.  Embolic  abscesses  can  not  often  be  recog- 
nized, and  the  local  symptoms  are  generally  masked  in  the  general  pyaemic 
manifestations.  The  character  of  the  sputum  is  of  great  importance  in  de- 
termining the  presence  of  abscess.  The  odor  is  offensive,  yet  it  rarely  has 
the  horrible  fetor  of  gangrene  or  of  putrid  bronchitis.  In  the  pus  fragments 
of  lung  tissue  can  be  seen,  and  the  elastic  tissue  may  be  very  abundant.  The 
presence  of  this  with  the  physical  signs  rarely  leaves  any  question  as  to  the 
nature  of  the  trouble.  Embolic  cases  usually  run  a  fatal  course.  Eecovery 
occasionally  occurs  after  pneumonia.  In  a  case  following  typhoid  fever  which 
I  saw  at  the  Garfield  Hospital  Kerr  removed  two  ribs  and  found  free  in  the 
pus  of  a  localized  empyema  a  sequestered  piece  of  lung,  the  size  of  the  palm 
of  the  hand,  which  had  sloughed  off  from  the  lower  lobe.  The  patient  made 
a  good  recovery. 

Medicinal  treatment  is  of  little  avail  in  abscess  of  the  lung.  When  well 
defined  and  superficial,  an  attempt  should  always  be  made  to  open  and  drain 
it.  A  number  of  successful  cases  have  already  been  treated  in  this  way. 


VII.    NEW  GROWTHS  IN  THE   LUNGS 

Etiology  and  Morbid  Anatomy. — While  primary  tumors  are  rare,  second- 
ary growths  are  not  uncommon.  Carcinoma  is  the  most  common  primary 
form.  Endothelium  and  sarcoma  are  less  frequently  met  with. 

Varieties. — The  following  groups  may  be  recognized: 

(a)  ACUTE  GALLOPING  ELEURO-PNEUMONIC  FORM,  with  a  very  rapid  course 
— dyspnosa,  cough,  asphyxia,  rapid  emaciation  and  death  in  from  six  to  twelve 
weeks.  Most  of  these  cases  are  secondary,  sometimes  to  unrecognized  disease 
elsewhere,  but  there  are  instances  of  the  primary  disease  of  this  type.  It  is  a 
remarkable  fact  that  cobalt  miners  of  Schneeberg  are  very  liable  to  a  primary 
carcinoma  of  the  lung  which  may  run  this  acute  course. 

(&)  CHRONIC  PLEURO-PULMONARY  CARCINOMA,  of  which  there  are  several 

types : 

(1)  Broncho-pulmonary  Form.— This,  the  most  typical  variety,  begins 
with  bronchial  symptoms,  bloody  sputum,  loss  of  weight  and  strength,  and 
anemia.  The  physical  signs  may  be  suggestive  of  tuberculosis,  but  the  earliest 
indications  are  usually  at  the  root  of  the  lung.  Later  there  may  be  cavity 
formation,  with  a  bronchiectatic  type  of  sputum.  Tubercle  bacilli  are  absent 


654  DISEASES    OF   THE    RESPIRATORY    SYSTEM 

and  there  may  be  very  large  round  cells  with  many  fatty  granules,  represent- 
ing degenerate  cancer  cells.  The  X-ray  picture  is  not  distinctive  and  the 
cases  are  usually  taken  for  tuberculosis. 

(2)  Mediastinal  Type. — Quite  early  in  this  form  the  glands  become  in- 
volved, increase  rapidly,  compress  the  adjoining  structures  and  the  type  of  the 
disease  is  that  of  a  mediastinal  tumor  with  its  dominant  pressure  symptoms. 

(3)  Pleuritic  Type. — The  earliest  and  dominant  symptoms  are  at  the 
back  with  pleuritic  pain,  cough,  friction,  progressive  effusion,  and  shortness 
of  breath.    On  tapping,  the  effusion  is  usually  bloody,  though  I  have  known  it 
at  first  to  be  clear.    In  other  instances  the  pleura  is  early  involved  with  rapid 
extension,  but  no  effusion.    There  may  be  little  or  no  cough,  and  very  slight 
dyspnoea,  with  progressive  weakness,  emaciation,  and  anaemia  as  the  chief 
Matures.     Subcutaneous  nodules  may  occur  along  the  ribs,  with  involvement 
of  both  cervical  and  axillary  glands. 

From  the  standpoint  of  treatment  not  much  is  to  be  expected.  The  new 
surgical  technique  has  made  the  thoracic  cavity  accessible,  and  it  is  quite  pos- 
sible that  early  explorations  may  become  common  in  doubtful  cases.  In  a  few 
instances  carcinoma  of  the  lung  has  been  operated  upon;  in  Lenhartz'  case 
the  patient  remained  well  for  a  year,  and  died  two  and  a  half  years  after 
operation. 

E.    DISEASES   OF   THE   PLEURA 
I.    ACUTE  PLEURISY 

Anatomically,  the  cases  may  be  divided  into  dry  or  adhesive  pleurisy  and 
pleurisy  with  effusion.  Another  classification  is  into  primary  or  secondary 
forms.  According  to  the  course  of  the  disease,  a  division  may  be  made  into 
acute  and  chronic  pleurisy,  and  as  it  is  impossible,  at  present,  to  group  the 
various  forms  etiologically,  this  is  perhaps  the  most  satisfactory  division.  The 
following  forms  of  acute  pleurisy  may  be  considered : 

1.    FIBRINOUS    OB   PLASTIC   PLEURISY 

In  this  the  pleural  membrane  is  covered  by  a  sheeting  of  lymph  of  variable 
thickness,  which  gives  it  a  turbid,  granular  appearance,  or  the  fibrin  may 
exist  in  distinct  layers.  It  occurs  (1)  as  an  independent  affection,  following 
cold  or  exposure.  This  form  of  acute  plastic  pleurisy  without  fluid  exudate 
is  not  common  in  perfectly  healthy  individuals.  Cases  are  met  with,  however, 
in  which  the  disease  sets  in  with  the  usual  symptoms  of  pain  in  the  side  and 
slight  fever,  and  there  are  the  physical  signs  of  pleurisy  as  indicated  by  the 
friction.  After  persisting  for  a  few  days,  the  friction  murmur  disappears  and 
no  exudation  occurs.  Union  takes  place  between  the  membranes,  and  possibly 
the  pleuritic  adhesions  which  are  found  in  such  a  large  percentage  of  all  bodies 
examined  after  death  originate  in  these  slight  fibrinous  pleurisies. 

Fibrinous  pleurisy  occurs  (2)  as  a  secondary  process  in  acute  diseases  of 
the  lung,  such  as  pneumonia,  which  is  always  accompanied  by  a  certain 
amount  of  pleurisy,  usually  of  this  form.  Cancer,  abscess,  and  gangrene  also 
cause  plastic  pleurisy  when  the  surface  of  the  lung  becomes  involved.  This 


ACUTE    PLEUKISY  655 

condition  is  specially  associated  in  a  large  number  of  cases  with  tuberculosis. 
Pleural  pain,  stitch  in  the  side,  and  a  dry  cough,  with  marked  friction  sounds 
on  auscultation,  are  the  initial  phenomena  in  many  instances  of  phthisis.  The 
signs  are  usually  basic. 

2.    SERO-FIBRINOUS   PLEURISY 

In  a  majority  of  cases  of  inflammation  of  the  pleura  there  is,  with  the 
fibrin,  a  variable  amount  of  fluid  exudate,  which  produces  the  condition  known 
as  pleurisy  with  effusion. 

Etiology. — Of  194  cases  in  fifteen  years  in  my  wards,  there  were  161  males 
and  33  females.  Under  twenty  years  of  age  there  were  20  patients;  18  were 
over  sixty  years  of  age.  The  greatest  number  was  in  the  fifth  decade,  59. 
Cold  acts  as  a  predisposing  agent,  which  permits  the  action  of  various  micro- 
organisms. We  have  not  yet,  however,  brought  all  the  acute  pleurisies  into 
the  category  of  microbic  affections,  and  the  fact  remains  that  pleurisy  does 
follow  with  great  rapidity  a  sudden  wetting  or  a  chill.  A  majority  of  the 
cases  are  tuberculous.  This  view  is  based  upon:  (1)  Post  mortem  evidence. 
Tubercles  have  been  found  in  acute  cases,  thought  to  have  been  rheumatic  or 
due  to  cold.  (2)  The  not  infrequent  presence  of  tuberculous  lesions,  often 
latent,  in  the  lung  or  elsewhere.  (3)  The  character  of  the  exudate.  If  coagu- 
lated and  the  coagulum  digested  and  centrifugalized  (Inoscopy),  tubercle 
bacilli  are  frequently  found.  Injected  into  a  guinea  pig,  in  amounts  of  15 
c.  c.  or  more,  tuberculosis  followed  in  62  per  cent.  (Eichhorst).  The  cyto- 
diagnosis  shows  that  as  in  other  tuberculous  exudates  the  mono-nuclear  leuco- 
cytes predominate.  (4)  The  tuberculin  reaction  is  given  in  a  considerable 
percentage  of  the  cases.  (5)  The  subsequent  history.  Of  90  cases  of  acute 
pleurisy  which  had  been  under  the  observation  of  H.  I.  Bowditch  between 
1849  and  1879,  32  died  of  or  had  phthisis.  Among  130  patients  with  primary 
pleurisy  with  effusion,  followed  for  a  period  of  seven  years  by  Hedges,  40  per 
cent,  became  tuberculous. 

Of  300  uncomplicated  cases  of  pleural  effusion  in  the  Massachusetts  Gen- 
eral Hospital,  followed  by  E.  C.  Cabot,  the  subsequent  history  was  ascertained 
in  221;  followed  five  years  until  death  or  phthisis,  117;  well  after  five 
years,  96. 

In  172  of  the  cases  of  pleurisy  with  effusion  in  the  Johns  Hopkins  Hos- 
pital Hamman  got  reports  from  88;  of  these  48  were  living  and  well,  30 
later  became  tuberculous,  in  2  the  result  was  questionable,  and  8  died  of  other 
diseases.  Twelve  of  the  88  had  tubercle  bacilli  in  the  sputum  while  in  the 
hospital  without  discoverable  pulmonary  lesion;  3  of  the  12  were  living  and 
well ;  in  8  the  signs  became  well  marked ;  one  died  of  unknown  cause.  Ham- 
man has  collected  562  cases  (including  the  above)  in  which  the  subsequent 
history  was  sought;  of  these  167,  29.7  per  cent,  became  tuberculous. 

Bacteriology  of  Acute  Pleurisy. — From  a  bacteriological  standpoint  we 
may  recognize  three  groups  of  cases,  caused  by  the  tubercle  bacillus,  the  pneu- 
mococcus,  and  the  streptococcus,  respectively. 

Bacillus  tuberculosis  is  present  in  a  very  large  proportion  of  all  cases  of 
primary  or  so-called  idiopathic  pleurisy.  The  exudate  is  usually  sterile  on 
cover  slips  or  in  the  culture  and  inoculation  tests  made  in  the  ordinary  way, 
as  the  bacilli  are  very  scanty.  It  has  been  demonstrated  clearly  that  a  large 


65G  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

amount  of  the  exudate  must  be  taken  to  make  the  test  complete,  either  in 
cultures  or  in  the  inoculation  of  animals.  Eichhorst  found  that  more  than 
62  per  cent,  were  demonstrated  as  tuberculous  when  as  much  as  15  c.  c.  of  the 
exudate  was  inoculated  into  test  animals,  while  less  than  10  per  cent,  of  the 
cases  showed  tuberculosis  when  only  1  c.  c.  of  the  exudate  was  used.  This  is  a 
point  to  which  observers  should  pay  very  special  attention.  Le  Damany  has 
demonstrated  the  tuberculous  character  of  all  but  4  in  55  primary  pleurisies. 
He  used  large  quantities  of  the  fluid  for  his  inoculation  experiments. 

The  pneumococcus  pleurisy  is  almost  always  secondary  to  a  focus  of 
inflammation  in  the  lung.  It  may,  however,  be  primary.  The  exudate  is 
usually  purulent  and  the  outlook  is  very  favorable. 

The  streptococcus  pleurisy  is  the  typical  septic  form  which  may  occur 
either  from  direct  infection  of  the  pleura  through  the  lung  in  broncho-pneu- 
monia, or  in  cases  of  streptococcus  pneumonia;  in  other  instances  it  follows 
infection  of  more  distant  parts.  The  acute  streptococcus  pleurisy  is  the  most 
serious  and  fatal  of  all  forms. 

Among  other  bacteria  which  have  been  found  are  the  staphylococcus, 
Friedlander's  bacillus,  the  typhoid  bacillus,  and  the  diphtheria  bacillus. 

Morbid  Anatomy. — In  sero-fibrinous  pleurisy  the  serous  exudate  is  abun- 
dant and  the  fibrin  is  found  on  the  pleural  surfaces  and  scattered  through 
the  fluid  in  the  form  of  flocculi.  The  proportions  of  these  constituents  vary 
a  great  deal.  In  some  instances  there  is  very  little  membranous  fibrin;  in 
others  it  forms  thick,  creamy  layers  and  exists  in  the  dependent  part  of  the 
fluid  as  whitish,  curd-like  masses.  The  fluid  of  sero-fibrinous  pleurisy  is  of 
a  lemon  color,  either  clear  or  slightly  turbid,  depending  on  the  number  of 
formed  elements.  In  some  instances  it  has  a  dark  brown  color.  The  micro- 
scopic examination  of  the  fluid  shows  leucocytes,  occasional  swollen  cells, 
which  may  possibly  be  derived  from  the  pleural  endothelium,  shreds  of  fibril- 
lated  fibrin,  and  a  variable  number  of  red  blood-corpuscles.  A  large  number 
of  cells  undergoing  mitotic  division  is  diagnostic  of,  malignant  disease.  On 
boiling,  the  fluid  is  found  to  be  rich  in  albumin.  Sometimes  it  coagulates 
spontaneously.  Its  composition  closely  resembles  that  of  blood  serum.  Cho- 
lesterin,  uric  acid,  and  sugar  are  occasionally  found.  The  amount  of  the 
effusion  varies  from  %  to  4  litres.  Enormous  amounts  are  sometimes 
removed,  188  ounces  in  one  case  (E.  C.  Carter).  The  lung  in  acute  sero- 
fibrinous  pleurisy  is  more  or  less  compressed.  If  the  exudation  is  limited  the 
lower  lobe  alone  is  atelectatic;  but  in  an  extensive  effusion  which  reaches  to 
the  clavicle  the  entire  lung  will  be  found  lying  close  to  the  spine,  dark  and 
airless,  or  even  bloodless — i.  e.,  carnified. 

In  large  exudations  the  adjacent  organs  are  displaced;  the  liver  is  de- 
pressed and  the  heart  dislocated.  With  reference  to  the  position  of  the  heart, 
the  following  statements  may  be  made:  (1)  Even  in  the  most  extensive  left 
sided  exudation  there  is  no  rotation  of  the  apex  of  the  heart,  which  in  no 
case  was  to  the  right  of  the  mid-sternal  line;  (2)  the  relative  position  of  the 
apex  and  base  is  usually  maintained ;  in  some  instances  the  apex  is  lifted,  in 
others  the  whole  heart  lies  more  transversely;  (3)  the  right  chambers  of  the 
heart  occupy  the  greater  portion  of  the  front,  so  that  the  displacement  is 
rather  a  definite  dislocation  of  the  mediastinum,  with  the  pericardium,  to  the 
right,  than  any  special  twisting  of  the  heart  itself;  (4)  the  kink  or  twist  in 


ACUTE    PLEURISY  657 

the  inferior  vena  cava  described  by  Bartels  was  not  present  in  any  of  my 
cases. 

Symptoms. — Prodromes  are  not  uncommon,  but  the  disease  may  set  in 
abruptly  with  a  chill,  followed  by  fever  and  a  severe  pain  in  the  side.  In 
very  many  cases,  however,  the  onset  is  insidious,  particularly  in  children  and 
in  elderly  persons.  A  little  dyspnoea  on  exertion  and  an  increasing  pallor 
may  be  the  only  features.  Washbourn  has  called  attention  to  the  frequency 
with  which  the  pneumococcus  pleurisy  sets  in  with  the  features  of  pneumonia. 
The  pain  in  the  side  is  the  most  distressing  symptom,  and  is  usually  referred 
to  the  nipple  or  axillary  regions.  It  must  be  remembered,  however,  that 
pleuritic  pain  may  be  felt  in  the  abdomen  or  low  down  in  the  back,  particularly 
when  the  diaphragmatic  surface  of  the  pleura  is  involved.  It  is  lancinating, 
sharp,  and  severe,  and  is  aggravated  by  cough.  At  this  early  stage,  on  aus- 
cultation, sometimes  indeed  on  palpation,  a  dry  friction  rub  can  be  detected. 
The  fever  rarely  rises  so  rapidly  as  in  pneumonia,  and  does  not  reach  the  same 
grade.  A  temperature  of  from  102°  to  103°  F.  is  an  average  pyrexia.  It 
may  drop  to  normal  at  the  end  of  a  week  or  ten  days  without  the  appearance  of 
any  definite  change  in  the  physical  signs,  or  it  may  persist  for  several  weeks. 
The  temperature  of  the  affected  is  higher  than  that  of  the  sound  side.  Cough 
is  an  early  symptom  in  acute  pleurisy,  but  is  rarely  so  distressing  or  so  fre- 
quent as  in  pneumonia.  There  are  instances  in  which  it  is  absent.  The 
expectoration  is  usually  slight  in  amount,  mucoid  in  character,  .and  occa- 
sionally streaked  with  blood. 

At  the  outset  there  may  be  dyspnoea,  due  partly  to  the  fever  and  partly 
to  the  pain  in  the  side.  Later  it  results  from  the  compression  of  the  lung, 
particularly  if  the  exudation  has  taken  place  rapidly.  In  the  cases  with 
very  rapid  effusion  the  dyspnoea  may  be  very  marked.  When,  however,  the 
fluid  is  effused  slowly,  one  lung  may  be  entirely  compressed  without  inducing 
shortness  of  breath,  except  on  exertion,  and  the  patient  will  lie  quietly  in  bed 
without  evincing  the  slightest  respiratory  distress.  When  the  effusion  is  large 
the  patient  usually  prefers  to  lie  upon  the  affected  side. 

PHYSICAL  SIGNS. — Inspection  shows  some  degree  of  immobility  on  th«j 
affected  side,  depending  upon  the  amount  of  exudation ;  and  in  large  effusions 
an  increase  in  volume,  which  may  appear  to  be  much  more  than  it  realty 
is  as  determined  by  mensuration.  The  intercostal  depressions  are  obliterated. 
In  the  right  sided  effusions  the  apex  beat  may  be  lifted  to  the  fourth  inter- 
space or  be  pushed  beyond  the  left  nipple,  or  may  even  be  seen  in  the 
axilla.  When  the  exudation  is  on  the  left  side,  the  heart's  impulse  may  not 
be  visible;  but  if  the  effusion  is  large  it  is  seen  in  the  third  and  fou/th 
spaces  on  the  right  side,  and  sometimes  as  far  out  as  the  nipple,  or  even 

beyond  it. 

Palpation  enables  us  more  successfully  to  determine  the  deficient  move- 
ments on  the  affected  side,  and  the  obliteration  of  the  intercostal  spaces,  and 
more  accurately  to  define  the  position  of  the  heart's  impulse.  In  simple  sero- 
fibrinous  effusion  there  is  rarely  any  cedema  of  the  chest  walls.  It  is  scarcely 
ever  possible  to  obtain  fluctuation.  Tactile  fremitus  is  greatly  diminished  or 
abolished  If  the  effusion  is  slight  there  may  be  only  enfeeblement.  The 
absence  of  the  voice  vibrations  in  effusions  of  any  size  constitutes  one  of  the 
most  valuable  of  physical  signs.  In  children  there  may  be  much  effusion  with 


658 

retention  of  fremitus.  In  rare  cases  the  vibrations  may  be  communicated  to 
the  chest  walls  through  localized  pleural  adhesions. 

Mensuration. — With  the  cyrtometer,  if  the  effusion  is  excessive,  a  differ- 
ence of  from  half  an  inch  to  an  inch,  or  even,  in  large  effusions,  an  inch  and 
a  half,  may  be  found  between  the  two  sides.  Allowance  must  be  made  for  the 
fact  that  the  right  side  is  naturally  larger  than  the  left.  With  the  saddle 
tape  the  difference  in  expansion  between  the  two  sides  can  be  conveniently 
measured. 

Percussion. — Early  in  the  disease  there  may  be  no  alteration  in  the  note, 
but  with  the  gradual  accumulation  of  the  fluid  the  resonance  becomes  de- 
fective, and  finally  gives  place  to  absolute  flatness.  From  day  to  day  the 
gradual  increase  in  height  of  the  fluid  may  be  studied.  In  a  pleuritic  effusion 
rising  to  the  fourth  rib  in  front  the  percussion  signs  are  usually  very  sug- 
gestive. In  the  subclavicular  region  the  attention  is  often  aroused  at  once 
by  a  tympanitic  note,  the  so-called  Skoda's  resonance,  which  is  heard  perhaps 
more  commonly  in  this  situation  with  pleural  effusion  than  in  any  other  con- 
dition. It  shades  insensibly  into  a  flat  note  in  the  lower  mammary  and 
axillary  regions.  Skoda's  resonance  may  be  obtained  also  behind,  just  above 
the  limit  of  effusion.  The  dulness  has  a  peculiarly  resistant,  wooden  quality, 
differing  from  that  of  pneumonia  and  readily  recognized  by  skilled  ringers. 
It  has  long  been  known  that  when  the  patient  is  in  the  erect  posture  the 
upper  line  of  dulness  is  not  horizontal,  but  is  higher  behind  than  it  is  in 
front,  forming  a  parabola.  The  curve  marking  the  intersection  of  the  plane 
of  contact  of  lung  and  fluid  with  the  chest  wall  is  known  as  "Ellis's  line  of 
flatness,"  which  Garland  has  verified  clinically  and  by  animal  experiments. 
With  medium-sized  effusions  this  line  begins  lowest  behind,  advances  upward 
and  forward  in  a  letter-S  curve  to  the  axillary  region,  whence  it  proceeds  in  a 
straight  decline  to  the  sternum.  This  curve  is  demonstrable  only  when  the 
patient  is  in  the  erect  position.  Grocco,  in  1902,  called  attention  to  the  exist- 
ence in  pleural  effusion  of  a  triangular  area  of  relative  dulness,  along  the 
spine,  on  the  side  opposite  to  the  pleurisy,  in  width'  from  2  to  5  cm.,  and 
with  the  apex  upward.  It  can  be  demonstrated  in  a  large  majority  of  all 
cases,  particularly  in  the  young  and  in  thin  persons.  It  is  possibly  due  to  the 
bulging  of  the  mediastinum,  by  the  fluid,  across  the  middle  line,  the  anatomi- 
cal possibility  of  which  has  been  pointed  out  by  Calvert. 

On  the  right  side  the  dulness  passes  without  change  into  that  of  the  liver. 
On  the  left  side  in  the  nipple  line  it  extends  to  and  may  obliterate  Traube's 
semilunar  space.  If  the  effusion  is  moderate,  the  phenomenon  of  movable 
dulness  may  be  obtained  by  marking  carefully,  in  the  sitting  posture,  the 
upper  limit  in  the  mammary  region,  and  then  in  the  recumbent  posture, 
noting  the  change  in  the  height  of  dulness.  This  infallible  sign  of  fluid  can 
not  always  be  obtained.  In  very  copious  exudation  the  dulness  may  reach  the 
clavicle  and  even  extend  beyond  the  sternal  margin  of  the  opposite  side. 

Auscultation. — Early  in  the  disease  a  friction  rub  can  usually  be  heard, 
which  disappears  as  the  fluid  accumulates.  It  is  a  to-and-fro  dry  rub,  close 
to  the  ear,  and  has  a  leathery,  creaking  character.  There  is  another  pleural 
friction  sound  which  closely  resembles,  and  is  scarcely  to  be  distinguished 
from,  the  fine  crackling  crepitus  of  pneumonia.  This  may  be  heard  at  the 
commencement  of  the  disease,  and  also,  as  pointed  out  in  1844  by  MacDonnell, 


ACUTE    PLEURISY  659 

Sr.,  of  Montreal,  when  the  effusion  has  receded  and  the  pleural  layers  come 
together  again. 

With  even  a  slight  exudation  there  is  weakened  or  distant  breathing.  Often 
inspiration  and  expiration  are  distinctly  audible,  though  distant,  and  have  a 
tubular  quality.  Sometimes  only  a  puffing  tubular  expiration  is  heard,  which 
may  have  a  metallic  or  amphoric  quality.  Loud  resonant  rales  accompanying 
this  may  forcibly  suggest  a  cavity.  These  pseudo-cavernous  signs  are  met 
with  more  frequently  in  children,  and  often  lead  to  error  in  diagnosis.  Above 
the  line  of  dulness  the  breath  sounds  are  usually  harsh  and  exaggerated,  and 
may  have  a  tubular  quality. 

The  vocal  resonance  is  usually  diminished  or  absent.  The  whispered  voice 
is  said  to  be  transmitted  through  a  serous  and  not  through  a  purulent  exudate 
(Baccelli's  sign),  but  this  is  not  always  true.  This  author  advises  direct 
auscultation  in  the  antero-lateral  region  of  the  chest.  There  may,  however,  be 
intensification — bronchophony.  The  voice  sometimes  has  a  curious  nasal, 
squeaking  character,  which  was  termed  by  Laennec  cegophony,  from  its  sup- 
posed resemblance  to  the  bleating  of  a  goat.  In  typical  form  this  is  not  com- 
mon, but  it  is  by  no  means  rare  to"  hear  a  curious  twang-like  quality  in  the 
voice,  particularly  at  the  outer  angle  of  the  scapula. 

In  the  examination  of  the  heart  in  cases  of  pleuritic  effusion  it  is  well 
to  bear  in  mind  that  when  the  apex  of  the  heart  lies  beneath  the  sternum 
there  may  be  no  impulse.  The  determination  of  the  situation  of  the  organ 
may  rest  with  the  position  of  maximum  loudness  of  the  sounds.  Over  the 
displaced  organ  a  systolic  murmur  may  be  heard.  When  the  lappet  of  lung 
over  the  pericardium  is  involved  on  either  side  there  may  be  a  pleuro-peri- 
cardial  friction. 

BLOOD  COUNT  IN  PLEURAL  EFFUSION. — Emerson  has  looked  over  for  me 
the  histories  of  89  cases  of  acute  pleurisy  with  effusion  in  which  the  blood 
counts  were  made  before  the  temperature  reached  normal.  Only  26  had  a 
leucocytosis  between  10,000  and  15,000;  one  only  above  15,000.  In  12  of  the 
cases  the  count  was  below  5,000. 

The  X-RAY  PICTURES  are  of  great  interest  and  of  much  value  in  diagnosis. 
They  have  shown  that  the  effusion  is  not  always  in  the  lower  portion  of  the 
chest  with  the  patient  in  the  upright  position,  but  that  it  may  represent  a 
vertical  column  in  the  lateral  aspect  of  the  chest,  compressing  the  lung 
toward  the  spine.  The  effusion  is  not  always  mobile,  but  may  be  fixed 
by  adhesions  in  one  position. 

Course.— The  course  of  acute  sero-fibrinous  pleurisy  is  very  variable. 
After  persisting  for  a  week  or  ten  days  the  fever  subsides,  the  cough  and 
pain  disappear,  and  a  slight  effusion  may  be  quickly  absorbed.  In  cases  m 
which  the  effusion  reaches  as  high  as  the  fourth  rib  recovery  is  usually  slower. 
Many  instances  come  under  observation  for  the  first  time,  after  two  or  three 
weeks'  indisposition,  with  the  fluid  at  a  level  with  the  clavicle.  The  fever 
may  last  from  ten  to  twenty  days  without  exciting  anxiety,  though,  as  a  rule, 
in  ordinary  pleurisy  from  cold,'  as  we  say,  the  temperature  in  cases  of  moder- 
ate severity  is  normal  within  eight  or  ten  days.  Left  to  itself,  the  natural 
tendency  is  to  resorption;  but  this  may  take  place  very  slowly  With  the 
absorption  of  the  fluid  there  is  a  redux-friction  crepitus,  either  leathery  and 
creaking  or  crackling  and  rale-like,  and  for  months,  or  even  longer,  the 


6GO  DISEASES    OF   THE   RESPIRATORY    SYSTEM 

defective  resonance  and  feeble  breathing  are  heard  at  the  base.  Rare  modes 
of  termination  are  perforation  and  discharge  through  the  lung,  and  externally 
through  the  chest  wall,  examples  of  which  have  been  recorded  by  Sahli. 

The  immediate  prognosis  in  pleurisy  with  effusion  is  good.  Of  320  cases 
at  St.  Bartholomew's  Hospital,  only  6.1  per  cent,  died  before  leaving  the  hos- 
pital (Hedges). 

A  sero-fibrinous  exudate  may  persist  for  months  without  change,  particu- 
larly in  tuberculous  cases,  and  will  sometimes  reaccumulate  after  aspiration 
and  resist  all  treatment.  After  persistence  for  more  than  twelve  months, 
in  spite  of  repeated  tapping,  a  serous  effusion  was  cured  by  incision  without 
deformity  of  the  chest  (S.  West).  When  one  pleura  is  full  and  the  heart 
is  greatly  dislocated,  the  condition,  although  in  a  majority  of  cases  producing 
remarkably  little  disturbance,  is  not  without  risk. 

3.    PURULENT   PLEUEISY 
(Empyema) 

Etiology. — Pus  in  the  pleura  is  due  to  (a)  infection  from  within,  as  a 
rule  directly  from  a  patch  of  pneumonia  or  a  septic  focus  due  to  the  pneumo- 
coccus  or  the  pus  organisms,  in  some  ;cases  a  tuberculous  broncho-pneumonia ; 
(b)  involvement  from  without,  as  in  fracture  of  a  rib,  penetrating  wound, 
disease  of  oesophagus,  etc. 

It  frequently  follows  the  infectious  diseases,  particularly  scarlet  fever.  It 
is  very  often  latent,  and  due  to  undiscovered  foci  of  lobar  or  lobular  pneu- 
monia. It  is  common  in  children,  more  in  boys  than  in  girls,  and  between 
the  ages  of  one  and  five  and  eight  and  nine. 

The  pneumococcus  is  the  most  common  organism,  then  the  ordinary  pus 
organisms  and  the  tubercle  bacilli.  The  pneumococcus  has  been  found  and  in 
rare  cases  the  influenza  bacillus,  and  even  psorosperms. 

Morbid  Anatomy. — On  opening  an  empyema  post  mortem  we  usually  find 
that  the  effusion  has  separated  into  a  clear,  greenish  yellow  serum  above  and 
the  thick,  cream-like  pus  below.  The  fluid  may  be  scarcely  more  than  turbid, 
with  flocculi  of  fibrin  through  it.  In  the  pneumococcus  empyema  the  pus  is 
usually  thick  and  creamy.  It  usually  has  a  heavy,  sweetish  odor,  but  in  some 
instances — particularly  those  following  wounds — it  is  fetid.  In  cases  of  gan- 
grene of  the  lung  or  pleura  the  pus  has  a  horribly  stinking  odor.  Microscop- 
ically it  has  the  characters  of  ordinary  pus.  The  pleural  membranes  are 
greatly  thickened,  and  present  a  grayish  white  layer  from  1  to  2  mm.  in 
thickness.  On  the  costal  pleura  there  may  be  erosions,  and  in  old  cases  fis- 
tulous  communications  are  common.  The  lung  may  be  compressed  to  a  very 
small  limit,  and  the  visceral  pleura  also  may  show  perforations. 

Symptoms. — Purulent  pleurisy  may  begin  abruptly,  with  the  symptoms 
already  described.  More  frequently  it  comes  on  insidiously  in  the  course  of 
other  diseases  or  follows  an  ordinary  sero-fibrinous  pleurisy.  There  may  be  no 
pain  in  the  chest,  very  little  cough,  and  no  dyspnoea,  unless  the  side  is  very 
full.  Symptoms  of  septic  infection  are  rarely  wanting.  If  in  a  child,  there 
is  a  gradually  developing  pallor  and  weakness;  sweats  occur,  and  there  is 
irregular  fever.  A  cough  is  by  no  means  constant.  The  leucocytes  are 


ACUTE    PLEURISY  661 

usually  much  increased;  in  one  fatal  case  they  numbered  115,000  per  cubic 
millimetre. 

PHYSICAL  SIGNS. — Practically  they  are  those  already  considered  in  pleu- 
risy with  effusion.  There  are,  however,  one  or  two  additional  points  to  be 
mentioned.  In  empyema,  particularly  in  children,  the  disproportion  between 
the  sides  may  be  extreme.  The  intercostal  spaces  may  not  only  be  obliterated, 
but  may  bulge.  Not  infrequently  there  is  oedema  of  the  chest  walls.  The 
network  of  subcutaneous  veins  may  be  very  distinct.  It  must  not  be  forgotten 
that  in  children  the  breath-sounds  may  be  loud  and  tubular  over  a  purulent 
effusion  of  considerable  size.  The  dislocation  of  the  heart  and  the  dis- 
placement of  the  liver  are  more  marked  in  empyema  than  in  sero-fibrinous 
effusion — probably,  as  Senator  suggests,  owing  to  the  greater  weight  of  the 
fluid. 

A  curious  phenomenon  associated  generally  with  empyema,  but  sometimes 
occurring  in  the  sero-fibrinous  exudate,  is  pulsating  pleurisy,  first  described 
by  MacDonnell,  Sr.,  of  Montreal.  In  95  cases  collected  by  Sailer  it  was  much 
more  frequent  in  males  than  in  females.  In  38  there  was  a  tumor;  that  is, 
empyema  necessitatis.  In  all  but  one  case  the  fluid  was  purulent.  Pneumo- 
thorax  may  be  present.  There  are  two  groups  of  cases,  the  intrapleural  pul- 
sating pleurisy  and  the  pulsating  empyema  necessitatis,  in  which  there  is  an 
external  pulsating  tumor.  No  satisfactory  explanation  has  been  offered  how 
the  heart  impulse  is  thus  forcibly  communicated  through  the  effusion. 

Empyema  is  a  chronic  affection,  which  in  a  few  instances  terminates 
naturally  in  recovery,  but  a  majority  of  cases,  if  left  alone,  ends  in  death. 
The  following  are  some  modes  of  natural  cure:  (a)  By  absorption  of  the 
fluid.  In  small  effusions  this  may  take  place  gradually.  The  chest  wall  sinks. 
The  pleural  layers  become  greatly  thickened  and  enclose  between  them  the 
inspissated  pus,  in  which  lime  salts  are  gradually  deposited.  Such  a  condition 
may  be  seen  once  or.  twice  a  year  in  the  post  mortem  room  of  any  large  hos- 
pital. (&)  By  perforation  of  the  lung.  Although  in  this  event  death  may 
take  place  rapidly,  by  suffocation,  as  Aretaus  says,  yet  in  cases  in  which  it 
occurs  gradually  recovery  may  follow.  Since  1873,  when  I  saw  a  case  of  this 
kind  in  Traube's  clinic,  and  heard  his  remarks  on  the  subject,  I  have  seen  a 
number  of  instances -of  the  kind  and  can  corroborate  his  statement  as  to  the 
favorable  termination  of  many  of  them.  Empyema  may  discharge  either  by 
opening  into  the  bronchus  and  forming  a  fistula,  or,  as  Traube  pointed  out, 
by  producing  necrosis  of  the  pulmonary  pleura,  sufficient  to  allow  the  soaking 
of  the  pus  through  the  spongy  lung  tissue  into  the  bronchi.  In  the  first  way 
pneumothorax  usually,  though  not  always,  develops.  In  the  second  way  the 
pus  is  discharged,  without  formation  of  pneumothorax.  Even  with  a  bron- 
chial fistula  recovery  is  possible,  (c)  By  perforation  of  the  chest  wall— 
empyema  necessitatis.  This  is  by  no  means  an  unfavorable  method,  as  many 
cases  recover.  The  perforation  may  occur  anywhere  in  the  chest  wall,  but  is, 
as  Cruveilhier  remarked,  more  common  in  front.  It  may  be  anywhere  from 
the  third  to  the  sixth  interspace,  usually,  according  to  Marshall,  in  the  fifth. 
It  may  perforate  in  more  than  one  place,  and  there  may  be  a  fistulous  com- 
munication which  opens  into  the  pleura  at  some  distance  from  the  external 
orifice.  The  tumor,  when  near  the  heart,  may  pulsate.  The  discharge  may 
persist  for  years.  In  Copeland's  Dictionary  is  mentioned  an  instance  of  a 


662  DISEASES    OF   THE    RESPIRATORY    SYSTEM 

Bavarian  physician  who  had  a  pleural  fistula  for  thirteen  years  and  enjoyed 
fairly  good  health. 

An  empyema  may  perforate  the  neighboring  organs,  the  oesophagus,  peri- 
toneum, pericardium,  or  the  stomach.  A  remarkable  sequel  is  a  pleuro- 
ossophageal  fistula,  of  which  cases  have  been  reported  by  Voelcker,  Thursfield, 
and  myself.  In  my  case  there  was  a  fistulous  communication  through  the 
chest  wall.  Very  remarkable  cases  are  those  which  pass  down  the  spine  and 
along  the  psoas  into  the  iliac  fossa,  and  simulate  a  psoas  or  lumbar  abscess. 

4.     TUBERCULOUS    PLEURISY 

This  has  already  been  considered  (p.  178),  and  the  symptoms  and  physical 
signs  do  not  require  any  description  other  than  that  already  given  in  connec- 
tion with  the  sero-fibrinous  and  purulent  forms. 

5.     OTHER   VARIETIES    OF   PLEURISY 

Hsemorrhagic  Pleurisy. — A  bloody  effusion  is  met  with  under  the  follow- 
ing conditions :  (a)  In  the  pleurisy  of  asthenic  states,  such  as  cancer,  Bright's 
disease,  and  occasionally  in  the  malignant  fevers.  It  is  interesting  to  note  the 
frequency  with  which  hasmorrhagic  pleurisy  is  found  in  cirrhosis  of  the  liver. 
It  occurred  in  the  very  patient  in  whom  Laennec  first  accurately  described 
this  disease.  While  this  may  be  a  simple  hasmorrhagic  pleurisy,  in  a  majority 
of  the  cases  which  I  have  seen  it  has  been  tuberculous.  (&)  Tuberculous  pleu- 
risy, in  which  the  bloody  effusion  may  result  from  the  rupture  of  newly 
formed  vessels  in  the  soft  exudate  accompanying  the  eruption  of  miliary 
tubercles,  or  it  may  come  from  more  slowly  formed  tubercles  in  a  pleurisy 
secondary  to  extensive  pulmonary  disease,  (c)  Cancerous  pleurisy,  whether 
primary  or  secondary,  is  frequently  hasmorrhagic.  (d)  Occasionally  hasmor- 
rhagic  exudation  is  met  with  in  perfectly  healthy  individuals,  in  whom  there 
is  not  the  slightest  suspicion  of  tuberculosis  or  cancer.  In  one  such  case,  a 
large,  able-bodied  man,  the  patient  was  to  my  knowledge  healthy  and  strong 
eight  years  afterward.  And,  lastly,  it  must  be  remembered  that  during 
aspiration  the  lung  may  be  wounded  and  blood  in  this  •  way  get  mixed  with 
the  sero-fibrinous  exudate.  The  condition  of  haemorrhagic  pleurisy  is  to  be 
distinguished  from  haemothorax,  due  to  the  rupture  of  aneurism  or  the  pres- 
sure of  a  tumor  on  the  thoracic  veins. 

Diaphragmatic  Pleurisy. — The  inflammation  may  be  limited  partly  or 
chiefly  to  the  diaphragmatic  surface.  This  is  often  a  dry  pleurisy,  but  there 
may  be  effusion,  either  sero-fibrinous  or  purulent,  which  is  circumscribed  on 
the  diaphragmatic  surface.  In  these  cases  the  pain  is  low  in  the  zone  of  the 
diaphragm  and  may  simulate  that  of  acute  abdominal  disease.  It  may  be 
intensified  by  pressure  at  the  point  of  insertion  of  the  diaphragm  at  the  tenth 
rib.  The  diaphragm  is  fixed  and  the  respiration  is  thoracic  and  short.  An- 
dral  noted  in  certain  cases  severe  dyspnoea  and  attacks  simulating  angina. 
As  mentioned,  the  effusion  is  usually  plastic,  not  serous.  Serous  or  purulent 
effusions  of  any  size  limited  to  the  diaphragmatic  surface  are  extremely  rare. 
Intense  subjective  with  trifling  objective  features  are  always  suggestive  of 
diaphragmatic  pleurisy. 


ACUTE    PLEURISY  663 

Encysted  Pleurisy.— The  effusion  may  be  circumscribed  by  adhesions  or 
separated  into  two  or  more  pockets  or  loculi,  which  communicate  with  each 
other.  This  is  most  common  in  empyema.  In  these  cases  there  have  usu- 
ally been,  at  different  parts  of  the  pleura,  multiple  adhesions  by  which  the 
fluid  is  limited.  In  other  instances  the  recent  false  membranes  may  encapsu- 
late the  exudation  on  the  diaphragmatic  surface,  for  example,  or  the  part  of 
the  pleura  posterior  to  the  mid-axillary  line.  The  condition  may  be  very 
puzzling  during  life,  and  present  special  difficulties  in  diagnosis.  In  some 
cases  the  tactile  fremitus  is  retained  along  certain  lines  of  adhesion.  The 
exploratory  needle  should  be  freely  used. 

Interlobar  pleurisy  forms  an  interesting  and  not  uncommon  variety.  In 
nearly  every  instance  of  acute  pleurisy  the  interlobar  serous  surfaces  are  also 
involved  and  closely  agglutinated  together,  and  sometimes  the  fluid  is  encysted 
between  them.  In  this  position  tubercles  are  to  be  carefully  looked  for.  In 
a  case  of  this  kind  following  pneumonia  there  was  between  the  lower  and 
upper  and  middle  lobes  of  the  right  side  an  enormous  purulent  collection, 
which  looked  at  first  like  a  large  abscess  of  the  lung.  These  collections  may 
perforate  the  bronchi,  and  the  cases  present  special  difficulties  in  diagnosis. 

Diagnosis  of  Pleurisy 

Acute  plastic  pleurisy  is  readily  recognized.  In  the  diagnosis  of  pleuritic 
effusion  the  first  question  is,  Does  a  fluid  exudate  exist?  the  second,  What 
is  its  nature?  In  large  effusions  the  increase  in  the  size  of  the  affected  side, 
the  immobility,  the  absence  of  tactile  fremitus,  together  with  the  displace- 
ment of  organs,  give  infallible  indications  of  the  presence  of  fluid.  The  chief 
difficulty  arises  in  effusions  of  moderate  extent,  when  the  dulness,  the  pres- 
ence of  bronchophony,  and,  perhaps,  tubular  breathing  may  simulate  pneu- 
monia. The  chief  points  to  be  borne  in  mind  are:  (a)  Differences  ia  the 
onset  and  in  the  general  characters  of  the  two  affections,  more  particularly 
the  initial  chill,  the  higher  fever,  more  urgent  dyspnoea,  and  the  rusty  expecto- 
ration, which  characterize  pneumonia.  As  already  mentioned,  some  of  the 
cases  of  pneumococcus  pleurisy  set  in  like  pneumonia.  (&)  Certain  physical 
signs — the  more  wooden  character  of  the  dulness,  the  greater  resistance,  and 
the  marked  diminution  or  the  absence  of  tactile  fremitus  in  pleurisy.  The 
auscultatory  signs  may  be  deceptive.  It  is  usually,  indeed,  the  persistence  of 
tubular  breathing,  particularly  the  high-pitched,  even  amphoric  expiration, 
heard  in  some  cases  of  pleurisy,  which  has  raised  the  doubt.  The  intercostal 
spaces  are  more  commonly  obliterated  in  pleuritic  effusion  than  in  pneumonia. 
As  already  mentioned,  the  displacement  of  organs  is  a  very  valuable  sign.  Now- 
adays with  the  hypodermic  needle  the  question  is  easily  settled.  A  separate 
small  syringe  with  a  capacity  of  two  drachms  should  be  reserved  for  explora- 
tory purposes,  and  the  needle  should  be  longer  and  firmer  than  in  the  ordi- 
nary hypodermic  instrument.  With  careful  preliminary  disinfection  the  in- 
strument can  be  used  with  impunity,  and  in  cases  of  doubt  the  exploratory 
puncture  should  be  made  without  hesitation.  Pneumothorax  is  an  occasional 
sequence,  The  hypodermic  needle  is  especially  useful  in  those  cases  in  which 
there  are  pseudo-cavernous  signs  at  the  base.  In  cases,  too,  of  massive  pneu- 
monia, in  which  the  bronchi  are  plugged  with  fibrin,  if  the  patient  has  not 
been  seen  from  the  outset,  the  diagnosis  may  be  impossible  without  it. 


664  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

On  the  left  side  it  may  be  difficult  to  differentiate  a  very  large  pericardia1! 
from  a  pleural  effusion.  The  retention  of  resonance  at  the  base,  the  presence 
of  Skoda's  resonance  toward  the  axilla,  the  absence  of  dislocation  of  the  heart- 
beat to  the  right  of  the  sternum,  the  feebleness  of  the  pulse  and  of  the  heavt- 
sounds,  and  the  urgency  of  the  dyspnoea,  out  of  all  proportion  to  the  extent 
of  the  effusion,  are  the  chief  points  to  be  considered.  Unilateral  hydrothorax, 
which  is  not  at  all  uncommon  in  heart-disease,  presents  signs  identical  with 
those  of  sero-fibrinous  effusion.  Certain  tumors  within  the  chest  may  simu- 
late pleural  effusion.  It  should  be  remembered  that  many  intrathoracic 
growths  are  accompanied  by  exudation.  Malignant  disease  of  the  lung  and 
of  the  pleura  and  hydatids  of  the  pleura  produce  extensive  dulness,  with  sup- 
pression of  the  breath-sounds,  simulating  closely  effusion. 

On  the  right  side,  abscess  of  the  liver,  subdiaphragmatic  abscess,  and 
hydatid  cysts  may  rise  high  into  the  pleura  and  produce  duluess  and  enfeebled 
breathing.  Often  in  these  cases  there  is  a  friction  sound,  which  should  excite 
suspicion,  and  the  upper  outline  of  the  dulness  is  sometimes  plainly  convex. 
In  a  case  of  cancer  of  the  kidney  the  growth  involved  the  diaphragm  very 
early,  and  for  months  there  were  signs  of  pleurisy  before  our  attention  was 
directed  to  the  kidne}r.  In  all  cases  of  doubt  the  X-ray  examination  is  a  great 
aid;  exploratory  puncture  should  be  done  without  hesitation. 

The  second  question,  as  to  the  nature  of  the  fluid,  is  quickly  decided  by 
the  use  of  the  needle.  The  persistent  fever,  the  occurrence  of  sweats,  a  leuco- 
cytosis,  and  the  increase  in  the  pallor  suggest  the  presence  of  pus.  In  chil- 
dren the  complexion  is  often  sallow  and  earthy.  In  protracted  cases,  even  in 
children,  when  the  general  symptoms  and  the  appearance  of  the  patient  have 
been  most  strongly  suggestive  of  pus,  the  syringe  has  withdrawn  clear  fluid. 
On  the  other  hand,  effusions  of  short  duration  may  be  purulent,  even  when 
the  general  symptoms  do  not  suggest  it.  In  pneumonia  the  practitioner 
should  be  on  the  alert  if  the  crisis  is  delayed  or  the  temperature  rises  after 
the  crisis,  if  chills  and  sweats  follow,  or  if  the  cough  changes  to  one  of 
paroxysmal  type  of  great  intensity.  There  are  three  groups :  (a)  The  pres- 
ence of  the  empyema  is  readily  detected.  (&)  It  is  suspected,  but  it  is  not 
possible  to  locate  the  pus  by  the  ordinary  physical  means.  The  exploratory 
needle  should  be  freely  used  with  the  aid  of  a  local  anaesthetic;  many  punc- 
tures may  be  made  without  discomfort,  (c)  In  a  few  instances  small  inter- 
lobar  collections,  small  mural  abscesses,  and  the  diaphragmatic  form  may 
escape  detection  until  an  operation  is  performed.  The  prognostic  import  of 
the  bacteriological  examination  of  the  aspirated  fluid  is  as  follows:  The 
pneumococcus  is  of  favorable  significance,  as  such  cases  usually  get  well 
rapidly,  even  with  a  single  aspiration.  The  streptococcus  empyema  is  the 
most  serious  form,  and  even  after  a  free  drainage  the  patient  may  succumb  to 
a  general  septicasmia.  A  sterile  fluid  indicates  in  a  majority  of  instances  a 
tuberculous  origin. 

Treatment 

At  the  onset  the  severe  pain  may  be  relieved  by  hot  or  cold  applications, 
hut  a  hypodermic  of  morphia  is  more  effective.  The  Paquelin  cautery  may  be 
Mghtly  but  freely  applied.  It  is  well  to  administer  a  mercurial  or  saline  purge. 
Fixing  the  side  by  careful  strapping  with  long  strips  of  adhesive  plaster,  which 


ACUTE    PLEURISY  665 

should  pass  well  over  the  middle  line,  drawn  tightly  and  evenly,  gives  great 
relief,  and  I  can  corroborate  the  statement  of  F.  T.  Roberts  as  to  its  efficacy. 
Cupping,  wet  or  dry,  is  now  seldom  employed.  Blisters  are  of  no  special 
service  in  the  acute  stages,  although  they  relieve  the  pain.  The  ice-bag  may 
be  used  as  in  pneumonia.  The  open-air  treatment  should  be  begun  early,  as 
a  majority  of  the  cases  are  tuberculous.  Medicines  are  rarely  required  and 
mercurials  are  not  indicated.  A  Dover's  powder  may  be  given  at  night. 

When  effusion  has  taken  place,  mustard  plasters  or  iodine,  producing 
slight  counter-irritation,  appear  useful,  particularly  in  the  later  stages. 
Iodide  of  potassium  is  of  doubtful  benefit.  By  some  the  salicylates  are  be- 
lieved to  be  of  special  efficacy ;  but  the  drug  treatment  of  the  disease  is  most 
unsatisfactory.  The  dry  diet  and  frequent  saline  purges  (given  in  concen- 
trated form  before  breakfast  in  Hay's  method)  may  be  tried.  Recently  it  has 
been  advised  to  use  a  salt-free  diet. 

Early  and  if  necessary  repeated  aspiration  of  the  fluid  is  the  most  satis- 
factory method  of  treatment.  The  results  obtained  by  Delafield  in  200  cases 
treated  by  early  aspiration  have  never  been  equalled  by  any  other  method. 
The  credit  of  introducing  aspiration  in  pleuritic  effusions  is  due  to  Morrill 
Wyman,  of  Cambridge,  Mass.,  and  Henry  I.  Bowditch,  of  Boston.  Years 
prior  to  Dieulafoy's  work,  aspiration  was  in  constant  use  at  the  Massachusetts 
General  Hospital  and  was  advocated  repeatedly  by  Bowditch.  As  the  ques- 
tion is  one  of  some  historical  interest,  I  give  Bowditch's  conclusions  concern- 
ing aspiration,  expressed  more  than  sixty  years  ago,  and  which  practically 
represent  the  opinion  of  to-day:  "(1)  The  operation  is  perfectly  simple,  but 
slightly  painful,  and  can  be  done  with  ease  upon  any  patient  in  however 
advanced  a  stage  of  the  disease.  (2)  It  should  be  performed  forthwith  in  all 
cases  in  which  there  is  complete  filling  up  of  one  side  of  the  chest.  (3)  He 
had  determined  to  use  it  in  any  case  of  even  moderate  effusion  lasting  more 
than  a  few  weeks  and  in  which  there  should  seem  to  be  a  disposition  to  resist 
ordinary  modes  of  treatment.  (4)  He  urged  this  practice  upon  the  profes- 
sion as  a  very  important  measure  in  practical  medicine ;  believing  that  by  this 
method  death  may  frequently  be  prevented  from  ensuing  either  by  sudden 
attack  of  dyspnoea  or  subsequent  phthisis,  and,  finally,  from  the  gradual 
wearing  out  of  the  powers  of  life  or  inability  to  absorb  the  fluid."  When  the 
fluid  reaches  to  the  clavicle  the  indication  for  aspiration  is  imperative.  Fever 
'is  not  a  contra-indication ;  indeed,  sometimes  with  serous  exudates  the  tem- 
perature falls  after  aspiration. 

The  operation  is  extremely  simple  and  is  practically  without  risk.  The 
2pot  selected  for  puncture  should  be  either  in  the  sixth  intercostal  space  in 
the  mid-axilla  or  at  the  outer  angle  of  the  scapula  in  the  eighth  space.  The 
arm  of  the  patient  should  be  brought  forward  with  the  hand  on  the  opposite 
shoulder,  so  as  to  widen  the  spaces.  The  needle  should  be  thrust  in  close  to 
the  upper  margin  of  the  rib,  so  as  to  avoid  the  intercostal  artery,  the  wounding 
of  which,  however,  is  an  exceedingly  rare  accident.  The  fluid  should  be  with- 
drawn slowly.  The  amount  will  depend  on  the  size  of  the  exudate.  If  the 
fluid  reaches  to  the  clavicle  a  litre  or  more  may  be  withdrawn  with  safety.  In 
chronic  cases  of  serous  pleurisy  after  the  failure  of  repeated  tappings  S.  West 
has  shown  the  great  value  of  free  incision  and  drainage.  He  has  reportsd 
cases  of  recovery  after  effusions  of  fifteen  and  eighteen  months'  standing. 
44 


666  DISEASES   OF   THE   RESPIRATORY    SYSTEM 

Repeated  tapping  may  be  required  in  some  cases.  In  the  chronic  cases  the 
injection  of  adrenalin  solution  (20  to  30  drops  of  a  1  to  1,000  solution)  into 
the  pleural  cavity  after  aspiration  has  proved  of  value. 

SYMPTOMS  AND  ACCIDENTS  DURING  PAKACENTESIS. — Pain  is  usually  com- 
plained of  after  a  certain  amount  of  fluid  has  been  withdrawn ;  it  is  sharp  and 
cutting  in  character.  Coughing  occurs  toward  the  close,  and  may  be  severe 
and  paroxysmal.  Pneumothorax  may  follow  an  exploratory  puncture  with  a 
hypodermic  needle;  it  is  rare  during  aspiration.  Subcutaneous  emphysema 
may  develop  from  the  point  of  puncture,  without  the  production  of  pneumo- 
thorax.  Cerebral  symptoms. — Faintness  is  not  uncommon.  Epileptic  con- 
vulsions may  occur  either  during  the  withdrawal  or  while  irrigating  the 
pleura.  These  symptoms  are  very  difficult  to  explain  and  are  regarded  by 
most  authors  as  of  reflex  origin.  Hemiplegia  may  follow.  And  lastly  sudden 
death  may  occur  either  from  syncope  or  during  the  convulsions. 

As  A.  E.  Russell  has  pointed  out, 'these  serious  and  even  fatal  events  may 
follow  exploratory  puncture  of  the  lung.  Such  accidents  of  paracentesis  and 
of  washing  out  the  pleura  are  explained  by  the  studies  of  Capp  and  Lewis, 
who  have  shown  that  a  sudden  and  sometimes  fatal  fall  in  blood  pressure  may 
follow  the  experimental  irrigation  of  the  pleura  in  dogs.  Occasionally  toxic 
symptoms  arise  resembling  those  of  the  "serum  illness" — pains  in  the  joints, 
albumin  in  the  urine,  and  oedema — suggestive  of  the  absorption  of  toxins  that 
act  like  a  heterogenous  serum.  Expectoration  of  a  large  quantity  of  albumin- 
ous fluid  may  occur  suddenly  after  the  tapping,  associated  with  dyspnoea. 
Some  cases  have  proved  rapidly  fatal,  with  the  features  of  an  acute  oedema  of 
the  lungs.  It  has  occurred  only  once  in  my  practice. 

The  after-treatment  of  pleurisy  is  important  and  the  patients  should  be 
handled  exactly  as  if  they  had  an  early  tuberculous  lung  lesion. 

Empyema. — A  majority  of  the  cases  get  well,  provided  that  free  drainage 
is  obtained,  and  it  makes  no  difference  practically  what  measures  are  followed 
so  long  as  this  indication  is  met.  The  good  results,  in  any  method  depend 
upon  the  thoroughness  with  which  the  cavity  is  drained.  Irrigation  of  the 
cavity  is  rarely  necessary  unless  the  contents  are  fetid.  In  the  subsequent 
treatment  a  point  of  great  importance  in  facilitating  the  closure  of  the  cavity 
is  the  distention  of  the  lung  on  the  affected  side.  This  may  be  accomplished 
by  the  method  advised  by  Ralston  James,  which  has  been  practiced  with  great 
success  in  the  surgical  wards  of  the  Johns  Hopkins  Hospital.  The  patient 
daily,  for  a  certain  length  of  time,  increasing  gradually  with  the  increase  of 
his  strength,  transfers  by  air-pressure  water  from  one  bottle  to  another.  The 
bottles  should  be  large,  holding  at  least  a  gallon  each,  and  by  the  arrange- 
ment of  tubes,  as  in  the  Wolff's  bottle,  an  expiratory  effort  of  the  patient 
forces  the  water  from  one  bottle  into  the  other.  Equally  efficacious  is  the 
plan  advised  by  Naunyn.  The  patient  sits  in  an  arm-chair  grasping  strongly 
one  of  the  rungs  with  the  hand  and  forcibly  compressing  the  sound  side 
against  the  arm  of  the  chair;  then  forcible  inspiratory  efforts  are  made  which 
act  chiefly  on  the  compressed  lung,  as  the  sound  side  is  fixed.  The  abscess 
cavity  is  gradually  closed,  partly  By  the  falling  in  of  the  chest  wall  and  partly 
by  the  expansion  of  the  lung.  In  some  instances  it  is  necessary  to  resect  por- 
tions of  one  or  more  ribs. 

Until  recently  efficient  drainage  has  been  regarded  as  the  most  important 


CHRONIC    PLEURISY  667 

consideration,  and  both  operative  and  drainage  proceedings  have  been  directed 
toward  making  the  chest  wall  conform  to  the  lung.  While  thoracotomy  and 
free  drainage  have  done  a  great  deal,  it  must  be  confessed  that  in  a  not  incon- 
siderable number  of  cases  the  obliteration  of  the  pus  cavity  has  been  a  long 
and  sometimes  hopeless  matter.  In  its  place  continuous  drainage  and  inter- 
mittent siphonage  have  been  used.  It  looks  as  if  surgeons  have  made  an 
important  departure  in  the  method  of  negative  tension  drainage  as  devised 
by  von  Eberts. 

The  physician  is  often  asked,  in  cases  of  empyema  with  emaciation,  hectic 
and  feeble,  rapid  pulse,  whether  the  patient-  could  stand  the  operation.  Even 
in  the  most  desperate  cases  the  surgeon  should  never  hesitate  to  make  a  free 
incision. 

II.    CHRONIC  PLEURISY 

This  affection  occurs  in  two  forms: 

Chronic  pleurisy  with  effusion  in  which  the  disease  may  set  in  insidi- 
ously or  may  follow  an  acute  sero-fibrinous  pleurisy.  There  are  cases  in  which 
the  liquid  persists  for  months  or  even  years  without  undergoing  any  special 
alteration  and  without  becoming  purulent.  Such  cases  have  the  characters 
which  we  have  described  under  pleurisy  with  effusion. 

Chronic  Dry  Pleurisy. — The  cases  are  met  with  (a)  as  a  sequence  of 
ordinary  pleural  effusion.  When  the  exudate  is  absorbed  and  the  layers  of  the 
pleura  come  together  there  is  left  between  them  a  variable  amount  of  fibrinous 
material  which  gradually  undergoes  organization,  and  is  converted  into  a 
layer  of  firm  connective  tissue.  This  process  goes  on  at  the  base,  and  is  repre- 
sented clinically  by  a  slight  grade  of  flattening,  deficient  expansion,  defective 
resonance  on  percussion,  and  enfeebled  breathing.  After  recovery  from  em- 
pyema the  flattening  and  retraction  may  be  still  more  marked.  In  both  cases 
it  is  a  condition  which  can  be  greatly  benefited  by  pulmonary  gymnastics.  In 
these  firm,  fibrous  membranes  calcification  may  occur,  particularly  after 
empyema.  It  is  not  very  uncommon  to  find  between  the  false  membranes  a 
small  pocket  of  fluid  forming  a  sort  of  pleural  cyst.  In  the  great  majority 
of  these  cases  the  condition  is  one  which  need  not  cause  anxiety.  There  may 
be  an  occasional  dragging  pain  at  the  base  of  the  lung  or  a  stitch  in  the  side, 
but  patients  may  remain  in  perfectly  good  health  for  years.  The  most  ad- 
vanced grade  of  this  secondary  dry  pleurisy  is  seen  in  those  cases  of  empyema 
which  have  been  left  to  themselves  and  have  perforated  and  ultimately  healed 
by  a  gradual  absorption  or  discharge  of  the  pus,  with  retraction  of  the  side  of 
the  chest  -and  permanent  carnification  of  the  lung.  Traumatic  lesions,  such 
as  gunshot  wounds,  may  be  followed  by  an  identical  condition.  Post  mortem, 
it  is  quite  impossible  to  separate  the  layers  of  the  pleura,  which  are  greatly 
thickened,  particularly  at  the  base,  and  surround  a  compressed,  airless,  fibroid 
lung.  Bronchiectasis  may  gradually  ensue,  and  in  one  remarkable  case  which 
I  saw  on  several  occasions  with  Blackader,  of  Montreal,  not  only  on  the 
affected  side,  but  also  in  the  lower  lobe  of  the  other  lung. 

(b)  Primitive  dry  pleurisy.— Tins  condition  may  directly  follow  the  acute 
plastic  pleurisy  already  described;  but  it  may  set  in  without  any  acute  symp- 
toms whatever,  and  the  patient's  attention  may  be  called  to  it  by  feeling  the 


668  DISEASES    OF    THE    RESPIRATORY    SYSTEM 

pleural  friction.  A  constant  effect  of  this  primitive  dry  pleurisy  is  the  adhe- 
sion of  the  layers.  This  is  probably  an  invariable  result,  whether  the  pleurisy 
is  primary  or  secondary.  The  organization  of  the  thin  layer  of  exudation  in 
a  pneumonia  will  unite  the  two  surfaces  by  delicate  bands.  Pleural  adhesions 
are  extremely  common,  and  it  is  rare  to  examine  a  body  entirely  free  from 
them.  They  may  be  limited  in  extent  or  universal.  Thin  fibrous  adhesions 
do  not  produce  any  alteration  in  the  percussion  characters,  and,  if  limited, 
there  is  no  special  change  heard  on  auscultation.  When,  however,  there  is 
general  synechia  on  both  sides  the  expansile  movement  of  the  lung  is  consid- 
erably impaired.  We  should  naturally  think  that  universal  adhesions  would 
interfere  materially  with  the  function  of  the  lungs,  but  practically  we  see 
many  instances  in  which  there  has  not  been  the  slightest  disturbance.  The 
physical  signs  of  total  adhesion  are  by  no  means  constant.  It  has  been  stated 
that  there  is  a  marked  disproportion  between  the  degree  of  expansion  of  the 
chest  walls  and  the  intensity  of  the  vesicular  murmur,  but  the  latter  is  a  very 
variable  factor,  and  under  perfectly  normal  conditions  the  breath-sounds,  with 
very  full  chest  expansion,  may  be  extremely  feeble.  The  diaphragm  phe- 
nomenon— Litten's  sign — is  absent. 

As  already  stated,  it  is  possible,  as  the  late  Sir  Andrew  Clark  held,  that 
a  primitive  dry  pleurisy  may  gradually  lead  to  great  thickening  of  the  mem- 
branes, and  ultimate  invasion  of  the  lung,  causing  a  cirrhosis. 

Lastly,  there  is  a  primitive  dry  pleurisy  of  tuberculous  origin.  In  it  both 
parietal  and  costal  layers  are  greatly  thickened — perhaps  from  2  to  3  mm. 
each— and  present  firm  fibroid,  caseous  masses  and  small  tubercles,  while 
uniting  these  two  greatly  thickened  layers  is  a  reddish-gray  fibroid  tissue, 
sometimes  infiltrated  with  serum.  This  may  be  a  local  process  confined  to  one 
pleura,  or  it  may  be  in  both.  These  cases  are  sometimes  associated  with  a 
similar  condition  in  the  pericardium  and  peritoneum. 

Occasionally  remarkable  vaso-motor  phenomena  occur  in  chronic  pleurisy, 
whether  simple  or  in  connection  with  tuberculosis  of  an  apex.  Flushing  or 
sweating  of  one  cheek  or  dilatation  of  the  pupil  ar'e  the  common  manifesta- 
tions. They  appear  to  be  due  to  involvement  of  the  first  thoracic  ganglion  at 
the  top  of  the  pleural  cavity. 

III.  HYDROTHORAX 

Hydrothorax  is  a  transudation  of  simple  non-inflammatory  fluid  into  the 
pleural  cavities,  and  occurs  as  a  secondary  process  in  many  affections.  The 
fluid  is  clear,  without  any  flocculi  of  fibrin,  and  the  membranes  are  smooth. 
It  is  met  with  more  particularly  in  connection  with  general  dropsy,  either 
renal,  cardiac,  or  haemic.  It  may,  however,  occur  alone,  or  with  only  slight 
oedema  of  the  feet.  A  child  was  admitted  to  the  Montreal  General  Hospital 
with  urgent  dyspnoea  and  cyanosis,  and  died  the  night  after  admission.  She 
had  extensive  bilateral  hydrothorax,  which  had  come  on  early  in  the  nephritis 
of  scarlet  fever.  In  renal  disease  hydrothorax  is  almost  always  bilateral,  but 
in  heart  affections  one  pleura  is  more  commonly  involved.  The  physical  signs 
are  those  of  pleural  effusion,  but  the  exudation  is  rarely  excessive.  In  kidney 
and  heart-disease,  even  when  there  is  no  general  dropsy,  the  occurrence  of 
dyspnoea  should  at  once  direct  attention  to  the  pleura,  since  many  patients 


PNETJMOTHORAX  669 

are  carried  off  by  a  rapid  effusion.  In  chronic  valvular  disease  the  effusion  is 
usually  on  the  right  side,  and  may  recur  for  months.  -  Stengel  attributes  the 
greater  frequency  of  the  dextral  effusion  to  compression  of  the  azygos  veins. 
Post  mortem  records  show  the  frequency  with  which  this  condition  is  over- 
looked.  The  saline  purges  will  in  many  cases  rapidly  reduce  the  effusion,  but, 
if  necessary,  aspiration  should  be  practiced  repeatedly. 

IV.  PNEUMOTHORAX 

(Hydro-Pneumothorax  and  Pyo-Pneumothorax) 

Air  alone  in  the  pleural  cavity,  to  which  the  term  pneumothorax  is  strictly 
applicable,  is  an  extremely  rare  condition.  It  is  almost  invariably  associated 
with  a  serous  fluid — hydro-pneumothorax,  or  with  pus — pyo-pneumothorax. 

Etiology. — There  exists  normally  within  the  pleural  cavity  of  an  adult 
a  negative  pressure  of  several  (3  to  5)  millimetres  of  mercury,  due  to  the 
recoil  of  the  distended,  perfectly  elastic  lung.  Hence,  through  any  opening 
connecting  the  pleural  cavity  with  the  external  air  we  should  expect  air  to 
rush  in  until  this  negative  pressure  is  relieved.  To  explain  the  absence  of 
pneumothorax  in  a  few  cases  of  external  injury  laying  the  pleura  bare,  in 
which  it  would  be  expected,  S.  West  has  assumed  the  existence  of  a  cohesion 
between  the  pleura?,  but  this  force  has  not  as  yet  been  satisfactorily  demon- 
strated. 

In  a  case  of  pneumothorax,  if  the  opening  causing  it  remain  patent,  which 
occurs  only  in  some  external  wounds,  or  especially  perforations  through  con- 
solidated areas  of  the  lungs,  the  intrathoracic  pressure  will  be  that  of  the 
atmosphere,  the  lung  will  be  found  to  have  collapsed  as  much  as  possible  by 
virtue  of  its  own  elastic  tension,  the  intercostal  grooves  obliterated,  the  heart 
displaced  to  the  other  side,  and  the  diaphragm  lower  than  normal,  because 
the  negative  pressure  by  reason  of  which  these  organs  are  partly  retained  in 
their  ordinary  position  has  been  relieved.  If  the  opening  becomes  closed  the 
intrathoracic  pressure  may  rise  above  the  atmospheric  and  the  above-men- 
tioned displacements  be  much  increased.  But  most  perforations  through  the 
lung  are  valvular,  a  property  of  lung  tissue,  and  the  intrapleural  pressure  is 
soon  about  7  mm.  of  mercury.  If  there  be  a  fluid  exudate  the  pressure  may  be 
higher,  but  the  high  pressures  supposed  are  more  apparent  than  real,  and  that 
measured  at  the  autopsy  table  is  quite  surely  not  that  during  life.  It  is  more 
a  question  of  the  amount  of  distention  than  the  actual  pressure  which  de- 
termines the  discomfort  of  the  patient. 

Pneumothorax  arises:  (1)  In  perforating  wounds  of  the  chest,  in  which 
case  it  is  sometimes  associated  with  extensive  cutaneous  emphysema.  It  may 
follow  exploratory  puncture  either  with  a  small  needle  or  an  aspirator.  There 
were  ten  cases  in  my  series.  Pneumothorax  rarely  follows  fracture  of  the 
rib,  even  though  the  lung  may  be  torn.  (2)  In  perforation  of  the  pleura 
through  the  diaphragm,  usually  by  malignant  disease  of  the  stomach  or  colon, 
or  abscess  of  the  liver  perforating  lung  and  pleura.  The  pleura  may  also  be 
perforated  in  cases  of  cancer  of  the  oesophagus.  (3)  When  the  lung  is  per- 
forated. This  is  by  far  the  most  common  cause,  and  may  occur:  (a)  In  the 
normal  lung  from  rupture  of  the  air-vesicles  during  straining  or  even  when 


C70  DISEASES    OF   THE   RESPIRATORY    SYSTEM 

at  rest.  Special  attention  has  been  called  to  this  accident  by  S.  West  and  De 
H.  Hall.  The  air  may  be  absorbed  and  no  ill  effect  follow.  It  does  not 
necessarily  excite  pleurisy,  as  pointed  out  many  years  ago  by  Gairdner,  but 
inflammation  and  effusion  are  the  usual  result.  In  one  of  my  cases  the  condi- 
tion developed  as  the  patient  was  going  down-stairs;  no  effusion  followed; 
he  did  not  react  to  tuberculin.  (&)  From  perforation  due  to  local  disease  of 
the  lung,  either  the  softening  of  a  caseous  focus  or  the  breaking  of  a  tubercu- 
lous cavity.  According  to  S.  West,  90  per  cent,  of  all  the  cases  are  due  to 
this  cause.  Less  common  are  the  cases  due  to  septic  broncho-pneumonia  and 
to  gangrene.  A  rare  cause  is  the  breaking  of  a  hsmorrhagic  infarct  in  chronic 
heart-disease,  of  which  I  met  an  instance  a  few  years  ago.  (c)  Perforation 
of  the  lung  from  the  pleura,  which  arises  in  certain  cases  of  empyema  and 
produces  a  pleuro-bronchial  fistula.  (4)  Spontaneously,  by  the  development 
in  pleural  exudates  of  the  gas  bacillus  (B.  aerogenes  capsulatus  Welch).  Of 
48  cases,  the  basis  of  Emerson's  exhaustive  monograph  (J.  H.  H.  Reports, 
vol.  xi),  22  were  tuberculous,  6  were  the  result  of  trauma,  10  of  aspiration. 
2  were  spontaneous,  2  followed  bronchiectasis,  2  abscess  of  the  lung,  1  gan- 
grene, 2  an  empyema,  and  1  abscess  of  the  liver  perforating  through  the  lung. 

Pneumothorax  occurs  chiefly  in  adults,  though  cases  are  met  with  in  very 
young  children.  It  is  more  frequent  in  males  than  in  females. 

A  remarkable  recurrent  variety  has  been  described  by  S.  West,  Goodhart, 
and  Furney.  In  Goodhart's  case  the  pneumothorax  developed  first  in  one 
side  and  then  in  the  other. 

Morbid  Anatomy. — If  the  trocar  or  blow-pipe  is  inserted  between  the  ribs, 
there  may  be  a  jet  of  air  of  sufficient  strength  to  blow  out  a  lighted  match. 
On  opening  the  thorax  the  mediastinum  and  pericardium  are  seen  to  be 
pushed,  or  rather,  as  Douglas  Powell  pointed  out,  "drawn  over"  to  the  oppo- 
site side;  but,  as  before  mentioned,  the  heart  is  not  rotated,  and  the  relation 
of  its  parts  is  maintained  much  as  in  the  normal  condition.  A  serous  or  puru- 
lent fluid  is  usually  present,  and  the  membranes  arex  inflamed.  The  cause  of 
the  pneumothorax  can  usually  be  found  without  difficulty.  In  the  great 
majority  of  instances  it  is  the  perforation  of  a  tuberculous  cavity  or  a  break- 
ing of  a  superficial  caseous  focus.  The  orifice  of  rupture  may  be  extremely 
small.  In  chronic  cases  there  may  be  a  fistula  of  considerable  size  communi- 
cating with  the  bronchi.  The  lung  is  usually  compressed  and  carnified. 

Symptoms. — The  onset  is  usually  sudden  and  characterized  by  severe  pain 
in  the  side,  urgent  dyspnoea,  and  signs  of  general  distress,  as  indicated  by 
slight  lividity  and  a  very  rapid  and  feeble  pulse — the  pneumothorax  acutis- 
simus  of  Unverricht.  There  may,  however,  be  no  urgent  symptoms,  particu- 
larly in  cases  of  long-standing  phthisis. 

PHYSICAL  SIGNS. — The  physical  signs  are  very  distinctive.  Inspection 
shows  marked  enlargement  of  the  affected  side  with  immobility.  The  heart 
impulse  is  usually  much  displaced.  On  palpation  the  fremitus  is  greatly 
diminished  or  more  commonly  abolished.  On  percussion  the  resonance  may  be 
tympanitic  or  even  have  an  amphoric  quality.  This,  however,  is  not  always 
the  case.  It  may  be  a  flat  tympany,  resembling  Skoda's  resonance.  In  some 
instances  it  may  be  a  full,  hyperresonant  note,  like  emphysema;  while  in 
others — and  this  is  very  deceptive — there  is  dulness.  These  extreme  variations 
depend  doubtless  upon  the  degree  of  intrapleural  tension.  On  several  occa- 


PNEUMOTHOKAX  .  671 

sions  I  have  known  an  error  in  diagnosis  to  result  from  ignorance  of  the  fact 
that,  in  certain  instances,  the  percussion  note  may  be  "muffled,  toneless,  almost 
dull"  (Walshe).  There  is  usually  dulness  at  the  base  from  effused  fluid,  which 
can  readily  be  made  to  change  the  level  by  altering  the  position  of  the  patient. 
Movable  dulness  can  be  obtained  much  more  readily  in  pneumothorax  than 
in  a  simple  pleurisy.  On  auscultation  the  breath-sounds  are  suppressed. 
Sometimes  there  is  only  a  distant  feeble  inspiratory  murmur  of  marked  am- 
phoric quality.  The  contrast  between  the  loud  exaggerated  breath-sounds  on 
the  normal  side  and  the  absence  of  the  breath-sounds  on  the  other  is  very 
suggestive.  The  rales  have  a  peculiar  metallic  quality,  and  on  coughing  or 
deep  inspiration  there  may  be  what  Laennec  termed  the  metallic  tinkling. 
The  voice,  too,  has  a  curious  metallic  echo.  What  is  sometimes  called  the 
coin-sound,  termed  by  Trousseau  the  bruit  d'airain,  is  very  characteristic. 
To  obtain  it  the  auscultator  should  place  one  ear  on  the  back  of  the  chest 
wall  while  the  assistant  taps  one  coin  on  another  on  the  front  of  the  chest. 
The  metallic  echoing  sound  which  is  produced  in  this  way  is  one  of  the  most 
constant  and  characteristic  signs  of  pneumothorax.  And,  lastly,  the  Hip- 
pocratic  succussion  splash  may  be  obtained  when  the  auscultator's  head  is 
placed  upon  the  chest  while  the  patient's  body  is  shaken.  A  splashing  sound 
is  produced,  which  may  be  audible  at  a  distance.  A  patient  may  himself 
notice  it  in  making  abrupt  changes  in  posture.  The  signs,  distention,  immo- 
bility, lack  of  vocal  fremitus,  hyperresonance,  absence  of  breath-sounds  and 
coin-sound,  are  those  of  the  pure  pneumothorax  of  Laennec.  The  metallic 
phenomena  may  be  present,  e.  g.,  the  metallic  tinkling  and  amphoric  respira- 
tion, but  these  are  best  heard  in  cases  with  a  consolidated  lung  and  thickened 
pleura,  such  as  occur  in  tuberculosis.  The  movable  dulness  and  splash  on 
succussion  depend  on  fluid.  Of  other  physical  signs  displacement  of  organs 
is  most  constant.  As  already  mentioned,  the  heart  may  be  much  "drawn 
over"  to  the  opposite  side,  and  the  liver  greatly  displaced,  so  that  its  upper 
surface  is  below  the  level  of  the  costal  margin,  a  degree  of  dislocation  never 
seen  in  simple  effusion. 

Diagnosis. — The  diagnosis  of  pneumothorax  rarely  offers  any  difficulty,  as 
the  signs  are  very  characteristic.  In  cases  in  which  the  percussion  note  is  dull 
the  condition  may  be  mistaken  for  effusion.  Diaphragmatic  or  congenital 
hernia  following  a  crush  or  other  accident  may  closely  simulate  pneumothorax. 

In  cases  of  very  large  phthisical  cavities  with  tympanitic  percussion  reso- 
nance and  rales  of  an  amphoric,  metallic  quality,  the  question  of  pneumotho- 
rax is  sometimes  raised.  In  those  rare  instances  of  total  excavation  of  one 
lung  the  amphoric  and  metallic  phenomena  may  be  most  intense,  but  the 
absence  of  dislocation  of  the  organs,  of  the  succussion  splash,  and  of  the  coin- 
sound  suffices  to  differentiate  this  condition.  While  this  is  true  in  the  great 
majority  of  cases,  I  have  heard  the  bruit  d'airain  over  a  large  cavity  in  the 
right  upper  lobe.  The  condition  of  pyo-pneumothorax  subphrenicus  may 
simulate  closely  true  pneumothorax. 

The  X-ray  examination  is  of  great  help,  and  the  picture  in  ordinary 
pneumothorax  is  very  characteristic.  There  is  a  remarkable  condition,  de- 
scribed by  Newton  Pitt,  associated  with  aneurism  of  the  aorta,,  in  which  the 
sac  pressing  on  the  bronchus  causes  inflation  of  one  lung  with  a  picture  simu- 
lating pneumothorax  very  closely. 


672  DISEASES    OF    THE    RESPIRATOBY    SYSTEM 

Prognosis. — The  prognosis  in  cases  of  pneumothorax  depends  largely  upon 
the  cause.  S.  West  gives  a  mortality  of  70  per  cent.  The  tuberculous  cases 
usually  die  within  a  few  weeks.  Of  39  cases,  29  died  within  a  fortnight 
(West)  ;  10  patients  died  on  the  first  day,  2  within  twenty  and  thirty  minutes 
respectively  of  the  attack.  Of  our  22  tuberculous  cases  20  died,  and  5  of  the 
10  cases  following  aspiration.  Pneumothorax  in  a  healthy  individual  often 
ends  in  recovery.  There  are  tuberculous  cases  in  which  the  pneumothorax, 
if  occurring  early,  seems  to  arrest  the  progress  of  the  tuberculosis.  There 
is  a  chronic  pneumothorax  which  may  last  for  between  three  and  four  years. 
It  may  be  a  chronic  condition,  as  in  the  case  just  mentioned,  and  a  fair 
measure  of  health  may  be  enjoyed. 

Treatment. — There  are  three  groups  of  cases :  First,  in  the  pneumothorax 
acutissimus,  with  urgent  dyspnrea,  great  displacement  of  the  heart,  cyanosis, 
and  low  blood  pressure,  an  opening  should  be  made  in  the  pleura  and  kept 
open,  converting  a  valvular  into  an  open  variety.  Immediate  aspiration  with 
a  trocar  has  saved  life.  Secondly,  the  spontaneous  cases  which  usually  do 
well,  as  the  air  is  quickly  absorbed ;  so  also  with  the  traumatic  variety.  Very 
many  of  the  tuberculous  cases  are  best  let  alone,  if  the  patient  is  doing  well, 
or  if  the  disease  in  the  other  lung  is  advanced.  Thirdly,  when  there  is  pus, 
and  the  patient  is  not  doing  well,  or  in  the  tuberculous  variety  if  the  other 
lung  is  not  involved,  pleurotomy,  or  resection  of  one  or  two  ribs,  may  be  done. 
Of  nine  cases  in  my  series  two  recovered. 


V.    AFFECTIONS    OF    THE    MEDIASTINUM 

Lymphadenitis. — The  greater  number  of  glands  are  on  the  right  side,  and 
the  right  bronchus  passes  off  at  a  higher  level  (fifth  dorsal  vertebra)  than  the 
left.  The  glands  are  constantly  enlarged  in  all  inflammatory  affections  of  the 
lungs.  In  all  the  acute  affections  of  childhood  they  are  found  swollen.  They 
are  almost  constantly  involved  in  tuberculosis  of  the  lungs  and  they  are  not 
infrequently  the  only  organs  of  the  body  found  tuberculous.  Often  in  children 
the  glands  on  the  lung  root  become  enlarged  and  caseous  and  penetrate  deeply 
into  the  hilus  and  into  the  lung  itself. 

The  symptoms  of  enlarged  mediastinal  glands  are  very  uncertain  in  the 
simple  and  tuberculous  forms.  On  the  other  'hand  in  Hodgkin's  disease  and 
in  sarcoma  pressure  symptoms  are  the  rule. 

Much  attention  has  been  paid  recently  to  the  diagnosis  of  this  condition 
and  authors  speak  quite  lightly  of  the  possibility  of  recognizing  by  percussion 
the  various  grades  of  enlargement.  Indeed,  it  is  claimed  by  Kronig  and 
others  that  the  pressure  of  the  glands  on  the  right  bronchus  may  cause  a 
dulness  in  the  right  lung  apex  due  to  slight,  collapse.  The  shadows  on  the 
X-ray  picture  cast  by  enlarged  glands  are  believed  to  be  distinctive,  and 
examined  in  this  way  the  percentage  of  cases  in  children  is  very  high,  50  to 
60  in  some  series. 

D'Espine  says  there  is  a  change  in  the  whispered  voice  which  has  a  bron- 
chial ring  at  the  level  of  the  seventh  cervical  and  last  dorsal,  and  the  respira- 
tory murmur  may  be  rougher  and  harsher. 

Suppurative  Lymphadenitis. — Occasionally    abscess   in   the   bronchial    or 


AFFECTIONS    OF    THE    MEDIASTINUM  673 

tracheal  lymph-glands  is  found.  It  may  follow  the  simple  adenitis,  but  is 
most  frequently  associated  with  the  presence  of  tubercle.  The  liquid  portion 
may  gradually  become  absorbed  and  the  inspissated  contents  undergo  calcifica- 
tion. Serious  accidents  occasionally  occur,  as  perforation  into  the  oesophagus 
or  into  a  bronchus,  or  in  rare  instances,  as  in  the  case  reported  by  Sidney 
Phillips,  perforation  of  the  aorta,  as  well  as  a  bronchus,  which,  it  is  remarka- 
ble to  say,  did  not  prove  fatal  rapidly,  but  caused  repeated  attacks  of  haemop- 
tysis during  a  period  of  sixteen  months. 

Tumors:  Cancer  and  Sarcoma. — In  Hare's  elaborate  study  of  520  cases 
of  disease  of  the  mediastinum  there  were  134  cases  of  cancer,  98  cases  of  sar- 
coma, 21  cases  of  lymphoma,  7  cases  of  fibroma,  11  cases  of  dermoid  cysts,  8 
cases  of  hydatid  cysts  and  instances  of  lipoma,  gumma  and  enchondroma. 
From  this  we  see  that  cancer  is  the  most  common  form  of  growth.  The  tumor 
occurred  in  the  anterior  mediastinum  alone  in  48  of  the  cases  of  cancer  and  in 
33  of  the  cases  of  sarcoma.  There  are  three  chief  points  of  origin,  the  thy- 
mus,  the  lymph-glands,  and  the  pleura  and  lung.  Sarcoma  is  more  frequently 
primary  than  cancer.  Males  are  more  frequently  affected  than  females.  The 
age  of  onset  is  most  commonly  between  thirty  and  forty. 

SYMPTOMS. — The  signs  of  mediastinal  tumor  are  those  of  intrathoracic 
pressure.  In  some  cases  almost  the  entire  chest  is  filled  with  the  masses. 
The  heart  and  lungs  are  pushed  back  and  it  is  marvelous  how  life  can  be 
maintained  with  such  dislocation  and  compression  of  the  organs.  Dyspncea 
is  one  of  the  earliest  and  most  constant  symptoms,  and  may  be  due  either  to 
pressure  on  the  trachea  or  on  the  recurrent  laryngeal  nerves.  It  may,  indeed, 
be  cardiac,  due  to  pressure  upon  the  heart  or  its  vessels.  In  a  few  cases  it 
results  from  the  pleural  effusion  which  so  frequently  accompanies  intratho- 
racic growths.  Associated  with  the  dyspnoea  is  a  cough,  often  severe  and 
paroxysmal  in  character,  with  the  brazen  quality  of  the  so-called  aneurismal 
cough  when  a  recurrent  nerve  is  involved.  The  voice  may  also  be  affected  from 
a  similar  cause.  Pressure  on  the  vessels  is  common.  The  superior  vena  cava 
may  be  compressed  and  obliterated,  and  when  the  process  goes  on  slowly 
the  collateral  circulation  may  be  completely  established.  Less  commonly  the 
inferior  vena  cava  or  one  or  other  of  the  subclavian  veins  is  compressed.  The 
arteries  are  much  more  rarely  obstructed.  There  may  be  dysphagia,  due  to 
compression  of  the  oesophagus.  In  rare  instances  there  are  pupillary  changes, 
either  dilatation  or  contraction,  due  to  involvement  of  the  sympathetic.  Ex- 
pectoration of  blood,  pus,  and  hair  is  characteristic  of  the  dermoid  cyst,  of 
which  Christian  has  collected  40  cases. 

Physical  Signs.— On  inspection  there  may  be  orthopnoea  and  marked 
cyanosis  of  the  upper  part  of  the  body.  In  such  instances,  if  of  long  dura- 
tion, there  are  signs  of  collateral  circulation  and  the  superficial  mammary 
and  epigastric  veins  are  enlarged.  In  these  cases  of  chronic  obstruction  the 
finger-tips  may  be  clubbed.  There  may  be  bulging  of  the  sternum  or  the 
tumor  may  erode  the  bone  and  form  a  prominent  subcutaneous  growth, 
rapidly  growing  lymphoid  tumors  more  commonly  than  others  perforate  the 
chest  wall.  In  4  of  13  cases  of  Hodgkin's  disease  there  was  mediastinal 
growth  and  in  3  instances  the  sternum  was  eroded  and  perforated.  The  per- 
foration may  be  on  one  side  of  the  breast-bone.  The  projecting  tumor  may 
pulsate;  the  heart  may  be  dislocated  and  its  impulse  much  out  of  place.  Con- 


674  DISEASES    OF   THE   RESPIRATORY    SYSTEM 

traction  of  one  side  of  the  thorax  has  been  noted  in  a  few  instances.  On  pal- 
pation the  fremitus  is  absent  wherever  the  tumor  reaches  the  chest  wall.  If 
pulsating,  it  rarely  has  the  forcible,  heaving  impulse  of  an  aneurismal  sac. 
On  auscultation  there  is  usually  silence  over  the  dull  region.  The  heart- 
sounds  are  not  transmitted  and  the  respiratory  murmur  is  feeble  or  inaudible, 
rarely  bronchial.  Vocal  resonance  is,  as  a  rule,  absent.  Signs  of  pleural 
effusion  occur  in  a  great  many  instances  of  mediastinal  growth,  and  in  doubt- 
ful cases  the  aspirator  needle  should  be  used. 

Tumors  of  the  anterior  mediastinum  originate  usually  in  the  thymus,  or 
its  remnants,  or  in  the  connective  tissue;  the  sternum  is  pushed  forward  and 
often  eroded.  The  growth  may  be  felt  in  the  suprasternal  fossa ;  the  cervical 
glands  are  usually  involved.  The  pressure  symptoms  are  chiefly  upon  the 
venous  trunks.  Dyspnoea  is  a  prominent  feature. 

Intrathoracic  tumors  in  the  middle  and  posterior  mediastinum  origi- 
nate most  commonly  in  the  lymph-glands.  The  symptoms  are  out  of 
all  proportion  to  the  physical  signs;  there  is  urgent  dyspnoea  and  cough, 
which  is  sometimes  loud  and  ringing.  The  pressure  symptoms  are  chiefly 
upon  the  gullet,  the  recurrent  laryngeal,  and  sometimes  upon  the  azygos 
vein. 

In  a  third  group,  tumors  originating  in  the  pleura  and  the  lung,  the 
pressure  symptoms  are  not  so  marked.  Pleural  exudate  is  very  much  more 
common ;  the  patient  becomes  anaemic  and  emaciation  is  rapid.  There  may  be 
secondary  involvement  of  the  lymph-glands  in  the  neck. 

DIAGNOSIS. — The  diagnosis  of  mediastinal  tumor  from  aneurism  is  some- 
times extremely  difficult.  An  interesting  case  reported  and  figured  by  Soko- 
losski,  in  Bd.  19  of  the.  Deutsches  Archiv  fur  klinische  Medicin,  in  which 
Oppolzer  diagnosed  aneurism  and  Skoda  mediastinal  tumor,  illustrates  how  in 
some  instances  the  most  skillful  of  observers  may  be  unable  to  agree.  Scarcely 
a  sign  is  found  in  aneurism  which  may  not  be  duplicated  in  mediastinal 
tumor.  This  is  not  strange,  since  the  symptoms  in  both  are  largely  due  to 
pressure.  The  cyanosis,  the  venous  engorgement,  the  signs  of  collateral  cir- 
culation are,  as  a  rule,  much  more  marked  in  tumor.  The  time  element  is 
important.  If  a  case  has  persisted  for  more  than  eighteen  months  the  dis- 
ease is  probably  aneurism.  There  are,  however,  exceptions  to  this.  By  far 
the  most  valuable  sign  of  aneurism  is  the  diastolic  shock  so  often  to  be  felt, 
and  in  a  majority  of  cases  to  be  heard,  over  the  sac.  This  is  rarely,  if  ever, 
present  in  mediastinal  growths,  even  when  they  perforate  the  sternum  and 
have  communicated  pulsation.  Tracheal  tugging  is  rarely  present  in  tumor. 
Another  point  of  importance  is  that  a  tumor,  advancing  from  the  mediasti- 
num, eroding  the  sternum,  and  appearing  externally,  if  aneurismal,  has  forci- 
ble, heaving,  and  distinctly  expansile  pulsations.  The  radiating  pain  in  the 
back  and  arms  and  neck  is  rather  in  favor  of  aneurism,  as  is  also  a  beneficial 
influence  on  it  of  iodide  of  potassium.  The  remarkable  traumatic  cyanosis 
of  the  upper  half  of  the  body  which  follows  compression  injuries  of  the  thorax 
could  scarcely  be  mistaken  for  the  effect  of  tumor.  In  skillful  hands  the 
X-ray  picture  gives  us  now  a  means  of  differentiating  aneurism  and  tumor 
which  is  rarely  at  fault. 

The  frequency  of  pleural  effusion  in  connection  with  mediastinal  tumor 
is  to  be  constantly  borne  in  mind.  It  may  .give  curiously  complex  characters 


AFFECTIOXS    OF    THE    MEDIASTINUM  675 

to  the  physical  signs — characters  which  are  profoundly  modified  after  aspira- 
tion of  the  liquid.     Occasionally  a  tumor  of  the  mediastinum  is  operable. 

Abscess  of  the  Mediastinum.— Hare  collected  115  cases  of  mediastinal 
abscess,  in  77  of  which  there  were  details  sufficient  to  permit  the  analysis. 
Of  these  cases  the  great  majority  occurred  in  males.  Forty-four  were  in- 
stances of  acute  abscess.  The  anterior  mediastinum  is  most  commonly  the 
seat  of  the  suppuration.  The  cases  are  most  frequently  associated  with 
trauma.  Some  have  followed  erysipelas  or  occurred  in  association  with 
eruptive  fevers.  Many  cases,  particularly  the  chronic  abscesses,  are  of  tuber- 
culous origin.  Of  sym.ptoms,  pain  behind  the  sternum  is  the  most  common. 
It  may  be  of  a  throbbing  character,  and  in  the  acute  cases  is  associated  with 
fever,  sometimes  with  chills  and  sweats.  If  the  abscess  is  large  there  may  be 
dyspncea.  The  pus  may  burrow  into  the  abdomen,  perforate  through  an  inter- 
costal space,  or  it  may  erode  the  sternum.  Instances  are  on  record  in  which 
the  abscess  has  discharged  into  the  trachea  or  oesophagus.  In  many  cases, 
particularly  of  chronic  abscess,  the  pus  becomes  inspissated  and  produces  no 
ill  effect.  The  physical  signs  may  be  very  indefinite.  A  pulsating  and  fluctu- 
ating tumor  may  appear  at  the  border  of  the  sternum  or  at  the  sternal  notch. 
The  absence  of  bruit,  of  the  diastolic  shock,  and  of  the  expansile  pulsation 
usually  enables  a  correct  diagnosis  to  be  made.  When  in  doubt  a  fine  hypo- 
dermic needle  may  be  inserted. 

Indurative  Mediastino-Pericarditis. — Harris  has  reviewed  the  subject.  In 
one  form  there  are  adherent  pericardium  and  great  increase  in  the  fibrous 
tissues  of  the  mediastinum;  in  another  there  is  adherent  pericardium  with 
union  to  surrounding  parts,  but  vei-y  little  mediastinitis ;  in  a  third  the  peri- 
cardium may  be  uninvolved.  The  disease  is  rare;  of  22  cases  17  were  in 
males;  only  2  were  above  thirty  years  of  age.  The  symptoms  are  essentially 
those  of  that  form  of  adhesive  pericardium  which  is  associated  with  great 
hypertrophy  and  dilatation  of  the  heart,  and  in  which  the  patients  present  a 
picture  of  cyanosis,  dyspncea,  anasarca,  etc.  The  pulsus  paradoxus,  described 
by  Kussmaul,  is  not  distinctive.  Occasionally  there  is  also  a  proliferative 
peritonitis.  Mediastinal  friction  is  sometimes  heard  in  patients  with  adhesive 
mediastino-pericarditis — dry,  coarse,  crackling  rales  heard  along  the  sternum, 
particularly  when  the  arms  are  raised. 

Miscellaneous  Affections. — In  Hare's  monograph  there  were  7  instances 
of  fibroma,  11  cases  of  dermoid  cyst,  8  cases  of  hydatid  cyst,  and  cases  of 
lipoma  and  gumma. 

Emphysema  of  the  Mediastinum. — Air  in  the  cellular  tissues  of  the  me- 
diastinum is  met  with  in  cases  of  trauma,  and  occasionally  in  fatal  cases  of 
diphtheria  and  in  whooping-cough.  It  may  extend  to  the  subcutaneous  tis- 
sues. Champneys  has  called  attention  to  its  frequency  after  tracheotomy,  in 
which,  he  says,  the  conditions  favoring  the  production  are  division  of  the  deep 
fascia,  obstruction  in  the  air-passages,  and  inspiratory  efforts.  The  deep 
fascia,  he  says,  should  not  be  raised  from  the  trachea.  It  is  often  associated 
with  pneumothorax,  and  more  often  in  rupture  of  the  lung  without  pneumo- 
thorax,  the  pleura  remaining  intact  and  the  air  dissecting  its  way  along  the 
bronchi  into  the  mediastinum  and  into  the  neck.  The  condition  seems  by  no 
means  uncommon.  Angel  Money  found  it  in  16  of  28  cases  of  tracheotomy, 
and  in  2  of  these  pnetfmothorax  also  was  present. 


SECTION  VII 
DISEASES  OF  THE  KIDNEYS 

I.    MALFORMATIONS 

Newman  classifies  the  malformations  of  the  kidney  as  follows:  A.  Dis- 
placements without  mobility — (1)  congenital  displacement  without  deform- 
ity; (2)  congenital  displacement  with  deformity;  (3)  acquired  displace- 
ments. B.  Malformations  of  the  kidney.  I.  Variations  in  number — (a)  su- 
pernumerary kidney;  (6)  single  kidney,  congenital  absence  of  one  kidney, 
atrophy  of  one  kidney;  (c)  absence  of  both  kidneys.  II.  Variations  in  form 
and  size — '(a)  general  variations  in  form,  tabulation,  etc.;  (&)  hypertrophy 
of  one  kidney;  (c)  fusion  of  two  kidneys — horseshoe  kidney,  sigmoid  kidney, 
disk-shaped  kidney.  C.  Variations  in  pelvis,  ureters,  and  blood-vessels. 

The  fused  kidneys  may  form  a  large  mass,  which  is  often  displaced,  be- 
ing either  in  an  iliac  fossa  or  in  the  middle  line  of  the  abdomen,  or  even  in 
the  pelvis.  Under  these  circumstances  it  may  be  mistaken  for  a  new  growth. 
In  Folk's  case  the  organ  was  removed  under  the  belief  that  it  was  a  floating 
kidney.  The  patient  lived  eleven  days,  had  complete  anuria,  and  it  was  found 
post  mortem  that  a  single  fused  kidney  had  been  removed.  A  second  case  of 
the  same  kind  has  been  reported. 

II.    MOVABLE  KIDNEY  ' 

(Floating  Kidney;  Palpable  Kidney;  Ren  mobilis;  Nephroptosis) 

Known  to  Eiolan  in  the  17th  century  and  to  Matthew  Baillie  and  to 
Rayer  in  the  first  half  of  the  19th  century,  it  is  only  during  the  past  quarter 
of  a  century  that  the  condition  has  attracted  widespread  attention. 

The  kidney  is  held  in  position  by  its  fatty  capsule,  by  the  peritoneum 
which  passes  in  front  of  it,  and  by  the  blood-vessels.  Normally  the  kidney 
is  firmly  fixed,  but  under  certain  circumstances  one  or  the  other  organ,  more 
rarely  both,  becomes  movable.  In  very  rare  cases  the  kidney  is  surrounded, 
to  a  greater  or  less  extent,  by  the  peritoneum,  and  is  anchored  at  the  hilus 
by  a  mesonephron.  Some  would  limit  the  term  floating  kidney  to  this  con- 
dition. 

Movable  kidney  is  almost  always  acquired.  It  is  more  common  in  women. 
Of  the  667  cases  collected  in  the  literature  by  Kuttner,  584  were  in  women 
and  only  83  in  men.  It  is  more  common  on  the  right  than  on  the  left  side. 
Of  727  cases  analyzed  by  this  author,  it  occurred  on  the-  right  iji  553  cases,  on 

676 


MOVABLE    KIDNEY  677 

the  left  in  81,  and  on  both  sides  in  93.  The  greater  frequency  of  the  con- 
dition in  women  may  be  attributed  to  compression  of  the  lower  thoracic  zone 
by  tight  lacing,  and,  more  important  still,  to  the  relaxation  of  the  abdominal 
walls  which  follows  repeated  pregnancies.  This  does  not  account  for  all  the 
cases,  as  movable  kidney  is  by  no  means  uncommon  in  nulliparse.  In  many 
cases  there  is  a  congenially  relaxed  condition  of  the  peritoneal  attachments. 
The  condition  has  been  met  with  in  infants  and  in  children.  Wasting  of  the 
fat  about  the  kidney  may  be  a  cause.  Trauma  and  the  lifting  of  heavy 
weights  are  occasionally  factors.  The  kidney  is  sometimes  dragged  down  by 
tumors.  .The  greater  frequency  011  the  right  side  is  probably  associated  with 
the  position  of  the  kidney  just  beneath  the  liver,  and  the  depression  to  which 
the  organ  is  subjected  with  each  descent  of  the  diaphragm  in  inspiration. 

And,  lastly,  movable  kidney  is  met  with  in  many  cases  which  present  that 
combination  of  neurasthenia  with  gastro-intestinal  disturbance  which  has  been 
described  by  Glenard  as  enteroptosis  (see  p.  548). 

To  determine  the  presence  of  a  movable  kidnay  the  patient  should  be 
placed  in  the  dorsal  position,  with  the  head  moderately  low  and  the  abdominal 
walls  relaxed.  The  left  hand  is  placed  in  the  lumbar  region  behind  the 
eleventh  and  twelfth  ribs;  the  right  hand  in  the  hypochondriac  region,  in 
the  nipple  line,  just  under  the  edge  of  the  liver.  Bimanual  palpation  may 
detect  the  presence  of  a  firm,  rounded  body  just  below  the  edge  of  the  ribs. 
If  nothing  can  be  felt,  the  patient  should  be  asked  to  draw  a  deep  breath, 
when,  if  the  organ  is  palpable,  it  is  touched  by  the  fingers  of  the  right  hand. 
Various  grades  of  mobility  may  be  recognized.  It  may  be  possible  barely  to 
feel  the  lower  edge  on  deep  palpation — palpable  Tcidney — or  the  organ  may 
be  so  far  displaced  that  on  drawing  the  deepest  breath  the  fingers  of  the  right 
hand  may  be,  in  a  thin  person,  slipped  above  the  upper  end  of  the  organ, 
which  can  be  readily  held  down,  but  can  not  be  pushed  below  the  level  of 
the  navel — movable  Tcidney.  In  a  third  group  of  cases  the  organ  is  freely 
movable,  and  may  even  be  felt  just  above  Poupart's  ligament,  or  may  be  in 
the  middle  line  of  the  abdomen,  or  can  even  be  pushed  over  beyond  this  point. 
To  this  the  term  floating  kidney  is  appropriate. 

The  movable  kidney  is  not  painful  on  pressure,  except  when  it  is  grasped 
very  firmly,  when  there  is  a  dull  pain,  or  sometimes  a  sickening  sensation. 
Examination  of  the  patient  from  behind  may  show  a  distinct  flattening  in 
the  lumbar  region  on  the  side  in  which  the  kidney  is  mobile. 

Symptoms. — In  a  large  majority  of  cases  there  are  no  symptoms,  and  if 
detected  accidentally  it  is  well  not  to  let  the  patient  know  of  its  presence. 
Far  too  much  stress  has  been  laid  upon  the  condition  of  late  years.  In  other 
instances  there  is  pain  in  the  lumbar  region  or  a  sense  of  dragging  and  dis- 
comfort, or  there  may  be  intercostal  neuralgia.  In  a  large  group  the  symp- 
toms are  those  of  neurasthenia  with  dyspeptic  disturbance.  In  women  the 
hysterical  symptoms  may  be  marked,  and  in  men  various  grades  of  hypo- 
chondriasis;  and  various  forms  of  insanity  have  been  attributed  to  it!  The 
gastric  disturbance  is  usually  a  form  of  nervous  dyspepsia-.  Dilatation  of  the 
stomach  has  been  observed,  owing,  as  suggested  by  Bartels,  to  pressure  of  the 
dislocated  kidney  upon  the  duodenum.  The  association  with  a  depressed 
stomach  is  common  in  women.  Constipation  is  not  infrequent.  Some 
writers  have  described  pressure  upon  the  gall-ducts,  with  jaundice,  but  this  is 


678  DISEASES    OP    TITE    KIDNEYS 

very  rare.     Faecal  accumulation  and  even  obstruction  may  be  associated  with 
the  displaced  organ. 

DIETI/S  CRISES. — In  connection  with  movable  kidney,  nearly  always  in 
women,  and  on  the  right  side,  there  are  remarkable  attacks  characterized  by 
pain,  chill,  nausea,  vomiting,  fever,  and  collapse.  They  were  described  first 
by  Dietl,  in  1864,  and  attributed  to  twist  or  kink  of  the  renal  vessels  or  of 
the  ureter.  In  the  subject  of  movable  kidney  they  may  recur  at  intervals  for 
months  or  years.  A  sudden  exertion,  an  error  in  diet,  or  standing  for  a  long 
time  may  bring  on  an  attack.  The  pain  is  in  the  renal  region,  of  great  in- 
tensity, simulating  colic,  and  radiates  down  to  the  ureter  and  through  to  the 
back.  The  patient  feels  nauseated  and  cold,  or  there  may  be  a  severe  chill; 
vomiting  is  common.  The  urine  is  scanty  and  contains  an  excess  of  urate 
and  oxalates;  sometimes  it  is  bloody.  Locally  there  are  two  conditions,  the 
affected  side  is  tender,  the  muscular  tension  increases,  and  the  kidney  may  be 
felt  enlarged,  sensitive  to  pressure  and  less  movable;  but  there  is  no  positive 
tumor.  In  other  cases  a  tumor  rapidly  forms  from  dilatation  of  the  pelvis 
of  the  kidney.  Appearing,  first  anteriorly,  at  the  edge  of  the  epigastric 
region,  it  may  gradually  reach  the  size  of  a  large  orange  or  a  cocoanut  and 
fills  the  entire  renal  region.  This  may  happen  within  thirty-six  or  forty- 
eight  hours.  The  nausea  persists,  there  is  fever,  the  patient  looks  ill,  and 
the  urine  may  be  scanty  or  bloody.  The  general  symptoms  abate,  the  local 
tenderness  lessens,  the  amount  of  urine  may  increase  rapidly,  and  in  ten  or 
twelve  hours  the  tumor  may  disappear.  In  a  month  or  two  with  a  return 
of  the  symptoms  the  tumor  re-appears,  and  again  subsides.  This  is  the  well- 
known  condition  of  intermittent  hy  drone  phrosis.,  which,  is  one  of  the  most 
serious  and  distressing  of  the  sequels  of  movable  kidney. 

Diagnosis. — The  diagnosis  of  movable  kidney  is  rarely  doubtful,  as  the 
shape  of  the  organ  is  usually  distinctive  and  the  mobility  marked.  Tumors 
of  the  gall-bladder,  ovarian  growths,  and  tumors  of  the  bowels  may  in  rare 
instances  be  confounded  with  it. 

Treatment. — In  many  instances  the  greatest  relief  is  experienced  from 
a  bandage  and  pad.  It  should  be  applied  in  the  morning,  with  the  patient 
in  the  dorsal  or  knee-breast  position,  and  she  should  be  taught  how  to  push 
up  the  kidney.  An  air  pad  may  be  used  if  the  organ  is  sensitive.  In  other 
cases  a  broad  bandage  well  padded  in  the  lower  abdominal  zone  pushes  up 
the  intestines  and  makes  them  act  as  a  support.  In  the  attacks  of  severe  colic 
morphia  is  required.  When  dependent,  as  seems  sometimes  the  case,  upon 
an  excess  of  uric  acid  or  the  oxalates,  the  diet  must  be  carefully  regulated. 
The  intermittent  hydronephrosis  may  be  relieved  by  the  pad  and  bandage. 
It  rarely  demands  immediate  operation.  The  kidney  may  have  to  be  stitched 
in  position. 

Stitching  of  the  kidney — nephrorrhaphy — is  the  most  suitable  procedure 
for  severe  cases,  and  relief  is  afforded  in  many  instances  by  the  operation, 
though  not  in  all.  Treatment  designed  to  increase  fat-formation  often  hdps 
to  hold  the  kidney  in  place.  In  the  neurasthenic  cases  a  prolonged  rest 
treatment  is  indicated. 


CIRCULATORY    DISTURBANCES  679 


m.    CIRCULATORY  DISTURBANCES 

Normally  the  secretion  of  urine  is  accomplished  by  the  maintenance  of 
a  certain  blood  pressure  within  the  glomeruli  and  by  the  activity  of  the  renal 
epithelium.  The  watery  elements  are  filtered  from  the  glorneruli,  the  amount 
depending  on  the  rapidity  and  the  pressure  of  the  blood  current;  the  quality, 
whether  normal  or  abnormal,  depending  upon  the  condition  of  the  capillary 
and  glomerular  epithelium ;  while  the  greater  portion  of  the  solid  ingredients 
are  excreted  by  the  epithelium  of  the  convoluted  tubules.  The  integrity  of 
the  epithelium  covering  the  capillary  tufts  within  Bowman's  capsule  is  essen- 
tial to  the  production  of  a  normal  urine.  If  under  any  circumstances  their 
nutrition  fails,  as  when,  for  example,  the  rapidity  of  the  blood  current  is  low- 
ered, so  that  they  are  deprived  of  the  necessary  amount  of  oxygen,  the  ma- 
terial which  filters  through  is  no  longer  normal  (i.  e.,  water),  but  contains 
serum  albumin.  Cohnheim  has  shown  that  the  renal  epithelium  is  extremely 
sensitive  to  circulatory  changes,  and  that  compression  of  the  renal  artery  for 
only  a  few  minutes  causes  serious  disturbance. 

The  circulation  of  the  kidney  is  remarkably  influenced  by  reflex  stimuli 
coming  from  the  skin.  Exposure  to  cold  causes  heightened  blood  pressure 
within  the  kidneys  and  increased  secretion  of  urine.  Bradford  has  shown 
that  after  excision  of  portions  of  the  kidney,  to  as  much  as  one-third  of  the 
total  weight,  there  is  a  remarkable  increase  in  the  flow  of  urine. 

Congestion  of  the  Kidneys. — (1)  ACTIVE  CONGESTION;  HYPEBJSMIA. — 
Acute  congestion  of  the  kidney  is  met  with  in  the  early  stage  of  nephritis, 
whether  due  to  cold  or  to  the  action  of  poisons  and  severe  irritants.  Turpen- 
tine, cubebs,  cantharides,  and  copaiba  cause  extreme  hyperaemia  of  the  organ. 
The  most  typical  congestion  of  the  kidney  which  we  see  post  mortem  is  that 
in  the  early  stage  of  acute  Bright's  disease,  when  the  organ  may  be  large, 
soft,  of  a  dark  color,  and  on  section  blood  drips  from  it  freely. 

It  has  been  held  that  in  all  the  acute  fevers  the  kidneys  are  congested, 
and  that  this  explained  the  scanty,  high  colored,  and  often  albuminous  urine. 
On  the  other  hand,  by  Eoy's  oncometer,  Walter  Mendelson  has  shown  that 
the  kidney  in  acute  fever  is  in  a  state  of  extreme  anaemia,  small,  pale,  and 
bloodless;  and  that  this  anasmia,  increasing  with  the  pyrexia  and  interfering 
with  the  nutrition  of  the  glomerular  epithelium,  accounts  for  the  scanty, 
dark-colored  urine  of  fever  and  for  the  presence  of  albumin.  In  the  pro- 
longed fevers,  however,  it  is  probable  that  relaxation  of  the  arteries  again 
takes  place.  Certainly  it  is  rare  to  find  post  mortem  such  a  condition  of  the 
kidney  as  is  described  by  Mendelson.  On  the  contrary,  the  kidney  of  fever 
is  commonly  swollen,  the  blood-vessels  are  congested,  and  the  cortex  fre- 
quently shows  traces  of  cloudy  swelling.  However,  the  circulatory  disturb- 
ances in  acute  fevers  are  probably  less  important  than  the  irritative  effects  of 
either  the  specific  agents  of  the  disease  or  the  products  produced  in  their 
growth  or  in  the  altered  metabolism  of  the  tissues.  The  urine  is  diminished 
in  amount,  and  may  contain  albumin  and  tube-casts,  sometimes  much  of  the 
former  and  few  of  the  latter. 

(2)  PASSIVE  CONGESTION;  MECHANICAL  HYPEILEMIA. — This  is  found  in 
cases  of  chronic  disease  of  the  heart  or  lung,  with  impeded  circulation,  and  as 


680  DISEASES    OF    THE    KIDNEYS 

a  result  of  pressure  upon  the  renal  veins  by  tumors,  the  pregnant  uterus,  or 
ascitic  fluid.  In  the  cardiac  kidney,  as  it  is  called,  the  cyanotic  induration 
associated  with  chronic  heart  disease,  the  organs  are  enlarged  and  firm,  the 
capsule  strips  off,  as  a  rule,  readily,  the  cortex  is  of  a  deep  red  color,  and  the 
pyramids  of  a  purple  red.  The  section  is  coarse  looking,  the  substance  is 
very  firm,  and  resists  cutting  and  tearing.  The  interstitial  tissue  is  increased, 
and  there  is  a  small-celled  infiltration  between  the  tubules.  Here  and  there 
the  Malpighian  tufts  have  become  sclerosed.  The  blood-vessels  are  usually 
thickened,  and  there  may  be  more  or  less  granular,  fatty,  or  hyaline  changes 
in  the  epithelium  of  the  tubules.  The  condition  is  indeed  a  diffuse  nephritis. 
The  urine  is  usually  reduced,  is  of  high  specific  gravity,  and  contains  more 
or  less  albumin.  Hyaline  tube  casts  and  blood  corpuscles  are  not  uncommon. 
In  some  cases  (over  half)  with  macroscopically  no  signs  of  chronic  or  acute 
nephritis  the  urinary  features  lead  to  the  diagnosis  of  acute  nephritis  (Emer- 
son). In  uncomplicated  cases  of  the  cyanotic  induration  uraemia  is  rare. 
On  the  other  hand,  in  the  cardiac  cases  with  extensive  arterio-sclerosis,  the 
kidneys  are  more  involved  and  the  renal  function  is  likely  to  be  disturbed. 


IV.    ANOMALIES   OF  THE  URINARY  SECRETION 

1.     ANTJEIA 

Total  suppression  of  urine  occurs  under  the  following  conditions: 

(a)  As  an  event  in  the  intense  congestion  of  acute  nephritis.  For  a  time 
no  urine  may  be  formed;  more  often  the  amount  is  greatly  reduced. 

(6)  More  commonly  complete  anuria  is  seen  in  subjects  of  renal  stone, 
fragments  of  which  block  both  ureters;  or  as  in  a  case  reported  by  Monod 
the  calculus  blocked  the  only  kidney,  the  other  being  represented  by  a  shell 
of  tissue.  In  this  "obstructive  suppression,"  as  it  is  called,  there  is  a  condi- 
tion which  has  been  called  latent  uraemia.  There  may  be  very  little  discom- 
fort, and  the  symptoms  are  very  unlike  those  of  ordinary  uraemia.  Convul- 
sions occurred  in  only  5  of  41  cases  (Herter) ;  headache  in  only  6;  vomiting 
in  only  12.  Consciousness  is  retained;  the  pupils  are  usually  contracted; 
the  temperature  may  be  low;  there  are  twitchings  and  perhaps  occasional 
vomiting.  Of  41  cases  in  the  literature,  35  occurred  in  males.  Of  36  cases 
in  which  there  was  absolute  anuria,  in  11  the  condition  lasted  more  than 
four  days,  in  18  cases  from  seven  to  fourteen  days,  and  in  7  cases  longer  than 
fourteen  days  (Herter).  Obstructive  suppression  is  met  with  also  when  can- 
cer compresses  both  ureters  and  involves  their  orifices  in  the  bladder. 

(c)  Cases  occur  occasionally  in  which  the  suppression  is  prerenal.  The 
following  are  among  the  more  important  conditions  with  which  this  form  of 
anuria  may  be  associated:  Fevers  and  inflammations;  acute  poisoning  by 
phosphorus,  lead,  and  turpentine;  in  the  collapse  after  severe  injuries  or 
after  operations,  or,  indeed,  after  the  passing  of  a  catheter;  in  the  collapse 
stage  of  cholera  and  yellow  fever;  and,  lastly,  there  is  an  hysterical  anuria,  of 
which  Charcot  reports  a  case  in  which  the  suppression  lasted  for  eleven  days. 
Bailey  reports  the  case  of  a  young  girl,  aged  eleven,  inmate  of  an  orphan 
asylum,  who  passed  no  urine  from  October  10th  to  December  12th  (when  8 


ANOMALIES    OF    THE    URINARY    SECRETION  681 

ounces  were  withdrawn),  and  again  from  this  date  to  March  1st!  The  ques- 
tion of  hysterical  deception  was  considered  in  the  case. 

A  patient  may  live  for  from  ten  days  to  two  weeks  with  complete  sup- 
pression. In  Folk's  case,  in  which  the  only  kidney  was  removed,  the  patient 
lived  eleven  days.  It  is  remarkable  that  in  many  instances  there  are  no  toxic 
features.  Adams  reports  a  case  of  recovery  after  nineteen  days  of  suppression. 

In  the  obstructive  cases  surgical  interference  should  be  resorted  to.  In 
the  non-obstructive  cases,  particularly  when  due  to  extreme  congestion  of 
the  kidney,  cupping  over  the  loins,  hot  applications,  free  purging,  and  sweat- 
ing with  pilocarpine  and  hot  air  are  indicated.  When  the  secretion  is  once 
started  diuretin  often  acts  well.  Large  hot  irrigations,  with  normal  salt  so- 
lution, with  Kemp's  double-current  rectal  tubes,  should  be  tried,  as  they  are 
stated  to  stimulate  the  activity  of  the  kidneys  in  a  remarkable  way. 

2.     HJEMATURIA 

Etiology. — The  following  division  may  be  made  of  the  condition  in  which 
hasmaturia  occurs: 

(1)  ESSENTIAL  H^MATURIA. — To  this  condition  much  attention  has  been 
paid  of  late,  as  the  surgeons  have  taught  us  to  recognize  its  frequency.    The 
not  very  happy  name  of  renal  hemophilia  has  been  given  to  it.    In  this  con- 
dition bleeding  takes  place  from  one  or  both  of  the  kidneys  without  any  evi- 
dence of  disease  to  the  naked  eye  or  to  the  microscope.    Angioma  and  capil- 
lary naavi  of  the  renal  papilte  and  of  the  pelves  of  the  kidney  are  excluded. 
The  subjects  are  usually  under  the  age  of  thirty.     The  bleeding  is  spontane- 
ous, often  associated  with  pain,  though  in  many  cases  the  attacks  are  pain- 
less.    The  X-ray  picture  is  negative,  the  haemorrhage  ceases  of  itself,  and 
only  in  a  few  cases  do  the  attacks  recur  with  such  frequency  that  the  patient 
becomes  anemic.     The  condition  has  been  referred  to  under  Gull's  name  of 
renal  epistaxis  in  several  previous  editions.     It  is  rarely  serious,  and  many 
cases  recover  spontaneously,  in  others  the  nephrotomy  stops  the  tendency  to 
bleeding,  though  why  it  should  do  so  is  difficult  to  say.     The  outlook  for 
patients  is  good  (see  Hale  White,  Q.  J.  M.,  1911). 

(2)  GENERAL  DISEASES.— In  the  malignant  specific  fevers,  in  purpura, 
and  occasionally  in  leukemia.  . 

(3)  RENAL  CAUSES.— Acute  congestion  and  inflammation,  as  m  Bright  s 
disease,  or  the  effect  of  toxic  agents,  such  as  turpentine,  carbolic  acid    and 
cantharides      When  the  carbolic  spray  was  in  use  many  surgeons  sutterec 
from  hematuria  in  consequence  of  this  poison.    Renal  infarction,  as  m  ulcer- 
ative  endocarditis.     New  growths,  in  which  the  bleeding  is  usually  profuse. 
In  tuberculosis  at  the  onset,  when  the  papillae  are  involved,  there  may  be 
bleeding.     Stone  in  the  kidney  is  a  frequent  cause.     Parasites:  The  Filana 
sanguinis  liominis  and  the  Bilharzia  cause  a  form  of  hsematuria  met  with 
in  the  tropics.     The  echinococcus  is  rarely  associated  with  hemorrhage. 

is  sometimes  met  with  in  floating  kidney. 

(4)  AFFECTIONS  OF  THE  URINARY  PASSAGES.-Stone  in  the  ureter,  tumor 
or  ulceration  of  the  bladder,  the  presence  of  a  calculus   parasites,  and    very 
rarelv    ruptured  veins  in  the  bladder.    Bleeding  from  the  urethra  occasion- 

Xff^^  and  as  a  result  of  the  lodgment  of  a  calculus.    Re- 
45 


682  DISEASES    OF    THE    KIDNEYS 

curring  hsematuria  may  be  an  early  symptom  in  enlarged  prostate.  An  un- 
usual cause  is  the  painful,  villous  tumor  of  the  renal  pelvis,  of  which  Savory 
and  Nash  report  a  remarkable  case  and  have  collected  49  others  from  the 
literature.  It  would  be  difficult  to  recognize  the  condition  from  stone.  An- 
gioma  and  capillary  naevi  of  the  papillae  may  cause  bleeding. 

(5)  TRAUMATISM. — Injuries  may  produce  bleeding  from  any  part  of  the 
urinary  passages.  By  a  fall  or  blow  on  the  back  the  kidney  may  be  ruptured, 
and  this  may  be  followed  by  very  free  bleeding;  less  commonly  the  blood 
comes  from  injury  of  the  bladder  or  of  the  prostate.  Blood  from  the  urethra 
is  frequently  due  to  injury  by  the  passage  of  a  catheter,  or  sometimes  to  falls. 
Transient  haematuria  follows  all  operations  on  the  kidney. 

The  malarial  haematuria  has  already  been  considered. 

Diagnosis. — The  diagnosis  of  haematuria  is  usually  easy.  The  color  of  the 
urine  varies  from  a  light  smoky  to  a  bright  red,  or  it  may  have  a  dark  porter 
color.  Examined  with  the  microscope,  the  blood-corpuscles  are  readily  recog- 
nized, either  plainly  visible  and  retaining  their  color,  in  which  case  they  are 
usually  crenated,  or  simply  as  shadows.  In  ammoniacal  urine  or  urines  of 
low  specific  gravity  the  haemoglobin  is  rapidly  dissolved  from  the  corpuscles, 
but  in  normal  urine  they  remain  for  many  hours  unchanged. 

It  is  important  to  distinguish  between  blood  coming  from  the  bladder 
and  from  the  kidneys,  though  this  is  not  always  easy.  From  the  bladder  the 
blood  may  be  found  only  with  the  last  portions  of  urine,  or  only  at  the  ter- 
mination of  micturition.  In  haemorrhage  from  the  kidneys  the  blood  and 
urine  are  intimately  mixed.  Clots  are  more  commonly  found  in  the  blood 
from  the  kidneys,  and  may  form  moulds  of  the  pelvis  or  of  the  ureter.  When 
the  seat  of  the  bleeding  is  in  the  bladder,  on  washing  out  this  organ,  the 
water  is  more  or  less  blood-tinged ;  but  if  the  source  of  the  bleeding  is  higher, 
the  water  comes  away  clear.  In  many  instances  it  is  difficult  to  settle  the 
question  by  the  examination  of  the  urine  alone,  and  the  symptoms  and  the 
physical  signs  must  also  be  taken  into  account.  Cystoscopic  examination  of 
the  bladder,  paying  especial  attention  to  the  urine  flowing  from  each  ureteral 
orifice,  and  catheterization  of  the  ureters  are  aids  in  the  diagnosis  of  doubt- 
ful cases. 

3.     H^MOGLOBINUEIA 

This  condition  is  characterized  by  the  presence  of  blood-pigment  in  the 
urine.  The  blood-cells  are  either  absent  or  in  insignificant  numbers.  The 
coloring  matter  is  not  haematin,  as  indicated  by  the  old  name,  hcematinuria, 
nor  in  reality  always  haemoglobin,  but  it  is  most  frequently  methaemoglobin. 
The  urine  has  a  red  or  brownish-red,  sometimes  quite  black,  color,  and  usually 
deposits  a  very  heavy  brownish  sediment.  When  the  haemoglobin  occurs  only 
in  small  quantities,  it  may  give  a  lake  or  smoky  color  to  the  urine.  Micro- 
scopic examination  shows  the  presence  of  granular  pigment,  sometimes  frag- 
ments of  blood  disks,  epithelium,  and  very  often  darkly  pigmented  urates. 
The  urine  is  also  albuminous.  The  number  of  red  blood  corpuscles  bears  no 
proportion  whatever  to  the  intensity  of  the  color  of  the  urine.  Examined 
spectroscopically,  there  are  either  the  two  absorption  bands  of  oxyhaemoglobin, 
which  is  rare,  or,  more  commonly,  there  are  the  three  absorption  bands  of 


ANOMALIES    OF   THE   tTEItfABY    SECRETION  683 

methsemoglobin,  of  which  the  one  in  the  red  near  C  is  characteristic.  Two 
clinical  groups  may  be  distinguished. 

Toxic  Hsemoglobinuria.— This  is  caused  by  poisons  which  produce  rapid 
dissolution  of  the  blood  corpuscles,  such  as  potassium  chlorate  in  large  doses, 
pyrogallic  acid,  carbolic  acid,  arseniuretted  hydrogen,  carbon  monoxide,  naph- 
thol,  and  muscarine;  also  the  poisons  of  scarlet  fever,  yellow  fever,  typhoid 
fever,  malaria,  and  syphilis.  It  has  also  followed  severe  burns.  Exposure  to 
excessive  cold  and  violent  muscular  exertion  are  stated  to  produce  hasmo- 
globinuria.  A  most  remarkable  toxic  form  occurs  in  horses,  coming  on  with 
great  suddenness  and  associated  with  paresis  of  the  hind  legs.  Death  may 
occur  in  a  few  hours  or  a  few  days.  The  animals  are  attacked  only  after 
being  stalled  for  some  days  and  then  taken  out  and  driven,  particularly  in 
cold  weather.  The  form  of  haemoglobinuria  from  cold  and  exertion  is  ex- 
tremely rare.  No  instance  of  it,  even  in  association  with  frost-bites,  came 
under  my  observation  in  Canada.  Blood  transfused  from  one  mammal  into 
another  causes  dissolution  of  the  corpuscles  with  the  production  of  haemo- 
globinuria ;  and,  lastly,  there  is  the  epidemic  hcemoglobinuria  of  the  new- 
born, associated  with  jaundice,  cyanosis,  and  nervous  symptoms. 

Paroxysmal  Haemoglobinuria.— This  rare  disease  is  characterized  by  the 
occasional  passage  of  bloody  urine,  in  which  the  coloring  matter  only  is  pres- 
ent. It  is  more  frequent  in  males  than  in  females,  and  occurs  chiefly  in 
adults.  It  seems  specially  associated  with  cold  and  exertion,  and  has  often 
been  brought  on,  in  a  susceptible  person,  by  the  use  of  a  cold  foot-bath.  It 
occurs,  too,  in  persons  subject  to  the  various  forms  of  Raynaud's  disease, 
and  the  relation  between  these  two  affections  is  extremely  close;  some  hold 
that  they  are  manifestations  of  one  and  the  same  disorder.  Druitt,  the  author 
of  the  well-known  Surgical  Vade-mecum,  has  given  a  graphic  description  of 
his  sufferings,  which  lasted  for  many  years,  and  were  accompanied  with  local 
asphyxia  and  local  syncope.  The  connection,  however,  is  not  very  common. 
In  only  one  of  the  cases  of  Raynaud's  disease  which  I  have  seen  was  paroxys- 
mal haBmoglobinuria  present,  and  in  it  epileptic  attacks  occurred  at  the  same 
time.  The  relation  of  hasmoglobinuria  to  malaria  has  been  considered. 

The  attacks  may  come  on  suddenly  after  exposure  to  cold  or  as  a  result 
of-  mental  or  bodily  exhaustion.  They  may  be  preceded  by  chills  and  pyrexia. 
In  other  instances  the  temperature  is  subnormal.  There  may  be  vomiting  and 
diarrhoea.  Pain  in  the  lumbar  region  is  not  uncommon.  The  hsemoglobinuria 
rarely  persists  for  more  than  a  day  or  two — sometimes,  indeed,  not  for  a  day. 
There  are  instances  in  which,  even  in  the  course  of  a  single  day,  there  have 
been  two  or  three  paroxysms,  and  in  the  intervals  clear  urine  has  been  passed. 
Jaundice  has  been  present  in  a  number  of  cases.  The  disease  is  rarely  if  ever 
fatal. 

Much  has  been  done  latterly  to  clear  up  the  nature  of  this  remarkable 
disease  by  the  studies  of  Eason,  Donath,  Landsteiner,  Hoover  and  Stone,  and 
Moss.  Briefly,  the  blood  serum  of  these  patients  contains  a  complex  haemo- 
lysin,  a  potential  toxin,  capable  of  dissolving  the  patient's  own  corpuscles  and 
those  of  other  individuals.  It  is  an  amboceptor  component  of  the  hsemolysin, 
not  the  complement,  that  is  peculiar,  and  this  amboceptor  differs  "from 
other  known  hsemolytic  amboceptors  in  that  it  will  unite  with  the  red  blood- 
corpuscles  only  at  a  low  temperature  in  the  presence  of  complement,  and 


684  DISEASES   OF   THE   KIDNEYS 

furthermore  in  that  it  is  capable  of  bringing  about  the  solution  of  the  pa- 
tient's own  cells  (auto-haemolytic  action),  and  those  of  other  members  of  the 
group  to  which  the  patient  belongs,  as  well  as  the  cells  of  members  of  other 
groups"  (Moss).  Atmospheric  cold  and  congestion  of  the  peripheral  ves- 
sels, as  in  Eaynaud's  disease,  will  reduce  the  temperature  of  the  blood  suffi- 
ciently to  permit  of  the  union  of  the  amboceptor  and  corpuscles,  and  haemol- 
ysis occurs  when  the  blood  passes  to  the  internal  organs. 

In  a  certain  number  of  cases  syphilis  is  present,  usually  congenital. 

Treatment. — In  all  forms  of  hasmaturia  rest  is  essential.  In  that  produced 
by  renal  calculi  the  recumbent  posture  may  suffice  to  check  the  bleeding.  Full 
doses  of  acetate  of  lead  and  opium  should  be  tried,  then  calcium  lactate,  ad- 
renalin, ergot,  gallic  acid  and  tannic  acid,  and  the  dilute  sulphuric  acid. 
The  oil  of  turpentine,  sometimes  recommended,  is  a  risky  remedy  in  ha?ma- 
turia.  Extr.  hamamelis  virgin,  and  extr.  hydrastis  canad.  are  also  recom- 
mended. Cold  may  be  applied  to  the  loins  or  dry  cups  in  the  lumbar  region. 
Incision  of  the  kidney  has  cured  the  so-called  "renal  epistaxis." 

The  treatment  of  paroxysmal  hasmoglobinuria  is  unsatisfactory.  Amyl 
nitrite  will  sometimes  cut  short  or  prevent  an  attack  (Chvostek).  During 
the  paroxysm  the  patient  should  be  kept  warm  and  given  hot  drinks.  If 
there  is  a  syphilitic  history,  iodide  of  potassium  in  full  doses  may  be  tried. 
In  a  warm  climate  the  attacks  are  much  less  frequent.  It  is  possible  that  an 
antitoxin  may  be  obtained  to  neutralize  the  haemolytic  amboceptor  of  the 
disease. 

4.    ALBUMINUEIA 

"Reasons  drawn  from  the  urine  are  as  brittle  as  the  urinal"  is  a  dictum 
of  Thomas  Fuller  peculiarly  appropriate  in  connection  with  this  subject. 

The  presence  of  albumin  in  the  urine,  formerly  regarded  as  indicative  of 
Bright's  disease,  is  now  recognized  as  occurring  under  many  circumstances 
without  the  existence  of  serious  organic  change  in  the  kidney.  Two  groups 
of  cases  may  be  recognized — those  in  which  the  ki'dneys  show  no  coarse  le- 
sions, and  those  in  which  there  are  evident  anatomical  changes. 

Albuminuria  without  Coarse  Renal  Lesions. — (a)  FUNCTIONAL,  SO-CALLED 
PHYSIOLOGICAL  ALBUMINURIA. — In  a  normal  condition  of  the  kidney  only 
the  water  and  the  salts  are  allowed  to  pass  from  the  blood.  When  albumi- 
nous substances  transude  there  is  probably  disturbance  in  the  nutrition  of 
the  epithelium  of  the  capillaries  of  the  tuft,  or  of  the  cells  surrounding  the 
glomerulus.  This  statement  is  still,  however,  in  dispute,  and  many  hold 
that  there  is  a  physiological  albuminuria  which  may  follow  muscular  work, 
the  ingestion  of  food  rich  in  albumin,  violent  emotions,  cold  bathing,  and 
dyspepsia.  On  one  point  all  agree,  that  the  cause  must  be  something  unusual 
and  excessive,  as  a  very  hard  tramp,  a  football  match,  a  race,  etc.  The  pres- 
ence of  albumin  in  the  urine,  in  any  form  and  under  any  circumstance,  may 
be  regarded  as  indicative  of  change  in  the  renal  or  glomerular  epithelium, 
a  change,  however,  which  may  be  transient,  slight,  and  unimportant,  de- 
pending upon  variations  in  the  circulation  or  upon  the  irritating  effects  of 
substances  taken  with  the  food  or  temporarily  present,  as  in  febrile  states. 

Albuminuria  of  adolescence  and  cyclic  albuminuria,  in  which  the  albumin 
is  present  only  at  certain  times  during  the  day — orthostatic  albuminuria — 


ANOMALIES    OF    THE    URINARY    SECRETION  685 

are  interesting  forms.  A  majority  of  the  cases  occur  in  young  persons — 
boys  more  commonly  than  girls— and  the  condition  is  often  discovered  acci- 
dentally. These  are  often  the  children  of  neurotic  parents,  and  have  well- 
marked  vasomotor  instability.  Some  cases  last  only  during  puberty,  some 
throughout  life.  The  condition  is  very  common,  particularly  in  young  men 
in  training — the  athletic  albuminuria  to  which  Collier  has  called  attention. 
Of  156  men  in  training  130  had  albumin  in  the  urine.  Erlanger  and  Hooker 
have  shown  that  the  alb'umin  is  excreted  only  during  periods  with  low  pulse 
pressure.  The  urine,  as  a  rule,  contains  only  a  very  small  amount  of  albumin, 
but  in  some  instances  large  quantities  are  present.  The  most  striking  fea- 
ture is  the  variability.  •  It  may  be  absent  in  the  morning  and  present  only 
after  exertion;  or  it  may  be  greatly  increased  after  taking  food,  particularly 
proteins.  Even  the  change  to  the  upright  position  (orthostatic)  may  suffice 
to  cause  it,  and  in  such  cases  there  may  be  tension  on  the  renal  veins  by 
increase  of  the  lumbar  curve,  since  it  has  been  shown  that  a  spinal  jacket 
will  prevent  the  appearance  of  the  albumin.  The  quantity  of  urine  may  be 
but  little,  if  at  all,  increased,  the  specific  gravity  is  usually  normal,  and  the 
color  may  be  high.  Occasionally  hyaline  casts  may  be  found,  and  in  some 
instances  there  has  been  transient  glycosuria.  As  a  rule,  the  pulse  is  not  of 
high  tension  and  the  second  aortic  sound  is  not  accentuated. 

Various  forms  of  this  affection  have  been  recognized  by  writers,  s-uch  as 
neurotic,  dietetic,  cyclic,  intermittent,  and  paroxysmal — names  which  indicate 
the  characters  of  the  different  varieties. 

Goodhart,  from  a  study  of  the  after  history  of  more  than  250  cases,  holds 
that  albuminuria  of  the  adolescent  has  no  sinister  effect  on  health  or  upon 
duration  of  life,  and  that  with  due  circumspection  such  cases  ought  not  to 
be  excluded  from  the  advantages  of  life  insurance,  or  from  clerkships  in 
banks  and  private  offices.  This  is  a  very  important  and  gratifying  statement 
from  a  man  who  has  made  a  special  study  of  the  subject. 

In  a  few  cases  the  albumin  is  persistent,  the  amount  is  larger,  though  it 
may  vary  from  day  to  day,  and  the  pulse  tension  is  increased,  and  there  are 
probably  indications  of  organic  changes  in  the  kidney. 

(&)  FEBRILE  ALBUMINURIA. — Pyrexia,  by  whatever  cause  produced,  may 
cause  slight  albuminuria.  The  presence  of  the  albumin  is  due  to  slight 
changes  in  the  glomeruli  induced  by  the  fever,  such  as  cloudy  swelling,  which 
can  not  be  regarded  as  an  organic  lesion.  It  is  extremely  common,  occurring 
in  pneumonia  (in  about  70  per  cent,  of  our  cases),  diphtheria,  typhoid  fever 
(about  60  per  cent,  of  our  cases),  malaria,  especially  the  aestivo-autumnal 
type,  and  even  in  the  fever  of  acute  tonsillitis.  The  amount  of  albumin  is 
slight,  and  it  usually  disappears  from  the  urine  with  the  cessation  of  the 
fever.  Hyaline  and  even  epithelial  casts  accompany  the  condition. 

(c)  H^EMIC  CHANGES.— Purpura,  scurvy,  chronic  poisoning  by  lead  or 
mercury,  syphilis,  leukgemia,  and  profound  anaemia  may  be  associated  with 
slight  albuminuria.    Abnormal  ingredients  in  the  blood,  such  as  bile  pigment 
and  sugar,  may  cause  the  passage  of  small  amounts  of  albumin. 

The  transient  albuminuria  of  pregnancy  may  belong  to  this  haBmic  group, 
although  in  a  majority  of  such  cases  there  are  changes  in  the  renal  tissue. 
Albumin  may  be  found  sometimes  after  the  inhalation  of  ether  or  chloroform. 

(d)  NERVOUS  SYSTEM.— Under  many  morbid  conditions  of  the  nervous 


G86  DISEASES    OF    THE    KIDNEYS 

system,  albumin  may  be  present  in  the  urine,  and  there  are  instances  in 
young  nervous  persons  which  are  not  easy  to  separate  from  the  so-called 
orthostatic  forms.  In  brain  tumors,  following  epileptic  attacks,  in  various 
types  of  meningitis,  albumin  has  been  present.  In  meningeal  haemorrhage, 
as  pointed  out  by  Guillain,  the  albumin  may  be  very  abundant,  5  to  20 
grams  in  the  litre. 

Albuminuria  with  Definite  Lesions  of  the  TJrinary  Organs. — (a)  Conges- 
tion of  the  kidney,  either  active,  such  as  follows  exposure  to  cold  and  is  as- 
sociated with  the  early  stages  of  nephritis,  or  passive,  due  to  obstructed  out- 
flow in  disease  of  the  heart  or  lungs,  or  to  pressure  on  the  renal  veins  by 
the  pregnant  uterus  or  tumors. 

(6)  Organic  disease  of  the  kidneys — acute  and  chronic  Bright's  disease, 
amyloid  and  fatty  degeneration,  suppurative  nephritis,  and  tumors. 

(c)  Affections  of  the  pelvis,  ureters,  bladder,  and  prostate,  when  associated 
with  the  formation  of  pus. 

Albumosuria. — Albumose,  peptone,  and  globulin  are  occasionally  found 
in  the  urine,  but  are  of  very  slight  clinical  significance.  They  are  found  in 
many  febrile  diseases,  in  chronic  suppuration,  and  whenever  protein  materials 
are  undergoing  autolysis,  as  in  pneumonia,  acute  yellow  atrophy,  and  during 
the  involution  of  the  uterus. 

Myelopathic  albumosnria,  "Kahler's  disease"  is  characterized  by  multiple 
myelomata  with  persistent  excretion  of  what  is  known  as  the  Bence-Jones 
body,  a  proteid  discovered  by  him  in  1848.  There  are  now  many  cases  on 
record.  Males  above  forty  years  of  age  are  usually  affected.  The  Bence- 
Jones  body  appears  rarely  with  other  tumors  of  the  bones.  The  myeloma  is 
a  true  tumor,  the  cells  of  which  resemble  the  plasma  rather  than  the  myelo- 
cytes  of  the  bone  marrow  (Christian).  In  a  case  which  I  saw  with  Ham- 
burger the  persistent  albumosuria  led  to  the  diagnosis  of  multiple  myelo- 
mata before  any  bone  tumors  could  be  felt.  The  disease  runs  a  fatal  course. 
The  simplest  reaction  is  the  white  precipitate  formed  on  adding  nitric  acid 
to  the  urine;  when  boiled  it  disappears,  to  reappear  on  cooling.  As  in  one 
of  Bradshaw's  cases,  the  urine  may  be  of  a  milky  white  color  when  passed. 

Prognosis. — Febrile  albuminuria  is  transient,  and  in  a  majority  of  the 
cases  depending  upon  hasmic  causes  the  condition  disappears  and  leaves  the 
kidneys  intact.  A  trace  of  albumin  in  a  man  over  forty,  with  or  without  a 
few  hyaline  casts,  is  not  of  much  significance,  except  as  an  indication  that 
his  kidneys,  like  his  hair,  are  beginning  to  turn  "gray"  with  age.  In  many 
instances  the  discovery  is  a  positive  advantage,  as  the  man  is  made  to  realize, 
perhaps  for  the  first  time,  that  he  has  been  living  carelessly.  I  have  discussed 
the  question  from  this  standpoint  in  a  paper  with  the  paradoxical  title  "On 
the  Advantages  of  a  Trace  of  Albumin  and  a  Few  Tube-casts  in  the  Urine  of 
Men  over  Fifty  Years  of  Age"  (N.  Y.  Med.  Jour.,  vol.  Ixxiv). 

The  persistence  of  a  slight  amount  of  albumin  in  young  men  without  in- 
creased arterial  tension  is  less  serious,  as  even  after  continuing  for  years  it 
may  disappear.  The  outlook  in  the  so-called  cyclic  albuminuria  has  been 
discussed. 

Practically  in  all  cases  the  presence  of  albumin  indicates  a  change  of 
some  sort  in  the  glomeruli,  the  nature,  extent,  and  gravity  of  which  it  is 
difficult  to  estimate;  so  that  other  considerations,  such  as  the  presence  of 


ANOMALIES   OF   THE   UMKABY   SECRETION  G8? 

tube-casts,  the  existence  of  increased  tension,  the  general  condition  of  the 
patient,  and  the  influence  of  digestion  upon  the  albumin,  must  be  carefully 
considered. 

The  physician  is  daily  consulted  as  to  the  relation  of  albuminuria  and 
life  assurance.  As  his  function  is  to  protect  the  interests  of  the  company, 
he  should  reject  all  cases  in  which  albumin  occurs  in  the  urine,  except  in 
young  persons  with  transient  albuminuria.  Naturally,  companies  lay  great 
stress  upon  the  presence  or  absence  of  albumin,  but  in  the  most  serious  and 
fatal  malady  with  which  they  have  to  deal — chronic  interstitial  nephritis — 
the  albumin  is  often  absent  or  transient,  even  when  the  disease  is  well  devel- 
oped. After  the  fortieth  year,  from  a  standpoint  of  life  insurance,  the  state 
of  the  arteries  and  the  blood  pressure  are  far  more  important  than  the  condi- 
tion of  the  urine. 

5.     BACTEEIUEIA 

Described  first  by  Eoberts  in  1881,  much  attention  has  been  paid  to  it  of 
late  years,  and  its  importance  recognized  both  as  a  secondary  and  a  primary 
affection.  The  secondary  form  is  best  illustrated  by  the  common  bacilluria 
of  typhoid  fever  already  described.  In  the  cases  in  which  there  is  no  recog- 
nizable cause  or  primary  focus  of  the  disease,  the  colon  bacillus,  streptococci, 
and  the  gonococcus  are  the  commonest  organisms.  The  bacilli  may  come 
directly  from  the  blood,  as  in  typhoid  fever,  and  probably  multiply  in  the 
urinary  passages,  or  they  may  come  from  a  focus  of  infection  anywhere  from 
Bowman's  capsule  to  the  prostate. 

Clinically  there  are  two  groups  of  cases,  the  bacilluria  pure  and  simple 
and  the  bacilluric  cystitis  or  pyelitis.  In  the  former  there  may  be  no  symp- 
toms; the  urine  may  have  a  slight  haziness  due  to  the  enormous  number  of 
organisms,  but  there  is  no  pus.  In  the  other  there  are  signs  of  inflammatory 
reaction  in  the  urinary  passages  and  there  is  pus.  Usually  with  the  Bacillus 
coli  infection  the  urine  is  acid,  with  the  staphylococcus  alkaline  and  often 
with  marked  phosphaturia.  The  cases  are  often  very  intractable.  Without 
cystitis  or  pyelitis  there  may  be  no  symptoms,  but  in  too  many  instances 
there  are  all  the  aggravated  phenomena  of  these  two  affections.  Many  cases 
clear  up  rapidly  with  hexamethylenamine.  Vaccine  therapy  has  been,  exten- 
sively used  but  not  with  very  good  results. 

6.     PYUEIA 
(Pus  in  the  Urine) 

Causes. — (a)  PYELITIS  AND  PYELONEPHRITIS. — In  large  abscesses  of  the 
kidney,  pyonephrosis,  the  pus  may  be  intermittent,  while  in  calculus  and 
tuberculous  pyelitis  the  pyuria  is  usually  continuous,  though  varying  in  in- 
tensity. In  cases  due  to  the  colon  or  tubercle  bacillus  the  urine  is  acid,  in 
those  due  to  the  proteus  bacillus  alkaline,  while  in  the  staphylococcus  cases 
the  urine  is  either  less  acid  than  normal,  or  alkaline.  In  the  pyelitis  and 
pyelonephritis  following  cystitis  the  urine  is  alkaline  or  acid,  depending  upon 
the  infecting  micro-organism;  more  mucus,  frequent  micturition,  and  a  pre- 
vious bladder  history  are  aids  in  diagnosis. 


688  DISEASES   OF   THE   KIDNEYS 

(6)  CYSTITIS. — The  urine  is  usually  acid,  especially  in  women,  since  the 
colon  bacillus  is  a  very  common  cause  of  these  infections.  The  pus  and  mucus 
are  more  ropy,  and  triple  phosphate  crystals  are  found  in  the  freshly  passed 
urine  in  the  alkaline  infections. 

(c)  URETHRITIS,  particularly  gonorrhoea.     The  pus  appears  first,  is  in 
small  quantities,  and  there  are  signs  of  local  inflammation. 

(d)  In  LEUCORRH(EA  the  quantity  of  pus  is  usually  small,  and  large  flakes 
of  vaginal  epithelium  are  numerous.     In  doubtful  cases,  when  leucorrhoea 
is  present,  the  urine  should  be  withdrawn  through  a  catheter. 

(e)  EDPTURE  OF  ABSCESSES  INTO  THE  URINARY  PASSAGES. — In  such  cases 
as  pelvic  or  perjtyphlitic  abscess  there  have  been  previous  symptoms  of  pus 
formation.    A  large  amount  is  passed  within  a  short  time,  then  the  discharge 
stops  abruptly  or  rapidly  diminishes  within  a  few  days. 

Pus  gives  to  the  urine  a  white  or  yellowish-white  appearance.  On  settling, 
the  sediment  is  sometimes  ropy,  the  supernatant  fluid  usually  turbid.  In 
cases  due  to  urea-decomposing  microbes  (proteus  bacillus,  various  staphylo- 
cocci)  the  odor  may  be  ammoniacal  even  in  fresh  urine.  Examination  with 
the  microscope  reveals  the  presence  of  a  large  number  of  pus-corpuscles, 
which  are  usually,  when  the  pus  comes  from  the  bladder,  well  formed;  the 
protoplasm  is  granular,  and  often  shows  many  translucent  processes. 

The  only  sediment  likely  to  be  confounded  with  pus  is  that  of  the  phos- 
phates; but  it  is  whiter  and  less  dense,  and  is  distinguished  immediately  by 
microscopic  examination  or  by  the  addition  of  acid. 

With  the  pus  there  is  always  more  or  less  epithelium  from  the  bladder 
and  pelves  of  the  kidneys,  but  since  in  these  situations  the  forms  of  cells  are 
practically  identical,  they  afford  no  information  as  to  the  locality  from  which 
the  pus  has  come. 

The  treatment  of  pus  in  the  urine  is  considered  under  the  conditions  in 
which  it  occurs. 

7.     CHYLUEIA— NON-PAEASITIC 

This  is  a  rare  affection,  occurring  in  temperate  regions  and  unassociated 
with  the  Filaria  bancrofti.  The  urine  is  of  an  opaque  white  color;  it  resem- 
bles milk  closely,  is  occasionally  mixed  with  blood  (hasmatochyluria),  and 
sometimes  coagulates  into  a  firm,  jelly-like  mass.  In  other  instances  there 
is  at  the  bottom  of  the  vessel  a  loose  clot  which  may  be  distinctly  blood  tinged. 
Under  the  microscope  the  turbidity  seems  to  be  caused  by  numerous  minute 
granules — more  rarely  oil  droplets  similar  to  those  of  milk.  In  Montreal  I 
made  the  dissection  in  a  case  of  thirteen  years'  duration  and  could  find  no 
trace  of  parasites.  The  urine  may  be  much  more  milky  shortly  after  taking 
food,  and  the  recumbent  posture  increases  the  milkiness.  It  has  been  shown 
in  one  case  that  the  urine  only  became  chylous  in  the  bladder,  and  Hertz 
found  obstruction  of  the  thoracic  duct  and  a  communicating  ruptured  lym- 
phatic vessel  in  the  bladder. 

8.    LITHUEIA 

The  general  relations  of  uric  acid  have  already  been  considered  in  speak- 
ing of  gout. 

Occurrence  in  the  Urine. — The  uric  acid  occurs  in   combination  chiefly 


ANOMALIES    OF    THE    URINARY    SECRETION  689 

with  ammonium,  and  sodium,  forming  the  acid  urates.  In  smaller  quan- 
tities are  the  potassium,  calcium,  and  lithium  salts.  The  uric  acid  may  be 
separated  from  its  bases  and  crystallizes  in  rhombs  or  prisms,  which  are 
usually  of  a  deep  red  color,  owing  to  the  staining  of  the  urinary  pigments. 
The  sediment  formed  is  granular  and  the  groups  of  crystals  look  like  grains 
of  Cayenne  pepper.  It  is  very  important  not  to  mistake  a  deposit  of  uric 
acid  for  an  excess.  The  deposition  of  numerous  grains  in  the  urine  within  a 
few  hours  after  passing  is  more  likely  to  be  due  to  conditions  which  diminish 
the  solvent  power  than  to  increase  in  the  quantity.  Of  the  conditions  which 
cause  precipitation  of  the  uric  acid  Roberts  gives  the  following:  "(1)  High 
acidity;  (2)  poverty  in  mineral  salts;  (3)  low  pigmentation;  and  (4)  high 
percentage  of  uric  acid."  The  grade  of  acidity  is  probably  the  most  impor- 
tant element. 

In  health  the  weight  of  uric  acid  excreted  bears  a  fairly  constant  ratio  to 
the  weight  of  urea  eliminated.  According  to  von  Noorden,  the  average  ratio 
is  1  to  50,  while  the  average  ratio  of  the  nitrogen  of  uric  acid  to  the  total 
nitrogen  eliminated  in  the  urine  is  1  to  70.  In  several  of  the  cases  of  gout  in 
my  wards  Futcher  found  that  in  the  intervals  between  the  acute  arthritic 
attacks  the  uric  acid  was  reduced  to  a  much  greater  extent  than  the  urea, 
so  that  the  ratio  of  the  former  to  the  latter  often  varied  between  1  to  300  up 
to  (in  one  case)  1  to  1,500,  a  return  to  about  the  normal  proportions  occur- 
ring during  the  acute  attacks. 

More  common  is  the  precipitation  of  amorphous  urates,  forming  the  so- 
called  brick-dust  or  lateritious  deposit,  which  has  a  pinkish  color,  due  to  the 
presence  of  urinary  pigment.  It  is  composed  chiefly  of  the  acid  sodium 
urates.  It  occurs  particularly  in  very  acid  urine  of  a  high  specific  gravity. 
As  the  urates  are  more  soluble  in  warm  solutions,  they  frequently  deposit  as 
the  urine  cools.  Here,  too,  the  deposition  does  not  necessarily,  indeed  usually 
does  not,  mean  an  excessive  excretion,  but  the  existence  of  conditions  favor- 
ing the  deposit. 

9.     OXALUEIA 

The  discovery  of  calcium  oxalate  crystals  in  the  urine  by  Donne  in  1838 
led  to  the  description  of  the  so-called  oxalic-acid  diathesis.  It  is  claimed  that 
all  the  oxalic  acid  found  in  the  urine  is  taken  into  the  body  with  the  food 
(Dunlop).  In  health  none,  or  only  a  trace,  is  formed  in  the  body.  The 
amount  fluctuates  with  the  quantity  of  food  taken,  and  is  usually  below  10 
milligrams  daily  (H.  Baldwin).  It  seems  to  be  formed  in  the  body  when 
there  is  an  absence  of  free  hydrochloric  acid  in  the  gastric  juice,  and  in 
connection  with  excessive  fermentation  in  the  intestines.  It  never  forms  a 
heavy  deposit,  but  the  crystals — usually  octahedral,  rarely  dumb-bell-shaped 
— collect  in  the  mucous  cloud  and  on  the  sides  of  the  vessel. 

When  in  excess  and  present  for  any  considerable  time,  the  condition  is 
known  as  oxaluria,  the  chief  interest  of  which  is  in  the  fact  that  the  crystals 
may  be  deposited  before  the  urine  is  voided,  and  form  a  calculus.  It  is  held 
by  many  that  there  is  a  special  diathesis  associated  with  its  presence  in  ex- 
cess and  manifested  clinically  by  dyspepsia,  particularly  the  nervous  form, 
irritability,  depression  of  spirits,  lassitude,  and  sometimes  marked  hypo- 
chondriasis.  There  may  be  in  addition  neuralgic  pains  and  the  general  symp- 


690  DISEASES    OF    THE    KIDNEYS 

toms  of  neurasthenia.  The  local  and  general  symptoms  are  probably  depend- 
ent upon  some  disturbance  of  metabolism  of  which  the  oxaluria  is  one  of  the 
manifestations.  It  is  a  feature  also  in  many  gouty  persons,  and  in  the  con- 
dition called  lithaemia. 

10.     CYSTINURIA 

This  rare  condition,  a  sort  of  chemical  malformation  (Garrod),  is  of 
clinical  importance  because  cystin  is  very  sparingly  soluble  and  calculi  may 
be  formed,  renal  or  vesical.  It  is  strongly  hereditary  and  has  been  traced 
through  three  generations.  The  quantity  excreted  is  about  0.5  gram  per 
diem,  and  the  excretion  persists  for  years,  or  even  for  life,  without  causing 
disturbance  of  health.  Cystin  is  one  of  the  primary  fractions  of  protein,  and 
its  excretion  is  one  of  the  as  yet  unexplained  errors  of  protein  metabolism. 
In  the  urinary  sediment  the  colorless  hexagonal  crystals  of  cystin  are  readily 
detected. 

11.     PHOSPHATUEIA 

The  phosphoric  acid  is  excreted  from  the  body  in  combination  with  potas- 
sium, sodium,  calcium,  and  magnesium,  forming  two  classes,  the  alkaline 
phosphates  of  sodium  and  potassium  and  the  earthy  phosphates  of  lime  and 
magnesia.  The  amount  of  phosphoric  acid  (P205)  excreted  in  the  twenty- 
four  hours  varies,  according  to  Hammarsten,  between  1  and  5  grams,  with 
an  average  of  2.5  grams.  It  is  derived  mainly  from  the  phosphoric  acid 
taken  in  the  food,  but  also  in  part  as  a  decomposition  product  from  nuclein, 
protagon,  and  lecithin.  Of  the  alkaline  phosphates,  those  in  combination  with 
sodium  are  the  most  abundant.  The  alkaline  phosphates  of  the  urine  are 
more  abundant  than  the  earthy  phosphates. 

Of  the  earthy  phosphates,  those  of  lime  are  abundant,  of  magnesium 
scanty.  In  urine  which  has  undergone  the  ammoniacal  fermentation,  either 
inside  or  outside  the  body,  there  is  in  addition  the  ammonio-magnesium  or 
triple  phosphate,  which  occurs  in  triangular  prisms  or  in  feathery  or  stellate 
crystals;  hence  the  term  of  stellar  phosphates  given  to  this  form.  The  earthy 
phosphates  occur  as  a  sediment  in  the  urine  when  the  alkalinity  is  due  to  a 
fixed  alkali,  or  under  certain  circumstances  the  deposit  may  take  place  within 
the  bladder,  and  then  the  phosphates  are  passed  at  the  end  of  micturition  as 
a  whitish  fluid,  which  is  popularly  confounded  with  spermatorrhoea.  Kecent 
study  of  these  cases  with  symptoms  of  neurasthenia  and  a  phosphate  sediment 
in  the  fresh  urine  would  indicate  an  abnormality  in  the  calcium  metabolism, 
an  absolute  increase  of  this  with  a  decrease  of  the  phosphoric  acid.  The  cal- 
cium phosphate  may  be  precipitated  by  heat  and  produce  a  cloudiness  which 
may  be  mistaken  for  albumin,  but  is  at  once  dissolved  upon  making  the  urine 
acid.  This  condition  is  very  frequent  in  persons  suffering  from  dyspepsia  or 
from  debility  of  any  kind.  The  phosphates  may  be  in  great  excess,  rising  in 
the  twenty-four  hours  to  from  7  to  9  grams  (Teissier),  whereas  the  normal 
amount  is  not  more  than  2.5  grams.  And,  lastly,  the  phosphates  may  be 
deposited  in  urine  which  has  undergone  decomposition,  in  which  the  carbonate 
of  ammonia  from  the  urea  combines  with  the  magnesium  phosphates,  forming 
the  triple  salt.  This  is  seen  in  cystitis,  due  to  a  urea  decomposing  microbe. 

The  clinical  significance  of  an  excess  of  phosphates,  to  which  the  term 


ANOMALIES   OF   THE   TTfcttfAfcY   SECftETtOtt  691 

phosphaturia  is  applied,  has  been  much  discussed.  It  must  be  remembered 
that  a  deposit  does  not  necessarily  mean  an  excess,  to  determine  which  a 
careful  analysis  of  the  twenty  four  hours'  secretion  should  be  made.  It  has 
long  been  thought  that  there  is  a  relation  between  the  activity  of  the  nerve 
tissues  and  the  output  of  phosphoric  acid ;  but  the  question  can  not  yet  be  con- 
sidered settled.  The  amount  is  increased  in  wasting  diseases,  such  as  phthi- 
sis, acute  yellow  atrophy  of  the  liver,  leukaemia,  and  severe  anaemia,  whereas 
it  is  diminished  in  acute  diseases  and  during  pregnancy. 

Teissier,  of  Lyons,  in  1876,  described  a  condition  to  which  he  gave  the 
name  of  "essential  phosphaturia,"  and  it  has  been  called  "phosphatic  dia- 
betes," the  symptoms  of  which  are  polyuria,  thirst,  emaciation,  and  a  great 
increase  in  the  excretion  of  phosphates,  which  would  rise  to  as  much  as  7  to 
9  grams  a  day.  The  condition  sometimes  simulates  true  diabetes  very  close- 
ly, even  to  the  pruritis  and  dry  skin.  In  a  remarkable  case  of  this  kind, 
under  my  observation  for  several  years,  Barker  studied  the  metabolism  very 
thoroughly,  and  found  it  normal  for  carbohydrates,  but  the  organic  phos- 
phorus percentage  was  high;  the  chief  abnormality,  however,  was  an  abnor- 
mally large  amount  of  organic  acids,  so  that  chemically  the  condition  was 
suggestive  of  an  acidosis. 

12.  INDICANUEIA 

The  substance  in  the  urine  which  has  received  this  name  is  the  indoxyl- 
sulphate  of  potassium,  in  which  form  it  appears  in  the  urine  and  is  color- 
less. When  concentrated  acids  or  strong  oxidizing  agents  are  added  to  the 
urine,  this  substance  is  decomposed  and  the  indigo  set  free.  It  is  present  only 
in  small  quantities  in  healthy  urine.  It  is  derived  from  the  indol,  a  product 
formed  in  the  intestine  by  the  decomposition  of  the  albumin  under  the  influ- 
ence of  bacteria.  When  absorbed,  this  is  oxidized  in  the  tissues  to  indoxyl, 
which  combines  with  the  potassium  sulphate,  forming  the  above  named  sub- 
stance. 

It  is  a  common  condition  met  with  accidentally  in  persons  of  good  health 
or  with  slight  digestive  complaints.  It  is  not  specially  associated  with  con- 
stipation (Allen  Jones).  In  gall-stone  attacks,  in  hyperchlorhydria,  in  re- 
curring appendicitis,  in  wasting  diseases,  in  peritonitis,  and  in  empyema  it 
is  usually  present.  In  a  few  cases  it  is  constantly  present  and  in  excess. 
In  a  recent  study  Barr  found  only  32  such  cases  among  2,092  patients,  and  in 
these  the  clinical  symptoms  did  not  suggest  an  intestinal  auto-intoxication, 
nor  did  the  lacto-bacillary  treatment  of  Metschnikoff  have  the  slightest  in- 
fluence on  the  condition. 

Indican  has  occasionally  been  found  in  calculi.  Though,  as  a  rule,  the 
urine  is  colorless  when  passed,  there  are  instances  in  which  the  decomposi- 
tion has  taken  place  within  the  body,  and  a  blue  color  has  been  noticed  im- 
mediately after  the  urine  was  voided.  Sometimes,  too,  in  alkaline  urine  on 
exposure  there  is  a  bluish  film  on  the  surface.  Methylene  blue,  a  coloring 
matter  for  candy,  etc.,  must  be  excluded. 

13.  MELANURIA 

Black  urine  may  be  dark  when  passed  or  may  become  so  later.  In  the 
following  conditions  melanuria  may  occur:  (1)  Jaundice.  Only  in' very 


692  DISEASES    OF   THE    KIDNEYS 

chronic  cases  of  deeply  bronzed  icterus  do  we  see  the  urine  quite  dark,  due 
to  the  presence  of  large  quantities  of  biliverdin.  (2)  Haematuria  and  haemo- 
globinuria.  Here  it  is  a  matter  of  the  exaggeration  of  the  smoky  tint  due  to 
the  presence  of  blood  in  various  quantities.  (3)  Hasmatoporphyrinuria,  to 
be  considered  later.  (4)  Melanuria,  in  which  the  urine  has,  as  a  rule,  the 
normal  color  when  passed,  and  on  standing  becomes  black  as  ink.  In  some 
instances  it  is  black  when  passed.  Melanuria  of  this  type  only  occurs  with 
the  presence  of  melanotic  tumors.  (5)  Alkaptonuria.  (6)  Indicanuria. 
When  rich  in  indoxyl  sulphate  the  urine  is  brown  in  color,  or  becomes  so 
after  standing,  due  to  the  oxidation  products  of  indol.  This  is  by  far  the 
most  common  cause  of  black  urine,  and  in  any  disease  leading  to  an  abun- 
dant secretion  of  indican,  as  in  intestinal  obstruction,  etc.,  black  urine  may 
be  passed.  As  Garrod  suggests,  it  is  probable  that  the  black  urine  in  cases 
of  tuberculosis  is  of  an  allied  nature.  (7)  After  certain  articles  of  diet  and 
drugs.  Some  dark  colored  vegetable  pigments,  as  black  cherries  and  plums 
and  bilberries,  cause  darkening  of  the  urine.  Eesorcin  may  do  the  same. 
Carboluria  is  by  no  means  uncommon,  and  was  frequently  seen  in  the  days 
of  the  antiseptic  spray.  It  has  been  ascribed  to  hydrochinone  formed  from 
phenol.  Naphthalene,  creosote,  and  the  salicylates  may  cause  darkening  of 
the  urine,  or  even  blackness. 

14.     ALKAPTONTJEIA 

"Alkaptonuria  is  not  the  manifestation  of  a  disease,  but  is  rather  of  the 
nature  of  an  alternative  course  of  metabolism,  harmless  and  usually  congen- 
ital and  lifelong"  (Garrod).  Of  40  known  examples,  19  occurred  in  seven 
families,  and  several  were  the  offspring  of  first  cousins  (Garrod).  There  are 
two  points  of  clinical  interest.  The  alkapton  urine  reduces  Fehling's  solu- 
tion, and  diabetes  may  be  suggested,  but  it  does  not  ferment,  and  it  is  opti- 
cally inactive.  The  linen  may  be  stained  by  the  urine,  which  in  some  cases 
is  dark  when  passed.  In  1866  Virchow  recorded  a  case  of  blackening  of  the 
cartilages  and  ligaments — ochronosis,  which  is  considered  elsewhere. 

15.     PNEUMATUEIA 

Gas  may  be  passed  with  the  urine — 

1.  After  mechanical  introduction  of  air  in  vesical  irrigation  or  cysto- 
scopic  examination  in  the  knee  elbow  position. 

2.  As  a  result  of  the  introduction  of  gas  forming  organisms  in  catheteri- 
zation  or  other  operation.     Glycosuria  has  been  present  in  a  majority  of  the 
cases.    The  yeast  fungus,  the  colon  bacillus,  and  the  Bacillus  aerogenes  cap- 
sulatus  have  been  found. 

3.  In  cases  of  vesico-enteric  fistula. 

In  gas  production  within  the  bladder  the  symptoms  are  those  of  a  mild 
cystitis,  with  the  passage  of  gas  at  the  end  of  micturition,  sometimes  with 
a  loud  sound.  The  diagnosis  is  readily  made  by  causing  the  patient  to  urinate 
in  a  bath  or  by  plunging  the  end  of  the  catheter  under  water. 


URAEMIA  693 

18.     OTHER    SUBSTANCES 

Lipuria. — Fat  in  the  urine,  or  lipuria,  occurs,  first,  without  disease  of  the 
kidneys,  as  in  excess  of  fat  in  the  food,  after  the  administration  of  cod  liver 
oil,  in  fat  embolism  occurring  after  fractures,  in  the  fatty  degeneration  in 
phosphorus  poisoning,  in  prolonged  suppuration,  as  in  phthisis  and  pyaemia, 
in  the  lipasmia  of  diabetes  mellitus;  secondly,  with  disease  of  the  kidneys,  as 
in  the  fatty  stage  of  chronic  Bright's  disease,  in  which  fat  casts  are  some- 
times present,  and,  according  to  Ebstein,  in  pyonephrosis ;  and,  thirdly,  in 
the  affection  known  as  chyluria.  The  urine  is  usually  turbid,  but  there  may 
be  fat  drops  as  well,  and  fatty  crystals  have  been  found.  In  a  few  rare  in- 
stances calculi  composed  of  fat  and  coated  with  phosphates  have  been  found. 

Lipaciduria  is  a  term  applied  by  von  Jaksch  to  the  condition  in  which 
there  are  volatile  fatty  acids  in  the  urine,  such  as  acetic,  butyric,  formic,  and 
propionic  acid. 

The  occurrence  of  acetone,  diacetic  acid,  and  fi-oxybutyric  acid  has  been 
sufficiently  considered  under  Diabetes. 

Choluria  and  glycosuria  have  already  been  considered  under  jaundice  and 
diabetes. 

Hsematoporphyrin  occasionally  occurs  in  the  urine.  It  was  first  recog- 
nized by  Hoppe-Seyler.  Nencki  and  Sieler  determined  its  exact  formula,  and 
the  former  demonstrated  that  the  only  chemical  difference  between  haematin 
and  hsematoporphyrin  is  that  the  latter  is  simply  haematin  free  from  iron.  It 
has  been  found  in  the  urine  in  pulmonary  tuberculosis,  pleurisy  with  effusion, 
acute  rheumatism,  lead  poisoning,  and  intestinal  haemorrhages.  This  pig- 
ment has  been  found  very  frequently  after  the  administration  of  -sulphonal, 
and  sometimes  imparts  a  very  dark  color  to  the  urine. 


V.    UREMIA 

Definition. — A  toxaemia  developing  in  the  course  of  nephritis  or  in  con- 
ditions associated  with  anuria.  The  nature  of  the  poison  or  poisons  is  as  yet 
unknown,  whether  they  are  the  retained  normal  products  or  the  products  of 
an  abnormal  metabolism. 

Theories  of  Uraemia. — There  are  four  chief  views:  (a)  That  it  is  due 
to  the  accumulation  in  the  blood  of  body  poisons  which  should  be  excreted 
by  the  kidney.  What  these  substances  are  is  not  known,  but  neither  the 
urea,  nor  the  salts,  nor  the  various  extractives  appear  to  be  capable  of  pro- 
ducing the  symptoms.  (&)  That  it  is  a  disturbance  of  the  normal  kidney 
metabolism.  Brown-Sequard  suggested  that  the  kidney  had  an  internal  se- 
cretion, to  the  disturbance  of  which  it  is  thought  that  the  symptoms  of  uraemia 
may  be  due.  Rose  Bradford's  experiments  show  how  profoundly  the  kid- 
neys influence  the  body  metabolism,  particularly  that  of  the  muscles.  If 
more  than  two-thirds  of  the  total  kidney  weight  is  removed,  there  is  an  ex- 
traordinary increase  in  the  production  of  urea  and  of  the  nitrogenous  bodies 
of  the  creatin  class.  From  a  study  of  the  question  Hughes  and  Carter  con- 
clude that  the  poison  is  of  an  albuminous  nature,  and  quite  different  from 
anything  in  normal  urine,  (c)  Uraemia  has  been  attributed  to  nephro/* 


G94  DISEASES    OF    THE    KIDNEYS 

lysins.  Broken  up  renal  substance  contains  a  material  which,  when  injected 
into  an  animal,  exerts  a  specific  destructive  action  upon  the  renal  cells.  This 
substance  may  be  found  in  the  serum,  and  such  a  blood  serum  injected  into 
another  animal  sets  up  nephritis  and  albuminuria.  It  is  suggested  that  the 
phenomena  of  uraemia  may  result  from  the  action  of  these  nephrolysins  upon 
the  nerve  centres.  F.  Miiller  has  pointed  out  that  uraemia  is  most  apt  to 
occur  in  those  forms  of  renal  disease  in  which  the  destruction  of  tissue  is 
most  extensive,  (d)  Lastly,  there  is  the  old  view  of  Traube  that  the  symp- 
toms of  uraemia,  particularly  the  coma  and  convulsions,  are  due  to  localized 
oedema  of  the  brain. 

Symptoms. — Clinically,  we  may  recognize  latent,  acute,  and  chronic  forms. 
The  latent  form  has  been  considered  under  the  section  on  anuria.  Acute 
uraemia  may  arise  in  any  form  of  nephritis.  It  is  more  common  in  the  post- 
febrile  varieties.  Bradford  thinks  that  it  is  specially  associated  with  a  form 
of  contracted  white  kidney  in  young  subjects.  Chronic  forms  of  uraemia 
are  more  frequent  in  the  arterio-sclerotic  and  granular  kidney.  For  con- 
venience the  symptoms  of  uraemia  may  be  described  under  cerebral,  dyspnceic, 
and  gastro-intestinal  manifestations. 

Among  the  CEREBRAL  symptoms  of  uraemia  may  be  described: 

(a)  Mania. — This  may  come  on  abruptly  in  an  individual  who  has  shown 
no  previous  indications  of  mental  trouble,  and  who  may  not  be  known  to 
have  Bright's  disease.  In  one  case  of  this  kind  the  patient  became  suddenly 
maniacal  and  died  in  six  days.  More  commonly  the  delirium  is  less  violent, 
but  the  patient  is  noisy,  talkative,  restless,  and  sleepless. 

(6)  Delusional  Insanity  (Folie  Brightique). — Cases  are  by  no  means  un- 
common, and  excellent  clinical  reports  have  been  issued  on  the  subject  from 
several  of  the  asylums,  particularly  by  Bremer,  Christian,  and  Alice  Ben- 
nett. Delusions  of  persecution  are  common.  One  of  my  patients  committed 
suicide  by  jumping  out  of  a  window.  The  condition  is  of  interest  medico- 
legally  because  of  its  bearing  on  testamentary  capacity.  Profound  melan- 
cholia may  also  supervene. 

(c)  Convulsions. — These  may  come  on  unexpectedly  or  be  preceded  by 
pain  in  the  head  and  restlessness.    The  attacks  may  be  general  and  identical 
with  those  of  ordinary  epilepsy,  though  the  initial  cry  may  not  be  present. 
The  fits  may  recur  rapidly,  and  in  the  interval  the  patient  is  usually  uncon- 
scious.    Sometimes  the  temperature  is  elevated,  but  more  frequently  it  is  de- 
pressed, and  may  sink  rapidly  after  the  attack.    Local  or  Jacksonian  epilepsy 
may  occur  in  most  characteristic  form  in  uraemia.    A  remarkable  sequence  of 
the  convulsions  is  blindness — urcemic  amaurosis — which  may  persist  for  sev- 
eral days.    This,  however,  may  occur  apart  from  the  convulsions.     It  usually 
passes  off  in  a  day  or  two.    There  are,  as  a  rule,  no  ophthalmoscopic  changes. 
Sometimes  uraemic  deafness  supervenes,  and  is  probably  also  a  cerebral  mani- 
festation.   It  may  also  occur  in  connection  with  persistent  headache,  nausea, 
and  other  gastric  symptoms. 

(d)  Coma. — Unconsciousness  invariably  accompanies  the  general  convul- 
sions, but  a  coma  may  develop  gradually  without  any  convulsive  seizures. 
Frequently  it  is  preceded  by  headache,  and  the  patient  gradually  becomes 
dull  and  apathetic.     In  these  cases  there  may  have  been  no  previous  indica- 
tions of  renal  disease,  and  unless  the  urine  is  examined  the  nature  of  the 


UREMIA  695 

case  may  be  overlooked.  Twitchings  of  the  muscles  occur,  particularly  in 
the  face  and  hands,  but  there  are  many  cases  of  coma  in  which  the  muscles 
are  not  involved.  In  some  of  these  cases  a  condition  of  torpor  persists  for 
weeks  or  even  months.  The  tongue  is  usually  furred  and  the  breath  very 
foul  and  heavy. 

(e)  Local  Palsies. — In  the  course  of  chronic  B  right's  disease  hemiplegia 
or  monoplegia  may  come  on  spontaneously  or  follow  a  convulsion,  and  post 
mortem  no  gross  lesions  of  the  brain  be  found,  but  only  a  localized  or  dif- 
fused oedema.  These  cases,  which  are  not  very  uncommon,  may  simulate 
almost  every  form  of  organic  paralysis  of  cerebral  origin. 

(/)  Of  other  cerebral  symptoms,  HEADACHE  is  important.  It  is  most 
often  occipital  and  extends  to  the  neck.  It  may  be  an  early  feature  and  asso- 
ciated with  giddiness.  Other  nervous  symptoms  of  uraemia  are  intense  itching 
of  the  skin,  numbness  and  tingling  in  the  fingers,  and  cramps  in  the  muscles 
of  the  calves,  particularly  at  night.  An  erythema  may  be  present. 

UILEMIC  DYSPNOEA  is  classified  by  Palmer  Howard  as  follows:  (a)  Con- 
tinuous dyspnoea;  (&)  paroxysmal  dyspnoea;  (c)  both  types  alternating;  and 
(d)  Cheyne-Stokes  breathing.  The  attacks  of  dyspnoea  are  most  commonly 
nocturnal;  the  patient  may  sit  up,  gasp  for  breath,  and  evince  as  much  dis- 
tress as  in  true  asthma.  Occasionally  the  breathing  is  noisy  and  stridulous. 
The  Cheyne-Stokes  type  may  persist  for  weeks  or  months.  One  patient,  up 
and  about,  could  feed  himself  only  in  the  apncea  period.  Though  usually 
of  serious  omen  and  occurring  with  coma  and  other  symptoms,  recovery  may 
follow  even  after  persistence  for  a  long  period. 

The  CASTRO-INTESTINAL  manifestations  of  uraemia  often  set  in  with  ab- 
ruptness. Uncontrollable  vomiting  may  come  on  and  its  cause  be  quite  un- 
recognizable. The  attacks  may  be  preceded  by  nausea  and  may  be  associated 
with  diarrhosa.  In  some  instances  the  diarrhoea  may  come  on  without  the 
vomiting;  sometimes  it  is  profuse  and  associated  with  an  intense  catarrhal 
or  even  diphtheritic  inflammation  of  the  colon. 

A  special  UR^EMIC  STOMATITIS  has  been  described  in  which  the  mucosa 
of  the  lips,  gums,  and  tongue  is  swollen  and  erythematous.  The  saliva  may 
be  increased,  and  there  is  difficulty  in  swallowing  and  in  mastication.  The 
tongue  is  usually  very  foul  and  the  breath  heavy  and  fetid.  A  cutaneous 
erythema  may  occur  and  a  remarkable  urea  "frost"  on  the  skin. 

FEVER  is  not  uncommon  in  uraemic  states,  and  may  occur  with  the  acute 
nephritis,  with  the  complications,  and  as  a  manifestation  of  the  uraemia  itself. 

Very  many  patients  with  chronic  uraemia  succumb  to  what  I  have  called 
terminal  infections — acute  peritonitis,  pericarditis,  pleurisy,  meningitis,  or 
endocarditis. 

Diagnosis. — Herter  called  attention  to  the  value  of  the  clinical  determina- 
tion of  the  urea  in  the  blood  (for  which  purpose  only  a  few  cubic  centimetres 
are  required)  as  an  index  of  the  degree  of  renal  inadequacy.  In  but  2  of 
96  cases  could  the  urea  determination  in  the  urine  have  been  of  any  value  in 
predicting  uraemia,  and  equal  drops  in  the  urea  occurred  without  this  symptom 
(Emerson)'.  The  test  of  the  functional  capacity  of  the  kidney  by  the  use  of 
phenol-sulphonephthalein  (Eowntree  and  Geraghty)  is  of  great  value  both  in 
differential  diagnosis  and  in  giving  warning  of  impending  uraemia.  In  urae- 
mia the  elimination  of  phthalein  is  nil  or  only  a  faint  trace  in  two  hours.  In 


696  DISEASES    OF   THE   KIDNEYS 

patients  with  chronic  nephritis  in  whom  the  elimination  in  two  hours  is 
below  10  per  cent,  there  is  grave  danger  of  uraemia. 

Uraemia  may  be  confounded  with : 

(a)  Cerebral  lesions,  such  as  haemorrhage,  meningitis,  or  even  tumor.  In 
apoplexy,  which  is  so  commonly  associated  with  kidney  disease  and  stiff  arte- 
ries, the  sudden  loss  of  consciousness,  particularly  if  with  convulsions,  may 
simulate  a  uraemic  attack;  but  the  mode  of  onset,  the  existence  of  complete 
hemiplegia,  with  conjugate  deviation  of  the  eyes,  suggest  hemorrhage.  As 
already  noted,  there  are  cases  of  uraemic  hemiplegia  or  monoplegia  which  can 
not  be  separated  from  those  of  organic  lesion  and  which  post  mortem  show 
no  trace  of  coarse  disease  of  the  brain.  Indeed,  in  some  of  these  cases  it  is 
quite  impossible  to  distinguish  between  the  two  conditions.  So,  too,  cases 
of  meningitis,  in  a  condition  of  deep  coma,  with  perhaps  slight  fever,  furred 
tongue,  but  without  localizing  symptoms,  may  readily  be  confounded  with 
uraemia. 

(6)  With  certain  infectious  diseases.  Uraemia  may  persist  for  weeks  or 
months  and  the  patient  lies  in  a  condition  of  torpor  or  even  unconsciousness, 
with  a  heavily  coated,  perhaps  dry,  tongue,  muscular  twitchings,  a  rapid  feeble 
pulse,  with  slight  fever.  This  state  not  unnaturally  suggests  the  existence  of 
one  of  the  infectious  diseases.  Cases  of  the  kind  are  not  uncommon,  and  I 
have  known  them  to  be  mistaken  for  typhoid  fever  and  for  miliary  tubercu- 
losis. 

(c)  Uraemic  coma  may  be  confounded  with  poisoning  by  alcohol  or  opium. 
In  opium  poisoning  the  pupils  are  contracted;  in  alcoholism  they  are  more 
commonly  dilated.  In  uraemia  they  are  not  constant;  they  may  be  either 
widely  dilated  or  of  medium  size.  The  examination  of  the  eye  grounds  should 
be  made  to  determine  the  presence  or  absence  of  albuminuric  retinitis.  The 
urine  should  be  drawn  off  and  examined.  The  odor  of  the  breath  sometimes 
gives  an  important  hint. 

The  condition  of  the  heart  and  arteries  should  also  be  taken  into  account. 
Sudden  uraemic  coma  is  more  common  in  the  chronic  interstitial  nephritis. 
The  character  of  the  delirium  in  alcoholism  is  sometimes  important,  and  the 
coma  is  not  so  deep  as  in  uraemia  or  opium  poisoning.  It  may  for  a  time  be 
impossible  to  determine  whether  the  condition  is  due  to  uraemia,  profound 
alcoholism,  or  haemorrhage  into  the  pons  Varolii. 

And,  lastly,  in  connection  with  sudden  coma,  it  is  to  be  remembered  that 
insensibility  may  occur  after  prolonged  muscular  exertion,  as  after  running 
a  ten-mile  race.  In  some  instances  unconsciousness  has  come  on  rapidly  with 
stertorous  breathing  and  dilated  pupils.  Cases  have  occurred  under  conditions 
in  which  sun-stroke  could  be  excluded;  and  Poore  considers  that  the  condi- 
tion is  due  to  the  too  rapid  accumulation  of  waste  products  in  the  blood,  and 
to  hyperpyrexia  from  suspension  of  sweating. 

The  treatment  will  be  considered  under  Chronic  Bright's  Disease. 


VI.    ACUTE  BRIGHT'S  DISEASE 

Definition. — Acute  diffuse  nephritis,  due  to  the  action  of  cold  or  of  toxic 
agents  upon  the  kidneys. 


ACUTE    BRIGHT'S    DISEASE  G9? 

In  all  instances  changes  exist  in  the  epithelial,  vascular,  and  intertubular 
tissues,  which  vary  in  intensity  in  different  forms;  hence  writers  have  de- 
scribed a  tubular,  a  glomerular,  and  an  acute  interstitial  nephritis.  Delafield 
recognizes  acute  exudative  and  acute  productive  forms,  the  latter  character- 
ized  by  proliferation  of  the  connective-tissue  stroma  and  of  the  cells  of  the 
Malpighian  tufts. 

Etiology. — The  following  are  the  principal  causes  of  acute  nephritis: 

(1)  Cold.     Exposure  to  cold  and  wet  is  one  of  the  most  common  causes. 
It  is  particularly  prone  to  follow  exposure  after  a  drinking-bout. 

(2)  The   poisons   of   the   specific    fevers,   particularly   scarlet   fever,   less 
commonly  typhoid  fever,  measles,  diphtheria,  small-pox,  chicken-pox,  malaria, 
cholera,  yellow  fever,  meningitis,  and,  very  rarely,  dysentery.     Acute  nephritis 
may   be  associated   with    syphilis   and   with   acute   tuberculosis,   particularly 
the    former.     Bradford    suggests    that    many    of    the    idiopathic    cases    and 
those   ascribed   to   cold   may   be    of   syphilitic    origin.     It   may   also    occur 
in    septicaemia    and    in    acute   tonsillitis.     In    exudative    erythema    and    the 
allied  purpuric  affections  acute  nephritis  is  not  uncommon.     Among  1,832 
cases  of  malaria  at  the  Johns  Hopkins  Hospital  there  were  26  of  nephritis 
(Thayer).    A  primary   infective  epidemic  nephritis  has  been  met  with  in 
Italy. 

(3)  Toxic  agents,   such  as  turpentine,   cantharides,   potassium   chlorate, 
and  carbolic  acid,  may  cause  an  acute  congestion  which  sometimes  terminates 
in  nephritis.    Alcohol  probably  never  excites  an  acute  nephritis. 

(4)  Pregnancy,  in  which  the  condition  is  probably  due  to  toxic  products 
as  yet  undetermined. 

(5)  Acute  nephritis  occurs  occasionally  in  connection  with  extensive  le- 
sions  of  the  skin,  as  in  burns  or   in  chronic  skin-diseases,   and  also  after 
trauma.     It  may  follow  operations  on  the  kidney. 

Morbid  Anatomy. — The  kidneys  may  present  to  the  naked  eye  in  mild 
cases  no  evident  alterations.  When  seen  early  in  more  severe  forms  the  organs 
are  congested,  swollen,  dark,  and  on  section  may  drip  blood.  Bright's  original 
description  is  as  follows : 

"The  kidneys,  .  .  .  stripped  easily  out  of  their  investing  membrane,  were 
large  and  less  firm  than  they  often  are,  of  the  darkest  chocolate  color,  in- 
terspersed with  a  few  white  points,  and  a  great  number  nearly  black;  and 
this,  with  a  little  tinge  of  red  in  parts,  gave  the  appearance  of  a  polished 
fine-grained  porphyry  or  greenstone.  .  .  .  On  (section)  these  colors  were 
found  to  pervade  the  whole  cortical  part;  but  the  natural  striated  appearance 
was  not  lost,  and  the  external  part  of  each  mass  of  tubuli  was  particularly 
dark  ...  a  very  considerable  quantity  of  blood  oozed  from  the  kidney,  show- 
ing a  most  unusual  accumulation  in  the  organ." 

In  other  instances  the  surface  is  pale  and  mottled,  the  capsule  strips  off 
readily,  and  the  cortex  is  swollen,  turbid,  and  of  a  grayish  red  color,  while 
the  pyramids  have  an  intense  beefy  red  tint.  The  glomeruli  in  some  instances 
stand  out  plainly,  being  deeply  swollen  and  congested;  in  other  instances 
they  are  pale. 

The  histology  may  be  thus  summarized:  (a)  Glomerular  changes.  The 
tufts  suffer  first,  and  there  is  either  an  acute  intracapillary  glomerulitis,  in 
which  the  capillaries  become  filled  with  cells  and  thrombi,  or  involvement  of 
46 


G98  DISEASES   OF   THE   KIDNEYS 

the  epithelium  of  the  tuft  and  of  Bowman's  capsule,  the  cavity  of  which  con- 
tains leucocytes  and  red  blood-corpuscles. 

(6)  The  alterations  in  the  tubular  epithelium  consist  in  cloudy  swelling, 
fatty  change,  and  hyaline  degeneration.  In  the  convoluted  tubules,  the  ac- 
cumulation of  altered  cells  with  leucocytes  and  blood-corpuscles  causes  the 
enlargement  and  swelling  of  the  organ. 

(c)  Interstitial  changes.  In  the  milder  forms  a  simple  inflammatory 
exudate — serum  mixed  with  leucocytes  and  red  blood-corpuscles — exists  be- 
tween the  tubules.  In  severer  cases  areas  of  small  celled  infiltration  occur 
about  the  capsules  and  between  the  convoluted  tubes. 

Symptoms. — The  onset  is  usually  sudden,  and,  when  the  nephritis  follows 
cold,  dropsy  may  be  noticed  within  twenty-four  hours.  After  fevers  the  on- 
set is  less  abrupt,  but  the  patient  gradually  becomes  pale  and  a  puffiness  of 
the  face  or  swelling  of  the  ankles  is  first  noticed.  In  children  there  may 
be  convulsions  at  the  outset.  Chilliness  or  rigors  initiate  the  attack  in  a 
limited  number  of  cases.  Pain  in  the  back,  nausea,  and  vomiting  may  be 
present.  The  fever  is  variable.  Many  cases  in  adults  have  no  rise  in  tem- 
perature. In  young  children  with  nephritis  from  cold  or  scarlet  fever  the 
temperature  may,  for  a  few  days,  range  from  101°  to  103°. 

The  most  characteristic  symptoms  are  the  urinary  changes.  There  may 
at  first  be  suppression;  more  commonly  the  urine  is  scanty,  highly  colored, 
and  contains  blood,  albumin,  and  tube  casts.  The  quantity  is  reduced  and 
only  4  or  5  ounces  may  be  passed  in  the  twenty-four  hours;  the  specific  grav- 
ity is  high — 1.025,  or  even  more;  the  color  varies  from  a  smoky  to  a  deep 
porter  color,  but  is  seldom  bright  red.  On  standing  there  is  a  heavy  deposit ; 
microscopically  there  are  blood  corpuscles,  epithelium  from  the  urinary  pas- 
sages, and  hyaline,  blood,  and  epithelial  tube  casts.  The  albumin  is  abundant, 
forming  a  curdy,  thick  precipitate.  The  largest  amounts  of  albumin  are 
seen  in  the  early  acute  nephritis  of  syphilis,  in  which  it  may  reach  8.5  per 
cent.  The  total  excretion  of  urea  is  reduced,  though  the  percentage  is  high. 

(Edema  is  an  early  and  marked  symptom.  In  'cases  of  extensive  dropsy 
effusion  may  take  place  into  the  pleura?,  and  peritoneum.  There  are  cases 
of  scarlatinal  nephritis  in  which  the  dropsy  of  the  extremities  is  trivial  and 
effusion  into  the  pleura?  extensive.  The  lungs  may  become  cedematous.  In 
rare  cases  there  is  oedema  of  the  glottis.  Epistaxis  may  occur  or  cutaneous 
ecchymoses  may  develop  in  the  course  of  the  disease. 

The  pulse  may  be  hard,  the  tension  increased,  and  the  second  sound  in 
the  aortic  area  accentuated.  Occasionally  dilatation  of  the  heart  comes  on 
rapidly  and  may  cause  sudden  death.  The  skin  is  dry  and  it  may  be  difficult 
to  induce  sweating. 

Urcemic  symptoms  occur  in  a  limited  number  of  cases,  either  at  the  onset 
with  suppression,  more  commonly  later  in  the  disease.  Ocular  changes  are 
not  so  common  in  acute  as  in  chronic  Bright's  disease,  but  haemorrhagic 
retinitis  may  occur  and  occasionally  papillitis. 

The  course  of  acute  Bright's  disease  varies  considerably.  The  description 
just  given  is  of  the  form  which  most  commonly  follows  cold  or  scarlet  fever. 
In  many  of  the  febrile  cases  dropsy  is  not  a  prominent  symptom,  and  the 
diagnosis  rests  rather  with  the  examination  of  the  urine.  Moreover,  the  con- 
dition may  be  transient  and  less  serious..  In  other  cases,  as  in  the  acute 


ACUTE    BRIGHT'S    DISEASE  899 

nephritis  of  typhoid  fever,  there  may  be  hsematuria  and  pronounced  signs  of 
interference  with  the  renal  function.  The  most  intense  acute  nephritis  may 
exist  without  anasarca. 

In  scarlatinal  nephritis,  in  which  the  glomeruli  are  most  seriously  affected, 
suppression  of  the,  urine  may  be  an  early  symptom,  the  dropsy  is  apt  to  be 
extreme,  and  uraamic  manifestations  are  common.  Acute  Bright's  disease  in 
children,  however,  may  set  in  very  insidiously  and  be  associated  with  transient 
or  slight  oedema,  and  the  symptoms  may  point  rather  to  affection  of  the 
digestive  system  or  to  brain  disease. 

Diagnosis. — It  is  very  important  to  bear  in  mind  that  the  most  serious 
involvement  of  the  kidneys  may  be  manifested  only  by  slight  cedema  of  the 
feet  or  puffiness  of  the  eyelids,  without  impairment  of  the  general  health.  On 
the  other  hand,  from  the  urine  alone  a  diagnosis  can  not  be  made  with  cer- 
tainty, since  simple  cloudy  swelling,  and  circulatory  changes  may  cause  a  sim- 
ilar condition  of  urine.  The  first  indication  of  trouble  may  be  a  urasmic 
convulsion.  This  is  particularly  the  case  in  the  acute  nephritis  of  pregnancy, 
and  it  is  a  good  rule  for  the  practitioner,  when  engaged  to  attend  a  case,  in- 
yariably  to  ask  that  during  the  seventh  and  eighth  months  the  urine  should 
occasionally  be  sent  for  examination. 

In  nephritis  from  cold  and  in  scarlet  fever  the  symptoms  are  usually 
marked  and  the  diagnosis  is  rarely  in  doubt.  As  already  mentioned,  every 
case  in  which  albumin  is  present  should  not  be  called  acute  Bright's  disease, 
not  even  if  tube  casts  be  present.  Thus  the  common  febrile  albuminuria, 
although  it  represents  the  first  link  in  the  chain  of  events  leading  to  acute 
Bright's  disease,  should  not  be  placed  in  the  same  category. 

There  are  occasional  cases  of  acute  Bright's  disease  with  anasarca,  in 
which  albumin  is  either  absent  or  present  only  as  a  trace.  This  is  a  rare 
condition.  Tube  casts  are  usually  found,  and  the  absence  of  albumin  is  rare- 
ly permanent.  The  urine  may  be  reduced  in  amount. 

The  character  of  the  casts  is  of  use  in  the  diagnosis  of  the  form  of 
Bright's  disease,  but  scarcely  of  such  extreme  value  as  has  been  stated.  Thus, 
the  hyaline  and  granular  casts  are  common  to  all  varieties.  The  blood  and 
epithelial  casts,  particularly  those  made  up  of  leucocytes,  are  most  common 
in  the  acute  cases. 

Prognosis. — The  outlook  varies  somewhat  with  the  cause  of  the  disease. 
Recoveries  in  the  form  following  exposure  to  cold  are  much  more  frequent 
than  after  scarlatinal  nephritis.  In  younger  children  the  mortality  is  high, 
amounting  to  at  least  one-third  of  the  cases.  Serious  symptoms  are  low 
arterial  tension,  the  occurrence  of  uraemia,  and  effusion  into  the  serous  sacs. 
The  persistence  of  the  dropsy  after  the  first  month,  intense  pallor,  and  a  large 
amount  of  albumin  indicate  the  possibility  of  the  disease  becoming  chronic. 
For  some  months  after  the  disappearance  of  the  dropsy  there  may  be  traces 
of  albumin  and  a  few  tube  casts. 

In  a  case  of  scarlatinal  nephritis,  if  the  progress  is  favorable,  the  dropsy 
diminishes  in  a  week  or  ten  days,  the  urine  increases,  the  albumin  lessens, 
and  by  the  end  of  a  month  the  dropsy  has  disappeared  and  the  urine  is  nearly 
free.  In  very  young  children  the  course  may  be  rapid,  and  I  have  known  the 
urine  to  be  free  from  albumin  in  the  fourth  week.  Other  cases  are  more 
insidious,  and  though  the  dropsy  may  disappear,  the  albumin  persists  in  the 


700  DISEASES    OF   THE    KIDNEYS 

urine,  the  anaemia  is  marked,  and  the  condition  becomes  chronic,  or,  after 
several  recurrences  of  the  dropsy,  improves  and  complete  recovery  takes  place. 

Treatment. — The  patient  should  be  in  bed  and  there  remain  until  all 
traces  of  the  disease  have  disappeared.  As  sweating  plays  such  an  important 
part  in  the  treatment,  it  is  well,  if  possible,  to  accustom  the  patient  to 
blankets.  He  should  also  be  clad  in  thin  Canton  flannel. 

The  diet  should  consist  of  milk  or  butter-milk,  gruels  made  of  arrow-root 
or  oat-meal,  barley  water,  and,  if  necessary,  beef  tea  and  chicken  broth.  It  is 
better,  if  possible,  to  confine  the  patient  to  a  strictly  milk  diet.  As  conva- 
lescence is  established,  bread  and  butter,  lettuce,  water  cress,  grapes,  oranges, 
and  other  fruits  may  be  given.  Meats  should  be  used  very  sparingly.  As 
there  is  marked  retention  of  the  chlorides,  which  seem  to  bear  a  relation  to 
the  dropsy,  salt  should  be  withheld. 

The  patient  should  drink  freely  of  alkaline  mineral  waters,  ordinary  water, 
or  lemonade.  The  fluids  keep  the  kidneys  flushed  and  wash  out  the  debris 
from  the  tubes.  A  useful  drink  is  a  drachm  of  cream  of  tartar  in  a  pint  of 
boiling  water,  to  which  may  be  added  the  juice  of  half  a  lemon  and  a  little 
sugar.  Taken  when  cold,  this  is  a  pleasant  and  satisfactory  diluent  drink- 
Fluid  may  be  given  by  the  bcwel  or  by  saline  infusion  if  it  is  not  well  taken 
by  mouth. 

No  remedies,  so  far  as  known,  control  directly  the  changes  which  are  going 
on  in  the  kidneys.  The  indications  are:  (1)  To  give  the  excretory  function  of 
the  kidney  rest  by  utilizing  the  skin  and  the  bowels,  in  the  hope  that  the 
natural  processes  may  be  sufficient  to  effect  a  cure;  (2)  to  meet  the  symptoms 
as  they  arise. 

In  a  case  of  scarlet  fever  it  may  occasionally  be  possible  to  avert  an  attack, 
the  premonitory  symptoms  of  which  are  marked  increase  in  the  arterial  ten- 
sion and  the  presence  of  blood  coloring  matter  in  the  urine  (Mahomed).  An 
active  saline  cathartic  may  completely  relieve  this  condition. 

At  the  onset,  when  there  is  pain  in  the  back  orx  haematuria,  the  Paquelin 
cautery  or  the  dry  or  wet  cups  give  relief.  The  last  should  not  be  used  in 
children.  Warm  poultices  are  often  grateful.  In  cases  which  set  in  with 
suppression  of  urine  these  measures  should  be  adopted,  and  in  addition  the 
hot  bath  with  subsequent  pack,  copious  diluents,  and  a  free  purge.  The 
dropsy  is  best  treated  by  hydrotherapy — either  the  hot  bath,  the  wet  pack, 
or  the  hot-air  bath.  In  children  the  wet  pack  is  usually  satisfactory.  It  is 
applied  by  wringing  a  blanket  out  of  hot  water,  wrapping  the  child  in  it, 
covering  this  with  a  dry  blanket,  and  then  with  a  rubber  cloth.  In  this  the 
child  may  remain  for  an  hour.  It  may  be  repeated  daily.  In  the  case  of 
adults,  the  hot  air  bath  or  the  vapor  bath  may  be  conveniently  given  by 
allowing  the  vapor  or  air  to  pass  from  a  funnel  beneath  the  bed  clothes,  which 
are  raised  on  a  low  cradle.  More  efficient,  as  a  rule,  is  a  hot  bath  of  from 
fifteen  or  twenty  minutes,  after  which  the  patient  is  wrapped  in  blankets. 
The  sweating  produced  by  these  measures  is  usually  profuse,  rarely  exhaust- 
ing, and  in  a  majority  of  cases  the  dropsy  can  in  this  way  be  relieved.  There 
are  some  cases,  however,  in  which  the  skin  does  not  respond  to  the  baths,  and 
if  the  symptoms  are  serious,  particularly  if  uraemia  supervenes,  jaborandi 
or  its  active  principle,  pilocarpine,  may  be  used.  The  latter  may  be  given 
hypodermically,  in  doses  of  from  a  sixth  to  an  eighth  of  a  grain  (0.01  to  0.008 


ACUTE   HEIGHT'S    DISEASE  701 

gin.)  in  adults,  and  from  a  twentieth  to  a  twelfth  of  a  grain  (0.003  to  0.005 
gm.)  in  children  of  from  two  to  ten  years. 

The  bowels  should  be  kept  open  by  a  morning  saline  purge;  in  children 
the  fluid  magnesia  is  readily  taken;  in  adults  the  sulphate  of  magnesia  may 
be  given  by  Hay's  method,  in  concentrated  form,  in  the  morning,  before  any- 
thing is  taken  into  the  stomach.  In  Bright's  disease  it  not  infrequently 
causes  vomiting.  The  compound  powder  of  jalap  (gr.  xx,  1.3  gm.)  or,  if 
necessary,  elaterium  may  be  used.  If  the  dropsy  is  not  extreme,  the  urine 
not  very  concentrated,  and  uraemic  symptoms  are  not  present,  the  bowels 
should  be  kept  loose  without  active  purgation.  If  these  measures  fail  to  re- 
duce the  dropsy  and  it  has  become  extreme,  the  skin  may  be  punctured  with 
a  lancet  or  drained  by  a  small  silver  cannula  (Southey's  tube),  which  is  in- 
serted beneath  it.  A  fine  aspirator  needle  may  be  used,  and  the  fluid  allowed 
to  drain  through  a  piece  of  long,  narrow  rubber  tubing  into  a  vessel  beneath 
the  bed.  If  the  dyspnoea  is  marked,  owing  to  pressure  of  fluid  in  the  pleurae, 
aspiration  should  be  performed.  In  rare  instances  the  ascites  is  extreme  and 
may  require  paracentesis,  or  a  Southey's  tube  may  be  inserted  and  the  fluid 
gradually  withdrawn.  If  uraemic  convulsions  occur,  the  intensity  of  the 
paroxysms  may  be  limited  by  the  use  of  chloroform ;  to  an  adult  a  pilocarpine 
injection  should  be  at  once  given,  and  from  a  robust,  strong  man  20  ounces 
of  blood  may  be  withdrawn.  In  children  the  loins  may  be  dry  cupped,  the 
wet  pack  used,  and  a  brisk  purgative  given.  Bromide  of  potassium  and 
chloral  sometimes  prove  useful. 

Vomiting  may  be  relieved  by  ice  and  by  restricting  the  amount  of  food. 
Drop  doses  of  creosote,  iodine,  and  carbolic  acid  may  be  given.  The  dilute 
hydrocyanic  acid  with  bismuth  is  often  effectual. 

The  question  of  the  use  of  diuretics  in  acute  Bright's  disease  is  not  yet 
settled.  The  best  diuretic,  after  all,  is  water,  which  may  be  taken  freely 
with  the  citrate  of  potash  or  the  benzoate  of  soda,  salts  which  are  held  to 
favor  the  conversion  of  the  urates  into  less  irritating  and  more  easily  excreted 
compounds.  Digitalis  and  strophanthus  are  useful  diuretics,  and  may  be 
employed  without  risk  when  the  arterial  tension  is  low  and  the  cardiac  im- 
pulse is  not  forcible.  I  have  never  seen  any  injurious  effects  from  their  em- 
ployment after  the  early  symptoms  had  lessened  in  intensity. 

For  the  persistent  albuminuria,  I  agree  with  Roberts  and  Rosenstein  that 
we  have  no  remedy  of  the  slightest  value.  Nothing  indicates  more  clearly  our 
helplessness  in  controlling  kidney  metabolism  than  inability  to  meet  this  com- 
mon symptom.  Astringents,  alkalies,  nitroglycerin,  and  mercury  have  been 
recommended. 

For  the  anaemia  associated  with  acute  Bright's  disease  iron  should  be 
employed.  It  should  not  be  given  until  the  acute  symptoms  have  subsided. 
In  the  adult  it  may  be  used  in  the  form  of  the  perchloride  in  increasing  doses, 
as  convalescence  proceeds.  In  children,  the  syrup  of  the  iodide  of  iron 
or  the  syrup  of  the  phosphate  of  iron  are  better  preparations.  Tyson 
has  recently  urged  caution  in  the  too  free  use  of  iron  in  kidney  disease. 
The  dilatation  of  the  heart  is  best  treated  with  digitalis,  strophanthus,  and 
strychnia. 

In  the  convalescence  from  acute  Bright's  disease,  care  should  be  taken  to 
guard  the  patient  against  cold.  The  diet  should  still  consist  chiefly  of  milk 


702  DISEASES    OF    THE    KIDNEYS 

and  a  return  to  mixed  food  should  be  gradual.     A  change  of  air  is  often 
beneficial,  particularly  a  residence  in  a  warm,  equable  climate. 

VH.    CHRONIC  BRIGHT 'S  DISEASE 

Here,  too,  in  all  forms  we  deal  with  a  diffuse  process,  involving  epithelial, 
interstitial,  and  glomerular  tissues.  Clinically  two  groups  are  recognized — 
(a)  the  chronic  parenchymatous  nephritis,  which  follows  the  acute  attack  or 
comes  on  insidiously,  is  characterized  by  marked  dropsy,  and  post  mortem  by 
the  large  white  kidney.  In  the  later  stages  of  this  process  the  kidney  may  be 
smaller — a  condition  known  as  the  small  white  kidney;  (&)  chronic  inter- 
stitial nephritis,  in  which  dropsy  is  not  common  and  the  cardio-vascular 
changes  are  pronounced.  Delafield  recognizes  a  chronic  diffuse  nephritis 
with  exudation  and  a  chronic  productive  diffuse  nephritis  without  exudation, 
the  latter  corresponding  to  the  contracted  kidney  of  authors. 

The  amyloid  kidney  is  usually  spoken  of  as  a  variety  of  Bright's  disease, 
but  in  reality  it  is  a  degeneration  which  may  accompany  any  form  of  nephritis. 

1.     CHEONIC    PAEENCHYMATOUS    NEPHEITIS 

(Chronic    Desquamative    and    Chronic    Tubal    Nephritis;    Chronic    Diffuse 
Nephritis  with   Exudation} 

Etiology. — In  many  cases  the  disease  follows  the  acute  nephritis  of  cold, 
scarlet  fever,  or  pregnancy.  More  frequently  than  is  usually  stated  the  disease 
has  an  insidious  onset  and  occurs  independently  of  any  acute  attack.  The 
fevers  may  play  an  important  role  in  certain  of  these  cases.  Eosenstein,  Bar- 
tels,  I.  E.  Atkinson,  and  Thayer  have  laid  special  stress  upon  malaria  as  a 
cause.  The  use  of  alcohol  is  believed  to  lead  to  this  form  of  nephritis.  In 
chronic  suppuration,  syphilis,  and  tuberculosis  the  diffuse  parenchymatous 
nephritis  is  not  uncommon,  and  is  usually  associated  with  amyloid  disease. 
Males  are  rather  more  subject  to  the  affection  than  females.  It  is  met  with 
most  commonly  in  young  adults,  and  is  by  no  means  infrequent  in  children 
as  a  sequence  of  scarlatinal  nephritis. 

Morbid  Anatomy. — Several  varieties  of  this  form  have  been  recognized. 
The  large  white  kidney  of  Wilks,  in  which  the  organ  is  enlarged,  the  capsule 
is  thin,  and  the  surface  white  with  the  stellate  veins  injected,  is  not  very  com- 
mon in  America.  On  section  the  cortex  is  swollen  and  yellowish  white  in 
color,  and  often  presents  .opaque  areas.  The  pyramids  may  be  deeply  con- 
gested. On  microscopic  examination  it  is  seen  that  the  epithelium  is  gran- 
ular and  fatty,  and  the  tubules  of  the  cortex  are  distended,  and  contain  tube 
casts.  Hyaline  changes  are  also  present  in  the  epithelial  cells.  The  glomeruli 
are  large,  the  capsules  thickened,  the  capillaries  show  hyaline  changes,  and 
the  epithelium  of  the  tuft  and  of  the  capsule  is  extensively  altered.  The 
interstitial  tissue  is  everywhere  increased,  though  not  to  an  extreme  degree. 

The  second  variety  of  this  form  results  from  the  gradual  increase  in  the 
connective  tissue  and  the  subsequent  shrinkage,  forming  what  is  called  the 
small  white  kidney  or  the  pale  granular  kidney.  It  is  doubtful  whether  this 
is  always  preceded  by  the  large  white  kidney.  Some  observers  hold  that  it 


CHRONIC    BEIGHT'S    DISEASE  703 

may  be  a  primary  independent  form.  The  capsule  is  thickened  and  the  sur- 
face is  rough  and  granular.  On  section  the  resistance  is  greatly  increased, 
the  cortex  is  reduced  and  presents  numerous  opaque  white  or  whitish  yellow 
foci,  consisting  of  accumulations  of  fatty  epithelium  in  the  convoluted  tu- 
bules. This  combination  of  contracted  kidney  with  the  areas  of  marked  fatty 
degeneration  has  given  the  name  of  small  granular  fatty  kidney  to  this  form. 
The  interstitial  changes  are  marked,  many  of  the  glomeruli  are  destroyed, 
the  degeneration  of  epithelium  in  the  convoluted  tubules  is  widespread,  and 
the  arteries  are  greatly  thickened. 

Belonging  to  this  chronic  tubal  nephritis  is  a  variety  known  as  the  chronic 
hcp.morrhagic  nephritis,  in  which  the  organs  are  enlarged,  yellowish  white  in 
color,  and  in  the  cortex  are  many  brownish  red  areas,  due  to  haemorrhage  into 
and  about  the  tubes.  In  other  respects  the  changes  are  identical  with  those 
in  the  large  white  kidney. 

Of  changes  in  the  other  organs  the  most  marked  are  thickening  of  the 
blood  vessels  and  hypertrophy  of  the  left  heart. 

Symptoms. — Following  an  acute  nephritis,  the  disease  may  present,  in  a 
modified  way,  the  symptoms  of  that  affection.  In  many  cases  it  sets  in  in- 
sidiously, and  after  an  attack  of  dyspepsia  or  a  period  of  failing  health  and 
loss  of  strength  the  patient  becomes  pale,  and  puffmess  of  the  eyelids  or  swol- 
len feet  are  noticed  in  the  morning. 

The  symptoms  are  as  follows:  The  urine  is,  as  a  rule,  diminished  in 
quantity,  averaging  500  c.  c.,  often  scanty.  It  has  a  dirty  yellow,  sometimes 
smoky,  color,  and  is  turbid  from  the  presence  of  urates.  On  standing,  a 
heavy  sediment  falls,  in  which  are  found  numerous  tube  casts  of  various  forms 
and  sizes,  hyaline,  both  large  and  small,  epithelial,  granular,  and  fatty  casts. 
Leucocytes  are  abundant;  red  blood-corpuscles  are  frequently  met  with,  and 
epithelium  from  the  kidneys  and  pelves.  The  albumin  is  abundant  and  may 
be  from  4  to  6  per  cent.  It  is  more  abundant  in  the  urine  passed  during  the 
day.  The  specific  gravity  may  be  high  in  the  early  stages — from  1.020  to 
1.025,  even  1.040 — though  in  the  later  stages  it  is  lower.  The  urea  is  always 
reduced  in  quantity.  As  the  case  improves  from  5  to  6  litres  of  urine  a  day 
may  be  voided. 

Dropsy  is  a  marked  and  obstinate  symptom  of  this  form  of  Bright's  dis- 
ease. The  face  is  pale  and  puffy,  and  in  the  m'orning  the  eyelids  are  cede- 
matous.  The  anasarca  is  general,  and  there  may  be  involvement  of  the  serous 
sacs.  In  these  chronic  cases  associated  with  large  white  kidney  there  is  often 
a  distinctive  appearance  in  the  face;  the  complexion  is  pasty,  the  pallor 
marked,  and  the  eyelids  are  cedematous.  The  dropsy  is  peculiarly  obstinate. 
Ursemic  symptoms  are  common,  though  convulsions  are  perhaps  less  frequent 
than  in  the  interstitial  nephritis. 

The  tension  of  the  pulse  is  usually  increased;  the  vessels  ultimately  become 
stiff  and  the  heart  hypertrophied,  though  there  are  instances  of  this  form  of 
nephritis  in  which  the  heart  is  not  enlarged.  The  aortic  second  sound  is 
accentuated.  Eetinal  changes,  though  less  frequent  than  in  the  chronic  in- 
terstitial nephritis,  occur  in  a  considerable  number  of  cases. 

Gastro-intestinal  symptoms  are  common.  Vomiting  is  frequently  a  dis- 
tressing and  serious  symptom,  and  diarrhoea  may  be  profuse.  Ulceration  of 
the  colon  may  occur  and  prove  fatal. 


704  DISEASES    OF    THE    KIDNEYS 

It  is  sometimes  impossible  to  determine,  even  by  the  most  careful  exami- 
nation of  the  urine  or  by  analysis  of  the  symptoms,  whether  the  condition  of 
the  kidney  is  that  of  the  large  white  or  of  the  small  white  form.  In  cases, 
however,  which  have  lasted  for  several  years,  with  the  progressive  increase  in 
the  renal  connective  tissue  and  the  cardio-vascular  changes,  the  clinical  pic- 
ture may  approach,  in  certain  respects,  that  of  the  contracted  kidney.  The 
urine  is  increased,  with  low  specific  gravity.  It  is  often  turbid,  may  contain 
traces  of  blood,  the  tube  casts  are  numerous  and  of  every  variety  of  form  and 
size,  and  the  albumin  is  abundant.  Dropsy  is  usually  present,  though  not  so 
extensive  as  in  the  early  stages. 

Prognosis. — The  prognosis  is  extremely  grave.  In  a  case  which  has  per- 
sisted for  more  than  a  year  recovery  rarely  takes  place.  Death  is  caused 
either  by  great  effusion  with  osdema  of  the  lungs,  by  uremia,  or  by  secondary 
inflammation  of  the  serous  membranes.  Occasionally  in  children,  even  when 
the  disease  has  persisted  for  two  years,  the  symptoms  disappear  and  recovery 
takes  place. 

Treatment. — Essentially  the  same  treatment  should  be  carried  out  as  in 
acute  Bright's  disease.  Milk  or  buttermilk  should  constitute  for  a  time  the 
chief  article  of  food.  Later  more  food  may  be  allowed,  oysters,  fresh  vege- 
tables, and  fruit.  The  dropsy  should  be  treated  by  the  hot  baths,  and  a  salt- 
free  diet.  Iron  preparations  should  be  given  when  there  is  marked  anaemia. 
It  is  to  be  remembered  that  the  pallor  of  the  face  may  not  be  a  good  index  of 
the  blood  condition.  The  acetate  of  potash,  digitalis,  and  diuretin  are  useful 
in  increasing  the  flow  of  urine.  Basham's  mixture  given  in  plenty  of  water 
will  be  found  beneficial. 


2.     CHRONIC    INTERSTITIAL    NEPHRITIS 

(Secondary   Contracted   Kidney;    Red    Granular   Kidney;    Gouty    Kidney; 
Arterio-sclerotic  Kidney;  Senile  Kidney] 

Etiology  and  Morbid  Anatomy. — Sclerosis  of  the  kidney  is  met  with 
(a)  as  a  sequence  of  the  large  white  kidney,  forming  the  so-called  pale  gran- 
ular or  secondary  contracted  kidney;  (&)  as  a  primary  independent  affection, 
the  red  granular  kidney;  (c)  as  a  sequence  of  arterio-sclerosis ;  and  (d)  as 
a  senile  change. 

(a)  SECONDARY  FORM. — The  small  white  kidney,  as  it  is  called,  has  al- 
ready been  described  as  a  sequel  to  chronic  parenchymatous  nephritis. 

(&)  In  the  PRIMARY  FORM,  known  also  as  the  red  granular  kidney,  the 
organ  is  smaller  than  in  the  secondary  interstitial  nephritis,  the  capsule  is 
very  adherent,  the  granulations  small,  the  organ  of  a  reddish  brown  color, 
the  cysts  numerous,  the  arteries  very  sclerotic,  and  the  cortex  greatly  reduced 
in  volume.  The  chief  reason  for  calling  this  primary  is  that  one  can  find  no 
history  of  previous  renal  disease.  It  is  met  with  in  the  members  of  gouty 
families,  and  there  are  doubtless  hereditary  influences  at  work,  for  Dickinson 
reported  a  remarkable  family  in  which  this  interstitial  nephritis  occurred 
in  four  generations.  Syphilis,  alcohol,  and  overeating  are  mentioned  as  con- 
tributary  causes.  Lead  is  a  rare  cause  in  America,  but  a  more  common 
cause  in  parts  of  England.  It  is  by  no'  means  always  easy  to  differentiate 


CHRONIC    BRIGHT'S    DISEASE  705 

between  the  secondary  and  the  primary  forms.  As  a  rule,  the  former  is  paler 
and  not  so  small.  Of  174  cases  of  chronic  interstitial  nephritis  from  my 
wards  which  came  to  autopsy,  in  79  the  combined  weight  of  the  kidneys  was 
about  300  grams,  in  57  cases  200  to  300  grams,  in  30  cases  150  to  200  grams, 
and  below  150  grams  in  8  cases  (Emerson).  Unilateral  nephritis  in  my  ex- 
perience is  extremely  rare,  not  occurring  once  in  the  series. 

j[c)  ARTERIO-SCLEROTIC  KIDNEY. — This  is  not  necessarily  a  contracted 
kidney.  The  organ  is  very  hard,  red,  and  often  heavier  than  normal.  Of 
the  cases  from  my  wards,  studied  by  Emerson,  in  61  per  cent,  the  combined 
weight  was  above  300  grams,  and  in  only  6  per  cent,  was  it  below  200  grams. 
The  surface  may  be  smooth  or  the  capsule  only  slightly  thickened  and  ad- 
herent, tearing  the  substance  very  little  as  it  is  stripped  off.  In  other  cases 
the  atrophy  is  in  spots,  affecting  certain  vascular  districts,  so  that  there  is 
a  large,  sunken,  deep  red  patch  on  the  surface,  or  one  pole  of  the  kidney  is 
shrunken,  or  the  process  is  general  in  both  kidneys,  but  the  resulting  con- 
traction gives  a  warty  rather  than  a  granular  surface. 

(d)  In  the  SENILE  FORM.,  met  with  in  the  aged,  the  organs  are  reduced  in 
size,  the  capsules  thickened  and  adherent,  the  pelvic  fat  much  increased,  both 
cortical  and  pyramidal  portions  uniformly  wasted,  and  the  arteries  of  the 
kidney  substance  very  prominent. 

Almost  invariably  associated  with  chronic  interstitial  nephritis  are  gen- 
eral arterio-sclerosis  and  hypertrophy  of  the  heart.  The  changes  in  the  ar- 
teries will  be  described  elsewhere.  In  the  red  granular  kidney  the  left  ven- 
tricle is  specially  hypertrophied,  but  in  all  forms  the  heart  is  greatly  en- 
larged, constituting  one  of  the  largest  forms  met  with.  In  many  cases  the 
disease  is  latent,  and  the  patients  die  of  apoplexy  or  of  acute  uraemia.  In 
the  arterio-sclerotic  form  death  is  more  commonly  cardiac,  and  the  condition 
of  the  kidneys  may  be  entirely  overlooked. 

Much  discussion  has  taken  place  as  to  the  association  of  hypertrophy  of 
the  heart  and  sclerosis  of  the  blood-vessels  with  the  renal  changes.  A  com- 
plete solution  of  the  many  problems  has  scarcely  yet  been  offered.  Briefly, 
there  are  two  views — the  mechanical  and  the  chemical.  Dating  from  the  time 
of  Bright  it  was  thought  that  the  heart  had  greater  difficulty  in  driving  the 
impure  blood  through  the  capillary  system.  Traube  held  that  the  oblitera- 
tion of  a  large  number  of  capillary  territories  in  the  kidney  raised  the  arterial 
pressure  and  in  this  way  led  to  hypertrophy  of  the  heart.  In  explanation 
of  the  muscular  hypertrophy  of  the  walls  of  the  smaller  arteries  George  John- 
son introduced  the  view  of  a  stop-cock  action  of  these  vessels  under  the  in- 
fluence of  irritating  ingredients  in  the  blood.  The  mechanical  view  was 
thus  put  by  Cohnheim.  The  activity  of  the  circulation  through  the  kidneys 
at  any  moment  does  not  depend  upon  the  need  of  these  organs  for  blood, 
but  solely  upon  the  amount  of  material  for  the  urinary  secretion  existing  in 
the  blood.  "When  parts  of  both  kidneys  have  undergone  atrophy,  the  blood 
flow  in  the  parts  remaining  must  be  as  great  as  it  would  have  been  to  the 
whole  of  the  organs,  had  they  been  intact;  but  in  order  that  such  a  quantity 
of  blood  should  pass  through  the  restricted  capillary  area  now  open  to  it  an 
excessive  pressure  is  necessary.  This  can  be  brought  to  bear  only  by  the  exer- 
tion of  an  increased  force  on  the  part  of  the  left  ventricle  with  the  mainte- 
nance of  a  corresponding  resistance  in  all  other  arterial  territories.  In  this 


706  DISEASES    OF   THE    KIDNEYS 

way  both  the  high  arterial  pressure  and  the  cardiovascular  changes  are  ex- 
plained. 

The  chemical  view,  which  has  been  much  discussed  of  late,  supposes  the 
production  (a)  by  the  kidneys,  (&)  by  the  supra-renal  glands,  of  certain 
pressor  substances.  So  far  as  the  kidney  is  concerned,  the  observations  are 
by  no  means  in  accord.  Practically  we  know  only  that  the  kidney  does  con- 
tain substances  capable  of  raising  the  blood-pressure.  According  to  Bingel 
those  so-called  rennin  preparations  act  in  a  manner  very  different  from  ad- 
renalin. In  chronic  interstitial  nephritis  there  is  often  hyperplasia  of  the 
cortical  substance  of  the  supra-renals,  and  many  recent  writers  have  claimed 
to  have  discovered  in  the  blood  of  chronic  nephritics  an  increase  in  the  pressor 
substances,  an  adrenalinaemia.  Through  their  influence,  from  one  or  both  of 
these  sources,  the  blood-pressure  is  raised,  with  the  inevitable  sequence  of 
hypertrophy  of  the  heart  and  sclerosis  of  the  arteries.  As  already  mentioned, 
the  question  is  still  under  discussion. 

Symptoms. — Many  cases  are  latent,  and  are  not  recognized  until  the  oc- 
currence of  one  of  the  serious  or  fatal  complications.  Even  an  advanced  grade 
of  contracted  kidney  may  be  compatible  with  great  mental  and  bodily  activity. 
There  may  have  been  no  symptoms  whatever  to  suggest  to  the  patient  the 
existence  of  a  serious  malady.  In  other  cases  the  general  health  is  disturbed. 
The  patient  complains  of  lassitude,  is  sleepless,  has  to  get  up  at  night  to 
micturate;  the  digestion  is  disordered,  the  tongue  is  furred;  there  are  com- 
plaints of  headache,  failing  vision,  and  breathlessness  on  exertion. 

So  complex  and  varied  is  the  clinical  picture  of  chronic  Bright's  disease 
that  it  will  be  best  to  consider  the  symptoms  under  the  various  systems. 

URINARY  SYSTEM. — In  the  small  contracted  kidney  polyuria  is  common. 
Frequently  the  patient  has  to  get  up  two  or  three  times  during  the  night  to 
empty  the  bladder,  and  there  is  increased  thirst.  It  is  for  these  symptoms 
occasionally  that  relief  is  sought.  And  yet  in  many  cases  with  very  small 
kidneys  this  feature  has  not  been  present.  A  careful  study  of  the  cases  from 
my  wards,  of  the  urine  and  the  anatomical  condition,  showed  that  almost 
no  parallelism  could  be  made  between  the  weight  of  the  kidney,  its  appear- 
ance, and  the  urine  it  secreted  before  death.  Of  the  174  cases  with  autopsy, 
in  almost  a  third  the  renal  changes  were  so  slight  that  the  nephritis  was  not 
mentioned  as  a  part  of  the  clinical  diagnosis  (Emerson).  The  color  of  the 
urine  is  a  light  yellow,  and  the  specific  gravity  ranges  from  1.005  to  1.012. 
Persistent  low  specific  gravity  is  one  of  the  most  constant  and  important  fea- 
tures of  the  disease.  Traces  of  albumin  are  found,  but  may  be  absent  at  times, 
particularly  in  the  early  morning  urine.  It  is  often  simply  a  slight  cloudiness, 
and  may  be  apparent  only  with  the  more  delicate  tests.  The  sediment  is  scanty, 
and  in  it  a  few  hyaline  or  granular  casts  are  found.  The  quantity  of  the  solid 
constituents  of  the  urine  is,  as  a  rule,  diminished,  though  in  some  instances 
the  urea  may  be  excreted  in  full  amount.  In  attacks  of  dyspepsia  or  bron- 
chitis, or  in  the  later  stages  when  the  heart  fails,  the  quantity  of  albumin  may 
be  greatly  increased  and  the  urine  diminished.  Occasionally  blood  occurs 
in  the  urine,  and  there  may  even  be  haematuria  (S.  West).  Slight  leakage, 
represented  by  the  constant  presence  of  a  few  red  cells,  may  be  present  early 
in  the  disease  and  persist  for  years.  In  the  arterio-sderotic  form  the  quan- 
tity of  urine  is  normal,  or  reduced  rather  than  increased ;  the  specific  gravity 


CHRONIC    BRIGHT'S    DISEASE  707 

is  normal  or  high,  the  color  of  the  urine  is  good,  and  there  are  hyaline  and 
finely  granular  casts.  The  amount  of  albumin  varies  greatly  with  the  food 
and  exercise,  and  is  usually  much  in  excess  of  that  seen  with  the  contracted 
kidneys,  and  does  not  show  so  often  the  albumin  free  intervals  of  that  form, 
also  it  is  more  common  to  find  albumin  without  casts,  while  in  the  contracted 
kidney  casts  may  occur  without  albumin. 

CIRCULATORY  SYSTEM. — The  pulse  is  hard,  the  tension  increased,  and 
the  vessel  wall,  as  a  rule,  thickened.  As  already  mentioned,  a  distinction 
must  be  made  between  increased  tension  and  thickening  of  the  arterial  wall. 
The  tension  may  be  plus  in  a  normal  vessel,  but  in  chronic  Bright's  disease 
it  is  more  common  to  have  increased  tension  in  a  stiff  artery. 

A  pulse  of  increased  tension  has  the  following  characters:  It  is  hard 
and  incompressible,  requiring  a  good  deal  of  force  to  overcome  it;  it  is  per- 
sistent, and  in  the  intervals  between  the  beats  the  vessel  feels  full  and  can 
be  rolled  beneath  the  finger.  These  characters  may  be  present  in  a  vessel 
the  walls  of  which  are  little,  if  at  all,  increased  in  thickness.  To  estimate 
the  latter  the  pulse  wave  should  be  obliterated  in  the  radial,  and  the  vessel 
wall  felt  beyond  it.  In  a  perfectly  normal  vessel  the  arterial  coats,  under 
these  circumstances,  can  not  be  differentiated  from  the  surrounding  tissue; 
whereas,  if  thickened,  the  vessel  can  be  rolled  beneath  the  finger.  Persistent 
high  blood  pressure  is  one  of  the  earliest  and  most  important  symptoms  of 
interstitial  nephritis.  During  the  disease  the  pressure  may  rise  to  250  mm. 
or  even  300  mm.  With  dropsy  and  cardiac  dilatation  the  pressure  may  fall, 
but  not  necessarily.  The  cardiac  features  are  equally  important,  though 
often  less  obvious.  Hypertrophy  of  the  left  ventricle  occurs  to  overcome  the 
resistance  offered  in  the  arteries.  The  enlargement  of  the  heart  ultimately 
becomes  more  general.  The  apex  is  displaced  downward  and  to  the  left;  the 
impulse  is  forcible  and  may  be  heaving.  In  elderly  persons  with  emphysema 
the  displacement  of  the  apex  may  not  be  evident.  The  first  sound  at  the  apex 
may  be  duplicated ;  more  commonly  the  second  sound  at  the  aortic  cartilage 
is  accentuated,  a  very  characteristic  sign  of  increased  tension.  The  sound  in 
extreme  cases  may  have  a  bell-like  quality.  In  many  cases  a  systolic  murmur 
develops  at  the  apex,  probably  as  a  result  of  relative  insufficiency.  It  may 
be  loud  and  transmitted  to  the  axilla.  Finally  the  hypertrophy  fails,  the 
heart  becomes  dilated,  gallop  rhythm  is  present,  and  the  general  condition  is 
that  of  a  chronic  heart-lesion.  In  the  arterio-sclerotic  form  the  picture  may 
be  cardiac  from  beginning  to  close — dyspnoea  and  signs  of  dilated  heart. 

RESPIRATORY  SYSTEM. — Sudden  oedema  of  the  glottis  may  occur.  Effu- 
sion into  the  pleurae  or  sudden  oedema  of  the  lungs  may  prove  fatal.  Acute 
pleurisy  and  pneumonia  are  not  uncommon.  Bronchitis  is  a  frequent  accom- 
paniment, particularly  in  the  winter.  Sudden  attacks  of  oppressed  breathing, 
particularly  at  night,  are  not  infrequent.  This  is  often  a  ursmic  symptom, 
but  is  sometimes  cardiac.  The  patient  may  sit  up  in  bed  and  gasp  for  breath, 
as  in  true  asthma.  Cheyne-Stokes  breathing  may  be  present,  most  commonly 
toward  the  close,  but  the  patient  may  be  walking  about  and  even  attending  to 
his  occupation. 

DIGESTIVE  SYSTEM. — Dyspepsia  and  loss  of  appetite  are  common.  Severe 
and  uncontrollable  vomiting  may  be  the  first  symptom.  This  is  usually  re- 
garded as  a  manifestation  of  urasmia,  but  it  may  occur  without  any  other 


708  DISEASES    OF    THE    KIDNEYS 

indications,  and  I  have  known  it  to  prove  fatal  without  any  suspicion  that 
chronic  Bright's  disease  was  present.  Severe  and  even  fatal  diarrhoea  may 
develop.  The  tongue  may  be  coated  and  the  breath  heavy  and  urinous. 

NERVOUS  SYSTEM. — Various  cerebral  manifestations  have  already  been 
mentioned  under  uraemia.  Headache,  sometimes  of  the  migraine  type,  may 
be  an  early  and  persistent  feature  of  chronic  Bright's  disease.  Cerebral 
apoplexy  is  closely  related  to  interstitial  nephritis.  The  hemorrhage  may 
take  place  into  the  meninges  or  the  cerebrum.  It  is  usually  associated  with 
marked  changes  in  the  vessels.  Neuralgias,  in  various  regions,  are  not  un- 
common. 

SPECIAL  SENSES. — Troubles  in  vision  may  be  the  first  symptom  of  the 
disease.  It  is  remarkable  in  how  many  cases  of  interstitial  nephritis  the  con- 
dition is  diagnosed  first  by  the  ophthalmic  surgeon.  The  flame  shaped  retinal 
hemorrhages  are  the  most  common.  Less  frequent  is  diffuse  retinitis  or 
papillitis.  Sudden  blindness  may  supervene  without  retinal  changes — uraemic 
amaurosis.  Diplopia  is  a  rare  event.  Recurring  conjunctival  and  palpebral 
haemorrhages  are  fairly  common,  particularly  in  the  arterio-sclerotic  form. 
Auditory  troubles  are  by  no  means  infrequent  in  chronic  Bright's  disease. 
Ringing  in  the  ears,  with  dizziness,  is  not  uncommon.  Various  forms  of 
deafness  may  occur.  Epistaxis  is  not  infrequent,  either  alone,  or  of  a  severe 
type  in  association  with  purpura. 

SKIN. — (Edema  is  not  common  in  interstitial  nephritis.  Slight  puffiness 
of  the  ankles  may  be  present,  but  in  a  majority  of  the  cases  dropsy  does  not 
supervene.  When  extensive,  it  is  almost  always  the  result  of  gradual  failure 
of  the  hypertrophied  heart.  The  skin  is  often  dry  and  pale,  and  sweats  are 
not  common.  In  some  instances  the  sweat  may  deposit  a  white  frost  of  urea 
on  the  surface  of  the  skin.  Eczema  is  a  common  accompaniment  of  chronic 
interstitial  nephritis.  Tingling  of  the  fingers  or  numbness  and  pallor — the 
dead  fingers — are  not.  as  some  suppose,  in  any  way  peculiar  to  Bright's  dis- 
ease. Intolerable  itching  of  the  skin  may  be  present,  and  cramps  in  the 
muscles  are  by  no  means  rare. 

Haemorrhages  are  not  infrequent;  epistaxis  may  prove  serious  and  exten- 
sive ;  purpura  may  occur.  Broncho-pulmonary  hemorrhages  are  said,  by  some 
French  writers,  to  be  common,  but  no  instance  of  it  has  come  under  my  ob- 
servation. Ascites  is  rare  except  in  association  with  cirrhosis  of  the  liver. 

Diagnosis. — The  autopsy  often  discloses  the  true  nature  of  the  disease, 
one  of  the  many  intercurrent  affections  of  which  may  have  proved  fatal.  The 
early  stages  of  interstitial  nephritis  are  not  recognizable.  In  a  patient  with 
increased  pulse  tension  (particularly  if  the  vessel  wall  is  sclerotic),  with  the 
apex  beat  of  the  heart  dislocated  to  the  left,  the  second  aortic  sound  ringing 
and  accentuated,  the  urine  abundant  and  of  low  specific  gravity,  with  a  trace 
of  albumin  and  an  occasional  hyaline  or  granular  cast,  the  diagnosis  of  inter- 
stitial nephritis  may  be  safely  made.  Of  all  the  indications,  that  offered  by 
the  pulse  is  the  most  important.  Persistent  high  tension  with  thickening  of 
the  arterial  wall  in  a  man  under  fifty  means  that  serious  mischief  has  already 
taken  place,  that  cardio-vascular  changes  are  certainly,  and  renal  most  prob- 
ably, present.  In  the  arterio-sclerotic  cases  the  history  is  of  the  "strenuous 
life" — work,  alcohol,  tobacco,  Venus — and  not  of  an  infection  or  of  lead  or 
gout.  The  urine  is  not  of  persistently  low  specific  gravity,  there  may  be  little  or 


CHRONIC    BRIGHT'S    DISEASE  709 

no  albumin  except  in  intercurrent  attacks;  the  symptoms  are  cardiac  rather 
than  renal  or  cerebral;  the  ocular  changes  are  haemorrhagic,  not  the  true 
albuminuric  retinitis 

Prognosis. — Chronic  Bright's  disease  is  an  incurable  affection,  and  the 
anatomical  conditions  on  which  it  depends  are  quite  as  much  beyond  the  reach 
of  medicines  as  wrinkled  skin  or  gray  hair.  Interstitial  nephritis,  however, 
is  compatible  with  the  enjoyment  of  life  for  many  years,  and  it  is  now  uni- 
versally recognized  that  increased  tension,  thickening  of  the  arterial  walls, 
and  polyuria  with  a  small  quantity  of  albumin,  neither  doom  a  man  to  death 
within  a  short  time  nor  necessarily  interfere  with  the  pursuits  of  an  active 
life  so  long  as  proper  care  be  taken.  I  know  patients  who  have  had  high 
tension  and  a  little  albumin  in  the  urine  with  hyaline  casts  for  ten,  twelve, 
or  even  fifteen  years.  Serious  indications  are  the  occurrence  of  uraemic  symp- 
toms, dilatation  of  the  heart,  the  onset  of  serous  effusions,  the  onset  of  Cheyne- 
Stokes  breathing,  persistent  vomiting,  and  diarrhrea.  The  phenolsulphoneph- 
thalein  test  gives  valuable  information  as  to  the  functional  capacity  of  the 
kidneys  and  is  a  material  aid  in  prognosis. 

Treatment. — Patients  without  local  indications  or  in  whom  the  condi- 
tion has  been  accidentally  discovered  should  so  regulate  their  lives  as  to 
throw  the  least  possible  strain  upon  heart,  arteries,  and  kidneys.  A  quiet  life 
without  mental  worry,  with  gentle  but  not  excessive  exercise,  and  residence 
in  an  equable  climate,  should  be  recommended.  In  addition  they  should  be 
told  to  keep  the  bowels  regular,  the  skin  active  by  a  daily  tepid  bath  with 
friction,  and  the  urinary  secretion  free  by  drinking  daily  a  definite  amount 
of  either  distilled  water  or  some  pleasant  mineral  water.  Alcohol  should  be 
strictly  prohibited.  Tea  and  coffee  are  allowable. 

The  diet  should  be  light  and  nourishing,  and  the  patient  should  be  warned 
not  to  eat  excessively,  and  not  to  take  meat  more  than  once  a  day.  Care  in 
food  and  drink  is  probably  the  most  important  element  in  the  treatment  of 
these  early  cases. 

A  patient  in  good  circumstances  may  be  urged  to  go  away  during  the 
winter  months,  or,  if  necessary,  to  move  altogether  to  a  warm  equable  climate, 
like  that  of  Southern  California.  There  is  no  doubt  of  the  value  in  these 
cases  of  removal  from  the  changeable,  irregular  weather  which  prevails  in  the 
temperate  regions  from  November  until  April. 

At  this  period  medicines  are  not  required  unless  for  certain  special  symp- 
toms. Patients  derive  much  benefit  from  an  annual  visit  to  certain  mineral 
springs,  such  as  Poland,  Bedford,  Saratoga,  in  America,  and  Vichy  and 
others  in  Europe.  Mineral  waters  have  no  curative  influence  upon  chronic 
Bright's  disease;  they  simply  help  the  interstitial  circulation  and  keep  the 
drains  flushed.  In  this  early  stage,  when  the  patient's  condition  is  good, 
the  tension  not  high,  and  the  quantity  of  albumin  small,  medicines  are  not 
indicated,  since  no  remedies  are  known  to  have  the  slightest  influence  upon 
the  progress  of  the  disease.  Sooner  or  later  SYMPTOMS  arise  which  demand 
treatment.  Of  these  the  following  are  the  most  important: 

(a)  Greatly  Increased  Arterial  Tension. — It  is  to  be  remembered  that  a 
certain  increase  of  tension  is  not  only  necessary  but  unavoidable  in  chronic 
Bright's  disease,  and  probably  the  most  serious  danger  is  too  great  lowering 
of  the  blood  tension.  The  happy  medium  must  be  sought  between  such 


710  DISEASES    OF    THE    KIDNEYS 

heightened  tension  as  throws  a  serious  strain  upon  the  heart  and  risks  rup- 
ture of  the  vessels  and  the  low  tension  which,  under  these  circumstances, 
is  specially  liable  to  be  associated  with  serous  effusions.  In  cases  with  per- 
sistent high  tension  the  diet  should  be  light,  an  occasional  saline  purge  should 
be  given,  and  sweating  promoted  by  means  of  hot  air  or  the  hot  bath.  If 
these  measures  do  not  suffice,  nitroglycerin  may  be  tried,  beginning  with  1 
minim  of  the  1-per-cent.  solution  three  times  a  day,  and  gradually  increasing 
the  dose  if  necessary.  Patients  vary  so  much  in  susceptibility  to  this  drug 
that  in  each  case  it  must  be  tested,  the  limit  of  dosage  being  that  at  which 
the  patient  experiences  the  physiological  effect.  As  much  as  10  minims  of 
the  1-per-cent.  solution  may  be  given  three  times  a  day.  In  many  cases  I 
have  given  it  in  much  larger  doses  for  weeks  at  a  time.  I  have  never  seen 
any  ill  effects  from  it.  If  the  dose  is  excessive  the  patients  complain  at  once 
of  flushing  or  headache.  Its  use  may  be  kept  up  for  six  or  seven  weeks,  then 
stopped  for  a  week  and  resumed.  Its  value  is  seen  not  only  in  the  reduction 
of  the  tension,  but  also  in  the  striking  manner  in  which  it  relieves  the  head- 
ache, dizziness,  and  dyspnoea.  The  sodium  nitrite  may  be  given  in  doses  of 
grs.  ii-v  (0.13  to  0.3  gm.)  three  times  a  day. 

(&)  More  or  less  ancemia  is  present  in  advanced  cases,  and  is  best  met 
by  the  use  of  iron.  Weir  Mitchell,  who  had  a  unique  experience  in  certain 
forms  of  chronic  Bright's  disease,  gave  the  tincture  of  the  perchloride  of 
iron  in  large  doses — from  half  a  drachm  to  a  drachm  three  times  a  day.  He 
thought  that  it  not  only  benefits  the  anaemia,  but  that  it  also  is  an  important 
means  of  reducing  the  arterial  tension. 

(c)  Many  patients  with  Bright's  disease  present  themselves  for  treat- 
ment with  signs  of  cardiac  dilatation;  there  is  a  gallop  rhythm  or  the  heart- 
sounds  have  a  fetal  character,  the  breath  is  short,  the  urine  scanty  and  highly 
albuminous,  and  there  are  signs  of  local  dropsy.    In  these  cases  the  treatment 
must  be  directed  to  the  heart.     A  morning  dose  of  salts  or  calomel  may  be 
given,  and  digitalis  in  10-minim  doses,  three  or  four  times  a  day.     Strychnia 
may  be  used  with  benefit  in  this  condition.    In  some  instances  other  cardiac 
tonics  may  be  necessary,  but  as  a  rule  the  digitalis  acts  promptly  and  well. 

(d)  Urcemic  Symptoms. — Even  before  marked  manifestations  are  present 
there  may  be  extreme  restlessness,  mental  wandering,  a  heavy,  foul  breath, 
and  a  coated  tongue.    Headache  is  not  often  complained  of,  though  intense 
frontal  headache  may  be  an  early  symptom  of  uraemia.     In  this  condition, 
too,  the  patient  may  complain  of  palpitation,  feelings  of  numbness,  and  some- 
times nocturnal  cramps.     For  these  symptoms  the  saline  purgatives  should 
be  ordered,  and  hot  baths,  so  as  to  induce  copious  sweating.     Grandin  states 
that  irrigation  of  the  bowel  with  water  at  a  temperature  from  120°  to  150° 
is  most  useful.  '  Nitroglycerin  also  may  be  used  to  reduce  the  tension.     For 
the  uraemic  convulsions,  if  severe,  inhalations  of  chloroform  may  be  used.    If 
the  patient  is  robust  and  full-blooded,  from  12  to  20  ounces  of  blood  should 
be  removed.     The  patient  should  be  freely  sweated,  and  if  the  convulsions 
tend  to  recur  chloral  may  be  given,  either  by  the  mouth  or  per  rectum,  or, 
better  still,  morphia.     Uraemic  coma  must  be  treated  by '  active  purgation, 
and  sweating  should  be  promoted  by  the  use  of  pilocarpine  or  the  hot  bath. 
For  the  restlessness  and  delirium  morphia  is  indispensable.     Since  its  recom- 
mendation in  uraemic  states  some  years  ago,  by  Stephen  MacKenzie,  I  hav? 


AMYLOID    DISEASE  711 

used  this  remedy  extensively  and  can  speak  of  its  great  value  in  these  cases. 
1  have  never  seen  ill  effects  or  any  tendency  to  coma  follow.  It  is  of  special 
value  in  the  dyspncsa  and  Cheyne-Stokes  breathing  of  advanced  arterio-scle- 
rosis  with  chronic  uraemia. 

SURGICAL  TREATMENT. — Edebohls  introduced  the  operation  of  decap- 
sulation of  the  kidneys  in  Bright's  disease  in  order  to  establish  new  vas- 
cular connections,  and  so  influence  the  nutrition  and  work  of  the  organs.  In 
his  work  records  are  given  of  72  cases;  7  died  within  two  weeks,  22  died  at 
periods  more  or  less  remote,  3  disappeared  from  observation,  and  40  were 
known  to  be  living — one  eleven  years  and  eight  months  after  the  operation. 
As  Edebohls  said  the  difficult  thing  to  determine  is  the  existence  of  chronic 
Bright's  disease  before  operation.  No  case  should  be  regarded  as  such  on  the 
urine  examination  alone.  The  cardio-vascular  condition  and  the  retinas 
should  be  studied.  There  is  probably  a  small  group  of  suitable  cases — the 
subacute  and  chronic  forms  which  follow  the  acute  infections — in  which  the 
outlook  is  hopeless  from  medical  treatment. 

VIII.    AMYLOID  DISEASE 

Amyloid  (lardaceous  or  waxy)  degeneration  of  the  kidneys  is  simply  an 
event  in  the  process  of  chronic  Bright's  disease,  most  commonly  in  the  chronic 
parenchymatous  nephritis  following  fevers,  or  of  cachectic  states.  It  has  no 
claim  to  be  regarded  as  one  of  the  varieties  of  Bright's  disease.  The  affection 
of  the  kidneys  is  generally  a  part  of  a  widespread  amyloid  degeneration  oc- 
curring in  prolonged  suppuration,  as  in  disease  of  the  bone,  in  syphilis,  tu- 
berculosis, and  occasionally  leukaemia,  lead  poisoning,  and  gout.  It  varies 
curiously  in  frequency  in  different  localities. 

Anatomically  the  amyloid  kidney  is  large  and  pale,  the  surface  smooth, 
and  the  venae  stellatae  well  marked.  On  section  the  cortex  is  large  and  may 
show  a  peculiar  glistening,  infiltrated  appearance,  and  the  glomeruli  are  very 
distinct.  The  pyramids,  in  striking  contrast  to  the  cortex,  are  of  a  deep  red 
color.  A  section  soaked  in  dilute  tincture  of  iodine  shows  spots  of  a  walnut 
or  mahogany  brown  color.  The  Malpighian  tufts  and  the  straight  vessels  may 
be  most  affected.  In  lardaceous  disease  of  the  kidneys  the  organs  are  not 
always  enlarged.  They  may  be  normal  in  size  or  small,  pale,  and  granular. 
The  amyloid  change  is  first  seen  in  the  Malpighian  tufts,  and  then  involves 
the  afferent  and  efferent  vessels  and  the  straight  vessels.  It  may  be  confined 
entirely  to  them.  In  later  stages  of  the  disease  the  tubules  are  affected,  chief- 
ly the  membrane,  rarely,  if  ever,  the  cells  themselves. 

Symptoms. — The  renal  features  alone  may  not  indicate  the  presence  of 
this  degeneration.  Usually  the  associated  condition  gives  a  hint  of  the  nature 
of  the  process.  The  urine,  as  a  rule,  shows  important  changes;  the  quantity 
is  increased,  and  it  is  pale,  clear,  and  of  low  specific  gravity.  The  albumin  is 
•usually  abundant,  but  it  may  be  scanty,  and  in  rare  instances  absent.  Pos- 
sibly the  variations  in  the  situation  of  the  amyloid  changes  may  account  for 
this,  since  albumin  is  less  likely  to  be  present  when  the  change  is  confined  to 
the  vasa  recta.  In  addition  to  ordinary  albumin  globulin  may  be  present. 
The  tube  casts  are  variable,  usually  hyaline,  often  fatty  or  finely  granular. 
Occasionally  the  amyloid  reaction  can  be  detected  in  the  hyaline  casts.  Dropsy 


712  DISEASES    OF    THE    KIDNEYS 

is  present  in  many  instances,  particularly  when  there  is  much  anaemia  or 
profound  cachexia.  It  is  not,  however,  an  invariable  symptom,  and  there 
are  cases  in  which  it  does  not  develop.  Diarrhoea  is  a  common  accompani- 
ment. 

Increased  arterial  tension  and  cardiac  hypertrophy  are  not  usually  pres- 
ent, except  in  those  cases  in  which  amyloid  degeneration  occurs  in  the  sec- 
ondary contracted  kidney;  under  which  circumstances  there  may  be  uraemia 
and  retinal  changes,  which,  as  a  rule,  are  not  met  with  in  other  forms. 

Diagnosis. — By  the  condition  of  the  urine  alone  it  is  not  possible  to  rec- 
ognize amyloid  changes  in  the  kidney.  Usually,  however,  there  is  no  diffi- 
culty, since  the  Bright's  disease  comes  on  in  association  with  syphilis,  pro- 
longed suppuration,  disease  of  the  bone,  or  tuberculosis,  and  there  is  evidence 
of  enlargement  of  the  liver  and  spleen.  A  suspicious  circumstance  is  the 
existence  of  polyuria  with  a  large  amount  of  albumin  in  the  urine  and  few 
casts,  or  when,  in  these  constitutional  affections,  a  large  quantity  of  clear, 
pale  urine  is  passed,  even  without  the  presence  of  albumin. 

The  prognosis  depends  rather  on  the  condition  with  which  the  nephritis  is 
associated.  As  a  rule  it  is  grave. 

IX.    PYELITIS 

(Consecutive  Nephritis;  Pyelonephritis;  Pyonephrosis) 

Definition. — Inflammation  of  the  pelvis  of  the  kidney  and  the  conditions 
which  result  from  it. 

Etiology. — Pyelitis  in  almost  all  cases  is  induced  by  bacterial  invasion 
and  multiplication,  rarely  by  the  irritation  of  various  substances  such  as  tur- 
pentine, cubebs,  or  sugar  (diabetes).  Normally  the  kidney  can  eliminate 
without  harm  to  itself,  apparently,  various  bacteria  carried  to  it  by  the  blood- 
current  from  the  intestinal  tract  or  some  focus  of  infection;  and  it  probably 
becomes  infected  only  when  its  resistance  is  lowered,  'as  a  result  of  some  gen- 
eral cause,  as  anemia,  malnutrition,  or  intercurrent  disease,  or  of  some  local 
cause,  as  nephritis,  displacement,  congestion  due  to  pressure  of  neoplasms 
upon  the  ureter,  twisted  ureter  (Dietl's  crisis),  or  of  operation,  or  when  the 
number  or  virulence  of  the  micro-organisms  is  increased.  These  same  factors 
probably  play  an  important  role  also  in  the  other  common  causes  of  pyelitis, 
ascending  infection  from  an  infected  bladder  (cystitis),  and  tuberculous  in- 
fection. Other  causes  described  are  various  fevers,  cancer,  hydatids,  the  ova 
of  certain  parasites,  cold,  and  overexertion.  Calculus  seems  not  to  be  a  com- 
mon cause.  It  is  a  not  uncommon  complication  of  pregnancy  (French).  In. 
T.  R.  Brown's  series  of  20  cases  the  colon  bacillus  was  obtained  7  times,  the 
tubercle  bacillus  6,  the  proteus  bacillus  4,  a  white  staphylococcus  twice,  while 
in  1  case  cultures  were  negative. 

Morbid  Anatomy. — In  the  early  stages  of  pyelitis  the  mucous  membrane 
is  turbid,  somewhat  swollen,  and  may  show  ecchymoses  or  a  grayish  pseudo- 
membrane.  The  urine  in  the  pelvis  is  cloudy,  and,  on  examination,  numbers 
of  epithelial  cells  are  seen. 

In  the  calculous  pyelitis  there  may  be  only  slight  turbidity  of  the  mem- 
brane, which  has  been  called  by  some  catarrhal  pyelitis.  More  commonly  the 


PYELITIS  713 

mucosa  is  roughened,  grayish  in  color,  and  thick.  Under  these  circumstances 
there  is  almost  always  more  or  less  dilatation  of  the  calyces  and  flattening  of 
the  papillae.  Following  this  condition  there  may  be  (a)  extension  of  the  sup- 
purative  process  to  the  kidney  itself,  forming  a  pyelonephritis;  (&)  a  gradual 
dilatation  of  the  calyces  with  atrophy  of  the  kidney  substance,  and  finally  the 
production  of  the  condition  of  pyonephrosis,  in  which  the  entire  organ  is 
represented  by  a  sac  of  pus  with  or  without  a  thin  shell  of  renal  tissue,  (c) 
After  the  kidney  structure  has  been  destroyed  by  suppuration,  if  the  obstruc- 
tion at  the  orifice  of  the  pelvis  persists,  the  fluid  portions  may  be  absorbed 
and  the  pus  become  inspissated,  so  that  the  organ  is  represented  by  a  series 
of  sacculi  containing  grayish,  putty  like  masses,  which  may  become  impreg- 
nated with  lime  salts. 

Tuberculous  pyelitis,  as  already  described,  usually  starts  upon  the  apices 
of  the  pyramids,  and  may  at  first  be  limited  in  extent.  Ultimately  the  condi- 
tion produced  may  be  similar  to  that  of  calculous  pyelitis.  Pyonephrosis  is 
quite  as  frequent  a  sequence,  while  the  final  transformation  of  the  pus  into 
a  putty-like  material  impregnated  with  salts,  forming  the  so-called  scrofulous 
kidney,  is  even  commoner. 

The  pyelitis,  consecutive  to  cystitis  is  generally  bilateral,  and  the  kidneys 
are  sometimes  involved,  forming  the  so-called  surgical  kidneys — acute  sup- 
purative  nephritis.  There  are  lines  of  suppuration  extending  along  the  pyra- 
mids, or  small  abscesses  in  the  cortex,  often  just  beneath  the  capsule ;  or  there 
may  be  wedge  shaped  abscesses.  The  pus  organisms  either  pass  up  the  tu- 
bules or,  as  Steven  has  shown,  through  the  lymphatics. 

Symptoms. — The  forms  associated  with  the  fevers  rarely  cause  any  symp- 
toms, even  when  the  process  is  extensive.  In  mild  grades  there  is  pain  in  the 
back  or  there  may  be  tenderness  on  deep  pressure  on  the  affected  side.  The 
urine,  turbid  and  containing  pus  cells,  some  mucus,  and  occasional  red  blood- 
cells,  is  acid  or  alkaline,  depending  on  the  infecting  microbe;  usually  the  al- 
buminuria  is  of  higher  grade  comparatively  than  the  pynria. 

Before  the  condition  of  pyuria  is  established  there  may  be  attacks  of  pain 
on  the  affected  side  (not  reaching  the  severe  agony  of  renal  colic),  rigors, 
high  fever,  and  sweats.  Under  these  circumstances  the  urine,  which  may 
have  been  clear,  becomes  turbid  or  smoky  from  the  presence  of  blood,  and  may 
contain  large  numbers  of  mucus  cells  and  transitional  epithelium. 

The  statement  is  not  infrequently  made  that  the  epithelium  in  the  urine 
in  pyelitis  is  distinctive  and  characteristic.  This  is  erroneous,  as  may  be  read- 
ily demonstrated  by  comparing  scrapings  of  the  mucosa  of  the  renal  pelvis  and 
of  the  bladder.  In  both  the  epithelium  belongs  to  what  is  called  the  transi- 
tional variety,  and  in  both  regions  the  same  conical,  fusiform,  and  irregular 
cells  with  long  tails  are  found,  and  yet  in  pyelitis  more  of  these  tailed  cells 
occur,  for  in  cystitis  one  must  often  search  long  for  them. 

When  the  pyelitis,  whether  calculous  or  tuberculous,  has  become  chronic 
and  discharges,  the  symptoms  are: 

(a)  Pyuria. — The  pus  is  in  variable  amount,  and  may  be  intermittent. 
Thus,  as  is  often  the  case  when  only  one  kidney  is  involved,  the  ureter  may  be 
temporarily  blocked,  and  normal  urine  is  passed  for  a  time;  then  "there  is  a 
sudden  outflow  of  the  pent  up  pus  and  the  urine  becomes  purulent.  Coin- 
cident with  this  retention,  a  tumor  mass  may  be  felt  on  the  side  affected.  The 


714  .DISEASES    OF    THE    KIDNEYS 

pus  has  the  ordinary  characters,  but  the  transitional  epithelium  is  not  so 
abundant  at  this  stage  and  comes  from  the  bladder  or  from  the  pelvis  of  the 
healthy  side.  Occasionally,  in  rapidly  advancing  pyelonephritis,  portions  of 
the  kidney  tissue,  particularly  of  the  apices  of  the  pyramids,  may  slough  away 
and  appear  in  the  urine;  or,  as  in  a  remarkable  specimen  shown  to  me  by 
Tyson,  solid  cheesy  moulds  of  the  calyces  are  passed.  Casts  from  the  kidney 
tubules  are  sometimes  present.  The  reaction  of  the  urine  depends  entirely 
upon  the  infecting  microbe,  whether  the  condition  is  unilateral  or  bilateral, 
and  whether  the  bladder  is  also  infected,  when  vesical  irritability  and  fre- 
quent micturition  may  be  present.  Polyuria  is  usually  present  in  the  chronic 
cases. 

(&)  Intermittent  fever  associated  with  rigors  is  usually  present  in  cases 
of  suppurative  pyelitis.  The  chills  may  recur  at  regular  intervals,  and  the 
cases  are  often  mistaken  for  malaria.  Owen-Kees  called  attention  to  the  fre- 
quent occurrence  of  these  rigors,  which  form  a  characteristic  feature  of  both 
calculous  and  tuberculous  pyelitis.  Ultimately  the  fever  assumes  a  hectic 
type  and  the  rigors  may  cease. 

(c)  The  general  condition  of  the  patient  often  indicates  prolonged  sup- 
puration.   There  is  more  or  less  wasting  with  anemia  and  a  progressive  fail- 
ure of  health.     Secondary  abscesses  may  develop  and  the  clinical  picture  be- 
comes that  of  pya3mia.    In  some  instances,  particularly  of  tuberculous  pyelitis, 
the  clinical  course  may  resemble  that  of  typhoid  fever.    There  are  instances 
of  pyuria  recurring,  at  intervals,  for  many  years  without  impairment  of  the 
bodily  vigor.     Some  of  the  chronic  cases  have  practically  no  discomfort. 

(d)  Physical  examination  in  chronic  pyelitis  usually  reveals  tenderness 
on  the  affected  side  or  a  definite  swelling,  which  may  vary  much  in  size  and 
ultimately  attain  large  dimensions  if  the  kidney  becomes  enormously  dis- 
tended, as  in  pyonephrosis. 

(e)  Occasionally  nervous  symptoms,  which  may  be  associated  with  dysp- 
noea, supervene,  ortthe  termination  may  be  by  coma,  not  unlike  that  of  dia- 
betes.   These  have  been  attributed  to  the  absorption'  of  the  decomposing  ma- 
terials in  the  urine,  whence  the  so-called  ammoniaemia.     A  form  of  para- 
plegia has  been  described  in  connection  with  some  cases  of  abscess  of  the 
kidney,  but  whether  due  to  a  myelitis  or  to  a  peripheral  neuritis  has  not  yet 
been  determined. 

In  suppurative  nephritis  or  surgical  kidney  following  cystitis,  the  patient 
complains  of  pain  in  the  back,  the  fever  becomes  high,  irregular,  and  asso- 
ciated with  chills,  and  in  acute  cases  a  typhoid  state  may  precede  the  fatal 
event. 

Diagnosis. — Between  the  tuberculous  and  the  calculous  forms  of  pyelitis 
it  may  be  difficult  or  impossible  to  distinguish,  except  by  the  detection  of 
tubercle  bacilli  in  the  pus.  The  examination  for  bacilli  should  be  made  sys- 
tematically, and  in  suspicious  cases  intraperitoneal  injections  of  guinea-pigs 
should  also  be  made.  From  perinephric  abscess  pyonephrosis  is  distinguished 
by  the  more  definite  character  of  the  tumor,  the  absence  of  cedematous  swell- 
ing in  the  lumbar  region,  and,  most  important  of  all,  the  history  of  the  case. 
The  urine,  too,  in  perinephric  abscess  may  be  free  from  pus.  There  are  cases, 
however,  in  which  it  is  difficult  indeed  to  make  a  satisfactory  diagnosis. 

Suppurative  pyelitis  and  cystitis  are  apt  to  be  confounded,  and  perineal 


HYDROXEPHROSIS  715 

section  is  not  infrequently  performed  on  the  supposition  of  the  existence  of 
the  latter.  The  two  conditions  may,  of  course,  coexist  and  prove  puzzling, 
but  the  history,  the  higher  relative  grade  of  albuminuria  in  pyelitis,  the 
polyuria,  the  mode  of  development,  the  local  signs  in  one  lumbar  region,  and 
the  absence  of  pain  in  the  bladder  should  be  sufficient  to  differentiate  the 
affections.  By  catheterizatioii  of  the  ureters,  it  may  be  definitely  determined 
whether  the  pus  comes  from  the  kidneys  or  from  the  bladder.  The  cystoscope 
may  be  used  for  this  purpose. 

Much  may  be  done  with  X-ray  examinations  to  determine  the  condition 
of  the  pelves  of  the  kidneys.  When  a  2-per-cent.  solution  of  collargol  is  in- 
jected by  means  of  the  ureteral  catheter  a  shadow  is  cast  giving  a  very  accu- 
rate outline  of  the  pelvis  of  the  organ. 

Prognosis. — Cases  coming  on  during  the  fevers  usually  recover.  Tuber- 
culous pyelitis  may  terminate  favorably  by  inspissation  of  the  pus  and  con- 
version into  a  putty-like  substance  with  deposition  of  lime  salts.  With  pyo- 
nephrosis  the  dangers  are  increased.  Perforation  may  occur  into  the  peri- 
toneum, the  patient  may  be  worn  out  by  the  hectic  fever,  or  amyloid  disease 
may  develop. 

Treatment. — Fluids  should  be  taken  freely,  particularly  the  alkaline  min- 
eral waters,  to  which  potassium  citrate  may  be  added. 

The  treatment  of  the  calculous  form  will  be  considered  later.  Practically 
there  are  no  remedies  which  have  much  influence  upon  the  pyuria.  Some 
of  the  urinary  antiseptics  seem  to  be  of  value,  especially  in  the  acute  cases. 
Urotropin  should  be  given  in  full  doses  (gr.  xv,  1  gm.,  three  or  four  times 
a  day)  ;  watch  should  be  kept  for  signs  of  irritation  and  the  dose  reduced  if 
they  appear.  Vaccine  therapy  is  sometimes  of  value.  Tonics  should  be 
given,  a  nourishing  diet,  and  milk  and  butter-milk  may  be  taken  freely. 
When  the  tumor  has  formed  or  even  before  it  is  perceptible,  if  the  symptoms 
are  serious  and  severe,  the  kidney  should  be  explored,  and,  if  necessary, 
nephrotomy  or  nephrectomy  should  be  performed. 

X.    HYDRONEPHROSIS 

Definition. — Dilatation  of  the  pelvis  and  calyx  of  the  kidney  with  atrophy 
of  its  substance,  caused  by  the  accumulation  of  non-purulent  fluids,  the  result 
of  obstruction. 

Etiology. — The  condition  may  be  congenital,  owing  to  some  abnormality 
in  the  ureter  or  urethra.  The  tumor  produced  may  be  large  enough  to  retard 
labor.  Sometimes  it  is  associated  with  other  malformations.  There  is  a 
condition  of  moderate  dilatation,  apparently  congenital,  which  is  not  con- 
nected with  any  obstruction  in  the  ducts. 

In  some  instances  there  has  been  contraction  or  twisting  of  the  ureter, 
or  it  has  been  inserted  into  the  kidney  at  an  acute  angle  or  at  a  high  level. 
In  adult  life  the  condition  may  be  due  to  lodgment  of  a  calculus,  or  to  a  cica- 
tricial  stricture  following  ulcer. 

There  is  a  remarkable  condition  of  hypertrophy  and  dilatation  of  the 
bladder  and  ureters  associated  with  congenital  defect  of  the  abdominal 
muscles.  The  bladder  may  form  a  large  abdominal  tumor  and  the  ureters 
may  be  as  large  and  visible  as  coils  of  the  small  intestine. 


716  DISEASES    OF    THE    KIDNEYS 

New  growths,  such  as  tubercle  or  cancer,  occasionally  induce  hydroneph- 
rosis; more  commonly,  pressure  upon  the  ureter  from  without,  particularly 
tumors  of  the  ovaries  and  uterus.  Occasionally  cicatricial  bands  compress  the 
ureter.  Obstruction  within  the  bladder  may  result  from  cancer,  from  hyper- 
trophy of  the  prostate  with  cystitis,  and  in  the  urethra  from  stricture.  It  is 
stated  that  slight  grades  of  hydronephrosis  have  been  found  in  patients  with 
excessive  polyuria. 

In  whatever  way  produced,  when  the  ureter  is  blocked  the  secretion  accu- 
mulates in  the  pelvis  and  infundibula.  Sometimes  acute  inflammation  fol- 
lows, but  more  commonly  the  slow,  gradual  pressure  causes  atrophy  of  the 
papillae  with  gradual  distention  and  wasting  of  the  organ.  In  acquired  cases 
from  pressure,  even  when  dilatation  is  extreme,  there  may  usually  be  seen  a 
thin  layer  of  renal  structure.  In  the  most  extreme  stages  the  kidney  is  rep- 
resented by  a  large  cyst,  which  may  perhaps  show  on  its  inner  surface  im- 
perfect septa.  The  fluid  is  thin  and  yellowish  in  color,  and  contains  traces 
of  urinary  salts,  urea,  uric  acid,  and  sometimes  albumin.  The  secretion  may 
be  turbid  from  admixture  with  small  quantities  of  pus. 

Total  occlusion  does  not  always  lead  to  a  hydronephrosis,  but  may  be  fol- 
lowed by  atrophy  of  the  kidney.  It  appears  that  when  the  obstruction  is  in- 
termittent or  not  complete  the  greatest  dilatation  is  apt  to  follow.  The  sac 
may  be  enormous,  and  cause  an  abdominal  tumor  of  the  largest  size.  The 
condition  has  even  been  mistaken  for  ascites.  Enlargement  of  the  other  kid- 
ney may  compensate  for  the  defect.  Hypertrophy  of  the  left  side  of  the  heart 
usually  follows. 

Symptoms.- — When  small,  it  may  not  be  noticed.  The  congenital  cases 
when  bilateral  usually  prove  fatal  within  a  few  days ;  when  unilateral,  the  tu- 
mor may  not  be  noticed  for  some  time.  It  increases  progressively  and  has  all 
the  characters  of  a  tumor  in  the  renal  region.  In  adult  life  many  of  the 
cases,  due  to  pressure  by  tumors,  as  in  cancer  of  the  uterus  and  enlargement 
of  the  prostate,  etc.,  give  rise  to  no  symptoms. 

In  intermittent  hydronephrosis  the  tumor  suddenly  disappears  with  the 
discharge  of  a  large  quantity  of  clear  fluid ;  the  sac  gradually  refills,  and  the 
process  may  be  repeated  for  years.  In  these  cases  the  obstruction  is  unilateral ; 
a  cicatricial  stricture  exists,  or  a  valve  is  present  in  the  ureter,  or  the  ureter 
enters  the  upper  part  of  the  pelvis.  Many  of  the  cases  are  in  women  and 
associated  with  movable  kidney. 

The  examination  of  the  abdomen  shows,  in  unilateral  hydronephrosis,  a 
tumor  occupying  the  renal  region.  When  of  moderate  size  it  is  readily  recog- 
nized, but  when  large  it  may  be  confounded  with  ovarian  or  other  tumors. 
In  young  children  it  may  ,be  mistaken  for  sarcoma  of  the  kidney  or  of  the 
retroperitoneal  glands,  the  common  cause  of  abdominal  tumor  in  early  life. 
Aspiration  alone  would  enable  us  to  differentiate  between  hydronephrosis  and 
tumor.  The  large  hydronephrotic  sac  is  frequently  mistaken  for  ovarian 
tumor.  The  latter  is,  as  a  rule,  more  mobile,  and  rarely  fills  the  deeper  por- 
tion of  the  lumbar  region  so  thoroughly.  The  ascending  colon  can  often  be 
detected  passing  over  the  renal  tumor,  and  examination  per  vaginam,  particu- 
larly under  ether,  will  give  important  indications  as  to  the  condition  of  the 
ovaries.  In  doubtful  cases  the  sac  should  be  aspirated.  The  fluid  of  the  renal 
cyst  is  clear,  or  turbid  from  the  presence  of  cell  elements,  rarely  colloid  in 


NEPHKOLITHIASIS  717 

character;  the  specific  gravity  is  low;  albumin  and  traces  of  urea  and  uric 
acid  are  usually  present;  and  the  epithelial  elements  in  it  may  be  similar  to 
those  found  in  the  pelvis  of  the  kidney.  In  old  sacs,  however,  the  fluid  may 
not  be  characteristic,  since  the  urinary  salts  disappear,  but  in  one  case  of 
several  years'  duration  oxalates  of  lime  and  urea  were  found. 

Perhaps  the  greatest  difficulty  is  offered  by  the  condition  of  hydronephrosis 
in  a  movable  kidney.  Here,  the  history  of  sudden  disappearance  of  the  tumor 
with  the  passage  of  a  large  quantity  of  clear  fluid  would  be  a  point  of  great 
importance  in  the  diagnosis.  In  those  rare  instances  of  an  enormous  sac  fill- 
ing the  entire  abdomen,  and  sometimes  mistaken  for  ascites,  the  character  of 
the  fluid  might  be  the  only  point  of  difference.  The  tumor  of  pyonephrosis 
may  be  practically  the  same  in  physical  characteristics.  Fever  is  usually  pres- 
ent, and  pus  is  often  found  in  the  urine.  In  these  cases,  when  in  doubt,  ex- 
ploratory puncture  should  be  made. 

The  outlook  in  hydronephrosis  depends  much  upon  the  cause.  When 
single,  the  condition  may  never  produce  serious  trouble,  and  the  intermittent 
cases  may  persist  for  years,  and  finally  disappear.  Occasionally  the  cyst  rup- 
tures into  the  peritoneum,  more  rarely  through  the  diaphragm  into  the  lung. 
A  remarkable  case  of  this  kind  was  under  the  care  of  my  colleague,  Halsted. 
A  man,  aged  twenty-one,  had,  from  his  second  year,  attacks  of  abdominal  pain 
in  which  a  swelling  would  appear  between  the  hip  and  costal  margin  and  sub- 
side with  the  passage  of  a  large  amount  of  urine.  In  January,  1888,  the  sac 
discharged  through  the  right  lung.  Eeaccumulations  occurred  on  several 
occasions,  and  on  June  9,  1891,  the  sac  was  opened  and  drained.  He  remains 
well,  though  there  is  still  a  sinus  through  which  a  clear,  probably  urinous, 
fluid  is  discharged. 

The  sac  may  discharge  spontaneously  through  the  ureter  and  the  fluid 
never  reaccumulate.  In  bilateral  hydronephrosis  there  is  a  danger  that  urasmia 
may  supervene.  There  are  instances,  too,  in  which  blocking  of  the  ureter  on 
the  sound  side  by  calculus  has  been  followed  by  ursmia.  And,  lastly,  the  sac 
may  suppurate,  and  the  condition  change  to  one  of  pyonephrosis. 

Treatment. — Cases  of  intermittent  hydronephrosis  which  do  not  cause 
serious  symptoms  should  be  let  alone.  It  is  stated  that,  in  sacs  of  moderate 
size,  the  obstruction  has  been  overcome  by  massage,  but,  if  practiced,  it  should 
be  done  with  great  care.  When  the  sac  reaches  a  large  size  aspiration  may  be 
performed  and  repeated  if  necessary.  Puncture  should  be  made  in  the  flank, 
midway  between  the  ilium  and  the  last  rib.  If  the -fluid  reaccumulates  and 
the  sac  becomes  large,  it  may  be  incised  and  drained,  or,  as  a  last  resort,  the 
kidney  may  be  removed.  In  women  a  carefully  adapted  pad  and  bandage  will 
sometimes  prevent  the  recurrence  of  an  intermittent  hydronephrosis. 

XL    NEPHROLITHIASIS 

(Renal  Calculus) 

Definition. — The  formation  in  the  kidney  or  in  its  pelvis  of  concretions, 
by  the  deposition  of  certain  of  the  solid  constituents  of  the  urine. 

Etiology  and  Pathology. — In  the  kidney  substance  itself  the  separation 
of  the  urinary-  salts  produces  a  condition  to  which,  unfortunately,  the  term 


718  DISEASES    OF   THE    KIDNEYS 

infarct  has  been  applied.  Three  varieties  may  be  recognized:  (1)  The  uric 
acid  infarct,  usually  met  with  at  the  apices  of  the  pyramids  in  new  born  chil- 
dren and  during  the  first  weeks  of  life.  The  priapism  and  attacks  of  crying 
in  the  new-born  have  been  attributed  to  the  passage  of  these  infarcts;  (2) 
the  sodium  urate  infarct,  sometimes  associated  with  ammonium  urate,  which 
forms  whitish  lines  at  the  apices  of  the  pyramids  and  is  met  with  chiefly, 
but  not  always,  in  gouty  persons;  and  (3)  the  lime  infarct?.  forming  very 
opaque  white  lines  in  the  pyramids,  usually  in  old  people. 

In  the  pelvis  and  calyces  concretions  of  the  following  forms  occur:  (a) 
Smal)  gritty  particles,  renal  sand,  ranging  in  size  from  the  individual  grains 
of  the  uric  acid  sediment  to  bodies  1  or  2  mm.  in  diameter.  These  may  be 
passed  in  the  urine  for  long  periods  without  producing  any  symptoms,  since 
they  are  too  fine  to  be  arrested  in  their  downward  passage. 

(&)  Larger  concretions,  ranging  in  size  from  a  small  pea  to  a  bean,  and 
either  solitary  or  multiple  in  the  calyces  and  pelvis.  It  is  the  smaller  of 
these  calculi  which,  in  their  passage,  produce  the  attacks  of  renal  colic.  They 
may  be  rounded  and  smooth,  or  present  numerous  irregular  projections. 

(c)  The  dendritic  form  of  calculus.  The  orifice  of  the  ureter  may  be 
blocked  by  a  Y-shaped  stone.  The  pelvis  itself  may  be  occupied  by  the  con- 
cretion, which  forms  a  more  or  less  distinct  mould.  These  are  the  remark- 
able coral  calculi,  which  form  in  the  pelvis  complete  moulds  of  infundibula 
and  calyces,  the  latter  even  presenting  cup-like  depressions  corresponding  to 
the  apices  of  the  papillae.  Some  of  these  casts  in  stone  of  the  renal  pelvis  are 
as  beautifully  moulded  as  Hyrtl's  corrosion  preparations. 

Chemically  the  varieties  of  calculi  are:  (1)  Uric  acid  and  urates,  most 
important,  and  forming  the  renal  sand,  the  small  solitary,  or  the  large  den- 
dritic stones.  They  are  very  hard,  the  surface  is  smooth,  and  the  color  red- 
dish. The  larger  stones  are  usually  stratified  and  very  dense.  Usually  the 
uric  acid  and  the  urates  are  mixed,  but  in  children  stones  composed  of  urates 
alone  may  occur. 

(2)  Oxalate  of  lime,  which  forms  mulberry-shaped  calculi,  studded  with 
points  and  spines.     They  are  often  very  dark  in  color,  intensely  hard,  and 
are  a  mixture  of  oxalate  of  lime  and  uric  acid. 

(3)  .Phosphatic  calculi  are  composed  of  the  calcium  phosphate  and  the 
ammonio-magnesium  phosphate,  sometimes  mixed  with,  a  small  amount  of 
calcium  carbonate.     They  are  quite  common,  although  the  phosphatic  salts 
are  often  deposited  about  the  uric  acid  or  the  calcium  oxalate  stones. 

(4)  Rare  forms  of  calculi  are  made  up  of  cystine,  xanthine,  carbonate  of 
lime,  indigo,  and  urostealith. 

The  mode  of  formation  of  calculi  has  been  much  discussed.  They  may 
be  produced  by  an  excess  of  a  sparingly  soluble  abnormal  ingredient,  such  as 
cystine  or  xanthine;  more  frequently  by  the  presence  of  uric  acid  in  a  very 
acid  urine  which  favors  its  deposition.  Sir  William  Roberts  thus  briefly 
states  the  conditions  which  lead  to  the  formation  of  the  uric  acid  concretions : 
high  acidity,  poverty  in  salines,  low  pigmentation,  and  high  percentage  of 
uric  acid.  Ord  suggests  that  albumin,  mucus,  blood,  and  epithelial  threads 
may  be  the  starting  point  of  stone.  The  demonstration  of  organisms  in  the 
centre  of  renal  calculi  renders  it  probable  that  in  many  cases  the  nucleus  of 
the  stone  is  an  agglutinated  mass  of  bacteria. 


NEPHROLITHIASIS  719 

Renal  calculi  are  most  common  in  the  early  and  later  periods  of  life.  They 
are  moderately  frequent  in  the  United  States,  but  there  do  not  appear  to  be 
special  districts,  corresponding  to  the  "stone  counties"  in  England.  Men  are 
more  often  affected  than  women.  Sedentary  occupations  seem  to  predispose 
to  stone. 

The  effects  of  the  calculi  are  varied.  It  is  by  no  means  uncommon  to  find 
a  dozen  or  more  stones  of  various  sizes  in  the  calyces  without  any  destruction 
of  the  mucous  membrane  or  dilatation  of  the  pelvis.  A  turbid  urine  fills  the 
pelvis,  in  which  there  are  numerous  cells  from  the  epithelial  lining.  There 
are  cases  of  this  sort  in  which,  apparently,  the  stones  may  go  on  forming 
and  are  passed  for  years  without  seriously  impairing  the  health  and  without 
inconvenience,  except  the  attacks  of  renal  colic.  Still  more  remarkable  are 
the  cases  of  coral  like  calculi,  which  may  occupy  the  entire  pelvis  and  calyces 
without  causing  pyelitis,  but  which  gradually  lead  to  more  or  less  induration 
of  the  kidney.  The  most  serious  effects  are  when  the  stone  excites  a  suppura- 
tive  pyelitis  and  pyonephrosis. 

Symptoms. — Patients  may  pass  gravel  for  years  without  having  an  attack 
of  renal  colic,  and  a  stone  may  never  lodge  in  the  ureter.  In  other  instances, 
the  formation  of  calculi  goes  on  year  by  year  and  the  patient  has  recurring 
attacks  such  as  have  been  so  graphically  described  by  Montaigne  in  his  own 
case.  A  patient  may  pass  enormous  numbers  of  calculi.  A  patient  may  pass 
a  single  calculus,  and  never  be  troubled  again.  The  large  coral  calculi  may 
excite  no  symptoms.  In  a  remarkable  specimen  of  the  kind,  presented  to 
the  McGill  Medical  Museum  by  J.  A.  Macdonald,  the  patient,  a  middle-aged 
woman,  died  suddenly  with  uraemic  symptoms.  There  was  no  pyelitis,  but 
the  kidneys  were  sclerotic. 

Renal  colic  ensues  when  a  stone  enters  the  ureter,  or  follows  an  acute  py- 
elitis. An  attack  may  set  in  abruptly  without  apparent  cause,  or  may  follow 
a  strain  in  lifting.  It  is  characterized  by  agonizing  pain,  which  starts  in  the 
flank  of  the  affected  side,  passes  down  the  ureter,  and  is  felt  in  the  testicle 
and  along  the  inner  side  of  the  thigh.  The  pain  may  also  radiate  through 
the  abdomen  and  chest,  and  be  very  intense  in  the  back.  In  severe  attacks 
there  are  nausea  and  vomiting  and  the  patient  is  collapsed.  The  perspiration 
breaks  out  upon  the  face  and  the  pulse  is  feeble  and  quick.  A  chill  may  pre- 
cede the  outbreak,  and  the  temperature  may  rise  as  high  as  103°.  No  one 
has  more  graphically  described  an  attack  of  "the  stone"  than  Montaigne,* 
who  was  a  sufferer  for  many  years:  "Thou  art  seen  to  sweat  with  pain,  to 
look  pale  and  red,  to  tremble,  to  vomit  well-nigh  to  blood,  to  suffer  strange 
contortions  and  convulsions,  by  starts  to  let  tears  drop  from  thine  eyes,  to 
urine  thick,  black,  and  frightful  water,  or  to  have  it  suppressed  by  some  sharp 
and  craggy  stone,  that  cruelly  pricks  and  tears  thee."  From  personal  ex- 
perience I  can  describe  three  sorts  of  pain  in  an  attack  of  renal  colic:  (a) 
A  constant  localized,  dull  pain,  the  area  of  which  could  be  covered  on  the 
skin  of  the  back  in  the  renal  region  by  a  penny  piece,  and  which  could  be 
imitated  exactly  by  deep  firm  pressure  on  a  superficial  bone.  (&)  Paroxysms 
of  pain  radiating  in  the  course  of  the  ureter  or  into  the  flank,  and  as  they 
increase  accompanied  by  sweating,  fainting,  and  nausea,  (c)  Flushes  or 

•Essays,  Book  111,  13. 


720  DISEASES    OF   THE   KIDNEYS 

rushes  of  hot  pain  at  intervals,  often  momentary,  usually  passing  to  the 
back,  less  often  toward  the  groin.  Dozens  of  these  flushes  relieved  the  monot- 
ony of  (&).  The  symptoms  persist  for  a  variable  period.  In  short  attacks 
they  do  not  last  longer  than  an  hour;  in  other  instances  they  continue  for  a 
day  or  more,  with  temporary  relief.  Micturition  is  frequent,  occasionally 
painful,  and  the  urine,  as  a  rule,  is  bloody.  There  are  instances  in  which  a 
large  amount  of  clear  urine  is  passed,  probably  from  the  other  kidney.  In 
rare  cases  the  secretion  of  urine  is  completely  suppressed,  even  when  the  kid- 
ney on  the  opposite  side  is  normal,  and  death  may  occur  from  uraemia.  This 
most  frequently  happens  when  the  second  kidney  is  extensively  diseased,  or 
when  only  a  single  kidney  exists. 

After  the  attack  of  colic  has  passed  there  is  more  or  less  aching  on  the 
affected  side,  and  the  patient  can  usually  tell  from  which  kidney  the  stone 
has  come.  Examination  during  the  attack  is  usually  negative.  Very  rarely 
the  kidney  becomes  palpable.  Tenderness  on  the  affected  side  is  common. 
In  very  thin  persons  it  may  be  possible,  on  examination  of  the  abdomen,  to  feel 
the  stone  in  the  ureter;  or  the  patient  may  complain  of  a  grating  sensation. 

When  the  calculi  remain  in  the  kidney  they  may  produce  very  definite  and 
characteristic  symptoms,  of  which  the  following  are  the  most  important : 

(a)  Pain,  usually  in  the  back,  which  is  often  no  more  than  a  dull  soreness, 
but  which  may  be  severe  and  come  on  in  paroxysms.  It  is  usually  on  the 
side  affected,  but  may  be  referred  to  the  opposite  kidney,  and  there  are  in- 
stances in  which  the  pain  has  been  confined  to  the  sound  side.  It  radiates 
in  the  direction  of  the  ureter,  and  may  be  felt  in  the  scrotum  or  even  in  the 
penis.  Pains  of  a  similar  nature  may  occur  in  movable  kidneys,  and  there  are 
several  instances  on  record  in  which  surgeons  have  incised  the  kidney  for 
stone  and  found  none.  In  an  instance  in  which  pain  was  present  for  a  couple 
of  years  the  exploration  revealed  only  a  contracted  kidney. 

(&)  HcematUria. — Although  this  occurs  most  frequently  when  the  stone 
becomes  engaged  in  the  ureter,  it  may  also  come  on  when  the  stones  are  in 
the  pelvis.  The  bleeding  is  seldom  profuse,  as  in,  cancer,  but  in  some  in- 
stances may  persist  for  a  long  time.  It  is  aggravated  by  exertion  and  lessened 
by  rest.  Frequently  it  only  gives  to  the  urine  a  smoky  hue.  The  urine  may 
be  free  for  days,  and  then  a  sudden  exertion  or  a  prolonged  ride  may  cause 
smokiness,  or  blood  may  be  passed  in  considerable  quantities. 

(c)  PyeUtis. — (1)  There  may  be  attacks  of  severe  pain  in  the  back,  not 
amounting  to  actual  colic,  which  are  initiated  by  a  heavy  chill  followed  by 
fever,  in  which  the  temperature  may  reach  104°  or  105°,  followed  by  profuse 
sweating.  The  urine,  which  has  been  clear,  may  become  turbid  and  smoky 
and  contain  blood  and  abundant  epithelium  from  the  pelvis.  Attacks  of  this 
description  may  recur  at  intervals  for  months  or  even  years,  and  are  generally 
mistaken  for  malaria,  unless  special  attention  is  paid  to  the  urine  and  to  the 
existence  of  the  pain  in  the  back.  This  renal  intermittent  fever,  due  to  the 
presence  of  calculi,  is  analogous  to  the  hepatic  intermittent  fever,  due  to 
gall-stones,  and  in  both  it  is  important  to  remember  that  the  most  intense 
paroxysms  may  occur  without  any  evidence  of  suppuration. 

(2)  More  frequently  the  symptoms  of  purulent  pyelitis,  which  have  al- 
ready been  described,  are  present;  pain  in  the  renal  region,  recurring  chills, 
and  pus  in  the  urine,  with  or  without  indications  of  pyonephrosis. 


NEPHROLITHIASIS  721 

(d)  Pyuria. — There  are  instances  of  stone  in  the  kidney  in  which  pus 
occurs  continuously  or  intermittently  in  the  urine  for  many  years. 

Patients  with  stone  in  the  kidney  are  often  robust,  high  livers,  and  gouty. 
Attacks  of  dyspepsia  are  not  uncommon,,  or  they  may  have  severe  headaches. 

Diagnosis. — The  X-ray  picture  is  rarely  at  fault,  and  specialists  in  this 
department  are  becoming  more  and  more  skillful,  so  that  mistakes  are  now 
rare.  Eenal  may  be  mistaken  for  intestinal  colic,  particularly  if  the  disten- 
tion  of  the  bowels  is  marked,  or  for  biliary  colic.  The  situation  and  direction 
of  the  pain,  the  retraction  and  tenderness  of  the  testicle,  the  occurrence  of 
haematuria,  and  the  altered  character  of  the  urine  are  distinctive  features. 
Attention  may  again  be  called  to  the  fact  that  attacks  simulating  renal  colic 
are  associated  with  movable  kidney,  or  even,  it  has  been  supposed,  without 
mobility  of  the  kidney,  with  the  accumulation  of  the  oxalates  or  uric  acid 
in  the  pelvis  of  the  kidney.  The  diagnosis  between  a  stone  in  the  kidney  and 
stone  in  the  bladder  is  not  always  easy,  though  in  the  latter  the  pain  is  par- 
ticularly about  the  neck  of  the  bladder,  and  not  limited  to  one  side.  In  the 
uric  acid  or  uratic  renal  stone,  the  urine  is  acid,  thus  aiding  us  in  differen- 
tiating it  from  a  bladder  stone,  when  alkaline  urine  is  the  rule.  It  is  stated 
that  certain  differences  occur  in  the  symptoms  produced  by  different  sorts  of 
calculi.  The  large  uric  acid  calculi  less  frequently  produce  severe  symptoms. 
On  the  other  hand,  as  the  oxalate  of  lime  is  a  rougher  calculus,  it  is  apt  to 
produce  more  pain  (often  of  a  radiating  character)  than  the  lithic  acid  form, 
and  to  cause  haemorrhage.  In  both  these  forms  the  urine  is  acid.  The  phos- 
phatic  calculi  are  stated  to  produce  the  most  intense  pain,  and  the  urine  is 
commonly  alkaline. 

Treatment. — In  the  attacks  of  renal  colic  great  relief  is  experienced  by 
the  hot  bath,  which  is  sometimes  sufficient  to  relax  the  spasm.  When  the 
pain  is  very  intense  morphia  should  be  given  hypodermically  and  inhalations 
of  chloroform  may  be  necessary  until  the  effects  of  the  anodyne  are  manifest. 
Local  applications  are  sometimes  grateful — hot  poultices,  or  cloths  wrung  out 
of  hot  water.  The  patient  may  drink  freely  of  hot  lemonade,  soda  water,  or 
barley  water.  Occasionally  change  in  posture  or  inversion  will  give  great 
relief.  Surgical  interference  should  be  considered  in  all  cases,  especially 
when  the  stone  is  large  or  the  associated  pyelitis  severe.  • 

In  the  intervals  the  patient  should,  as  far  as  possible,  live  a  quiet  life, 
avoiding  sudden  exertion  of  all  sorts.  The  essential  feature  in  the  treatment 
is  to  keep  the  urine  abundant  and,  in  the  uric  acid  or  uratic  cases,  alkaline. 
The  patient  should  drink  daily  a  large  but  definite  quantity  of  mineral  wa- 
ters* or  distilled  water,  which  is  just  as  satisfactory.  The  citrate  or  bi- 
carbonate of  potash  may  be  added.  The  aching  pains  in  the  back  are  often 
greatly  relieved  by  this  treatment.  Many  patients  find  benefit  from  a  stay 
at  Saratoga,  Bedford,  Poland,  or  other  mineral  springs  in  the  United  States, 
or  at  Vichy  or  Ems  in  Europe. 

The  diet  should  be  carefully  regulated,  and  similar  to  that  indicated  in 
the  early  stages  of  gout.  Sir  William  Roberts  recommends  what  is  known  as 
the  solvent  treatment  for  uric  acid  calculi.  The  citrate  of  potash  is  given  in 
large  doses,  half  a  drachm  to  a  drachm,  every  three  hours  'in  a  tumblerful  of 

*Some  of  these,  if  we  judge  by  the  laudatory  reports,  are  as  potent  as  the  waters  of 
Corsena,  declared  by  Montaigne  to  be  "powerful  enough  to  break  stones." 


722  DISEASES    OF    THE    KIDNEYS 

water.  This  should  be  kept  up  for  several  months.  I  have  had  no  success 
with  this  treatment,  nor,  when  one  considers  the  character  of  the  uric  acid 
stones  usually  met  with  in  the  kidney,  does  it  seem  likely  that  any  solvent 
action  could  be  exercised  upon  them  by  changes  in  the  urine.  This  treatment 
should  be  abandoned  if  the  urine  becomes  ammoniacal. 

The  value  of  piperazine  as  a  solvent  of  uric  acid  gravel  or  of  uric  acid 
stones  has  been  much  discussed.  While  outside  the  body  a  watery  solution 
of  the  drug  has  this  power  in  a  marked  degree,  the  amount  excreted  in  the 
urine  as  given  in  the  ordinary  doses  of  15  grains  daily  seems  to  have  very 
little  influence.  Several  observers  have  shown  that  the  percentage  of  piper- 
azine excreted  in  the  urine,  when  taken  in  doses  of  from  1  to  2  grams,  has, 
when  tested  outside  of  the  body,  little  or  no  influence  as  a  solvent  (Fawcett, 
Gordon) . 

XII.    TUMORS   OF   THE   KIDNEY 

These  are  benign  and  malignant.  Of  the  benign  tumors,  the  most  com- 
mon are  the  small  nodular  fibromata  which  occur  frequently  in  the  pyra- 
mids, and  occasionally  lipoma,  angioma,  or  lymphadenoma.  The  adenomata 
may  be  congenital.  In  one  of  my  cases  the  kidneys  were  greatly  enlarged, 
contained  small  cysts,  and  numerous  adenomatous  structures  throughout  both 
organs. 

Malignant  growths — cancer  or  sarcoma — may  be  either  primary  or  secon- 
dary. The  sarcomata  are  the  most  common,  either  alveolar  sarcoma  or  the 
remarkable  form  containing  striped  muscular  fibres — rhabdomyoma.  One 
of  the  most  common  and  important  renal  tumors  is  the  Jiypernephroma, 
growing  in  or  upon  the  organ  from  the  adrenal  tissue — the  aberrant  "rests" 
of  Grawitz.  Of  163  cases  only  6  were  extra-renal  (Ellis).  They  may  be 
small  and  in  the  renal  cortex  or  form  large  tumors  with  extensive  metastases, 
particularly  in  the  lungs.  Most  of  the  primary  carcinomas  and  alveolar 
sarcomas  of  the  kidney  are  really  hypernephromata. '  Adami  holds  that  they 
may  arise  from  either  renal  or  adrenal  tissues. 

The  tumors  attain  a  very  large  size,  and  almost  fill  the  abdomen.  In  chil- 
dren they  may  be  enormous.  They  grow  rapidly,  are  often  soft,  and  hemor- 
rhage frequently  takes  place  into  them.  In  the  sarcomata,  invasion  of  the 
pelvis  or  of  the  renal  vein  is  common.  The  rhabdomyomata  rarely  form  very 
large  tumors,  and  death  occurs  shortly  after  birth.  In  one  of  my  cases  the 
child  at  the  age  of  three  years  and  a  half  died  suddenly  of  embolism  of  the 
pulmonary  artery  and  tricuspid  orifice  by  a  fragment  of  the  tumor,  which 
had  grown  into  the  renal  vein. 

Symptoms. — The  following  are  the  most  important:  (a)  Efematuria  in 
one-half  the  cases,  which  may  be  the  first  indication.  The  blood  is  fluid  or 
clotted,  and  there  may  be  very  characteristic  moulds  of  the  pelvis  of  the  kid- 
ney and  of  the  ureter.  It  would  no  doubt  be  possible  for  such  to  form  in 
the  hasmaturia  from  calculus,  but  I  have  never  met  with  a  case  of  blood  casts 
of  the  pelvis  and  of  the  ureter,  either  alone  or  together,  except  in  cancer.  It 
is  rare,  indeed,  that  cancer  elements  can  be  recognized  in  the  urine,  and  yet 
the  diagnosis  has  been  made  in  this  way. 

(6)    Pain  is  an  uncertain  symptom.     In  several  of  the  largest  tumor?. 


CYSTIC    DISEASE    OF    THE    KIDNEY  723 

which  have  come  under  my  observation  there  has  been  no  discomfort  from 
beginning  to  close.  When  present,  it  is  of  a  dragging,  dull  character,  situ- 
ated in  the  flank  and  radiating  down  the  thigh.  The  passage  of  the  clots 
may  cause  great  pain.  In  one  case  the  growth  was  at  first  upward,  and  the 
symptoms  for  some  months  were  those  of  pleurisy. 

(c)  Progressive  emaciation.  The  loss  of  flesh  is  usually  marked  and 
advances  rapidly.  There  may,  however,  be  a  very  large  tumor  without 
emaciation. 

PHYSICAL  SIGNS. — In  almost  all  instances  tumor  is  present.  When  small 
and  on  the  right  side,  it  may  be  very  movable ;  in  some  instances,  occupying 
a  position  in  the  iliac  fossa,  it  has  been  mistaken  for  ovarian  tumor.  The 
large  growths  fill  the  flank  and  gradually  extend  toward  the  middle  line, 
occupying  the  right  or  left  half  of  the  abdomen.  Inspection  may  show  two 
or  three  hemispherical  projections  corresponding  to  distended  sections  of  the 
organ.  In  children  the  abdomen  may  reach  an  enormous  size  and  the  veins 
are  prominent  and  distended.  On  bimanual  palpation  the  tumor  is  felt  to 
occupy  the  lumbar  region  and  can  usually  be  lifted  slightly  from  its  bed;  in 
some  cases  it  is  very  movable,  even  when  large;  in  others  it  is  fixed,  firm, 
and  solid.  The  respiratory  movements  have  but  slight  influence  upon  it. 
Rapidly  growing  renal  tumors  are  soft,  and  on  palpation  may  give  a  sense  of 
fluctuation.  A  point  of  considerable  importance  is  the  fact  that  the  colon 
crosses  the  tumor,  and  can  usually  be  detected  without  difficulty. 

Diagnosis. — In  children  very  large  abdominal  tumors  are  either  renal  or 
retroperitoneal.  The  retroperitoneal  sarcoma  (Lobstein's  cancer)  is  more 
central,  but  may  attain  as  large  a  size.  If  the  case  is  seen  only  toward  the 
end,  a  differential  diagnosis  may  be  impossible;  but,  as  a  rule,  the  sarcoma 
is  less  movable.  It  is  to  be  remembered  that  these  tumors  may  invade  the 
kidney.  On  the  left  side  an  enlarged  spleen  is  readily  distinguished,  as  the 
edge  is  very  distinct  and  the  notch  or  notches  well  marked;  it  descends  dur- 
ing respiration,  and  the  colon  lies  behind,  not  in  front  of  it.  On  the  right 
side  growths  of  the  liver  are  occasionally  confounded  with  renal  tumors;  but 
such  instances  are  rare,  and  there  can  usually  be  detected  a  zone  of  resonance 
between  the  upper  margin  of  the  renal  tumor  and  the  ribs.  Late  in  the 
disease,  however,  this  is  not  possible,  for  the  renal  tumor  is  in  close  union 
with  the  liver. 

A  malignant  growth  in  a  movable  kidney  may  be  very  deceptive  and  may 
simulate  cancer  of  the  ovary  or  myoma  of  the  uterus.  The  great  mobility 
upward  of  the  renal  growth  and  the  negative  result  of  examination  of  the 
pelvic  viscera  are  the  reliable  points. 

When  the  growth  is  small  and  the  patient  in  good  condition  removal  of 
the  organ  may  be  undertaken,  but  the  percentage  of  cases  of  recovery  is  very 
small,  only  5.4  per  cent.  (G.  Walker). 

XHI.    CYSTIC  DISEASE   OF  THE  KIDNEY 

The  following  varieties  of  cysts  are  met  with : 

Small  Cysts. — The  small  cysts,  already  described  in  connection  with  the 
chronic  nephritis,  which  result  from  dilatation  of  obstructed  tubules  or  of 
Bowman's  capsules.  There  are  cases  very  difficult  to  classify,  in  which  the 


DISEASES    OF   THE   KIDNEYS 

kidneys  are  greatly  enlarged,  and  very  cystic  in  middle-aged  or  elderly  per- 
sons, and  yet  not  so  large  as  in  the  congenital  form. 

Solitary  Cysts. — Solitary  cysts,  ranging  in  size  from  a  marble  to  an 
orange,  or  even  larger,  are  occasionally  found  in  kidneys  which  present  no 
other  changes.  In  exceptional  cases  they  may  form  tumors  of  considerable 
size.  Newman  operated  on  one  which  contained  25  ounces  of  blood.  They, 
too,  in  all  probability,  result  from  obstruction. 

Polycystic  Kidneys. — The  polycystic  kidneys,  in  which  the  greatly  en- 
larged organs,  weighing  even  as  much  as  six  pounds,  are  represented  by  a 
conglomeration  of  cysts,  varying  in  size  from  a  pea  to  a  marble.  Little  or 
no  renal  tissue  may  be  noticeable,  although  in  microscopic  sections  it  is  seen 
that  a  considerable  amount  remains  in  the  interspaces.  The  cysts  contain  a 
clear  or  turbid  fluid,  sometimes  reddish  brown  or  even  blackish  in  color,  and 
may  be  of  a  colloidal  consistence.  Albumin,  blood  crystals,  cholesterin,  with 
triple  phosphates  and  fat  drops,  are  found  in  the  contents.  Urea  and  uric 
acid  are  rarely  present.  The  cysts  are  lined  by  a  flattened  epithelium.  They 
occur  in  the  fetus,  and  sometimes  are  of  such  a  size  as  to  obstruct  labor.  In 
the  adult  they  are  usually  bilateral,  and  there  is  every  reason  to  believe  that 
they  begin  in  early  life  and  increase  gradually.  Indeed,  a  progressive  growth 
has  been  noticed  in  some  cases  (Alfred  King).  They  may  be  found  in  con- 
nection with  cystic  disease  of  the  liver  and  other  organs.  It  is  difficult  to 
account  for  the  origin  of  this  remarkable  condition,  which  some  regard  as  a 
defect  of  development  rather  than  a  pathological  change,  and  point  to  the 
association  in  the  fetal  cases  of  other  anomalies,  as  imperforate  anus.  Others 
believe  the  condition  to  be  a  new  growth — a  sort  of  mucoid  endothelioma. 

It  is  interesting  to  note  that  several  members  of  a  family  may  be  affected. 
I  have  reported  an  instance  in  which  mother  and  son  were  the  subjects  of 
the  disease. 

SYMPTOMS. — Of  five  cases  which  I  have  seen  in  adults  the  condition  was 
recognized  during  life  in  four.  The  features  are  characteristic. 

(a)  Bilateral  tumors  in  the  renal  regions,  which  may  increase  in  size 
under  observation.  They  may  cause  great  enlargement  of  the  upper  zone  of 
the  abdomen.  The  colon  and  stomach  are  in  front  of  the  tumors,  on  the 
surface  of  which  in  very  thin  subjects  the  cysts  may  be  palpable. 

(&)  Haematuria,  which  may  recur  at  intervals  for  years. 

(c)  The  signs  of  a  chronic  interstitial  nephritis — (1)  pallor  or  muddy 
complexion;  in  rare  instances  a  bronzing  of  the  skin;  (2)  sclerosis  of  the 
arteries;  (3)  hypertrophy  of  the  heart  with  accentuated  second  sound;  (4) 
urine  abundant,  of  low  specific  gravity,  with  albumin,  and  hyaline  and  gran- 
ular tube  casts,  and  in  one  of  my  cases  there  were  cholesterin  crystals.  Death 
occurs  from  uremia  or  the  cardio-vascular  complications  of  chronic  Bright's 
disease.  A  rare  event  is  rupture  of  a  cyst  with  the  formation  of  a  peri- 
nephric  abscess  and  peritonitis.  In  two  of  my  cases  the  skin  became  much 
pigmented. 

While  both  kidneys  are,  as  a  rule,  involved,  one  may  be  much  smaller 
than  the  other. 

Operation,  by  exposing  the  kidney  and  draining  the  cysts,  has  been  suc- 
cessful. When  the  condition  is  unilateral  the  kidney  has  been  removed  and 
the  patients  have  remained  well  for  years.  • 


PEKINEPHRIC    ABSCESS  725 

Other  Varieties. — Occasionally  the  kidneys  and  liver  present  numerous 
small  cysts  scattered  through  the  substance.  The  spleen  and  the  thyroid  also 
may  be  involved,  and  there  may  be  congenital  malformation  of  the  heart. 
The  cysts  in  the  kidney  are  small,  and  neither  so  numerous  nor  so  thickly  set 
as  in  the  conglomerate  form,  though  in  these  cases  the  condition  is  probably 
the  result  of  some  congenital  defect.  There  are  cases,  however,  in  which  the 
kidneys  are  very  large.  It  is  more  common  in  the  lower  animals  than  in 
man.  I  have  seen  several  instances  of  it  in  the  hog;  in  one  case  the  liver 
weighed  40  pounds,  and  was  converted  into  a  mass  of  simple  cysts.  The 
kidneys  were  less  involved.  Charles  Kennedy  found  references  to  12  cases 
of  combined  cystic  disease  of  the  liver  and  kidneys. 

The  echinococcus  cysts  have  been  described  under  the  section  on  parasites. 
Paranephric  cysts  (external  to  the  capsule)  are  rare;  they  may  reach  a  large 
size. 

XIV.    PERINEPHRIC  ABSCESS 

Suppuration  in  the  connective  tissue  about  the  kidney  may  follow  (1) 
blows  and  injuries;  (2)  the  extension  of  inflammation  from  the  pelvis  of  the 
kidney,  the  kidney  itself,  or  the  ureters;  (3)  perforation  of  the  bowel,  most 
commonly  the  appendix,  in  some  instances  the  colon;  (4)  extension  of  sup- 
puration from  the  spine,  as  in  caries,  or  from  the  pleura,  as  in  empyema; 
(5)  as  a  sequel  of  the  fevers,  particularly  in  children. 

Post  mortem  the  kidney  is  surrounded  by  pus,  particularly  at  the  posterior 
part,  though  the  pus  may  lie  altogether  in  front,  between  the  kidney  and  the 
peritoneum.  Usually  the  abscess  cavity  is  extensive.  The  pus  is  often  offen- 
sive and  may  have  a  distinctly  fscal  odor  from  contact  with  the  large  bowel. 
It  may  burrow  in  various  directions  and  burst  into  the  pleura  and  be  dis- 
charged through  the  lungs.  A  more  frequent  direction  is  down  the  psoas 
muscle,  when  it  appears  in  the  groin,  or  it  may  pass  along  the  iliacus  fascia 
and  appear  at  Poupart's  ligament.  It  may  perforate  the  bowel  or  rupture  into 
the  peritoneum;  sometimes  it  penetrates  the  bladder  or  vagina. 

Post  mortem  we  occasionally  find  a  condition  of  chronic  perinephritis  in 
which  the  fatty  capsule  of  the  kidney  is  extremely  firm,  with  numerous  bands 
of  fibrous  tissue,  and  is  stripped  off  from  the  proper  capsule  with  the  greatest 
difficulty.  Such  a  condition  probably  produces  no  symptoms. 

Symptoms. — There  may  be  intense  pain,  aggravated  by  pressure,  in  the 
lumbar  region.  In  other  instances  the  onset  is  insidious,  without  pain  in  the 
renal  region;  on  examination  signs  of  deep  seated  suppuration  may  be  de- 
tected. On  the  affected  side  there  is  usually  pain,  which  may  be  referred  to 
the  neighborhood  of  the  hip  joint  or  to  the  joint  itself,  or  radiate  down  the 
thigh  and  be  associated  with  the  retraction  of  the  testis.  The  patient  lies 
with  the  thigh  flexed,  so  as  to  relax  the  psoas  muscle,  and  in  walking  throws, 
as  far  as  possible,  the  weight  on  the  opposite  leg.  He  also  keeps  the  spine 
immobile,  assumes  a  stooping  posture  in  walking,  and  has  great  difficulty  in 
voluntarily  adducting  the  thigh  (Gibney). 

There  may  be  pus  in  the  urine  if  the  disease  has  extended  from  the  pelvis 
or  the  kidney,  but  in  other  forms  the  urine  is  clear.  When  pus  has  formed 
there  are  usually  chills  with  irregular  fever  and  sweats.  On  examination, 


726  DISEASES    OF    THE    KIDNEYS 

deep  seated  induration  is  felt  between  the  last  rib  and  the  crest  of  the  ilium. 
Bimanual  palpation  may  reveal  a  distinct  tumor  mass.  (Edema  or  puffmess 
of  the  skin  is  frequently  present. 

Diagnosis. — The  diagnosis  is  usually  easy;  when  doubt  exists  the  aspirator 
needle  should  be  used.  We  can  not  always  differentiate  the  primary  forms 
from  those  due  to  perforation  of  the  kidney  or  of  the  bowel.  This,  however, 
makes  but  little  difference,  for  the  treatment  is  identical.  It  is  usually  pos- 
sible by  the  history  and  examination  to  exclude  diseases  of  the  vertebra.  In 
children  hip-joint  disease  may  be  suspected,  but  the  pain  is  higher,  and  the*re 
is  no  fullness  or  tenderness  over  the  hip-joint  itself. 

Treatment. — The  treatment  is  clear — early,  free,  and  permanent  drain- 
age, 


SECTION   VIII 
DISEASES  OF  THE  BLOOD 

I.    ANEMIA 

Anaemia,  a  reduction  of  the  amount  of  blood  as  a  whole  or  of  its  cor« 
puscles,  or  of  certain  of  its  constituents,  may  be  due  to  failure  in  the  manu- 
facture, to  increase  in  the  consumption,  or  to  a  sudden  loss,  as  in  haemor- 
rhage. Defective  formation,  haematogenesis,  is  responsible  for  a  large  group 
of  what  are  known  as  the  primary  anaemias.  Increased  destruction,  or  haemol- 
ysis, is  the  basis  of  the  majority  of  all  cases  in  which  anaemia  is  secondary 
to  some  existing  disease. 

Anaemia  may  be  local,  confined  to  certain  parts,  or  general,  involving  the 
entire  body. 

LOCAL   ANAEMIA 

Tissue  irrigation  with  blood  is  primarily  from  the  heart,  but  in  all  ex- 
tensive systems  of  this  sort  provision  is  made  at  the  local  territories  for 
variations  in  the  supply,  according  to  the  needs  of  a  part.  The  sluices  are 
arranged  by  means  of  the  stop-cock  action  of  the  arteries,  which  contract  or 
expand  under  the  influence  of  the  vaso-motor  ganglia,  central  and  peripheral. 
If  the  sluices  of  one  large  district  are  too  widely  open,  so  much  blood  may 
enter  that  other  important  regions  have  not  enough  to  keep  them  at  work. 
Local  anaemia  of  the  brain,  causing  swooning,  ensues  when  the  mesenteric 
channels,  capable  of  holding  all  the  blood  of  the  body,  are  wide  open.  Emo- 
tional stimuli,  reflex  from  pain,  etc.,  removal  of  pressure,  as  after  tapping 
in  ascites,  may  cause  this.  It  is  probable  that  many  of  the  nervous  and  other 
symptoms  in  enteroptosis  are  due  to  the  relative  anaemia  of  the  cerebral  and 
spinal  systems,  owing  to  the  persistent  overfilling  of  the  mesenteric  reservoir. 
We  know  very  little  of  local  anaemia  of  the  various  organs,  but  possibly  func- 
tional disturbance  in  the  liver,  kidneys,  pancreas,  heart,  etc.,  may  result  from 
a  permanently  low  pressure  in  the  local  blood  "mains."  Anaemia  from  spasm 
of  the  arterial  walls  is  seen  in  Eaynaud's  disease,  which  usually  affects  the 
peripheral  vessels,  causing  local  syncope  of  the  fingers,  but  it  may  occur  in 
the  visceral  vessels,  particularly  of  the  brain,  and  cause  temporary  hemiplegia, 
aphasia,  etc. 

In  local  anaemia  we  are  sometimes  deceived  by  the  appearance  of  the  skin 
and  mucous  membranes.  A  marked  pallor  may  exist  with  normal  corpuscles 
and  haemoglobin ;  for  example,  the  pallor  after  a  drinking  bout,  or  of  nausea ; 
in  certain  cases  of  heart  disease,  in  lead-workers,  and  in  the  morphia  habitue 

727 


728  DISEASES    OF    THE    BLOOD 

the  skin  is  often  permanently  pale.    There  are  a  few  healthy  people  who  are 
always  pale,  and  yet  have  a  practically  normal  blood  count  and  color  index. 

GENERAL    ANAEMIA 

The  general  anaemias  may  be  divided  into  the  secondary  or  symptomatic, 
and  the  primary  or  essential. 

Acute  /Secondary  Ancemia 

Etiology. — Haemorrhage,  certain  acute  infections,  and  intoxications  are  the 
important  causes.  A  typical  form  is  that  which  follows  haemorrhage,  either 
traumatic  or  spontaneous.  In  rupture  of  a  large  vessel,  or  of  an  aneurism, 
in  the  peptic  ulcer,  or  in  injury  to  blood  vessels  the  loss  of  three  or  four 
pounds  of  blood  may  prove  fatal.  Seven  and  a  half  pounds  is  the  largest 
quantity  I  have  known  shed  into  one  cavity  (rupture  of  an  aneurism  into 
the  pleura).  A  patient  with  haematemesis  lost  ten  pounds  of  blood  in  one 
week,  and  yet  recovered  from  the  immediate  effects.  Even  after  the  severest 
traumatic  haemorrhage  the  blood  count  is  rarely  so  low  as  in  certain  forms 
of  primary  anaemia.  Thus  in  the  case  of  haematemesis  just  mentioned  the  red 
blood-corpuscles  were  1,390,000  per  c.  mm. 

Acute  secondary  anaemia  may  follow  haemolysis  in  certain  infections,  as 
malaria,  acute  endocarditis,  sepsis,  and  a  profound  anaemia  may  be  induced 
in  the  course  of  a  week.  Less  often  do  we  see  an  acute  secondary  anaemia 
follow  toxic  substances,  such  as  mercury  or  nitro-benzol. 

Symptoms. — Dyspnoea,  rapid  action  of  the  heart,  and  faintness  are  the 
prominent  symptoms  of  an  acutely  produced  anaemia.  There  is  marked  pallor 
of  the  skin  and  mucous  membranes,  the  pulse  becomes  small,  the  temperature 
is  low,  the  patient  feels  giddy  and  faint  and  has  noises  in  the  ears.  If  the 
bleeding  continues  there  may  be  nausea,  vomiting,  and,  with  the  rapid  loss 
of  large  quantities  of  blood,  convulsions.  Examination  of  the  blood  shows  a 
great  diminution  of  the  red  blood-corpuscles,  often  in  severe  haemorrhage  to 
two  millions  per  c.  mm.  The  haemoglobin  is  proportionately  lower,  giving  a 
color  index  of  about  0.8.  Irregularity  in  the  red  blood-corpuscles  is  seen; 
nucleated  red  corpuscles,  usually  normoblasts,  appear  early;  the  leucocytes 
are  increased,  usually  the  multi-nuclear  neutrophiles.  The  process  of  re- 
generation goes  on  with  great  rapidity;  the  watery  and  saline  constituents 
are  readily  restored  by  absorption;  the  albuminous  elements  are  quickly  re- 
newed, but  it  may  take  weeks  or  months  for  the  red  blood-corpuscles  to  reach 
the  normal  standard.  Thus  in  a  case  of  purpura  the  red  blood-corpuscles 
fell  between  the  20th  and  30th  April  to  below  two  millions,  and  the  leuco- 
cytes rose  to  12,000.  It  was  not  until  July  that  the  red  blood-corpuscles 
reached  four  million,  and  the  blood  was  not  normal  until  September.  The 
ha?moglobin  is  always  restored  more  slowly  than  the  corpuscles.  This  is  very 
well  illustrated  in  the  accompanying  chart  (page  729). 

In  repeated  haemorrhages  the  picture  depends  upon  the  interval  between 
the  losses  of  blood.  If  long  enough  to  allow  of  complete  regeneration  each 
time  the  total  amount  of  blood  lost  may  be  very  great.  Ehrlich  mentions 
the  case  of  a  patient  with  haemoptysis  who  lost  20  kilograms  of  blood  in  QV2 


ANEMIA 


729 


months.  If,  however,  the  intervals  are  short,  so  that  complete  recovery  from 
each  loss  of  blood  is  not  possible,  a  chronic  anaemia  is  soon  induced  with  a 
very  watery  plasma,  a  low  color  index,  and  lymphocytosis. 

Chronic  Secondary  Anaemia 

Etiology. — There  are  very  many  causes,  of  which  the  following  are  the 
most  important: 

(a)  Inanition. — This  may  be  brought  about  by  defective  food  supply,  or 
by  conditions  which  interfere  with  the  proper  reception  and  preparation  of 


APR  L.                                      MAY. 

JtNE.                                  JULY. 

110* 

100* 

5,000,000 

' 

90* 

__4 

80* 

4,000,000 

f 

/> 

i 

/ 

70* 

s7                                                                   / 

*                                                                       £ 

--""" 

^  <• 

60* 

3,000,000 

if    7  ""-' 

s''' 

\  j 

^ 

50* 

I  ^ 

"'*'*** 

T                      ,,*** 

40* 

2,000,000 

-4-         /*      '" 

^    L 

30* 

*  i 

-&  —  *  —  -•&— 

is  —  •&-  -  ••/•  —  ,fr  -v  —  -if  —  ft  —  -•}•- 

-  -f  -  -*  -  -i  •-  -  -if-  -•!  -  ••!  -  -  *-  -  4 

14,000 

12,000 

10,OOO 

*5'-[ 

8,OOO 

y           *      . 

6,000 

'                 S 

4.OOO 

.,_..  _ 

2,OOO 

^L 

BLACK,  RED  CORPUSCLES.  RED,  HEMOGLOBIN,  BLUE,   COLORLESS  CORPUSCLES. 

CHART   XV. — THE  KAPIDITY  WITH  WHICH  ANAEMIA  is  PRODUCED  IN  PURPUKA 

KHAGICA,  AND  THE  GRADUAL   EECOVERY. 

the  food,  as  in  cancer  of  the  oesophagus  and  chronic  dyspepsia.  The  reduc- 
tion of  the  blood  mass  may  be  extreme,  but  the  plasma  suffers  proportionately 
more  than  the  corpuscles,  which,  even  in  the  wasting  of  cancer  of  the  oesopha- 
gus, may  not  be  reduced  more  than  one-half  to  three-fourths.  The  reduction 
in  the  plasma  may  be  so  great  that  the  corpuscles  show  a  relative  increase. 

(&)  Infections. — In  nearly  all  acute  fevers  angemia  is  produced,  which 
may  persist  after  the  infection  has  subsided.  We  see  this  particularly  in 
typhoid  fever,  rheumatic  fever,  sepsis,  syphilis,  and  malaria.  Certain  forms 
of  animal  parasites,  as  the  anchylostoma  and  bothriocephalus,  cause  a  pro- 
found anaemia. 
48 


730  DISEASES   OF   THE   BLOOD 

(c)  Intoxications. — Inorganic   poisons,   such  as  lead,  mercury,   arsenic; 
organic  poisons,  as  the  toxins   of  various   fevers;  and  certain  autogenous 
poisons  occurring  in  chronic  affections,  such  as  nephritis  and  jaundice. 

(d)  Hcemorrhage. — This,  if  repeated,  may  cause  severe  anaemia.     This 
is  particularly  shown  in  cases  of  persistent  Weeding  from  hsemorrhoids. 

(e)  Long  continued  drains  upon  the  system,  as  in  chronic  suppuration, 
prolonged  lactation,  and  in  rapidly  growing  tumors  of  all  sorts. 

Symptoms. — Loss  of  bodily  and  mental  vigor  with  loss  of  weight  and  ob- 
vious ansemia  are  the  important  features.  The  patient  tires  easily,  the  ap- 
petite is  poor,  digestion  often  faulty,  palpitation  is  complained  of,  and  there 
may  be  feelings  of  faintnesfc,  and,  as  the  anemia  progresses,  swelling  of  the 
feet.  There  is  not  infrequently  slight  fever.  Petechiae  on  the  skin  are  not 
uncommon,  and  retinal  hemorrhages  may  occur.  The  blood  picture  is  dis- 
tinctive. The  red  blood-corpuscles  are  reduced,  but  rarely  below  two  millions 
per  c.  mm.  In  59  cases  of  cancer  of  the  stomach  the  average  count  was 
3,712,186  per  c.  mm.  In  only  8  cases  was  the  count  below  two  millions, 
in.  none  below  one  million  per  c.  mm.  The  haemoglobin  is  proportionately 
low  in  the  cases  just  mentioned;  the  average  was  44.9  per  cent.;  in  only  9 
cases  was  it  below  30  per  cent.  The  red  blood-corpuscles  are  irregular  in 
shape,  nucleated  forms  are  present,  and  the  leucocytes  are  usually  increased 
in  number. 

PEIMAEY    OE    ESSENTIAL    ANEMIA 
1.  Chlorosis 

Definition. — An  anaemia  of  unknown  cause,  occurring  in  young  girls, 
characterized  by  a  marked  relative  diminution  of  the  haemoglobin. 

Etiology. — It  is  a  disease  of  girls,  more  often  of  blondes  than  of  brunettes. 
It  is  doubtful  if  males  are  ever  affected.  The  age  of  onset  is  between  the 
fourteenth  and  seventeenth  years;  under  the  age  of  twelve  cases  are  rare. 
Eecurrences,  which  are  common,  may  extend  into  the  third  decade.  Of  the 
essential  cause  of  the  disease  we  know  nothing.  There  exists  a  lowered  energy 
in  the  blood-making  organs,  associated  in  some  obscure  way  with  the  evolution 
of  the  sexual  apparatus  in  women.  Hereditary  influences,  particularly  chloro- 
sis and  tuberculosis,  play  a  part  in  some  cases.  Sometimes,  as  Virchow 
pointed  out,  the  condition  exists  with  a  defective  development  (hypoplasia) 
of  the  circulatory  and  generative  organs. 

The  disease  is  most  common  among  the  ill-fed,  overworked  girls  of  large 
towns,  who  are  confined  all  day  in  close,  badly  lighted  rooms,  or  have  to  do 
much  stair-climbing.  Cases  occur,  however,  under  the  most  favorable  condi- 
tions of  life,  but  not  often  in  country-bred  girls,  as  Maudlin  sings  in  the 
Compleat  Angler.  Lack  of  proper  exercise  and  of  fresh  air  and  the  use  of 
improper  food  are  important  factors.  Emotional  and  nervous  disturbances 
may  be  prominent — so  prominent  that  certain  writers  have  regarded  the  dis- 
ease as  a  neurosis.  De  Sauvages  speaks  of  a  chlorose  par  amour.  Newly 
arrived  Irish  girls  were  very  prone  to  the  disease  in  Montreal.  The  "corset 
and  chlorosis"  expresses  0.  Eosenbach's  opinion.  Menstrual  disturbances  are 
not  uncommon,  but  are  probably  a  sequence,  not  a  cause,  of  chlorosis.  Sir 
Andrew  Clark  believed  that  constipation  played  an  important  role  and  that 


ANEMIA 


731 


the  condition  is  in  reality  a  coprcemia  due  to  the  absorption  of  poisons  from 
the  large  bowel. 

Symptoms. —  (a)  GENERAL. — The  symptoms  of  chlorosis  are  those  of 
ansemia.  The  subcutaneous  fat  is  well  retained  or  even  increased  in  amount. 
The  complexion  is  peculiar;  neither  the  blanched  aspect  of  haemorrhage  nor 
the  muddy  pallor  of  grave  anaemia,  but  a  curious  yellow  green  tinge,  which 
has  given  to  the  disease  its  name,  and  its  popular  designation,  the  green  sick- 
ness. Occasionally  the  skin  shows  areas  of  pigmentation,  particularly  about 
the  joints.  In  cases  of  moderate  grade  the  color  may  be  deceptive,  as  the 


120* 
110* 
100$ 
90* 

80* 
70* 
60* 
50* 
40* 
30* 
20* 

JANUARY. 

FEBRUARY. 

MARCH. 

6,000,000 

A 

/  N 

/ 

V 

"*~'j 

/ 

\ 

£ 

,--" 

5,000,000 

/ 

v  / 

/ 

V 

it 
f 

/' 

f  \ 

\\\ 

4,000,000 

/ 

/ 

^•i 

+  *  . 

~^~~. 

^ 

/ 

/ 

s  * 

«• 

/ 

3,000,000 

/ 

' 

/ 

* 

r. 

4 

2,000,000 

.- 

t^ 

^ 

/ 

e. 

;• 

\r 

- 

• 

1,000.000 

*-*-*- 

:•- 

-•:•-.- 

--.- 

- 

•4 

••- 

-*- 

--<-.- 

--1 

i-- 

ft- 

-•  t-  -  ••'. 

..  -  .}.-  -  * 

_-.% 

-  *- 

14,000 

12,000 

JO.OOO 

/ 

- 

;  B  a  •  •  • 

.  -   - 

.  -  ^ 

8.000 

- 

— 

¥ 

f 

6,000 

"- 

"--, 

-- 

_  /  ..  _ 

4,000 

2,OOO 

MEAN  NOHM. 
NUMBER  Of 

WHITE 
CORPUSCLE* 


BLACK,  RED  CORPUSCLES. 


RED,  HAEMAGLOBIN. 

:T  XVI. — CHLOROSIS. 


BLUE,  COLORLESS  CORPUSCLES^ 


cheeks  have  a  reddish  tint,  particularly  on  exertion  (chlorosis  rubra).  The 
subjects  complain  of  breathleasness  and  palpitation,  and  there  may  be  a  ten- 
dency to  fainting — symptoms  which  often  lead  to  the  suspicion  of  heart  or 
lung  disease.  Puffiness  of  the  face  and  swelling  of  the  ankles  may  suggest 
nephritis.  The  disposition  often  changes,  and  the  girl  becomes  low-spirited 
and  irritable.  The  eyes  have  a  peculiar  brilliancy  and  the  sclerotics  are  of  a 
bluish  color. 

(&)  SPECIAL  FEATURES. — Blood. — The  drop  as  expressed  looks  pale,    Jo- 


732  DISEASES    OF    THE    BLOOD 

hann  Duncan,  in  1867,  first  called  attention  to  the  fact  that  the  essential 
feature  was  not  a  great  reduction  in  the  number  of  the  corpuscles,  but  a 
quantitative  change  in  the  haemoglobin.  The  corpuscles  themselves  look  pale. 
In  63  consecutive  cases  examined  at  my  clinic  by  Thayer  the  average  num- 
ber per  cubic  millimetre  of  the  red  blood-corpuscles  was  4,096,544,  or  over 
80  per  cent.,  whereas  the  percentage  of  haemoglobin  for  the  total  number  was 
42.3  per  cent.  The  accompanying  chart  illustrates  well  these  striking  dif- 
ferences. There  may,  however,  be  well-marked  actual  anaemia.  The  lowest 
blood-count  in  the  series  of  cases  referred  to  above  was  1,932,000.  There 
may  be  all  the  physical  characteristics  and  symptoms  of  a  profound  anaemia 
with  the  number  of  the  blood-corpuscles  nearly  at  the  normal  standard.  Thus 
in  one  instance  the  globular  richness  was  over  85  per  cent.,  with  the  hemo- 
globin about  35.  No  other  form  of  anaemia  presents  this  feature,  at  least  with 
the  same  constancy  and  in  the  same  degree.  The  importance  of  the  reduction 
in  the  haemoglobin  depends  upon  the  fact  that  it  is  the  iron-containing  ele- 
ments of  the  blood  with  which  in  respiration  the  oxygen  enters  into  combina- 
tion. This  marked  diminution  in  the  iron  has  also  been  determined  by  chem- 
ical analysis  of  the  blood.  The  microscopic  characteristics  of  the  blood  are  as 
follows:  In  severe  cases  the  corpuscles  may  be  extremely  irregular  in  size 
and  shape — poikilocytosis,  which  may  occasionally  be  as  marked  as  in  some 
cases  of  pernicious  anaemia.  The  large  forms  of  red  blood  cells  are  not  as 
common,  and  the  average  size  is  stated  to  be  below  normal.  The  color  of 
the  corpuscles  is  noticeably  pale  and  the  deficiency  may  be  seen  either  in  in- 
dividual corpuscles  or  in  the  blood  mixture  prepared  for  counting.  Nucle- 
ated red  corpuscles  (normoblasts)  are  not  very  uncommon,  and  may  vary 
greatly  in  numbers  in  the  same  case  at  different  periods.  The  leucocytes  may 
show  a  slight  increase;  the  average  in  the  63  cases  above  referred  to  was 
8,467  per  cubic  millimetre. 

(c)  G  ASTRO-INTESTINAL  SY.MPTOMS. — The  appetite  is  capricious,  and  pa- 
tients often  have  a  longing  for  unusual  articles,  particularly  acids.     In  some 
instances  they  eat  all  sorts  of  indigestible  things,  such  as  chalk  or  even  earth. 
Superacidity  of  the  gastric  juice  is  common.     Distress  after  eating  and  even 
cardialgic  attacks  may  be  present.     Constipation  is  a  common  symptom,  and, 
as  already  mentioned,  has  been  regarded  as  an  important  element  in  causing 
the  disease.    A  majority  of  chlorotic  girls  who  wear  corsets  have  gastroptosis, 
and  on  inflation  the  stomach  will  be  found  vertically  placed;  sometimes  the 
organ  is  very  much  dilated.    The  motor  power  is  usually  well  retained.     En- 
teroptosis  with  palpable  right  kidney  is  not  uncommon. 

(d)  CIRCULATORY  SYMPTOMS.— Palpitation  of  the  heart  occurs  on  exer- 
tion, and  may  be  the  most  distressing  sympttmi  of  which  the  patient  com- 
plains.    Percussion  may  show  slight  increagfPm  the  transverse  dulness.     A 
systolic  murmur  is  heard  at  the  apex  or  at  |th»  base ;  more  commonly  at  the 
latter,  but  in  extreme  cases  at  both.     A  diastolic  murmur  is  rarely  heard. 
The  systolic  ^  murmur  is  usually  loudest  in  the  second  left  intercostal  space, 
where  there  is  sometimes  a  distinct  pulsation.    The  exact  mode  of  production 
is  still  in  dispute.    Balfour  holds  that  it  is  produced  at  the  mitral  orifice  by 
relative  insufficiency  of  the  valves  in  the  dilated  condition  of  the  ventricle. 
On  the  right  side  of  the  neck  over  the  jugular  vein  a  continuous  murmur 
may  be  heard,  the  bruit  de  didble,  or  humming-top  murmur. 


ANEMIA  733 

The  pulse  is  usually  full  and  soft.  Visible  impulse  is  present  in  the  veins 
of  the  neck,  as  noted  by  Lancisi.  Pulsation  in  the  peripheral  veins  is  some- 
times seen.  Thrombosis  in  the  veins  may  occur,  most  commonly  in  the 
femoral,  but  occasionally  in  the  cerebral  sinuses.  In  86  cases  the  veins  of 
the  legs  were  affected  in  48,  the  cerebral  sinuses  in  29  (Lichtenstern).  The 
chief  danger  in  thrombosis  of  the  extremities  is  pulmonary  embolism,  which 
occurred  in  13  of  53  cases  collected  by  Welch. 

As  in  all  forms  of  essential  anemia,  fever  is  not  uncommon.  Chlorotic 
patients  suffer  frequently  from  headache  and  neuralgia,  which  may  be  parox- 
ysmal. The  hands  and  feet  are  often  cold.  Dermatographia  is  common. 
Hysterical  manifestations  are  not  infrequent.  Menstrual  disturbances  are 
very  common — amenorrhcea  or  dysmenorrhcea.  With  the  improvement  in  the 
blood  condition  this  function  is  usually  restored. 

Diagnosis. — The  green  sickness,  as  it  is  sometimes  called,  is  in  many  in- 
stances recognized  at  a  glance.  The  well-nourished  condition  of  the  girl,  the 
peculiar  complexion,  which  is  most  marked  in  brunettes,  and  the  white  or 
bluish  sclerotics  are  very  characteristic.  A  special  danger  exists  in  mistak- 
ing the  apparent  anaemia  of  the  early  stage  of  pulmonary  tuberculosis  for 
chlorosis.  Mistakes  of  this  sort  may  often  be  avoided  by  the  very  simple  test 
furnished  by  allowing  a  drop  of  blood  to  fall  on  a  white  towel  or  a  piece  of 
blotting  paper — a  deficiency  in  haemoglobin  is  readily  appreciated.  The  pal- 
pitation of  the  heart  and  shortness  of  breath  frequently  suggest  heart-disease, 
and  the  oedema  of  the  feet  and  general  pallor  cause  the  cases  to  be  mistaken 
for  Bright's  disease.  In  the  great  majority  of  cases  the  characters  of  the 
blood  readily  separate  chlorosis  from  other  forms  of  anaemia. 

2.  Idiopathic  or  Pernicious  Anaemia 

Definition. — A  recurring  and  usually  fatal  anaemia  of  unknown  origin, 
characterized  by  haemolysis  and  imperfect  action  of  the  blood-making  organs. 

History. — Addison  (1855)  gave  the  first  accurate  account,  and  it  is  some- 
times known  as  Addison's  anaemia.  Channing  described  cases  of  severe  anaemia 
in  the  puerperal  state.  The  writings  of  Gusserow  and  Biermer  in  the  early 
seventies  did  much  to  awaken  interest  in  the  disease.  The  studies  of  Pepper 
(Secundus),  H.  C.  Wood,  and  Palmer  Howard  made  the  disease  very  familiar 
to  American  and  Canadian  physicians.  The  special  methods  introduced  by 
Ehrlich  have  greatly  increased  our  knowledge  of  the  state  of  the  blood  and 
the  bone  marrow  in  the  disease. 

Distribution. — It  is  a  common  and  widespread  disease.  It  was  of  fre- 
quent occurrence  in  Montreal;  I  saw  many  cases  in  Philadelphia  and  also 
at  the  Johns  Hopkins  Hospital,  and  it  seems  quite  as  common,  or  even  more 
so,  in  England.  As  Cabot  remarks,  the  incidence  of  the  disease  is  a  good  deal 
a  matter  of  keenness  on  the  part  of  the  practitioners  of  any  district. 

Etiology. — The  figures  here  quoted  are  from  Cabot's  analysis  of  some 
1,200  cases  given  in  his  article  in  my  "System  of  Medicine."  It  is  a  disease 
of  middle  life;  a  great  majority — 922 — occurred  over  the  age  of  36.  The 
youngest  patient  I  have  seen  was  a  boy  of  ten  years.  Two  or  three  cases 
may  occur  in  one  family,  as  a  father  and  two  girls. 

Of  special  etiological  factors  much  stress  has  been  laid  upon  pregnancy 


734  DISEASES    OF   THE   BLOOD 

and  the  puerperal  state.  Doubtless  many  of  the  patients  reported  by  Chan- 
ning  and  Gusserow  do  not  belong  in  this  group.  Of  the  true  disease  it  forms 
a  very  small  fraction,  according  to  Cabot  only  18  among  the  1,200  cases  of 
his  series. 

Sex. — It  is  twice  as  common  in  males  as  in  females,  but  it  is  slightly  com- 
moner in  women  under  the  age  of  36. 

Buccal  and  Gastro-intestinal  Infection. — William  Hunter,  who  has  done 
so  much  good  work  on  the  subject,  claims  that  a  large  number  of  cases  grouped 
as  pernicious  anemia  are  really  of  an  infective  nature,  and  not  related  to 
the  true  Addisonian  anaemia,  which  he  regards  as  a  chronic  infection  due  to 
a  specific  glossitis  with  oral,  gastric,  and  intestinal  sepsis.  In  a  few  cases 
there  is  a  history  of  long  standing  diarrhoea. 

Intestinal  Parasites. — Anaemia  of  a  very  severe,  and  even  of  a  pernicious, 
type  may  be  induced  by  the  bothriocephalus  and  by  the  hookworm. 

Atrophy  of  the  Stomach. — In  a  certain  number  of  cases — 61  in  Cabot's 
series — there  was  atrophy  of  the  gastro-intestinal  mucosa,  but  it  seems  not 
improbable,  as  he  suggests,  that  when  these  two  diseases  are  associated  the 
atrophy  is  a  result  rather  than  a  cause  of  the  anaemia. 

Haemorrhage. — As  a  rule  the  anemia  which  follows  repeated  haemorrhages 
is  of  the  secondary  type  with  a  very  different  blood  picture,  but  in  every  long 
series  of  cases  of  Addison's  anaemia  there  will  be  found  a  few  with  a  history 
of  bleeding  piles,  of  recurring  nose  bleeding,  or  of  repeated  hemorrhages 
from  other  sources. 

Nervous  shock  and  emotional  strain  have  been  present  in  a  few  instances. 

We  have  not  got  much  beyond  the  position  of  Addison,  who  character- 
ized the  disease  which  he  was  describing  as  "a  general  anaemia  occurring  with- 
out any  discoverable  cause  whatever;  cases  in  which  there  had  been  no  pre- 
vious loss  of  blood,  no  existing  diarrhoea,  no  chlorosis,  no  purpura,  no  renal, 
splenic,  myasmatic,  glandular,  strumous,  or  malignant  disease." 

Pathology  and  Morbid  Anatomy. — The  body  is  rarely  emaciated.  A  lem- 
on tint  of  the  skin  is  present  in  a  majority  of  the 'cases.  The  muscles  often 
are  intensely  red  in  color,  like  horse  flesh,  while  the  fat  is  light  yellow. 
Haemorrhages  are  common  on  the  skin  and  serous  surfaces.  The  heart  is 
usually  large,  flabby,  and  empty.  In  one  instance  I  obtained  only  2  drachms 
of  blood  from  the  right  heart,  and  between  3  and  4  from  the  left.  The  muscle 
substance  of  the  heart  is  intensely  fatty,  and  of  a  pale,  light  yellow  color. 
In  no  affection  do  we  see  more  extreme  fatty  degeneration.  The  lungs  show 
no  special  changes.  The  stomach  in  many  instances  is  normal,  but  in  some 
•cases  of  fatal  anaemia  the  mucosa  has  been  extensively  atrophied.  In  the  case 
described  by  Henry  and  myself  the  mucous  membrane  had  a  smooth,  cuticular 
appearance,  and  there  was  complete  atrophy  of  the  secreting  tubules.  The 
liver  may  be  enlarged  and  fatty.  In  most  of  my  autopsies  it  was  normal  in 
size,  but  usually  fatty.  The  iron  is  in  excess,  a  striking  contrast  to  the  con- 
dition in  cases  of  secondary  anaemia.  It  is  deposited  in  the  outer  and  middle 
zones  of  the  lobules. 

The  spleen  shows  no  important  changes.  In  one  of  Palmer  Howard's 
cases  the  organ  weighed  only  1  ounce  and  5  drachms.  The  iron  pigment  is 
usually  in  excess.  The  lymph  glands  may  be  of  a  deep  red  color  (haemo-lymph 
gland).  The  amount  of  iron  pigment  is  increased  in  the  kidneys,  chiefly  in 


ANEMIA  735 

the  convoluted  tubules.  The  bone-marrow  is  usually  red,  lymphoid  in  char- 
acter, showing  great  numbers  of  nucleated  red  corpuscles,  especially  the  lar- 
ger forms  called  by  Ehrlich  gigantoblasts.  There  are  cases  in  which  the  bone- 
marrow  shows  no  signs  of  activity— aplastic  anaemia. 

Spinal  cord  lesions  were  present  in  84  per  cent,  of  the  post  mortems  col- 
lected by  Cabot.  They  affect  chiefly  the  posterior  columns  of  the  cervical 
region. 

The  exact  nature  of  the  disease  is  unknown.  Two  views  prevail :  one  that 
it  is  a  haemolysis  produced  by  poisons  intestinal  or  metabolic.  Bunting  has 
shown  that  a  picture  very  similar  to  that  of  pernicious  anaemia  may  be  pro- 
duced experimentally  in  animals  by  the  injection  of  small  doses  of  ricin. 
The  investigations  of  Schaumann  and  others  have  shown  the  bothriocephalus 
anaemia  to  be  a  haemolysis  caused  by  a  lipoid  substance  that  may  be  extracted 
from  the  segments  of  the  worm.  From  the  intestinal  mucosa  of  persons  dead 
of  pernicious  anaemia  lipoid  substances  have  been  extracted  with  haemolytic 
action  of  remarkable  potency,  causing  anaemia  of  a  severe  and  fatal  type  in 
animals.  These  are  interesting  and  suggestive  facts,  the  only  ones  I  know  in 
favor  of  a  special  hsemolytic  body.  The  majority  of  patients  with  pernicious 
anaemia  have  good  appetites  and  good  digestion,  and  usually  get  well  from  the 
first  and  second  attacks  without  any  special  change  in  the  condition  of  the 
bowels. 

The  view  has  been  put  forward  by  Moffitt  and  others  that  pernicious 
anaemia  is  an  infection,  possibly  protozoal  in  character,  in  favor  of  which 
are  the  facts  that  anaemia  is  a  very  striking  feature  in  many  protozoal  dis- 
eases, the  occurrence  of  fever,  the  remarkable  remissions,  the  nervous  lesions, 
and  the  value  of  arsenic  in  treatment. 

Symptoms. — The  first  thing  that  often  attracts  attention  in  a  case  of  per- 
nicious anaemia  is  the  combination  of  pallor  with  good  nutrition.  As  a  rule 
there  is  very  slight  loss  in  weight  and  the  fat  layer  is  well  preserved,  so  that 
the  condition  offers  a  striking  contrast  to  most  of  the  secondary  anaemias, 
with  which  wasting  is  associated.  The  description  given  by  Addison  pre- 
sents the  chief  features  of  the  disease  in  a  masterly  way:  "It  makes  its  ap- 
proach in  so  slow  and  insidious  a  manner  that  the  patient  can  hardly  fix  a 
date  to  the  earliest  feeling  of  that  languor  which  is  shortly  to  become  so  ex- 
treme. The  countenance  gets  pale,  the  whites  of  the  eyes  become  pearly,  the 
general  frame  flabby  rather  than  wasted,  the  pulse  perhaps  large,  but  re- 
markably soft  and  compressible,  and  occasionally  with  a  slight  jerk,  especially 
under  the  slightest  excitement.  There  is  an  increasing  indisposition  to  exer- 
tion, with  an  uncomfortable  feeling  of  faintness  or  breathlessness  in  attempt- 
ing it;  the  heart  is  readily  made  to  palpitate;  the  whole  surface  of  the  body 
presents  a  blanched,  smooth,  and  waxy  appearance ;  the  lips,  gums,  and  tongue 
seem  bloodless,  the  flabbiness  of  the  solids  increases,  the  appetite  fails,  ex- 
treme languor  and  faintness  supervene,  breathlessness  and  palpitations  are 
produced  by  the  most  trifling  exertion  or  emotion;  some  slight  oedema  is 
probably  perceived  about  the  ankles;  the  debility  becomes  extreme — the  pa- 
tient can  no  longer  rise  from  bed;  the  mind  occasionally  wanders;  he  falls 
into  a  prostrate  and  half-torpid  state,  and  at  length  expires;  nevertheless,  to 
the  very  last,  and  after  a  sickness  of  several  months'  duration,  the  bulkiness 
of  the  general  frame  and  the  amount  of  obesity  often  present  a  most  striking 


736  DISEASES    OF    THE    BLOOD 

contrast    to    the    failure    and    exhaustion    observable    in    every    other    re- 
spect." 

A  surprising  fact  is  that  there  are  patients  with  extreme  anaemia  who 
are  remarkably  vigorous.  I  recently  saw  a  powerfully  built  man  with  2,300,- 
000  red  blood-corpuscles  per  c.  mm.,  who  insisted  that  he  was  able  to  do  every- 
thing as  usual  except  that  he  was  a  little  short  of  breath. 

The  appearance  of  the  patient  is  usually  very  characteristic.  The  com- 
bination of  a  lemon-yellow  tint  of  the  skin  with  retention  of  the  fat  gives  a 
very  suggestive  picture.  Sometimes  the  tint  is  icteroid.  In  rare  cases  there 
is  a  white,  anaemic  pallor,  and  in  a  third  group  a  brownish  tinge  of  the  skin 
(which  is  sometimes  associated  with  leucoderma)  deep  enough  to  suggest 
Addison's  disease.  Muscular  weakness,  palpitation,  headache,  dyspnoaa,  ver- 
tigo, and  redema  of  the  feet  are  common  in  this  as  in  other  types  of  anaemia. 

G astro-intestinal  symptoms  are  not  uncommon.  Paroxysms  of  pain  in 
the  stomach  with  or  without  diarrhoea  may  occur  in  crises.  In  fully  one-half 
of  the  cases  diarrhoea  occurs  at  some  time  during  the  course.  The  hydro- 
chloric acid  is  usually  greatly  diminished  or  absent,  and  there  may  be  com- 
plete achylia.  A  sore  mouth  and  tongue,  a  feature  to  which  attention  was 
called  especially  by  William  Hunter,  has  not  been  common  in  my  experience. 
There  may  be  marked  glossitis  and  ulcers.  Pyorrhoea  alveolaris  may  be  said 
to  be  present  in  all  cases,  and  the  teeth  are  often  very  bad.  Not  infrequently 
the  patients  come  for  palpitation  and  disturbance  of  the  heart.  Slight  dila- 
tation is  common;  murmurs  are  rarely  missed,  generally  haemic  and  basic. 

Apex  diastolic  murmurs  may  occur  without  valve  lesions.  Extraordinary 
throbbing  of  the  arteries  may  occur,  so  that  aneurism  may  be  suspected;  the 
pulse  may  be  collapsing.  (Edema  is  common,  usually  in  the  feet,  sometimes 
in  the  hands. 

The  urine  is  usually  of  low  specific  gravity,  pale,  and  with  diminished 
pigments.  Sometimes,  as  pointed  out  by  Hunter  and  Mott,  it  is  of  a  deep 
sherry  color,  due  to  great  excess  of  urobilin. 

Nervous  Symptoms. — Numbness  and  tingling  'are  common.  Sometimes 
there  are  marked  neuritic  pains.  Anatomically  it  has  been  shown  that  le- 
sions of  the  spinal  cord  are  not  at  all  uncommon.  There  are  three  groups  of 
cases : 

(a)  The  patient  may  have  had  no  special  symptoms  pointing  to  involve- 
ment of  the  nervous  system,  but  post  mortem  well  marked  lesions  of  the  cord 
are  found. 

(6)  With  the  anaemia  there  are  signs  of  spinal  cord  lesions,  either  of  a 
lateral  sclerosis  with  spastic  features  and  increased  reflexes,  or  the  picture 
may  be  rather  of  the  tabetic  type — lightning  pains,  girdle  sensation,  areas 
of  anaesthesia,  loss  of  the  reflexes. 

(c)  There  is  a  remarkable  group  carefully  described  by  Eisien  Eussell,  Bat- 
ten, and  Collier,  in  which  the  nervous  symptoms,  usually  those  of  a  postero- 
lateral  sclerosis,  precede  the  anaemia. 

As  the  disease  progresses  there  may  be  great  depression,  sometimes  delu- 
sions, but  mental  symptoms,  as  a  rule,  are  not  marked. 

Haemorrhages  are  not  very  uncommon,  chiefly  in  the  form  of  small 
petechiae  in  the  skin.  Eetinal  haemorrhages  are  frequent.  Optic  neuritis  is 
very  rare. 


ANAEMIA 


737 


Blood. — The  total  quantity  in  the  body  is  much  diminished.  The  drop 
may  look  of  good  color,  but  it  is  abnormally  fluid.  The  red  blood-corpuscles 
are  greatly  diminished;  the  average  count  in  81  cases,  when  they  came  under 
observation,  was  1,575,000  per  c.  mm.  As  Cabot  says,  there  is  no  other  dis- 
ease which  so  often  reduces  the  number  of  red  blood-corpuscles  below  two 
millions  per  c.  mm.  In  12  per  cent,  of  my  cases  the  count  was  under  one 
million.  The  lowest  count  on  record  is  in  a  patient  of  Quincke's,  143,000 
per  c.  mm. 


no* 

100* 
90* 
80* 
70* 
60* 
50* 
40* 
30* 
20* 
10* 

FEB. 

MAR. 

APR. 

MAY 

JUNE 

JULY 

AUG. 

SEPT.                 OCT. 

.   »  2  £  S 

-  0    "    S 

*>    ~     S    Z 

»»*ss^:^3 

110* 

5^000,000 

.100* 

90* 

4,000,000 

80* 

f" 

- 

70* 

1     i 

"^. 

•—  . 

— 

•* 
"^ 

>. 

3,000,000 

' 

/     / 
/ 

s; 

S 

60* 

'       , 

f 

s 

s 

s 

r 

- 
-- 

50* 

w 

"- 

^ 

S 

V. 

2,000,000 

M 

V. 

^s 

•v 

^ 

40* 

1 

N 

N 

-• 

'! 

-; 

30* 

/ 

S 

1  —  . 

•-. 

N 

1,000,000 

•~- 

1  —  *, 

-«* 

s 

s 

20* 

V 

^S 

500,000 

10* 

-*—*—*—#- 
8,000 

—  : 

.— 

IZ 

••s-  ->  •• 

--: 

•- 

--- 

-,, 

-*- 

:,- 

—  : 

:- 

r— 

1  1 

1 

6,000 

K 

^ 

A 

< 

MEAN  NORM. 
NUMBER  OF 

4,000 

; 

^' 

-? 

\ 

~^- 

i  »- 

,^ 

fc± 

^^ 

^=-, 

*  = 

— 

~^^ 

^-» 

^ 

CORPUSCLE! 

2,000 

i 

s^ 

-" 

•— 

BLACK,   RED  CORPUSCLES. 


RED,  HEMOGLOBIN. 

CHART  XVII. — PERNICIOUS  ANEMIA. 


BLUE,  'OLORLES8  CORPUSCLES. 


The  haemoglobin,  though  quantitatively  reduced,  is  relatively  high.  This 
is  one  of  the  most  constant  and  distinctive  features  of  the  disease,  connected 
probably  with  an  average  increase  in  the  size  of  the  red  blood-corpuscles. 
Stained  films  of  the  blood  show  great  variation  in  the  shape  of  the  red  blood- 
corpuscles — poikilocytosis.  There  are  large  giant  forms,  megalocytes,  ovoid, 
measuring  8,  11,  or  even  15  /«..  As  Laache  showed,  this  is  one  of  the  most 
pathognomonic  features  of  the  disease.  On  the  other  hand,  there  are  a  great 


738  DISEASES    OF    THE    BLOOD 

many  very  small  red  corpuscles — microcytes,  from  2  to  6  /*  in  diameter,  and 
of  a  deep  red  color.  The  irregularity  in  the  shape  of  the  red  corpuscles  is 
remarkable.  Some  are  elongated,  rod-like,  others  pyriform;  one  end  of  the 
corpuscle  may  be  of  normal  shape,  while  the  other  is  extended  like  the  neck 
of  a  bottle.  Stippling  of  the  red  blood-corpuscles  is  common  with  dark  blue 
or  blackish  discoloration — the  so-called  polychromatophilia. 

Nucleated  red  blood-corpuscles  are  constantly  present,  varying  very  much 
in  numbers  from  day  to  day.  There  are  two  types — normoblasts  of  the  aver- 
age size,  and  the  megaloblasts,  which  are  much  larger.  There  are  frequently 
intermediate  forms  between  these  two  groups.  These  nucleated  red  cells  vary 
extraordinarily  in  different  cases,  and  there  may  be  what  have  been  called 
blood  crises,  in  which  a  large  number  of  the  nucleated  reds  appear.  In  one 
such  crisis  there  were  14,388  normoblasts,  460  intermediates,  and  138  megalo- 
blasts per  c.  mm.  These  crises  are  sometimes  followed  by  gains  in  the  blood 
count,  but  they  may  be  terminal  events,  and  not  specially  indicative  of  ac- 
tive blood  regeneration. 

The  leucocytes  are  generally  normal  or  diminished  in  number.  Poly- 
nuclear  cells  are  rarely  reduced.  Occasionally  there  is  a  marked  increase  in 
the  small  mononuclear  forms.  Myelocytes  are  frequently  present,  even  up  to 
8  and  10  per  cent.  Blood-platelets  are  usually  low;  counts  of  100,000  and 
less  are  not  uncommon  (Pratt). 

Chart  XVIII  gives  a  very  good  idea  of  the  blood  condition  in  a  case  during 
nine  months. 

APLASTIC  ANAEMIA. — A  certain  number  of  cases  of  primary  anaemia  run 
a  rapid  and  progressive  course,  without  remissions;  and  death  occurs  within 
a  few  months  from  the  beginning  of  the  attack.  Post  mortem,  instead  of 
an  active  hyperplasia  of  the  bone  marrow,  there  is  atrophy  or  aplasia.  To 
these  cases  the  term  "aplastic  anemia"  has  been  given.  It  is  a  sub-type  of 
pernicious  anaemia  with  identical  clinical  features,  except  that  it  runs  a  more 
rapid  course,  is  met  with  in  younger  persons,  the  color  index  may  be  low, 
haemorrhages  are  more  common,  there  may  be  leucbpenia,  and  erythroblasts 
are  usually  absent.  The  haemorrhages  may  be  very  severe,  and  some  of  the 
cases  are  of  a  pronounced  purpuric  type. 

The  diagnosis  is  only  certain  after  an  examination  of  the  bones,  when  it 
is  found  that  the  marrow  of  the  long  bones  is  fatty,  and  even  the  red  marrow 
may  have  disappeared  from  the  short  bones. 

Forms  of  splenic  anaemia,  suggesting  the  primary  pernicious  form,  and 
leukanaemia  will  be  discussed  elsewhere. 

Prognosis  and  Course. — The  disease  sometimes  runs  a  very  acute  course. 
In  a  patient  seen  with  Finley  in  Montreal  the  fatal  termination  occurred 
within  ten  days  of  the  onset  of  the  symptoms.  In  other  cases  the  course  is 
from  six  to  twelve  weeks,  but,  as  a  rule,  it  is  a  chronic  malady  with  remark- 
able remissions.  It  is  rare  to  meet  with  a  case  in  which  recovery  does  not 
take  place  from  the  first  attack.  The  number  of  remissions  varies  from  two 
or  three  to  five  or  six.  In  524  cases  analyzed  by  Cabot  for  this  special  point, 
29G  had  one  remission,  118  two,  65  three,  21  four,  and  24  five.  The  duration 
of  the  remission  may  be  from  three  months  to  four  years.  In  81  cases 
treated  in  my  wards  death  occurred  in  27  while  under  observation.  The 
average  duration  in  these  cases  was  about  a  year. 


ANEMIA  739 

The  ultimate  prognosis  in  a  great  majority  of  cases  is  bad;  only  one  case 
in  our  series  appears  to  have  recovered  completely,  another  was  alive  and  in 
good  health  six  years  after  the  last  attack,  and  a  third  four  years  after.  In 
Cabot's  series  there  were  ten  cases  which  had  lasted  seven  years  or  more,  but 
there  were  only  6  out  of  the  1,200  cases  analyzed  which  he  regarded  as  hav- 
ing completely  recovered. 

Diagnosis. — Few  diseases  are  more  readily  recognized  at  sight.  There 
is  something  very  characteristic  about  the  general  appearance  of  a  patient 
with  Addisonian  anaemia,  and  nowadays  practitioners  are  much  more  alert, 
and  the  disease  is  better  known.  The  lemon  colored  tint  -of  the  skin  may 
suggest  jaundice;  the  anaemia,  puffy  face,  swollen  ankles,  and  albumin  in  the 
urine,  Bright's  disease;  the  pigmentation,  Addison's  disease;  the  shortness  of 
breath  and  palpitation,  heart  disease;  the  pallor  and  gastric  symptoms,  cancer 
of  the  stomach.  The  retention  of  fat,  the  insidious  onset,  the  absence  of 
signs  of  local  disease,  and  the  blood  features  already  discussed  are  the  impor- 
tant diagnostic  points.  From  cancer  of  the  stomach  pernicious  anaemia  is 
distinguished  by  the  absence  of  wasting,  the  high  color  index  of  the  blood, 
the  lower  corpuscular  count,  and  by  the  marked  improvement  in  the  first  at- 
tacks under  proper  treatment. 

TEEATMENT    OF    ANEMIA 

Secondary  Anaemia. — The  traumatic  cases  do  best,  and  with  plenty  of 
good  food  and  fresh  air  the  blood  is  readily  restored.  The  extraordinary 
rapidity  with  which  the  normal  percentage  of  red  blood-corpuscles  is  reached 
without  any  medication  whatever  is  an  important  lesson.  The  cause  of  the 
hasmorrhage  should  be  sought  and  the  necessary  indications  met.  The  large 
group  depending  on  the  drain  on  the  albuminous  materials  of  the  blood,  as 
in  Bright's  disease,  suppuration,  and  fever,  is  difficult  to  treat  successfully, 
and  so  long  as  the  cause  keeps  up  it  is  impossible  to  restore  the  normal  blood 
condition.  The  anaemia  of  inanition  requires  plenty  of  nourishing  food.  When 
dependent  on  organic  changes  in  the  gastro-intestinal  mucosa  not  much  can 
be  expected  from  either  food  or  medicine.  In  the  toxic  cases  due  to  mercury 
and  lead  the  poison  must  be  eliminated  and  a  nutritious  diet  given  with 
full  doses  of  iron.  In  a  great  majority  of  these  cases  there  is  deficient  blood 
formation,  and  the  indications  are  briefly  three:  plenty  of  food,  an  open-air 
life,  and  iron.  As  a  rule,  it  makes  but  little  difference  what  form  of  the 
drug  is  administered.  In  severe  forms  the  patient  should  be  at  rest  in  bed 
and  in  the  open  air,  if  possible. 

Chlorosis. — The  treatment  of  chlorosis  affords  one  of  the  most  brilliant 
instances — of  which  we  have  but  three  or  four — of  the  specific  action  of  a 
remedy.  Apart  from  the  action  of  quinine  in  malarial  fever,  and  of  mercury 
and  iodide  of  potassium  in  syphilis,  there  is  no  other  drug  the  beneficial  ef- 
fects of  which  we  can  trace  wifti  the  accuracy  of  a  scientific  experiment.  It 
is  a  minor  matter  how  the  iron  cures  chlorosis.  In  a  week  we  give  to  a  case 
as  much  iron  as  is  contained  in  the  entire  blood,  as  even  in  the  worst  case 
of  chlorosis  there  is  rarely  a  deficit  of  more  than  2  grams  of  this  metal.  Iron 
is  present  in  the  fasces  of  chlorotic  patients  before  they  are  placed  upon  any 
treatment,  so  that  the  disease  does  not  result' from  any  deficiency  of  available 


740  DISEASES    OF    THE    BLOOD 

iron  in  the  food.  Bunge  believes  that  it  is  the  sulphur  which  interferes  with 
the  digestion  and  assimilation  of  this  natural  iron.  The  sulphides  are  pro- 
duced in  the  process  of  fermentation  and  decomposition  in  the  faeces,  and 
interfere  with  the  assimilation  of  the  normal  iron  contained  in  the  food.  By 
the  administration  of  an  inorganic  preparation  of  iron,  with  which  these  sul- 
phides unite,  the  natural  organic  combinations  in  the  food  are  spared. 

In  studying  charts  of  chlorosis,  it  is  seen  that  there  is  an  increase  in  the 
red  blood-corpuscles  under  the  influence  of  the  iron,  and  in  some  instances 
the  globular  richness  rises  above  normal.  The  increase  in  the  hemoglobin  is 
slower  and  the  maximum  percentage  may  not  be  reached  for  a  long  time.  I 
have  for  years  in  the  treatment  of  chlorosis  used  with  the  greatest  success 
Blaud's  pills,  made  and  given  according  to  the  formula  in  Niemeyer's  text- 
book, in  which  each  pill  contains  2  grains  of  the  sulphate  of  iron.  During 
the  first  week  one  pill  is  given  three  times  a  day;  in  the  second  week,  two 
pills;  in  the  third  week,  three  pills,  three  times  a  day.  This  dose  should  be 
continued  for  four  or  five  weeks  at  least  before  reduction.  An  important 
feature  in  the  treatment  is  to  persist  in  the  use  of  the  iron  for  at  least  three 
months,  and,  if  necessary,  subsequently  to  resume  it  in  smaller  doses,  as  re- 
currences are  so  common.  The  diet  should  consist  of  good,  easily  digested 
food.  Special  care  should  be  directed  to  the  bowels,  and  if  constipation  is 
present  a  saline  purge  should  be  given  each  morning.  The  dyspeptic  symp- 
toms may  be  relieved  by  alkalies.  Dilute  hydrochloric  acid,  manganese,  phos- 
phorus, and  oxygen  have  been  recommended.  Rest  in  bed  is  important  in 
severe  cases. 

Pernicious  Anaemia. — There  are  five  essentials:  first,  a  diagnosis;  sec- 
ondly, rest  in  bed  for  weeks  or  even  months,  if  possible  (thirdly)  in  the  open 
air ;  fourthly,  all  the  good  food  the  patient  can  take ;  the  outlook  depends 
largely  on  the  stomach ;  fifthly,  arsenic ;  Fowler's  solution  in  increasing  doses, 
beginning  with  ITj,  iii  or  v  (0.2  to  0.3  c.  c.)  three  times  a  day,  and  increasing 
fit  i  each,  week  until  the  patient  takes  TT\,  xv  (1  c.  c.)  tb,ree  times  a  day.  Other 
forms  of  arsenic  may  be  tried,  as  the  sodium  cacodylate  or  the  atoxyl  hypo- 
dermically.  Atoxyl  can  be  given  in  doses  of  gr.  ss  (0.032  gm.)  every  five 
days,  and  the  amount  gradually  increased.  Accessories  are  oil  inunctions; 
bone-marrow,  which  has  the  merit  of  a  recommendation  by  Galen;  in  some 
cases  iron  seems  to  do  good.  Care  should  be  taken  of  the  mouth  and  teeth. 
Gastric  lavage  and  irrigations  of  the  colon  are  useful  in  some  cases. 

Splenectomy  has  been  done  in  a  number  of  cases,  but  it  is  well  to  be 
cautious  in  judging  of  its  value.  Some  patients  have  been  helped  for  a  time, 
but  it  is  not  yet  proved  that  permanent  benefit  results. 

Injections  of  blood  serum  and  defibrinated  blood  have  been  given.  The 
serum  is  given  in  small  amounts,  10  to  20  c.  c.,  usually  into  a  vein ;  rabbit 
serum  is  perhaps  the  best.  Defibrinated  human  blood  should  be  given  in- 
travenously in  large  amounts,  up  to  500  c.  c.  This  is  better  than  to  attempt 
direct  transfusion.  It  is  important  to  test  the  blood  so  that  there  is  certainty 
of  using  a  homologous  serum  (see  Moss,  Johns  Hopkins  Hosp.  Bull.,  1911, 
xxii,  p.  238).  This  treatment  should  only  be  carried  out  by  those  who  are 
familiar  with  the  problems  involved, and  is  not  advisable  for  general  use. 

After  recovery  the  patient  should  be  told  to  watch  the  earliest  indications 
of  return  of  the  trouble  and  at  once  resume  ine  arsenic. 


LEUKAEMIA  741 


II.    LEUKEMIA 

Definition. — A  disease  characterized  by  a  permanent  increase  in  the  leuco- 
cytes of  the  blood,  associated  with  hyperplasia  of  the  leucoblastic  tissues. 

History. — In  October,  1845,  Hughes  Bennett  recorded  a  case  of  "suppura- 
tion of  the  blood  with  enlargement  of  the  spleen  and  liver,"  and  he  afterward 
gave  the  disease  the  name  of  "leukocythaemia."  A  month  later  Virchow  de- 
scribed a  similar  condition  of  "white  blood"  to  which  he  gave  the  name  of 
"leukemia."  In  1870  Keumann  determined  the  importance  of  the  changes 
in  the  bone  marrow  in  connection  with  the  disease. 

Varieties.  — The  whole  haematopoietic  system — marrow,  spleen,  and  lymph 
glands — is  involved  in  the  disease.  Formerly  we  spoke  of  three  different 
groups — the  splenic,  lymphatic,  and  medullary,  but  we  now  recognize  that 
the  leucoblastic  hyperplasia  may  begin  in  any  part  of  the  blood-glandular 
system,  marrow,  lymph  glands,  and  probably  in  the  spleen.  The  differences 
in  the  types  of  the  disease  depend  upon  the  dominance  of  the  lymphoid  or  the 
myeloid  process,  so  that  we  now  divide  the  cases  roughly  into  two  great 
groups:  (1)  the  myelocytic  or  myeloid,  corresponding  to  the  spleno-medullary 
type,  and  (2)  the  lymphoid,  which  represents  the  lymphatic  variety.  Some 
cases  not  fitting  accurately  into  either  are  spoken  of  as  "atypical"  or  "transi- 
tional" forms. 

The  nature  of  the  disease  is  unknown.  The  acutely  fatal  cases  resemble 
an  infection,  but  no  organisms  have  been  determined.  Banti,  Warthin,  and 
others  regard  the  disease  as  related  to  myeloma  and  sarcoma. 

I.  MYELOID  LEUKAEMIA. — Etiology. — The  disease  is  not  very  rare.  There 
were  24  cases  in  my  wards  at  the  Johns  Hopkins  Hospital  in  fifteen  years. 
It  certainly  is  not  more  frequent  in  malarial  regions. 

It  is  rather  more  common  in  males  than  in  females,  and  between  the  30th 
and  50th  years.  The  youngest  of  my  patients  was  a  child  of  eight  months. 

In  some  instances  it  has  followed  a  blow.  Some  of  the  patients  have  had 
a  tendency  to  haemorrhage,  but,  as  a  rule,  the  disease  appears  in  fairly  healthy 
persons  without  any  recognizable  cause.  It  may  occur  during  pregnancy, 
and  a  leukaemic  patient  of  Cameron's  of  Montreal  passed  through  three  preg- 
nancies, bearing  on  each  occasion  a  non-leukaemic  child.  One  of  this  patient's 
children  had  leukaemia  before  the  mother  showed  signs  of  the  disease,  and 
another  died  of  it.  This  patient's  grandmother,  mother,  and  brother  suf- 
fered from  symptoms  strongly  suggestive  of  leukemia. 

Morbid  Anatomy. — Dropsy  is  sometimes  present.  There  is  in  many 
cases  a  condition  of  polyaemia;  the  heart  and  veins  are  distended  with  large 
blood-clots.  In  Case  XI  of  my  series  the  weight  of  blood  in  the  heart  cham- 
bers alone  was  620  grams.  There  may  be  remarkable  distention  of  the  por- 
tal, cerebral,  pulmonary,  and  subcutaneous  veins.  The  blood  is  usually  clot- 
ted, and  the  enormous  increase  in  the  leucocytes  gives  a  pus  like  appearance 
to  the  coagula,  so  that  it  has  happened  more  than  once,  as  in  Virchow's 
memorable  case,  that  on  opening  the  right  auricle  the  observer  at  first  thought 
he  had  cut  into  an  abscess.  The  coagula  have  a  peculiar  greenish  color,  some- 
what like  the  fat  of  a  turtle.  Sometimes  this  is  so  intense  as  to  suggest  the 
color  of  chloroma,  described  later.  The  alkalinity  of  the  blood  is  diminished. 


742  DISEASES    OF    THE    BLOOD 

The  fibrin  is  increased.  Charcot's  octahedral  crystals  may  separate  from  the 
blood  after  death. 

In  the  myelitic  form  the  spleen  is  greatly  enlarged,  the  capsule  may  be 
thickened,  and  the  vessels  at  the  hilus  enlarged.  The  weight  may  range  from 
2  to  18  pounds.  The  organ  is  in  a  condition  of  chronic  hyperplasia.  It 
cuts  with  resistance,  has  a  uniformly  reddish  brown  color,  and  the  Malpighian 
bodies  are  invisible.  Grayish  white,  circumscribed,  lymphoid  tumors  may 
occur  throughout  the  organ,  contrasting  strongly  with  the  reddish  brown  mat- 
rix. Instead  of  a  fatty  tissue,  the  medulla  of  the  long  bones  may  resemble 
the  consistent  matter  which  forms  the  core  of  an  abscess,  or  it  may  be  dark 
brown  in  color.  There  may  be  hasmorrhagic  infarctions.  There  may  be 
much  expansion  of  the  shell  of  bone,  and  localized  swellings  which  are  tender 
and  may  even  yield  to  firm  pressure. 

In  some  instances  there  are  leukasmic  enlargements  in  the  solitary  and 
agminated  glands  of  Peyer.  In  a  case  of  Willcocks'  there  were  growths  on 
the  surface  of  the  stomach  and  gastro-splenic  omentum.  The  thymus  is  rarely 
involved,  though  it  has  been  enlarged  in  some  of  the  acute  cases.  The  liver 
may  be  greatly  enlarged,  due  to  a  diffuse  leukasmic  infiltration.  There  may 
be  definite  leukemia  growths.  There  are  rarely  changes  of  importance  in  the 
lungs.  The  kidneys  are  often  enlarged  and  pale,  the  capillaries  may  be  dis- 
tended with  leucocytes,  and  leukemia  tumors  may  occur.  The  skin  may 
present  leukemic  tumors. 

Leukemic  tumors  in  the  organs  are  not  common.  In  159  cases  collected 
by  Gowers  there  were  only  13  instances  of  leuksemic  nodules  in  the  liver  and 
10  in  the  kidneys. 

Symptoms. — The  onset  is  insidious,  and,  as  a  rule,  the  patient  seeks  ad- 
vice for  progressive  enlargement  of  the  abdomen  and  shortness  of  breath,  or 
the  pallor,  palpitation,  and  other  symptoms  of  anaemia.  Bleeding  at  the  nose 
is  common.  Gastro-intestinal  symptoms  may  precede  the  onset.  Occasionally 
the  first  symptoms  are  of  a  very  serious  nature.  In  one  of  the  cases  of  my 
series  the  boy  played  lacrosse  two  days  before  the  onset  of  the  final  hemate- 
mesis;  and  in  another  case  a  girl,  who  had,  it  was  supposed,  only  a  slight 
chlorosis,  died  of  fatal  hemorrhage  from  the  stomach  before  any  suspicion 
had  been  aroused  as  to  the  true  condition. 

Anaemia  is  not  a  necessary  accompaniment  of  all  stages  of  the  disease;  the 
subjects  may  look  very  healthy  and  well. 

The  gradual  increase  in  the  volume  of  the  spleen  is  the  most  prominent 
feature  in  a  majority  of  the  cases.  Pain  and  tenderness  are  common,  though 
the  progressive  enlargement  may  be  painless.  A  creaking  fremitus  may  be 
felt  on  palpation.  The  enlarged  organ  extends  downward  to  the  right,  and 
may  be  felt  just  at  the  costal  edge,  or  when  large  it  may  extend  as  far  over 
as  the  navel.  In  many  cases  it  occupies  fully  one  half  of  the  abdomen,  reach- 
ing to  the  pubes  below  and  extending  beyond  the  middle  line.  As  a  rule,  the 
edge,  in  some  the  notch  or  notches,  can  be  felt  distinctly.  Its  size  varies 
greatly  from  time  to  time.  It  may  be  perceptibly  larger  after  meals.  A 
hemorrhage  or  free  diarrhoea  may  reduce  the  size.  The  pressure  of  the  en- 
larged organ  may  cause  distress  after  eating;  in  one  case  it  caused  fatal  ob- 
struction of  the  bowels.  On  auscultation  a  murmur  may  sometimes  be  heard 
over  the  spleen,  and  Gephardt  has  described  a  pulsation  in  it. 


LEUKEMIA  ?43 

The  pulse  is  usually  rapid,  soft,  compressible,  but  often  full  in  volume. 
There  are  rarely  any  cardiac  symptoms.  The  apex  beat  may  be  lifted  an  in- 
terspace by  the  enlarged  spleen.  Toward  the  close  oedema  may  occur  in  the 
feet  or  general  anasarca.  Haemorrhage  is  common.  There  may  be  most 
extensive  purpura,  or  haemorrhagic  exudate  into  pleura  or  peritoneum.  Epi- 
staxis  is  the  most  frequent  form.  Haemoptysis  and  hasmaturia  are  rare.  Bleed- 
ing from  the  gums  may  be  present.  Haematemesis  proved  fatal  in  two  of  my 
cases,  and  in  a  third  a  large  cerebral  haemorrhage  rapidly  killed.  The  leukae- 
mic  retinitis  is  a  part  of  the  haemorrhagic  manifestations.  J.  Hughes  Ben- 
net's  first  leukaemic  patient  died  suddenly,  without  obvious  cause. 

Local  gangrene  may  develop,  with  signs  of  intense  infection  and  high 
fever.  There  are  very  few  pulmonary  symptoms.  The  shortness  of  breath  is 
due,  as  a  rule,  to  the  anaemia.  Toward  the  end  there  may  be  oedema  of  the 
lungs,  or  pneumonia  may  carry  off  the  patient.  The  gastro-intestinal  symp- 
toms are  rarely  absent.  Nausea  and  vomiting  are  early  features  in  some 
cases,  and  diarrhrea  may  be  very  troublesome,  even  fatal.  Intestinal  haemor- 
rhage is  not  common.  There  may  be  a  dysenteric  process  in  the  colon.  Jaun- 
dice rarely  occurs,  though  in  one  case  of  my  series  there  were  recurrent  at- 
tacks. Ascites  may  be  a  prominent  symptom,  probably  due  to  the  presence 
of  the  splenic  tumor.  A  leukaemic  peritonitis  also  may  be  present,  due  to  new 
growths  in  the  membranes. 

The  nervous  system  is  not  often  involved.  Facial  paralysis  has  been  noted. 
Headache,  dizziness,  and  fainting  spells  are  due  to  anaemia.  The  patients  are 
usually  tranquil.  Coma  may  follow  cerebral  haemorrhage. 

The  special  senses  are  often  affected.  There  is  a  peculiar  retinitis,  due 
chiefly  to  the  extravasation  of  blood,  but  there  may  be  aggregations  of  leuco- 
cytes, forming  small  leukasmic  growths.  Optic  neuritis  is  rare.  Deafness  has 
frequently  been  observed;  it  may  appear  early  and  possibly  is  due  to  haemor- 
rhage. Features  suggestive  of  Meniere's  disease  may  come  on  quite  suddenly, 
due  to  leukaemic  infiltration  or  haemorrhage  into  the  semi-circular  canal. 

The  urine  presents  no  constant  changes.  The  uric  acid  excreted  is  always 
in  excess. 

Priapism  is  a  curious  symptom  which  has  been  present  in  a  large  num- 
ber of  cases.  It  may,  as  in  one  of  our  patients,  be  the  first  symptom.  In  one 
of  my  patients  it  persisted  for  seven  weeks.  The  cause  is  not  known. 

Fever  was  present  in  two-thirds  of  my  series.  Periods  of  pyrexia  may 
alternate  with  prolonged  intervals  of  freedom.  The  temperature  may  range 
from  102°  to  103°  F. 

Blood.— In  all  forms  of  the  disease  the  diagnosis  must  be  made  by  the 
examination  of  the  blood,  as  it  alone  offers  distinctive  features. 

The  striking  change  is  an  increase  in  the  colorless  corpuscles.  The  average 
in  my  series  was  298,700  per  c.  mm.,  and  the  average  ratio  to  the  red  cells 
was  1  to  10.  Counts  above  500,000  per  c.  mm.  are  common,  and  they  may 
rise  above  1,000,000  per  c.  mm.  The  proportion  of  white  to  red  cells  may 
be  1  to  5,  or  may  even  reach  1  to  1.  There  are  instances  on  record  in  which 
the  number  of  leucocytes  has  exceeded  that  of  the  red  corpuscles. 

The  increase  is  in  all  the  forms.  The  polynuclear  neutrophiles  make  up 
from  30  to  50  per  cent.;  both  the  small  and  the  large  lymphocytes  are  in- 
creased; the  eosinophiles  and  the  mast  cells  show  both  a  percentage  and  ab« 


744 


DISEASES   OF   THE   BLOOD 


solute  increase.  The  abnormal  cells,  the  myelocytes,  range  from  30  to  50  per 
cent.  Normoblasts  and  megaloblasts  are  common.  There  is  no  anaemia  at 
first.  The  red  cell  count  may  be  normal,  but  sooner  or  later  anaemia  comes 
on,  and  the  count  may  fall  to  2,000,000  per  c.  mm.  The  color  index  is  ueu- 


BLACK,  RED  CORPUSCLE 


RED,    HEMOGLOBIN. 

CHART  XVIII. — LEUKAEMIA. 


BLUE,  COLORLESS  CORPUSCLES. 


ally  low.  The  blood  platelets  are  increased.  Charcot-Leyden  crystals  may 
separate  from  the  clots  and  the  hemoglobin  shows  a  remarkable  tendency  to 
crystalize. 

II.  LYMPHOID  LEUKEMIA. — Symptoms. — This  less  common  form  occurs 
more  frequently  in  males.    There  are  two  varieties,  the  acute  and  the  chronic. 


LEUKAEMIA  745 

Acute  lymphatic  leukaemia,  one  of  the  most  terrible  of  all  the  blood  diseases, 
may  run  a  malignant  course  unparalleled  by  any  of  them.  Among  the  early 
symptoms  are  angina,  often  of  an  ulcerative  character,  involving  the  tonsils 
and  the  pharynx.  Haemorrhages  occur  early,  usually  into  the  skin,  or  there 
is  profuse  nose-bleeding.  The  swelling  of  the  glands,  most  commonly  of  the 
neck,  is  then  noticed ;  the  patient  rapidly  becomes  anaemic,  and  death  has  oc- 
curred as  early  as  the  seventh  day.  There  may  be  marked  fever,  to  103°  or 
105°  F.,  and  the  case  may  be  mistaken  for  malignant  typhoid  or  typhus 
fever.  The  real  nature  of  the  disease  may  not  be  evident  until  the  lymph 
glands  begin  to  swell;  in  some  cases  there  is  no  evident  glandular  enlarge- 
ment. 

The  chronic  form  is  a  very  different  disease,  occurring  later  in  life,  and 
beginning  with  a  general  enlargement  of  the  lymph  glands,  first  the  cervical, 
then  the  axillary.  The  spleen  may  be  slightly  enlarged,  and  anaemia  even- 
tually comes  on,  but  the  disease  may  last  for  years  without  any  special  anae- 
mia.  Haemorrhages  are  rare.  Fever  is  not  common.  A  pruritus  of  great 
intensity  may  be  present,  sometimes  with  ecthymatous  patches.  The  skin 
may  become  deeply  pigmented.  Localized  leukaemic  tumors  of  the  skin  have 
been  described. 

Blood. — The  drop  may  be  sticky  and  viscous,  spreading  with  difficulty. 
The  most  remarkable  feature  is  the  increase  of  lymphocytes,  which  are  very 
often  above  90  per  cent.,  and  may  reach  even  99  per  cent.  There  are  two 
chief  forms,  the  large  and  the  small  mononuclear.  The  majority  of  the 
chronic  cases  have  the  small  lymphocytes,  and  the  total  percentage  is  rarely 
so  high.  The  number  of  leucocytes  is  less  than  in  the  myeloid  form,  the 
average  in  34  cases  being  180,000  (Cabot).  In  20  cases  the  first  count  was 
below  60,000. 

ATYPICAL  LEUKAEMIAS. —  (1)  Mixed  leukcemias,  in  part  myeloid  and  in 
part  lymphoid;  but  in  nearly  all  cases  of  the  ordinary  spleno-medullary 
leukaemia  a  certain  percentage  of  lymphocytes  are  present,  which  toward  the 
end  may  be  materially  increased. 

(2)  Cases  with  atypical  blood  changes,  such  as  a  very  high  percentage  of 
eosinophiles,  or  a  condition  with  a  very  high  proportion  of  plasma  cells. 

(3)  Chloroma  is  an  atypical  lymphoid  leukaemia  in  which  the  lymphatic 
tumors  have  a  greenish  color.     The  tumor  growths  occur  chiefly  in  the  skull, 
the  orbit,  the  long  bones,  and  throughout  the  viscera.     The  blood  picture  is 
like  that  of  leukaemia  and  the  condition  is  generally  fatal  within  six  or  eight 
months. 

(4)  In  a  few  rare  instances  a  condition  of  leukaemia  has  been  found  with- 
out changes  in  the  blood-making  organs. 

(5)  Leukancemia. — This  term  was  invented  by  Leube  to  describe  a  condi- 
tion showing  features  both  of  leukaemia  and  severe  anaemia.     The  cases  are 
now  regarded  as  a  myeloid  leukaemia  with  severe  anaemia.     Glandular  en- 
largement is  usually  present;  the  onset  may  be  like  the  acute  types  of  leukae- 
mia, and  the  blood  picture  may  be  either  of  the  lymphoid  or  of  the  myeloid 
type. 

Diagnosis. — The  recognition  of  the  acute  forms  may  be  difficult,  particu- 
larly those  which  begin  with  marked  angina   and  cutaneous  haemorrhages. 
It  may  not  be  until  a  blood  examination  is  made  or  the  glands  enlarge  that 
49 


746  DISEASES    OF   THE   BLOOD 

suspicion  is  aroused.  The  chronic  forms  are  easily  recognized.  The  enlarged 
spleen  at  once  suggests  a  blood  count,  upon  which  alone  the  diagnosis  rests. 
Twice  I  have  had  cases  of  leukaemia  sent  from  the  ophthalmic  surgeon,  one 
case  with  the  diagnosis.  In  the  lymphatic  form,  too,  the  diagnosis  rests  with 
the  blood  examination.  One  has  to  recognize  that  there  are  certain  cases  of 
sepsis  with  marked  lymphocytosis,  in  which  the  white  blood-corpuscles  may 
reach  30,000  or  40,000  per  c.  mm.  When  the  regional  lymph  glands  are  in- 
volved this  may  raise  a  doubt.  Cabot  gives  an  instance  of  a  child  in  whom 
after  pneumonia  and  whooping-cough  there  was  a  leucocytosis  of  94,000  per 
c.  mm.  It  is  important  to  remember  that  in  the  ordinary  myelitic  forms  un- 
der treatment  with  arsenic  or  with  X-rays  the  increase  of  leucocytes  may  dis- 
appear, but  the  differential  count  may  still  be  characteristic. 

Prognosis. — Eecovery  in  leukaemia  is  practically  unknown.  The  acute 
cases  die  within  three  months ;  the  chronic  forms  last  from  six  months  to  four 
or  five  years.  The  chronic  lymphatic  form  seems  to  be  the  most  protracted. 
One  case  in  my  hospital  series  lasted  three  years.  A  private  patient  with  ac- 
curate blood  counts,  in  whom  the  diagnosis  was  made  by  W.  H.  Draper,  was 
seen  by  me  ten  years  subsequently;  the  cervical,  axillary,  and  inguinal  glands 
were  greatly  enlarged ;  the  leucocytes  were  242,000  per  c.  mm.,  above  90  per 
cent,  being  lymphocytes. 

Association  with  Other  Diseases. — Tuberculosis  is  not  uncommon.  Dock 
has  collected  27  cases,  in  none  of  which  did  the  tuberculosis  show  any  special 
influence.  Intercurrent  infections  are  not  rare,  such  as  influenza,  erysipelas, 
or  sepsis — often  with  a  remarkable  effect  upon  the  disease.  In  a  case  reported 
by  Dock,  after  an  attack  of  influenza  the  leucocytes  fell  from  367,000  to 
7,500  per  c.  mm.  Various  other  conditions  influence  the  disease,  and  the 
leucocytes  have  disappeared  under  the  use  of  arsenic,  quinine,  tuberculin, 
and  the  X-rays. 

Treatment. — Fresh  air,  good  diet,  and  abstention  from  mental  worry  and 
care  are  the  important  general  indications.  The  indicatio  morbi  can  not  be 
met.  There  are  certain  remedies  which  have  an  influence  upon  the  disease. 
Of  these,  arsenic,  given  in  large  doses,  is  the  best.  I  have  repeatedly  seen 
improvement  under  its  use.  On  the  other  hand,  there  are  curious  remissions 
in  the  disease,  as  mentioned  above,  which  render  therapeutic  deductions  very 
fallacious. 

Quinine  may  be  given  in  cases  with  a  malarial  history.  Iron  may  be 
of  value  in  some  cases,  as  may  also  inhalations  of  oxygen.  Treatment  with 
the  X-rays  should  be  tried.  Some  observers  have  reported  very  good  results. 
Personally,  I  have  not  seen  any  very  striking  permanent  improvement. 

Excision  of  the  leukgemic  spleen  has  been  performed  43  times,  with  5 
recoveries  (J.  C.  Warren). 


III.    HODGKIN'S  DISEASE 

Definition. — A  disease  characterized  by  enlargement  of  the  lymph-glands 
with  progressive  anaemia  and  a  fatal  termination. 

Anatomically  there  is  an  increase  in  the  adenoid  tissue  of  the  glands, 
proliferation  of  the  endothelial  cells,  formation  of  mononuclear  and  multi- 


HODGKI3PS    DISEASE  747 

nuclear  giant  cells,  the  presence  of  eosinophiles,  and  thickening  of  the  fibrous 
reticulum. 

History. — In  1832  Hodgkin  recorded  a  series  of  cases  of  enlargement  of 
the  lymphatic  glands  and  spleen.  From  the  motley  group  that  Hodgkin  de- 
scribed, Wilks  picked  out  the  disease  and  called  it  ancemia  lymphatica.  Other 
names  that  have  been  given  to  it  are  adenie  by  Trousseau,  pseudo-leukcemia 
by  Cohnheim,  and  generalized  lymphadenoma. 

Etiology. — A  widely  spread  disease  in  Europe  and  America,  a  majority  of 
the  cases  occur  in  young  adults,  and  more  frequently  in  males  than  in  fe- 
males. Twins  and  sisters  have  been  known  to  be  attacked.  The  cause  is  un- 
known. Certain  features  suggest  an  acute  infection:  the  rapid  course  of 
some  cases,  the  association  with  local  irritation  in  the  mouth  and  tonsils,  the 
frequency  with  which  the  disease  starts  in  the  cervical  glands,  the  gradual 
extension  from  one  gland  group  to  another,  and  the  recurring  exacerbations 
of  fever.  Various  organisms  have  been  described,  but  nothing  definite  has 
been  determined.  Possibly  the  disease  is  a  spirillosis — in  favor  of  which  are 
the  presence  of  eosinophilia,  so  characteristic  of  infection  with  animal  para- 
sites, the  presence  of  eosinophilic  cells  in  the  glands,  and  the  influence  of 
arsenic  on  the  disease.  Sternberg  suggested  that  the  disease  was  a  special 
form  of  tuberculosis;  but  the  histological  changes  in  the  glands  are  quite 
characteristic,  tubercle  bacilli  are  not  present  in  uncomplicated  cases,  the 
tuberculin  test  may  be  negative,  and  when  present  the  tuberculosis  appears 
to  be  a  terminal  infection. 

Morbid  Anatomy.- — The  superficial  lymph  glands  are  found  most  exten- 
sively involved,  and  from  the  cervical  groups  they  form  continuous  chains 
uniting  the  mediastinal  and  axillary  glands.  The  masses  may  pass  beneath 
the  pectoral  muscles  and  even  beneath  the  scapulae.  Of  the  internal  glands, 
those  of  the  thorax  are  most  often  affected,  and  the  tracheal  and  bronchial 
groups  may  form  large  masses.  The  trachea  and  the  aorta  with  its  branches 
may  be  completely  surrounded ;  the  veins  may  be  compressed,  rarely  the  aorta 
itself.  The  masses  perforate  the  sternum  and  invade  the  lung  deeply.  The 
retroperitoneal  glands  may  form  a  continuous  chain  from  the  diaphragm  to 
the  inguinal  canals.  They  may  compress  the  ureters,  the  lumbar  and  sacral 
nerves,  and  the  iliac  veins.  They  may  adhere  to  the  broad  ligament  and  the 
uterus  and  simulate  fibroids.  At  an  early  stage  the  glands  are  soft  and  elas- 
tic; later  they  may  become  firm  and  hard.  Fusion  of  contiguous  glands  does 
not  often  occur,  and  they  tend  to  remain  discrete,  even  after  attaining  a  large 
size.  The  capsule  may  be  infiltrated,  and  adjacent  tissues  invaded.  On  sec- 
tion the  gland  presents  a  grayish  white  semi-translucent  appearance,  broken 
by  intersecting  strands  of  fibrous  tissue;  there  is  no  caseation  or  necrosis 
unless  a  secondary  infection  has  occurred. 

The  spleen  is  enlarged  in  75  per  cent,  of  the  cases ;  in  young  children  the 
enlargement  may  be  great,  but  the  organ  rarely  reaches  the  size  of  the  spleen 
in  ordinary  leukaemia .  In  more  than  half  of  the  cases  lymph oid  growths  are 
present. 

The  marrow  of  the  long  bones  may  be  converted  into  a  rich  lymphoid 
tissue.  The  lymphatic  structures  of  the  tonsillar  ring  and  of  the  intestines 
may  show  marked  hyperplasia.  The  liver  is  often  enlarged,  and  may  present 
scattered  nodular  tumors,  which  may  also  occur  in  the  kidneys. 


748  DISEASES    OF    THE    BLOOD 

Histology. — The  studies  of  Andrewes  and  of  Dorothy  Eeed  show  a  very 
characteristic  microscopic  picture — proliferation  of  the  endothelial  and  reticu- 
lar  cells,  with  the  formation  of  lymphoid  cells  of  uniform  size  and  shape, 
and  characteristic  giant  cells,  the  so-called  lymphadenoma  cells,  containing 
four  or  more  nuclei.  Eosinophiles  are  always  present,  and  proliferation  of 
the  stroma  leads  to  fibrosis  of  the  gland.  The  difference  between  the  soft 
and  hard  forms  depends  largely  upon  the  stage  of  the  disease.  When  tubercu- 
losis occurs  as  a  secondary  infection  the  two  processes  may  be  readily  distin- 
guished in  sections  of  the  gland. 

Symptoms. — A  tonsillitis  may  precede  the  onset.  Enlargement  of  the 
cervical  glands  is  usually  an  initial  symptom;  it  is  rare  to  find  other  super- 
ficial groups  or  the  deeper  glands  attacked  first.  Months  or  even  several  years 
may  elapse  before  the  glands  in  the  axillae  and  groin  become  involved.  Dur- 
ing what  may  be  called  the  first  stage  the  patient's  general  condition  is  good ; 
then  anaemia  comes  on,  not  marked  at  first,  but  usually  progressive.  In  the 
majority  of  cases  the  spleen  is  enlarged,  but  it  never  reaches  the  dimension 
of  the  leukaemic  organ.  There  may  be  very  little  pain  until  the  internal 
glands  become  involved.  With  swelling  of  the  mediastinal  glands  there  are 
cough,  dyspnoea,  and  often  intense  cyanosis,  with  all  the  signs  of  intra- 
thoracic  tumor.  There  may  be  moderate  fever.  Bronzing  of  the  skin  may 
occur,  apart  altogether  from  the  use  of  arsenic.  Pruritis  may  be  a  very  de- 
pressing symptom,  and  boils  and  ecthymatous  blebs  may  occur.  The  leuco- 
cytes show  no  characteristic  changes.  There  may  be  a  moderate  eosinophilia 
and,  as  the  anaemia  progresses,  nucleated  red  corpuscles  appear,  and  toward 
the  end  there  are  instances  of  a  great  increase  in  the  lymphocytes.  As  the 
disease  progresses  there  is  marked  emaciation  with  great  asthenia,  and  some- 
times anasarca.  This  represents  the  common  clinical  course,  but  there  are 
many  variations,  among  which  the  following  are  the  most  common : 

(a)  An  ACUTE  FORM  has  been  described.  I  saw  a  remarkable  case  begin- 
ning, like  so  many  cases  of  lymphatic  leukaemia,  with  angina,  in  which  the 
whole  course  was  less  than  ten  weeks.  Ziegler  mentions  two  cases  of  death 
within  a  month. 

(6)  LOCALIZED  FORM. — The  enlargement  may  be  localized  to  certain 
groups,  those  in  the  neck,  the  groin,  the  retroperitoneum,  or  the  thorax.  Some 
of  these  cases  present  great  difficulty  in  diagnosis,  particularly  when  there 
are  febrile  paroxysms  with  very  slight  involvement  of  the  external  groups. 
The  disease  may  be  confined  to  one  region  for  a  year  or  more  before  there  is 
any  extension.  The  localized  mediastinal  group  often  presents  a  very  re- 
markable picture — pressure  signs,  pain,  orthopncea — and,  unless  there  are 
other  groups  involved,  or  enlargement  of  the  spleen,  it  may  be  impossible  to 
make  the  diagnosis  during  life. 

(c)  WITH  RELAPSING  PYREXIA. — To  this  remarkable  type  Pel  and  af- 
terward Ebstein  called  attention.  MacNalty  has  recently  made  a  very  care- 
ful study  of  this  syndrome,  which  is  one  of  the  most  remarkable  met  with  in 
the  practice  of  medicine.  The  relapsing  pyrexia  may  occur  in  cases  with  in- 
volvement of  the  internal  glands  alone,  or,  more  frequently,  with  a  general 
involvement  of  all  the  groups.  "Following  on  a  period  of  low  pyrexia,  or  of 
normal  or  subnormal  temperature,  there  is  a  steady  rise  occupying  two  or 
four  days  to  a  maximum,  which  may  reach  105°.  For  about  three  days  the 


HODGKIX'S    DISEASE  749 

temperature  remains  at  a  high  level,  and  then  there  is  a  gradual  fall  by  lysis 
occupying  about  three  days,  and  the  temperature  then  becomes  sub-normal" 
(MacXalty).  An  afebrile  period  of  ten  days  or  two  weeks  then  occurs,  to 
be  followed  by  another  bout  of  fever.  This  may  be  repeated  for  many  months. 
In  one  of  my  cases  the  pyrexia  lasted  for  accurately  fourteen  days  for  many 
successive  paroxysms.  During  the  fever  the  glands  swell  and  may  become 
hot  and  tender.  This  febrile  type  may  occur  in  connection  with  involvement 
of  the  internal  glands  alone.  In  one  patient  whose  cervical  glands  had  been 
thoroughly  removed  there  were  typical  Pel-Ebstein  paroxysms,  and  we  could 
find  no  enlarged  glands,  internal  or  external. 

(d)  LATENT  TYPE. — In  his  recent  monograph  Ziegler  has  called  attention 
to  the  importance  of  this  form,  in  which  anemia,  fever,  and  constitutional 
symptoms  may  be  present  with  enlargement  of  the  internal  glands.     One  of 
my  early  cases  was  of  this  type — a  very  stout  man,  in  whom  the  retroperi- 
toneal  glands  alone  were  involved.     Symmers  has  reported  an  instance  in 
which  the  glands  and  the  hilus  of  the  liver  were  attacked. 

(e)  SPLEXOMEGALIC  FORM. — Enlargement  of  the  spleen  is  present  in  a 
large  proportion  of  cases  of  Hodgkin's  disease.     Whether  or  not  there  is  a 
type  involving  the  spleen  alone  without  the  lymph  glands  is  still  a  question. 
Formerly,   under  the  name  pseudo-leukasmia    of   Cohnheim,  many  cases   of 
simple  enlargement  of  the  spleen  with  or  without  anemia  were  spoken  of  as 
pseudo-leukaemia  splenica.    It  is  not  improbable  that  the  disease  may  originate 
in  the  lymphoid  tissue  of  the  spleen,  and  several  cases  have  been  reported  of 
late  years  by  Ziegler,   Symmers,  Warrington,  and  others.     It  must  be  very 
difficult  to  distinguish  such  cases  clinically  from  the  early  stages  of  Banti's 
disease. 

(/)  Lastly,  a  LYMPHADEXIA  OSSIUM  has  been  described — cases  in  which 
there  have  been  multiple  bone  tumors  of  the  bone  marrow  and  of  the  perios- 
teum with  enlargement  of  the  glands  and  spleen.  How  far  these  should  be 
grouped  with  Hodgkin's  disease  seems  to  me  very  doubtful. 

Diagnosis. —  (a)  TUBERCULOSIS. — There  are  both  acute  and  chronic  forms 
of  general  tuberculous  adenitis  (already  described),  but  they  do  not  often 
present  difficulty  in  diagnosis.  In  the  case  of  enlargement  of  the  glands  on 
one  side  of  the  neck  beginning  in  a  young  person,  it  is  often  not  at  all  easy 
to  determine  whether  the  disease  is  tuberculosis  or  beginning  Hodgkin's  dis- 
ease. Two  points  should  be  decided.  First,  under  cocaine  one  of  the  small 
glands  of  the  affected  side  should  be  excised  and  the  structure  carefully 
studied.  The  histological  changes  differ  markedly  in  Hodgkin's  disease  from 
those  in  tuberculosis.  Secondly,  tuberculin  should  be  used  if  the  patient  is 
afebrile.  In  early  tuberculosis  of  the  glands  of  the  neck  the  reaction  is 
prompt  and  decisive.  In  the  later  stages,  when  many  groups  of  glands  are 
involved  and  the  cachexia  is  well  advanced,  the  tuberculin  reaction  may  be 
present  in  Hodgkin's  disease,  but  even  then  the  histological  changes  are  dis- 
tinctive. Other  points  to  be  noted  are  the  tendency  in  the  tuberculous  adenitis 
to  coalescence  of  the  glands,  adhesion  to  the  skin,  with  suppuration,  etc.,  and 
the  liability  to  tuberculosis  of  the  lung  or  pleura. 

(&)  LEUKEMIA. — As  a  rule,  the  blood  examination  gives  the  diagnosis  at 
a  glance,  as  Hodgkin's  disease  presents  only  a  slight  leucocytosis.  A  dif- 
ficulty arises  only  in  those  rare  instances  of  leukaemia,  usually  the  acute  lym- 


750  DISEASES   OP   THE   BLOOD 

phatic  form,  in  which  the  leucocytes  gradually  decrease  or  in  which  the  num- 
ber for  a  time  may  become  normal.  Histologically  there  are  striking  differ- 
ences between  the  structure  of  the  glands  in  the  two  conditions. 

(c)  LYMPHO-SARCOMA. — Clinically  the  cases  may  resemble  Hodgkin's  dis- 
ease very  closely,  and  in  the  literature  the  two  diseases  have  been  confounded. 
The  glands,  as  a  rule,  form  larger  masses,  the  capsules  are  involved,  and 
adjacent  structures  are  attacked,  but  this  may  be  the  case  in  Hodgkin's  dis- 
ease. Pressure  signs  in  the  chest  and  abdomen  are  much  more  common  in 
lympho-sarcoma.  But  the  easiest  and  most  satisfactory  mode  of  diagnosis  is 
examination  of  sections  of  a  gland,  as  the  structure  is  very  different  from 
that  seen  in  Hodgkin's  disease.  The  blood  condition,  the  type  of  fever,  etc., 
need  a  more  careful  study  in  this  group  of  cases. 

Course. — There  are  acute  cases  in  which  the  enlargements  spread  rapidly 
and  death  follows  in  a  few  months.  As  a  rule,  the  disease  lasts  for  two  or 
three  years.  Eemarkable  periods  of  quiescence  may  occur,  in  which  the 
glands  diminish  in  size,  the  fever  disappears,  and  the  general  condition  im- 
proves. Even  a  large  group  of  glands  may  almost  completely  disappear,  or 
a  tumor  mass  on  one  side  of  the  neck  may  subside  while  the  inguinal  glands 
are  enlarging.  Usually  a  cachexia  with  anaemia  and  swelling  of  the  feet  pre- 
cedes death.  A  fatal  event  may  occur  early  from  great  enlargement  of  the 
mediastinal  glands. 

Treatment. — When  the  glands  are  small  and  limited  to  one  side  of  the 
neck,  operation  should  be  advised;  even  when  both  sides  of  the  neck  are  in- 
volved, if  there  are  no  signs  of  mediastinal  growth,  operation  is  justifiable. 
The  course  of  the  disease  may  be  delayed,  even  if  cure  does  not  follow. 

There  is  a  possibility  that  the  X-rays  may  do  good  in  selected  cases.  Cer- 
tainly the  glands  have  been  reduced  in  size,  but  I  know  of  no  case  in  which 
complete  cure  has  been  reported.  Local  treatment  of  the  glands  seems  to  do 
but  little  good. 

Arsenic  is  the  only  drug  which  has  a  positive  value  in  the  disease.  In 
some  cases  the  effects  on  the  glands  are  striking.  It  may  be  given  in  the  form 
of  Fowler's  solution  in  increasing  doses.  Eecoveries  have  been  reported  ( ?) . 
Ill  effects  from  the  larger  doses  are  rare.  Peripheral  neuritis  followed  the 
use  of  §  iv,  3j,  IT],  xviij  during  a  period  of  less  than  three  months.  Phosphorus 
is  recommended  by  Gowers  and  Broadbent,  and  may  be  tried  if  arsenic  is 
not  well  borne.  Quinine,  iron,  and  cod-liver  oil  are  useful  as  tonics.  For 
the  pressure  pains  morphia  should  be  given. 

IV.    PURPURA 

Strictly  speaking,  purpura  is  a  symptom,  not  a  disease;  but  under  this 
term  are  conveniently  arranged  a  number  of  affections  characterized  by  ex- 
travasations of  the  blood  into  the  skin.  In  the  present  state  of  our  knowledge 
a  satisfactory  classification  can  not  be  made.  W.  Koch  groups  all  forms,  in- 
cluding haemophilia,  under  the  designation  hcemorrhagic  diathesis,  believing 
that  intermediate  forms  link  the  mild  purpura  simplex  and  the  most  intense 
purpura  haemorrhagica.  For  a  full  discussion  of  the  subject  and  an  analysis 
of  my  cases,  see  Pratt's  article  in  my  "System  of  Medicine,"  Vol.  IV. 

The  purpuric  spots  vary  from  1  to  3  or  4  mm.  in  diameter.    When  small 


PTJKPUEA  751 

and  pin-point-like  they  are  called  petechige;  when  large,  they  are  known  as 
ecchymosee.  At  first  bright  red  in  color,  they  become  darker,  and  gradually 
fade  to  brownish  stains.  They  do  not  disappear  on  pressure. 

In  some  forms  of  purpura  the  coagulation  time  of  the  blood  is  retarded 
to  ten  or  fifteen  minutes,  and  in  hemophilia  it  has  been  delayed  to  fifty 
minutes. 

The  following  is  a  provisional  grouping  of  the  cases: 

Symptomatic  Purpura.  —  (a)  INFECTIOUS. — In  pyaemia,  septica?mia,  and 
malignant  endocarditis  (particularly  in  the  last  affection)  ecchymoses  may 
be  very  abundant.  In  typhus  fever  the  rash  is  always  purpuric.  Measles, 
scarlet  fever,  and  more  particularly  small-pox  and  cerebro-spinal  fever,  have 
each  a  variety  characterized  by  an  extensive  purpuric  rash. 

(6)  Toxic. — The  virus  of  snakes  produces  extravasation  of  blood  with 
great  rapidity — a  condition  which  has  been  very  carefully  studied  by  Weir 
Mitchell.  Certain  medicines,  particularly  copaiba,  quinine,  belladonna,  mer- 
cury, ergot,  and  the  iodides  occasionally,  are  followed  by  a  petechial  rash. 
Purpura  may  follow  the  use  of  comparatively  small  doses  of  iodide  of  potas- 
sium. A  fatal  event  may  be  caused  by  a  small  amount,  as  in  a  case  reported 
by  Stephen  Mackenzie  of  a  child  which  died  after  a  dose  of  2~y2  grains.  An 
erythema  may  precede  the  haemorrhage.  It  is  not  always  a  simple  purpura, 
but  may  be  an  acute  febrile  eruption  of  great  intensity.  Workers  with  ben- 
zol, which  is  used  as  a  solvent  for  rubber,  may  be  attacked  with  severe  pur- 
pura. Cases  such  as  those  reported  by  Selling  have  been  in  connection  with 
the  coating  of  tin  cans,  while  the  Swedish  cases  occurred  in  connection  with 
the  manufacture  of  bicycle  tires.  Under  this  division,  too,  comes  the  purpura 
so  often  associated  with  jaundice. 

(c)  CACHECTIC. — Under  this  heading  are  best  described  the  instances  of 
purpura  which  occur  in  the  constitutional  disturbance  of  cancer,  tuberculo- 
sis, Hodgkin's  disease,  Bright's  disease,  scurvy,  and  in  the  debility  of  old  age. 
In  these  cases  the  spots  are  usually  confined  to  the  extremities.    They  may  be 
very  abundant  on  the  lower  limbs  and  about  the  wrists  and  hands.     This 
constitutes,  probably,  the  commonest  variety  of  the  disease,  and  many  exam- 
ples of  it  can  be  seen  in  the  wards  of  any  large  hospital. 

(d)  NEUROTIC. — One  variety  is  met  with  in  cases  of  organic  disease.     It 
is  the  so-called  myelopathic  purpura,  which  is  seen  occasionally  in  locomotor 
ataxia,  particularly  following  attacks  of  the  lightning  pains  and,  as  a  rule, 
involving  the  area  of  the  skin  in  which  the  pains  have  been  most  intense. 
Cases  have  been  met  with  also  in  acute  myelitis  and  in  transverse  myelitis, 
and  occasionally  in  severe  neuralgia.     Another  form  is  the  remarkable  hys- 
terical condition  in  which  stigmata,  or  bleeding  points,  appear  upon  the  skin. 

(e)  MECHANICAL. — This  variety  is  most  frequently  seen  in  venous  stasis 
of  any  form,  as  in  the  paroxysms  of  whooping  cough  and  in  epilepsy  and 
about  tight  bandages. 

Arthritic  Purpura. — This  form  is  characterized  by  involvement  of  the 
joints.  It  is  usually  known,  therefore,  as  rheumatic,  though  in  reality  the 
evidence  upon  which  this  view  is  based  is  not  conclusive.  Of  200  cases  of 
purpura  analyzed  by  Stephen  Mackenzie,  61  had  a  history  of  rheumatism. 
For  the  present  it  seems  more  satisfactory  to  use  the  designation  arthritic. 
Three  groups  of  cases  may  be  -recognized : 


752  DISEASES    OF    THE    BLOOD 

(a)  PURPURA  SIMPLEX. — A  mild  form,  often  known  as  purpura  simplex, 
seen  most  commonly  in  children,  in  whom,  with  or  without  articular  pain, 
a  crop  of  purpuric  spots  appears  upon  the  legs,  less  commonly  upon  the  trunk 
and  arms.  As  pointed  out  by  Graves,  this  form  is  not  infrequently  associated 
with  diarrhoea.  The  disease  is  seldom  severe.  There  may  be  loss  of  appetite, 
and  slight  anaemia.  Fever  is  not,  as  a  rule,  present,  and  the  patients  get  well 
in  a  week  or  ten  days.  Usually  regarded  as  rheumatic,  and  certainly  asso- 
ciated, in  some  instances,  with  undoubted  rheumatic  manifestations,  yet  in  a 
majority  of  the  patients  the  arthritis  is  slighter  than  in  the  ordinary  rheuma- 
tism of  children,  and  no  other  manifestations  are  present. 

(&)  PURPURA  (PELIOSJS)  EHEUMATICA  (Sclwnleins  Disease}. — This  re- 
markable affection  is  characterized  by  multiple  arthritis  and  an  eruption 
which  varies  greatly  in  character,  sometimes  purpuric,  more  commonly  asso- 
ciated with  urticaria  or  with  erythema  exudativum.  The  disease  is  most 
common  in  males  between  the  ages  of  twenty  and  thirty.  It  not  infrequently 
sets  in  with  sore  throat,  a  fever  from  101°  to  103°,  and  articular  pains.  The 
rash,  which  makes  its  appearance  first  on  the  legs  or  about  the  affected  joints, 
may  be  a  simple  purpura  or  may  show  ordinary  urticarial  wheals.  In  other 
instances  there  are  nodular  infiltrations,  not  to  be  distinguished  from  eryth- 
ema nodosum.  The  combination  of  wheals  and  purpura,  the  purpura  urti- 
cans,  is  very  distinctive.  Much  more  rarely  vesication  is  met  with,  the  so- 
called  pemphigoid  purpura.  The  amount  of  oedema  is  variable;  occasionally 
it  is  excessive.  These  are  the  cases  which  have  been  described  as  febrile  pur- 
puric cedema.  The  temperature  range,  in  mild  cases,  is  not  high,  but  may 
reach  102°  or  103°  F. 

The  urine  is  sometimes  reduced  in  amount  and  may  be  albuminous.  The 
joint  affections  are  usually  slight,  though  associated  with  much  pain,  par- 
ticularly as  the  rash  comes  out.  Relapses  may  occur  and  the  disease  may 
return  at  the  same  time  for  several  years  in  succession. 

The  diagnosis  of  Schb'nlein's  disease  offers  no  difficulty.  The  association 
of  multiple  arthritis  with  purpura  and  urticaria  is  very  characteristic. 

Schb'nlein's  peliosis  is  thought  by  most  writers  to  be  of  rheumatic  origin, 
and  certainly  many  of  the  cases  have  the  characters  of  ordinary  rheumatic 
fever,  plus  purpura.  By  many,  however,  it  is  regarded  as  a  special  affection, 
of  which  the  arthritis  is  a  manifestation  analogous  to  that  which  occurs  in 
haemophilia  and  in  scurvy.  The  frequency  with  which  sore  throat  precedes 
the  attack,  and  the  occasional  occurrence  of  endocarditis  or  pericarditis,  are 
certainly  very  suggestive  of  true  rheumatism. 

The  cases  usually  do  well,  and  a  fatal  event  is  extremely  rare.  The  throat 
symptoms  may  persist  and  give  trouble.  In  two  instances  I  have  seen  necrosis 
and  sloughing  of  a  portion  of  the  uvula. 

VISCERAL  LESIONS  IN  PURPURA. — In  any  form  of  purpura,  in  the  ery- 
themas, and  in  urticaria  visceral  lesions  may  occur,  (a)  Gastro-intestinal 
crises,  pain,  vomiting,  melaena,  and  diarrhoea.  The  attacks  have  often  been 
mistaken  for  appendicitis  or  for  intussusception,  and  at  operation  the  con- 
dition has  been  found  to  be  an  acute  sero-ha3morrhagic  infiltration  of  a  lim- 
ited area  of  the  stomach  or  bowel.  Identical  attacks  occur  in  angio-neurotic 
cedema.  These  crises  may  occur  for  years  in  children  before  an  outbreak  of 
purpura  or  urticaria  gives  a  clue  to  their  nature.  (&)  Enlargement  of  the 


PURPURA 


753 


spleen  is  usually  present  in  these  cases,  (c)  Albuminuria  and  acute  nephritis 
may  occur  and  form  the  most  serious  complication,  of  which  seven  cases  in 
my  series  died  (Am.  J.  Med.  Sciences,  Jan.,  1904).  The  combination  of 
purpura  with  colic  is  usually  spoken  of  as  Henoch's  purpura. 


APR  L.                                      MAY. 

JUNE.                                  JULY. 

no* 

, 

100;? 

5,000,000 

90* 

--• 

80* 

4,000,000 

>  

/                                                                ^ 

70* 

/                                                                 ./ 

4.                                                                »•* 

_                                 __^_       

60* 

3,000,000 

's                I        =~"  "" 

"N        1 

„*'* 

50* 

*         '                                                                                    •* 

3 

t~~           ^          ^"'^    ~ 

40* 

2,000,000 

^      / 

^^ 

80* 

-*-*_*- 

IriSr  lit 

-  *-  -•*  -  :—  -  *-  -•*••  -  -.'  -  -  *-  -  -i 

14,OOO 

12,000 

L  ^-^ 

10,000 

V 

8,OOO 

6,000 

"^^^ 

4,000 

"*-<^L 

2,OOO 

MEAN  NORM. 

NUMBER  OF 

WHITE 

CORPUSCLE* 


BLACK,  RED  CORPUSCLES. 


RED,  HytKOGLOBIN. 


BLUE,  COLORLESS  CORPUSCLES. 


CHART  XIX. — THE  RAPIDITY    WITH  WHICH    ANEMIA   IS   PRODUCED   IN   PURPURA    H-SM- 
ORRHAGICA,  AND  THE  GRADUAL  EECOVERY. 

Purpura  Hgemorrhagica. — Under  this  heading  may  be  considered  cases  of 
very  severe  purpura  with  haemorrhages  from  the  mucous  membranes.  The 
affection,  known  as  the  morbus  maculosus  of  Werlhof,  is  most  commonly  met 
with  in  young  and  delicate  individuals,  particularly  in  girls;  but  the  disease 
may  attack  adults  in  full  vigor.  After  a  few  days  of  weakness  and  debility, 
purpuric  spots  appear  on  the  skin  and  rapidly  increase  in  number  and  size. 
Bleeding  from  the  mucous  surfaces  sets  in,  and  the  epistaxis,  haematuria,  and 
haemoptysis  may  cause  profound  anaemia.  Death  may  take  place  from  loss  of 
blood,  or  from  haemorrhage  into  the  brain.  Slight  fever  usually  accompanies 
the  disease.  In  favorable  cases  the  affection  terminates  in  from  ten  days  to 
two  weeks.  There  are  instances  of  purpura  haemorrhagica  of  great  malignan- 
cy, which  may  prove  fatal  within  twenty-four  hours — purpura  fulminans. 
This  form  is  most  commonly  met  with  in  children,  and  is  characterized 
chiefly  by  cutaneous  haemorrhages,  and  death  may  occur  before  any  bleeding 
takes  place  from  the  mucous  membranes. 


754  DISEASES    OF    THE    BLOOD 

In  the  diagnosis  of  purpura  hg>morrhagica  it  is  important  to  exclude 
scurvy,  which  may  be  done  by  the  consideration  of  the  previous  health,  the 
circumstances  under  which  the  disease  occurs,  and  by  the  absence  of  swelling 
of  the  gums.  The  malignant  forms  of  the  fevers,  particularly  small-pox  and 
measles,  are  distinguished  by  the  prodromes  and  the  higher  temperature. 

Treatment. — In  symptomatic  purpura  attention  should  be  paid  to  the  con- 
ditions under  which  it  occurs,  and  measures  should  be  employed  to  increase 
the  strength  and  to  restore  a  normal  blood  condition.  Tonics,  good  food,  and 
fresh  air  meet  these  indications.  In  the  simple  purpura  of  children,  or  that 
associated  with  slight  articular  trouble,  arsenic  in  full  doses  should  be  given. 
No  good  is  obtained  from  the  small  doses,  but  the  Fowler's  solution  should  be 
pushed  freely  until  physiological  effects  are  obtained.  In  peliosis  rheumatica 
the  sodium  salicylate  may  be  given,  but  with  discretion.  I  confess  not  to 
have  seen  any  special  control  of  the  haemorrhages  by  this  remedy. 

Aromatic  sulphuric  acid,  ergot,  turpentine,  acetate  of  lead,  or  tannic  and 
gallic  acids  may  be  given,  and  in  some  instances  they  seem  to  check  the 
bleeding.  Oil  of  turpentine  is  perhaps  the  best  remedy,  in  10  or  15-minim 
(1  c.  c.)  doses  three  or  four  times  a  day.  The  calcium  salts,  preferably  the 
lactate,  may  be  given  in  doses  of  15  grains  (1  gm.)  three  or  four  times  a  day 
for  a  few  days,  to  increase  the  coagulability  of  the  blood.  In  bleeding  from 
the  mouth,  gums,  and  nose  the  inhalation  of  carbon  dioxide,  irrigations  with 
2-per-cent.  gelatin  solution,  and  adrenalin  should  be  tried.  The  last  remedy 
has  often  acted  promptly.  The  treatment  of  the  severe  forms  is  the  same  as 
that  given  in  haemophilia. 

HJEMOEEHAGIC    DISEASES    OF    THE    NEW-BORN 

Syphilis  Haemorrhagica  Neonatorum. — The  child  may  be  born  healthy, 
or  there  may  be  signs  of  haemorrhage  at  birth.  Then  in  a  few  days  there 
are  extensive  cutaneous  extravasations  and  bleeding  from  the  mucous  sur- 
faces and  from  the  navel.  The  child  may  become  Deeply  jaundiced.  The 
post  mortem  shows  numerous  extravasations  in  the  internal  organs  and  exten- 
sive syphilitic  changes  in  the  liver  and  other  organs. 

Epidemic  Haemoglobinuria  (WincJcel's  Disease). — Haemoglobinuiia  in  the 
new-born,  which  occasionally  occurs  in  epidemic  form  in  lying-in  institu- 
tions, is  a  very  fatal  affection,  which  sets  in  usually  about  the  fourth  day 
after  birth.  The  child  becomes  jaundiced,  and  there  are  marked  gastro-in- 
testinal  symptoms,  with  fever,  jaundice,  rapid  respiration,  and  sometimes 
cyanosis.  The  urine  contains  albumin  and  blood  coloring  matter — methaemo- 
globin.  The  disease  has  to  be  distinguished  from  the  simple  icterus  neona- 
torum,  with  which  there  may  sometimes  be  blood  or  blood  coloring  matter 
in  the  urine.  The  post  mortem  shows  an  absence  of  any  septic  condition  of 
the  umbilical  vessels,  but  the  spleen  is  swollen,  and  there  are  punctiform 
haemorrhages  in  different  parts.  Some  cases  have  shown  in  a  marked  degree 
acute  fatty  degeneration  of  the  internal  organs — the  so-called  Buhl's  disease. 

Morbus  Maculosus  Neonatorum. — Apart  from  the  common  visceral  haem- 
orrhages, the  result  of  injuries  at  birth,  bleeding  from  one  or  more  of  the 
surfaces  is  a  not  uncommon  event  in  the  new-born,  particularly  in  hospital 
practice.  Forty-five  cases  occurred  in  6,700  deliveries  (C.  W.  Townsend). 


HEMOPHILIA  755 

The  bleeding  may  be  from  the  navel  alone,  but  more  commonly  it  is  general. 
Of  Townsend's  50  cases,  in  20  the  blood  came  from  the  bowels  (melcena  neo- 
natorum),  in  14  from  the  stomach,  in  14  from  the  mouth,  in  12  from  the 
nose,  in  18  from  the  navel,  in  3  from  the  navel  alone.  The  bleeding  begins 
within  the  first  week,  but  in  rare  instances  is  delayed  to  the  second  or  third. 
Thirty-one  of  the  cases  died  and  19  recovered.  The  disease  is  usually  of  brief 
duration,  death  occurring  in  from  one  to  seven  days.  The  temperature  is 
often  elevated.  The  nature  of  the  disease  is  unknown.  As  a  rule,  nothing 
abnormal  is  found  post  mortem.  The  general  and  not  local  nature  of  the 
affection,  its  self  limited  character,  the  presence  of  fever,  and  the  greater 
prevalence  of  the  disease  in  hospitals  suggest  an  infectious  origin  (Town- 
send).  The  bleeding  may  be  associated  with  intense  haematogenous  jaundice. 
Not  every  case  of  bleeding  from  the  stomach  or  bowels  belongs  in  this  cate- 
gory. Ulcers  of  the  oesophagus,  stomach,  and  duodenum  have  been  found  in 
the  new-born  dead  of  melcena  neonatorum.  The  child  may  draw  the  blood 
from  the  breast  and  subsequently  vomit  it. 

V.    HAEMOPHILIA 

Definition. — A  disease  characterized  by  excessive  and  chronic  liability  to 
immoderate  haemorrhage.  The  liability  is  hereditary,  and  is  confined  to  the 
male  sex  (Bulloch  and  Fildes). 

History. — The  origin  of  our  knowledge  of  this  remarkable  condition  dates 
from  1803,  when  John  C.  Otto,  a  Philadelphia  physician,  published  "an  ac- 
count of  an  hsemorrhagic  disposition  occurring  in  certain  families";  and  he 
first  used  the  word  "bleeder."  The  works  of  Grandidier  and  of  Wickham 
Legg  give  full  clinical  details,  and  the  monograph  of  Bulloch  and  Fildes 
(Dulan  &  Co.,  London,  1911)  presents  in  extraordinary  detail  every  aspect 
of  the  disease. 

Distribution. — A  majority  of  the  cases  have  been  reported  from  Germany, 
Switzerland,  and  the  United  States.  Jews  are  supposed  to  be  more  prone 
than  others  to  the  disease,  but  this  Bulloch  doubts,  and  he  discredits  the  negro 
cases. 

SEX. — Bulloch  and  Fildes  claim  to  have  established  by  their  researches 
the  fact  of  immunity  in  females,  denying  the  authenticity  of  all  the  published 
cases  (19).  "In  none  of  the  families  of  bleeders  ...  do  we  find  any  un- 
equivocal evidence  of  abnormality  in  the  women,  that  is  to  say,  any  abnormal- 
ity beyond  what  might  be  expected  in  any  collection  of  females  taken  at 
random." 

INHERITANCE. — Otto  pointed  out  in  his  original  paper  that  while  the  fe- 
males do  not  themselves  bleed  they  alone  transmit  the  tendency.  Of  171 
recorded  instances  of  transmission,  160  conform  to  the  "law  of  Nasse"  that 
the  disease  is  transmitted  by  the  unaffected  female — "the  conductor"  (Bul- 
loch and  Fildes).  They  explain  the  11  exceptions,  and  conclude  that  the 
disease  is  not  capable  of  being  propagated  through  a  male.  Instances  of 
haemophilia  without  demonstrable  inheritance  are  very  rare. 

Pathoiogy. — Recent  studies  point  to  disturbance  in  the  fibrin  forming 
factors  as  the  essential  feature  of  the  disease.  Almroth  Wright  showed  that 
the  coagulation  time  in  haemophilics  was  much  delayed,  and  the  recent  ob- 


756  DISEASES    OF    THE    BLOOD 

serrations  of  Addis  in  12  cases  have  shown  that  the  delay  may  be  as  much 
as  40  to  60  minutes.  According  to  the  development  of  Buchanan  and 
Schmidt's  views  the  factors  in  coagulation  are  fibrinogen,  prothrombin, 
thrombokinase,  and  calcium,  and  by  the  interaction  of  the  last  three  thrombin 
is  produced,  which,  acting  on  the  fibrinogen,  precipitates  fibrin.  Set  free 
when  a  wound  takes  place,  the  thrombokinase  present  in  the  tissues  in  the 
presence  of  calcium  rapidly  forms  a  new  bod}r — thrombin.  Sahli,  whose 
studies  on  haemophilia  have  been  most  important  and  interesting,  believes  that 
there  is  an  anomaly  of  the  cellular  elements  of  the  blood,  and  of  certain  other 
cells,  especially  in  the  walls  of  the  vessels,  so  that  the  thrombokinase  is  not 
produced.  Horowitz  believes  that  thrombokinase  is  derived  from  the  leuco- 
cytes or  from  the  platelets.  One  of  the  difficulties  in  explaining  the  bleeding 
in  haemophilia  is  the  fact  that  the  haemorrhage  continues  in  spite  of  the  pres- 
ence of  clots  in  and  about  the  wound.  Addis  believes  that  a  higher  amount 
of  thrombokinase  is  required  to  produce  rapid  clotting  in  haemophilic  than 
in  normal  blood.  In  a  wound,  coagulation  may  occur  only  in  those  parts,  as 
at  the  side,  where  the  concentration  of  this  material  is  highest;  but  the  clot 
itself  prevents  the  addition  of  further  quantities  of  the  thrombokinase  from 
the  tissues,  and  when  the  quantity  of  thrombin  set  free  from  the  primary  clot 
is  insufficient  completely  to  coagulate  the  blood  in  the  centre  of  the  wound, 
the  bleeding  may  continue  indefinitely. 

Symptoms. — "The  cardinal  symptoms  are  three  in  number  ...  an  in- 
herited tendency  in  males  to  bleed"  (Bulloch  and  Tildes).  A  trifling  in- 
jury, of  no  moment  in  a  normal  person,  determines  a  haemorrhage,  which 
has  no  tendency  to  stop,  but  the  blood  trickles  or  oozes  until  death  follows 
or  there  is  spontaneous  arrest.  The  bleeding  may  be  external,  internal,  or 
into  joints.  A  majority  of  the  attacks  may  be  traced  to  trauma  but  spontane- 
ous bleeding  may  occur.  The  liability  is  first  noticed  in  children  and  per- 
sists to  adult  life,  gradually  diminishing  and  eventually  disappearing.  Tooth 
extraction  is  a  very  common  cause.  Epistaxis  is  a  frequent  occurrence, 
heading  the  list  in  Grandidier's  series  of  334  cases.  Other  localities  were: 
mouth  43,  stomach  15,  bowels  36,  urethra  16,  lungs  17,  and  a  few  instances 
of  bleeding  from  the  tongue,  finger-tips,  tear  papilla,  eyelids,  external  ear, 
vulva,  navel,  and  scrotum.  Trivial  operations,  as  circumcision,  have  been 
followed  by  fatal  haemorrhage. 

Haemarthrosis  and  periarticular  bleedings  are  common.  The  knee  is  most 
commonly  attacked,  and  the  affection  has  been  mistaken  for  tuberculosis. 
Konig  distinguishes  three  stages — haemarthrosis,  panarthritis,  and  deformity. 

Diagnosis.— Karl  Pearson's  new  iatro-mathematical  school  of  medicine 
has  done  good  work  in  making  the  profession  more  careful  about  its  facts, 
as  well  as  its  figures.  Bulloch's  monograph  should  be  read  by  all  who  value 
accuracy  of  observation  and  of  investigation.  Forms  of  bleeding  are  so  com- 
mon that  it  is  a  simple  matter  to  construct  a  pedigree  showing  an  inherited 
"haemorrhagic  diathesis."  It  is  essential  for  the  diagnosis  that  the  individual 
should  have  been  more  or  less  subject  to  bleeding  from  various  parts  through- 
out his  life.  "No  solitary  haemorrhage,  however  inexplicable,  should,  in  our 
opinion,  be  regarded  as  haemophilia ;  it  is  necessary  to  show  that  the  individual 
has  been  repeatedly  attacked,  if  not  from  birth,  from  infancy"  (Bulloch  and 
Fildes). 


EKYTHR.EMIA  757 

Treatment.' — Eecent  work  of  a  most  encouraging  character  indicates  that 
injections  of  serum  or  of  defibrinated  blood,  or  direct  transfusion  have  remark- 
able effects  in  these  severe  haemorrhagic  cases,  particularly  in  haemophilia. 
The  method  has  been  introduced  by  Weil,  who  recommends  the  subcutaneous 
injection  of  30  c.  c.  of  fresji  human  or  animal  serum  or  the  intravenous  in- 
jection of  15  c.  c.  The  method  has  been  successful  in  the  hsemorrhagic  dis- 
eases of  the  new-born,  injecting  subcutaneously  10  c.  c.,  and  giving  as  much 
as  100  or  even  200  c.  c.  in  four  or  five  days  (Moss).  The  serum  may  be  ap- 
plied locally  to  the  bleeding  spot  in  haemophilia.  Cure  has  followed  the  use 
of  the  anti-diphtheritic  serum.  Injection  of  defibrinated  blood  has  been 
successful  in  several  cases,  and  melaena  neonatorum  has  been  cured  by  direct 
transfusion.  Lambert's  case  is  remarkable,  as  the  haemorrhage  had  been 
going  on  for  three  days  and  the  child  was  dying.  In  the  severer  cases  the 
direct  transfusion  should  be  tried  and  the  technique  is  not  now  a  matter  of 
difficulty. 

VI.    ERYTHR^MIA 

(Vaquez'  Disease,  Polycythcemia  Vera) 

Definition. — A  disease  characterized  by  a  persistent  increase  of  the  red 
blood-corpuscles,  a  condition  of  plethora,  splenomegaly,  and  at  times  cyanosis. 
Cases  were  reported  by  Eendu  and  Widal,  Vaquez,  Cabot,  McKeen,  Saundby 
and  Russell,  and  since  1903,  when  I  tried  to  put  the  disease  on  a  firm  clinical 
basis,  great  interest  has  been  aroused  in  the  condition. 

Pathology, — We  see  polycythaemia  as  a  secondary  condition  in  high  alti- 
tudes, and  in  stasis  of  the  blood  in  congenital  heart  disease,  and  in  emphysema 
of  the  lungs.  The  high  altitude  hyperglobulism  is  compensatory  to  lack  of 
oxygen  in  the  air,  and  there  is  an  increased  activity  of  the  bone  marrow.  In 
erythraemia  proper  this  same  increased  activity  of  the  bone  marrow  is  pres- 
ent, and  the  disease  is  regarded  as  a  primary  lesion  of  the  erythroblastic  tis- 
sues of  the  bone  marrow,  just  as  leukaemia  is  an  affection  of  the  leucoblastic 
elements.  There  is  also  an  increased  viscosity  of  the  blood  which  favors  the 
stasis  and  capillary  engorgement. 

Symptoms. — The  three  cardinal  features  are  a  change  in  the  appearance 
of  the  patient,  enlargement  of  the  spleen,  and  hyperglobulism.  The  super- 
ficial blood  vessels,  capillaries,  and  veins  look  full,  so  that  the  skin  is  always 
congested,  in  warm  weather  of  a  brick  red  color,  in  cold  weather  cyanosed. 
The  engorgement  of  the  face  may  be  extreme,  extending  to  the  conjunctivas, 
and  in  the  cold  the  cyanosis  of  the  face  and  hands  may  be  as  marked  as  any 
that  is  ever  seen.  There  is  often,  too,  a  remarkable  vasomotor  instability, 
e.  g.,  the  hand  becoming  deeply  engorged  when  held  down,  and  rapidly  anaemic 
when  held  up. 

The  spleen  is  usually  enlarged,  but  not  to  the  great  extent  of  leukaemia. 
It  may  vary  in  size  from  time  to  time.  It  is  hard,  firm,  and  painless. 

The  total  bulk  of  blood  is  enormously  increased,  and  the  ratio  of  cor- 
puscles to  plasma  is  high.  The  polycythaemia  ranges  from  7  to  12  or  even 
13  millions  of  red  corpuscles  per  c.  mm.  As  a  rule,  they  are  normal  in  ap- 
pearance and  shape;  nucleated  red  blood-corpuscles  may  be  present,  the  hae- 


758  DISEASES    OF    THE    BLOOD 

moglobin  ranging  from  130  to  160  per  cent.,  but  the  color  index  is  relatively 
low.  Moderate  leucocytosis  is  the  rule  without  any  characteristic  differential 
change;  a  few  myelocytes  may  he  present.  The  specific  gravity  is  high. 

Of  other  symptoms  the  most  common  are  headache,  flushing,  and  giddi- 
ness. Constipation  is  common,  and  albuminuria  is  usually  present.  The 
blood  pressure  is  high;  occasionally  there  may  be  haemorrhages  into  the  skin 
and  from  the  mucous  membranes.  Recurring  ascites,  probably  in  association 
with  splenic  tumor,  was  present  in  two  of  my  cases. 

Morris  has  reported  a  couple  of  cases  with  the  general  appearance  of  the 
disease  and  with  slight  enlargement  of  the  spleen,  but  without  polycythaemia. 
Geisbock  has  described  a  variety,  polycythcemia  hypertonica,  with  increased 
tension,  arterio-sclerosis,  and  nephritis. 

Diagnosis.- — The  triad  of  features  above  referred  to  are  sufficient  in  the 
absence  of  congenital  heait  disease,  emphysema,  and  forms  of  cyanosis  asso- 
ciated with  poisoning  by  coal  tar  products.  In  a  few  rare  cases  the  poly- 
cythaemia  has  been  associated  with  tuberculosis  of  the  spleen. 

Prognosis. — The  prognosis  is  bad  for  cure,  but  the  condition  may  persist 
for  years  with  reasonably  good  health.  Cardiac  failure,  haemorrhage,  and 
recurring  ascites  have  been  the  usual  modes  of  death. 

Treatment. — When  there  is  much  fullness  of  the  head  and  vertigo,  re- 
peated bleedings  have  given  relief.  Inhalations  of  oxygen  may  be  tried  when 
the  cyanosis  is  extreme.  Saline  purges  and  low  diet  are  also  helpful.  The 
X-rays  have  done  no  good  in  my  cases.  Splenectomy  should  not  be  performed. 


VII.    ENTEROGENOUS  CYANOSIS 

(Methcemoglobincemia  and  Sulplicemoglobincemia) 

Definition. — A  form  of  permanent  cyanosis  due  to  changes  in  the  compo- 
sition of  the  haemoglobin  of  the  blood. 

Etiology. — It  has  long  been  known  that  with  the  use  of  certain  drugs 
changes  were  induced  in  the  haemoglobin.  In  poisoning  by  potassium  chlorate 
methaemoglobinaemia  occurs  often  with  an  active  haemolysis.  Carbon  monox- 
ide, sulphuretted  hydrogen,  the  coal-tar  products,  acetanilide,  phenacetin, 
sulphonal,  and  trional  may  cause  a  chronic  cyanosis.  Stokvis  brought  for- 
ward evidence  to  show  that  certain  cases  of  chronic  cyanosis  are  associated 
with  intestinal  disturbances,  and  he  gives  this  form  the  name  "enterog- 
enous." Some  of  the  forms  are  associated  with  methaemoglobinasmia,  others 
with  sulphaemoglobinaemia.  In  a  doubtful  case,  with  absence  of  lesions  of 
the  heart  or  lungs,  a  spectroscopic  examination  of  the  blood  will  determine 
if  the  cyanosis  is  of  this  nature,  and  which  of  the  two  derivatives  of  haemo- 
globin is  causing  it. 

There  have  been  some  15  or  20  cases  now  on  record  of  both  forms  (see 
Garrod,  Allbutt  and  Eolleston's  System). 

Methsemoglobinaemia. — Several  of  the  patients  have  had  chronic  diarrhoea, 
in  two  associated  with  parasites.  In  Stokvis'  case  there  was  clubbing  of  the 
fingers  without  any  recognizable  cause.  Gibson  and  Douglas  obtained  from 
the  blood  of  their  patient  a  pure  culture  of -a  colon  organism  and  suggested 


ENTEROGENOUS    CYANOSIS  739 

the  name  "Microbic  cyanosis."  In  connection  with  this  observation  it  may 
be  mentioned  that  methaemoglobinsemia  has  been  met  with  in  Winckel's  dis- 
ease, in  one  case  of  which  the  staphylococcus  has  been  isolated  from  the  blood. 
But  a  still  more  striking  confirmation  is  Boycott's  discovery  of  an  infective 
methasmoglobinaBmia  in  rats,  caused  by  Gaertner's  bacillus,  which  gives  a  re- 
markable bluish  tint  to  the  skin  of  white  rats. 

Sulphsemoglobinaemia. — The  appearance  of  the  patients  is  very  much  the 
same.  They  look  very  badly,  even  death-like,  but  feel  comfortable,  and  there 
is  no  shortness  of  breath.  The  absence  of  symptoms  at  once  suggests  a  drug 
habit  as  a  cause,  but  the  history  is  negative.  In  the  case  reported  by  Wood 
Clarke,  the  first  in  this  country,  the  cultures  were  negative.  Intestinal  dis- 
turbances have  been  present  in  a  number  of  cases,  and  Garrod  suggests  that 
it  is  a  chronic  poisoning  by  hydrogen  sulphide,  possibly  absorbed  from  the 
intestines. 


SECTION  IX 

DISEASES  OF  THE   CIRCULATORY  SYSTEM 
A.    DISEASES    OF    THE    PERICARDIUM 

I.    PERICARDITIS 

Pericarditis  is  the  result  of  infective  processes,  primary  or  secondary,  or 
arises  by  extension  of  inflammation  from  contiguous  organs. 

Etiology. — PRIMARY,  so-called  idiopathic,  inflammation  is  rare;  but  it  has 
been  met  with  in  children  without  any  evidence  of  rheumatism  or  of  any  local 
or  general  disease.  Certain  of  the  cases  are  tuberculous. 

Pericarditis  from  injury  usually  comes  under  the  care  of  the  surgeon  in 
connection  with  the  primary  wound.  The  trauma  may  be  from  within,  due 
to  the  passage  of  a  foreign  body — a  needle,  a  pin,  or  a  bone — through  the 
resophagus — a  variety  exceedingly  common  in  cows  and  horses. 

SECONDARY:  (a)  Occurs  most  frequently  in  connection  with  rheumatic 
fever.  The  percentage  given  by  different  authors  ranges  from  thirty  to  sev- 
enty. In  our  330  cases  of  rheumatic  fever  (Johns  Hopkins  Hospital)  peri- 
carditis occurred  in  twenty — practically  6  per  cent.  The  articular  trouble  may 
be  slight  or,  indeed,  the  disease  may  be  associated  with  acute  tonsillitis  in 
rheumatic  subjects.  Certain  of  the  so-called  idiopathic  cases  have  their  origin 
in  an  acute  tonsillitis.  The  pericarditis  may  precede  the  arthritis.  (6)  In 
septic  processes ;  in  the  acute  necrosis  of  bone  and  in  puerperal  fever  it  is  not 
uncommon,  (c)  In  tuberculosis,  in  which  the  disease  may  be  primary  or  part 
of  a  general  involvement  of  the  serous  sacs  or  associated  with  extensive  pul- 
monary disease,  (d)  In  the  fevers.  Not  infrequent  after  scarlatina,  it  is  rare 
in  measles,  small-pox,  typhoid  fever,  and  diphtheria.  In  pneumonia  it  is  not 
uncommon,  occurring  in  31  among  665  in  my  clinic  (J.  A.  Chatard).  In  184 
post  mortems  there  were  29  instances  of  pericarditis.  It  is  most  frequent  in 
double  pneumonia,  and  in  our  series  with  disease  of  the  right  side,  if  only 
one  lung  was  involved.  Pericarditis  sometimes  complicates  chorea;  it  was 
present  in  19  of  73  autopsies  which  I  collected ;  in  only  8  of  these  was  arthri- 
tis present,  (e)  Terminal  pericarditis.  In  gout,  in  chronic  Bright's  disease 
' — pericardite  brightique  of  the  French — in  arterio-sclerosis,  in  scurvy,  in 
diabetes,  and  in  chronic  illness  of  all  sorts  a  latent  pericarditis  is  common 
and  is  usually  overlooked. 

(/)  By  Extension. — In  pleuro-pneumonia  it  forms  a  serious  complication, 
and  was  present  in  5  cases  of  100  post  mortems.  It  is  most  often  met  with 
in  the  pleuro-pneumonia  of  children  and  of  alcoholics.  With  simple  pleurisy 
it  is  rare.  In  ulcerative  endocarditis,  purulent  myocarditis,  and  in  aneurism 

760 


PERICARDITIS  761 » 

of  the  aorta  pericarditis  is  occasionally  found.  It  may  also  follow  extension 
of  the  disease  from  the  mediastinal  glands,  the  ribs,  sternum,  vertebrae,  and 
even  from  the  abdominal  viscera. 

The  ordinary  pus  cocci,  the  pneumococcus,  and  the  tubercle  bacillus  are 
the  chief  organisms  met  with  in  acute  pericarditis. 

Pericarditis  occurs  at  all  ages.  Cases  have  been  reported  in  the  fetus. 
In  the  new-born  it  may  result  from  septic  infection  through  the  navel. 
Throughout  childhood  the  incidence  of  rheumatic  fever  and  scarlet  fever 
makes  it  a  frequent  affection,  whereas  late  in  life  it  is  most  often  associated 
with  tuberculosis,  Bright's  disease,  and  gout.  Males  are  somewhat  more 
frequently  attacked  than  females.  The  so-called  epidemics  of  pericarditis 
have  been  outbreaks  of  pneumonia  with  this  us  a  frequent  complication. 

ACUTE    FIBKINOUS    PEEICAEDITIS 

This,  the  most  common  and  benign  form,  is  distinguished  by  the  small 
amount  of  exudate  which  coats  the  surface  in  a  thin  layer. 

It  may  be  partial  or  general.  In  the  mildest  grades  the  membrane  looks 
lustreless  and  roughened,  due  to  the  presence  of  a  thin  fibrinous  sheeting, 
which  can  be  lifted  with  the  knife,  showing  beneath  an  injected  or  ecchymotic 
serosa.  As  the  fibrinous  sheeting  increases  in  thickness  the  constant  move- 
ment of  the  adjacent  surfaces  gives  to  it  sometimes  a  ridge-like,  at  others  a 
honeycombed  appearance.  With  more  abundant  fibrinous  exudation  the 
membranes  present  an  appearance  resembling  buttered  surfaces  which  have 
been  drawn  apart.  The  fibrin  is  in  long  shreds,  and  the  heart  presents  a 
curiously  shaggy  appearance — the  hairy  heart  of  old  writers,  cor  wllosum. 

In  mild  grades  the  subjacent  muscle  looks  normal,  but  in  the  more  pro- 
longed and  severe  cases  there  is  myocarditis,  and  for  2  or  3  mm.  beneath  the 
visceral  layer  the  muscle  presents  a  pale,  turbid  appearance.  Many  of  these 
acute  cases  are  tuberculous  and  the  granulations  are  easily  overlooked  in  a 
superficial  examination. 

There  is  usually  a  slight  amount  of  fluid  entangled  in  the  meshes  of  fibrin, 
but  there  may  be  very  thick  exudate  without  much  serous  effusion. 

Symptoms. — Unless  sought  for  there  may  be  no  objective  signs,  and  for 
this  reason  it  is  often  overlooked,  and  in  hospitals  the  disease  is  relatively 
more  common  in  the  post  mortem  room  than  in  the  wards 

Pain  is  a  variable  symptom,  not  usually  intense,  and  in  this  form  rarely 
excited  by  pressure.  It  is  more  marked  in  the  early  stage,  and  may  be 
•eferred  either  to  the  prsecordia  or  to  the  region  of  the  xiphoid  cartilage. 
Instances  are  recorded  of  pain  of  an  aggravated  and  most  distressing  character 
resembling  angina.  Fever  is  usually  present,  but  it  is  not  always  easy  to 
say  how  much  depends  upon  the  primary  disease,  and  how  much  upon  the 
pericarditis.  It  is  as  a  rule  not  high,  rarely  exceeding  102.5°  F.  In  rheu- 
matic cases  hyperpyrexia  has  been  observed. 

PHYSICAL  SIGNS. — Inspection  is  negative;  palpation  may  reveal  the  pres- 
ence of  a  distinct  fremitus  caused  by  the  rubbing  of  the  roughened  pericardial 
surfaces.  This  is  usually  best  marked  over  the  right  ventricle.  It  is  not 
always  to  be  felt,  even  when  the  friction  sound  on  auscultation  is  loud  and 
clear.  Auscultation:  The  friction  sound,  due  to  the  movement  of  the  peri- 
50 


762  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

cardial  Burfaces  upon  each  other,  is  one  of  the  most  distinctive  of  physical 
signs.  It  is  double,  corresponding  to  the  systole  and  diastole;  but  the  syn- 
chronism with  the  heart  sounds  is  not  accurate,  and  the  to  and  fro  murmur 
usually  outlasts  the  time  occupied  by  the  first  and  second  sound.  In  rare 
instances  the  friction  is  single ;  more  frequently  it  appears  to  be  triple  in  char- 
acter— a  sort  of  canter  rhythm.  The  sounds  have  a  peculiar  rubbing,  grating 
quality,  characteristic  when  once  recognized,  and  rarely  simulated  by  endo- 
cardial  murmurs.  Sometimes  instead  of  grating  there  is  a  creaking  quality— 
the  bruit  de  cuir  neuf — the  new  leather  murmur  of  the  French.  The  peri- 
cardial  friction  appears  superficial,  very  close  to  the  ear,  and  is  usually  inten- 
sified by  pressure  with  the  stethoscope.  It  is  best  heard  over  the  right  ven- 
tricle, the  part  of  the  heart  which  is  most  closely  in  contact  with  the  front 
of  the  chest — that  is,  in  the  fourth  and  fifth  interspaces  and  adjacent  portions 
of  the  sternum.  There  are  instances  in  which  the  friction  is  most  marked  at 
the  base,  over  the  aorta,  and  at  the  superior  reflection  of  the  pericardium. 
Occasionally  it  is  best  heard  at  the  apex.  It  may  be  limited  to  a  very  narrow 
area,  or  it  may  be  transmitted  up  and  down  the  sternum.  There  are,  how- 
ever, no  definite  lines  of  transmission  as  in  endocardial  murmurs.  An  im- 
portant point  is  the  variability  of  the  sounds,  both  in  position  and  quality; 
they  may  be  heard  at  one  visit  and  not  at  another.  The  maximum  of  in- 
tensity will  be  found  to  vary  with  position.  Friction  may  be  present  with  a 
thin,  almost  imperceptible,  layer  of  exudate;  on  the  other  hand  it  may  not  be 
present  with  a  thick,  buttery  layer.  The  rub  may  be  entirely  obscured  by 
the  loud  bronchial  rales  in  pneumonia,  in  which  disease  pericarditis  is  not 
recognized  clinically  in  more  than  half  the  cases,  only  13  in  31  cases  in  my 
series. 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  presence  of 
a  dry  pericarditis,  for  the  friction  sounds  are  distinctive.  The  double  murmur 
of  aortic  incompetency  may  simulate  closely  the  to  and  fro  pericardial  rub. 
I  recall  several  instances  in  which  this  mistake  was  made.  The  constant  char- 
acter of  the  aortic  murmur,  the  direction  of  transmission,  the  phenomena  in 
the  aiteries,  and  the  associated  conditions  of  the  disease  should  be  sufficient  to 
prevent  this  error. 

Pleuro-pericardial  friction  is  very  common,  and  may  be  associated  with 
endo-pericarditis,  particularly  in  cases  of  pleuro-pneumonia.  It  is  frequent, 
too,  in  tuberculosis.  It  is  best  heard  over  the  left  border  of  the  heart,  and  is 
much  affected  by  the  respiratory  movement.  Holding  the  breath  or  taking 
a  deep  inspiration  may  annihilate  it.  The  rhythm  is  not  the  simple  to  and 
fro  diastolic  and  systolic,  but  the  respiratory  rhythm  is  superadded,  usually 
intensifying  the  murmur  during  expiration  and  lessening  it  on  inspiration. 
In  tuberculosis  of  the  lungs  there  are  instances  in  which,  with  the  friction, 
a  loud  systolic  click  is  heard,  due  to  the  compression  of  a  thin  layer  of  lung 
and  the  expulsion  of  a  bubble  of  air  from  a  small  softening  focus  or  from  a 
bronchus. 

4.  id,  lastly,  it  is  not  very  uncommon,  in  the  region  of  the  apex  beat,  to 
hear  a  series  of  fine  crepitant  sounds,  systolic  in  time,  often  very  distinct, 
suggestive  of  pericardial  adhesions,  but  heard  too  frequently  for  this  cause. 

Course  and  Termination. — Simple  fibrinous  pericarditis  never  kills,  but  it 
occurs  so  often  in  connection  with  serious  affections  that  we  have  frequent 


PEEICAEDITIS  763 

i 

opportunities  to  see  all  stages  of  its  progress.  In  the  majority  of  cases  the 
inflammation  subsides  and  the  thin  fibrinous  laminae  gradually  become  con- 
verted into  connective  tissue,  which  unites  the  pericardial  leaves  firmly  to- 
gether. A  very  thin  layer  may  "clear"  without  leaving  adhesions.  In  other 
instances  the  inflammation  progresses,  with  increase  of  the  exudation,  and  the 
condition  is  changed  from  a  "dry"  to  a  "moist"  pericarditis,  or  the  pericarditis 
with  effusion. 

In  a  few  instances — probably  always  tuberculous — the  simple  plastic  peri- 
carditis becomes  chronic,  and  great  thickening  of  both  visceral  and  parietal 
layers  is  gradually  induced. 

PEEICAEDITIS    WITH    EFFUSION 

Etiology. — Commonly  a  direct  sequence  of  the  dry  or  plastic  pericarditis, 
of  which  it  is  sometimes  called  the  second  stage,  this  form  is  found  most 
frequently  in  association  with  rheumatic  fever,  tuberculosis,  and  septicaemia, 
and  sets  in  usually  with  the  symptoms  above  described,  namely,  prascordial 
pain,  with  slight  fever  or  a  distinct  chill. 

In  children  the  disease  may,  like  pleurisy,  come  on  without  local  symp- 
toms, and,  after  a  week  or  two  of  failing  health,  slight  fever,  shortness  of 
breath,  and  increasing  pallor,  the  physician  may  find,  to  his  astonishment, 
signs  of  most  extensive  pericardial  effusion.  These  latent  cases  are  often 
tuberculous.  W.  Ewart  has  called  special  attention  to  latent  and  ephemeral 
pericardial  effusions,  which  he  thinks  are  often  of  short  duration  and  of 
moderate  size,  with  an  absence  of  the  painful  features  of  pericarditis. 

Morbid  Anatomy. — The  effusion  may  be  sero-fibrinous,  hsmorrhagic,  or 
purulent.  The  amount  varies  from  200  to  300  c.  c.  to  2  litres.  In  the  cases  of 
sero-fibrinous  exudation  the  pericardial  membranes  are  covered  with  thick, 
creamy  fibrin,  which  may  be  in  ridges  or  honeycombed,  or  may  present  long, 
villous  extensions.  The  parietal  layer  may  be  several  millimetres  in  thickness 
and  may  form  a  firm,  leathery  membrane.  The  hemorrhagic  exudation  is 
usually  associated  with  tuberculous,  or  with  cancerous  pericarditis,  or  with 
the  disease  in  the  aged.  The  lymph  is  less  abundant,  but  both  surfaces  are 
injected  and  often  show  numerous  hemorrhages.  Thick,  curdy  masses  of 
lymph  are  usually  found  in  the  dependent  part  of  the  sac.  In  many  cases  the 
effusion  is  really  sero-purulent,  a  thin,  turbid  exudation  containing  flocculi  of 
fibrin. 

The  pericardial  layers  are  greatly  thickened  and  covered  with  fibrin. 
When  the  fluid  is  pus,  they  present  a  grayish,  rough,  granular  surface.  Some- 
times there  are  distinct  erosions  on  the  visceral  membrane.  The  heart  muscle 
in  these  cases  becomes  involved  to  a  greater  or  less  extent  and,  on  section,  the 
tissue,  for  a  depth  of  from  2  to  3  mm.,  is  pale  and  turbid,  and  shows  evidence 
of  fatty  and  granular  change.  Endocarditis  coexists  frequently,  but  rarely 
results  from  the  extension  of  the  inflammation  through  the  wall  of  the  heart. 

Symptoms. — Even  with  copious  effusion  the  onset  and  course  may  be  so 
insidious  that  no  suspicion  of  the  true  nature  of  the  disease  is  aroused. 

As  in  the  simple  pericarditis,  pain  may  be  present,  either  sharp  and  stab- 
bing or  as  a  sense  of  distress  and  discomfort  in  the  cardiac  region.  It  is  more 
frequent  with  effusion  than  in  the  plastic  form.  Pressure  at  the  lower  end  of 


764  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

the  sternum  usually  aggravates  it.  Dyspnoea  is  a  common  and  important 
symptom,  one  which,  perhaps,  more  than  any  other,  excites  suspicion  of  grave 
disorder  and  leads  to  careful  examination  of  heart  and  lungs.  The  patient  is 
restless,  lies  upon  the  left  side  or,  as  the  effusion  increases,  sits  up  in  bed. 
Associated  with  the  dyspnoea  is  in  many  cases  a  peculiarly  dusky,  anxious 
countenance.  The  pulse  is  rapid,  small,  sometimes  irregular,  and  may  present 
the  characters  known  as  pulsus  paradoxus,  in  which  during  each  inspiration 
the  pulse  beat  becomes  very  weak  or  is  lost.  These  symptoms  are  due,  in  great 
part,  to  the  direct  mechanical  effect  of  the  fluid  within  the  pericardium  which 
embarrasses  .the  heart's  action.  Other  pressure  effects  are  distention  of  the 
veins  of  the  neck,  dysphagia,  which  may  be  a  marked  symptom,  and  irritative 
cough  from  compression  of  the  trachea.  Aphonia  is  not  uncommon,  owing 
to  compression  or  irritation  of  the  recurrent  laryngeal  as  it  winds  round  the 
aorta.  In  massive  effusion  the  pericardial  sac  occupies  a  large  portion  of  the 
antero-lateral  region  of  the  left  side  and  the  condition  has  frequently  been 
mistaken  for  pleurisy.  Even  in  moderate  grades  the  left  lung  is  somewhat 
compressed,  an  additional  element  in  the  production  of  the  dyspnoea. 

Great  restlessness,  insomnia,  and  in  the  later  stages  low  delirium  and  coma 
are  symptoms  in  the  more  severe  cases.  Delirium  and  marked  cerebral  symp- 
toms are  associated  with  the  hyperpyrexia  of  rheumatic  cases,  but  apart  from 
the  ordinary  delirium  there  may  be  peculiar  mental  symptoms.  The  patient 
may  become  melancholic  and  show  suicidal  tendencies.  In  other  cases  the 
condition  resembles  closely  delirium  tremens.  Sibson,  who  has  specially  de- 
scribed this  condition,  states  that  the  majority  of  such  cases  recover.  Chorea 
may  also  occur,  as  was  pointed  out  by  Bright.  Epilepsy  is  a  rare  complica- 
tion which  has  occurred  during  paracentesis. 

PHYSICAL  SIGNS. — Inspection. — In  children  the  prascordia  bulges  and 
with  copious  exudation  the  antero-lateral  region  of  the  left  chest  becomes 
enlarged.  A  wavy  impulse  may  be  seen  in  the  third  and  fourth  interspaces,  or 
there  may  be  no  impulse  visible.  The  intercostal  spaces  bulge  somewhat  and 
there  may  be  marked  cedema  of  the  wall.  The  epigastrium  may  be  more 
prominent.  Perforation  externally  through  a  space  is  very  rare.  Owing  to 
the  compression  of  the  lung,  the  expansion  of  the  left  side  is  greatly  dimin- 
ished. The  diaphragm  and  left  lobe  of  the  liver  may  be  pushed  down  and 
may  produce  a  distinct  prominence  in  the  epigastric  region. 

Palpation. — A  gradual  diminution  and  final  obliteration  of  the  cardiac 
impulse  is  a  striking  feature  in  progressive  effusion.  The  position  of  the 
apex  beat  is  not  constant.  In  large  effusions  it  is  usually  not  felt.  In  children 
as  the  fluid  collects  the  pulsation  may  be  best  seen  in  the  fourth  space,  but 
this  may  not  be  the  apex  itself.  The  pericardial  friction  may  lessen  with 
the  effusion,  though  it  often  persists  at  the  base  when  no  longer  palpable 
over  the  right  ventricle,  or  may  be  felt  in  the  erect  and  not  in  the  recumbent 
posture.  Fluctuation  can  rarely,  if  ever,  be  detected. 

Percussion  gives  most  important  indications.  The  gradual  distention  of 
the  pericardial  sac  pushes  aside  the  margins  of  the  lungs  so  that  a  large  area 
comes  in  contact  with  the  chest  wall  and  gives  a  greatly  increased  percussion 
dulness.  The  form  of  this  dulness  is  irregularly  pear-shaped;  the  base  or 
broad  surface  directed  downward  and  the  stem  or  apex  directed  upward 
toward  the  manubrium.  There  is  a  disproportionate  extension  of  dulness 


PERICARDITIS  765 

upward  and  to  the  right,  with  dulness  in  the  right  fifth  interspace  extending 
one  or  two  inches  to  the  right  of  the  sternum  (Rotch's  sign).  The  dulness 
may  extend  to  the  left  beyond  the  apex  beat.  There  may  be  marked  differ- 
ences in  the  area  of  flatness  in  the  erect  and  recumbent  postures.  In  large 
effusions  there  may  be  impaired  resonance  in  the  left  axilla,  and  Bamberger 
called  attention  to  an  area  of  dulness  near  the  angle  of  the  scapula  with 
bronchial  breathing,  which  may  alter  when  the  patient  leans  forward. 

Auscultation. — The  friction  sound  heard  in  the  early  stages  may  dis- 
appear when  the  effusion  is  copious,  but  often  persists  at  the  base  or  at  the 
limited  area  of  the  apex.  It  may  be  audible  in  the  erect  and  not  in  the  recum- 
bent posture.  With  the  absorption  of  the  fluid  the  friction  returns.  One  of 
the  most  important  signs  is  the  gradual  weakening  of  the  heart  sounds,  which 
with  the  increase  in  the  effusion  may  become  so  muffled  and  indistinct  as  to 
be  scarcely  audible.  The  heart's  action  is  usually  increased  and  the  rhythm 
disturbed.  Occasionally  a  systolic  endocardial  murmur  is  heard.  Early  and 
persistent  accentuation  of  the  pulmonary  second  sound  may  be  present. 

Important  accessory  signs  in  large  effusion  are  due  to  pressure  on  the  left 
lung.  The  antero-lateral  margin  of  the  lower  lobe  is  pushed  aside  and  in 
some  instances  compressed,  so  that  percussion  in  the  axillary  region,  in  and 
just  below  the  transverse  nipple  line,  gives  a  modified  percussion  note,  usually 
a  flat  tympany.  Variations  in  the  position  of  the  patient  may  change  mate- 
rially this  modified  percussion  area,  over  which  on  auscultation  there  is  either 
feeble  or  tubular  breathing. 

Course. — Cases  vary  extremely  in  the  rapidity  with  which  the  effusion 
takes  place.  In  every  instance,  when  a  pericardial  friction  murmur  has  been 
detected,  the  practitioner  should  first  outline  with  care — using  the  aniline 
pencil — the  upper  and  lateral  limits  of  cardiac  dulness,  secondly  mark  the 
position  of  the  apex  beat,  and  thirdly  note  the  intensity  of  the  heart  sounds. 
In  many  instances  the  exudation  is  slight  in  amount,  reaches  a  maximum 
within  forty-eight  hours,  and  then  gradually  subsides.  In  other  instances 
the  accumulation  is  more  gradual  and  progressive,  increasing  for  several 
weeks.  To  such  cases  the  term  chronic  has  been  applied.  The  rapidity  with 
which  a  sero-fibrinous  effusion  may  be  absorbed  is  surprising.  The  possibility 
of  the  absorption  of  a  purulent  exudate  is  shown  by  the  cases  in  which  the 
pericardium  contains  semi-solid  grayish  masses  in  all  stages  of  calcification. 
With  sero-fibrinous  effusion,  if  moderate  in  amount,  recovery  is  the  rule,  with 
inevitable  union,  however,  of  the  pericardial  layers.  In  some  of  the  septic 
cates  there  is  a  rapid  formation  of  pus  and  a  fatal  result  may  follow  in 
three  or  four  days.  More  commonly,  when  death  occurs  with  large  effusion,  it 
is  not  until  the  second  or  third  week  and  takes  place  by  gradual  asthenia. 

Prognosis. — In  the  sero-fibrinous  effusions  the  outlook  is  good,  and  a  large 
majority  of  all  the  rheumatic  cases  recover.  The  purulent  effusions  are,  of 
course,  more  dangerous ;  the  septic  cases  are  usually  fatal,  and  recovery  is  rare 
in  the  slow,  insidious  tuberculous  forms. 

Diagnosis. — Probably  no  serious  disease  is  so  frequently  overlooked  by  the 
practitioner.  Post  mortem  experience  shows  how  often  pericarditis  is  not 
recognized,  or  goes  on  to  resolution  and  adhesion  without  attracting  notice. 
In  a  case  of  rheumatic  fever,  watched  from  the  outset,  with  the  attention 
directed  daily  to  the  heart,  it  is  one  of  the  simplest  of  diseases  to  diagnose; 


766  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

but  when  one  is  called  to  a  case  for  the  first  time  and  finds  perhaps  an  in- 
creased area  of  prascordial  dulness,  it  is  often  very  hard  to  determine  with 
certainty  whether  or  not  effusion  is  present. 

The  difficulty  usually  lies  in  distinguishing  between  dilatation  of  the 
heart  and  pericardial  effusion.  Although  the  differential  signs  are  simple 
enough  on  paper,  it  is  notoriously  difficult  in  certain  cases,  particularly  in 
stout  persons,  to  say  which  of  the  conditions  exists.  The  points  which  deserve 
attention  are: 

(a) -The  character  of  the  impulse,  which  in  dilatation,  particularly  in 
thin-chested  people,  is  commonly  visible  and  wavy. 

(&)  The  shock  of  the  cardiac  sounds  is  more  distinctly  palpable  in  dila- 
tation. 

(c)  The  area  of  dulness  in  dilatation  rarely  has  a  triangular  form;  nor 
does  it,  except  in  cases  of  mitral  stenosis,  reach  so  high  along  the  left  sternal 
margin  or  so  low  in  the  fifth  and  sixth  interspaces  without  visible  or  palpable 
impulse.    An  upper  limit  of  dulness  shifting  with  change  of  position  speaks 
strongly  for  effusion. 

(d)  In  dilatation  the  heart  sounds  are  clearer,  often  sharp,  valvular,  or 
fetal  in  character;  gallop  rhythm  is  common,  whereas  in  effusion  the  sounds 
are  distant  and  muffled. 

(e)  Rarely  in  dilatation  is  the  distention  sufficient  to  compress  the  lung 
and  produce  the  tympanitic  note  in  the  axillary  region,  or  flatness  behind. 

(/)  The  X-ray  picture  may  be  very  definite,  and  unlike  any  form  of  dila- 
tation or  hypertrophy  of  the  heart. 

The  number  of  excellent  observers  who  have  acknowledged  that  they  have 
failed  sometimes  to  discriminate  between  these  two  conditions,  and  who  have 
indeed  performed  paracentesis  cordis  instead  of  paracentesis  pericardii,  is  per- 
haps the  best  comment  on  the  difficulties. 

Massive  (iy2  to  2-litre)  exudations  have  been  confounded  with  a  pleural 
effusion.  On  more  than  one  occasion  the  pericardium  has  been  tapped  under 
the  impression  that  the  exudate  was  pleuritic.  The  flat  tympany  in  the  infra- 
scapular  region,  the  absence  of  well  defined  movable  dulness,  and  the  feeble, 
muffled  sounds  are  indicative  points.  Followed  from  day  to  day  there  is 
rarely  much  difficulty,  but  it  is  different  when  a  patient  seen  for  the  first  time 
presents  a  large  area  of  dulness  in  the  antero-lateral  region  of  the  left  chest, 
and  there  is  no  to  and  fro  pericardial  friction  murmur.  Many  of  the  cases 
have  been  regarded  as  encapsulated  pleural  effusions. 

A  special  difficulty  exists  in  recognizing  the  large  exudate  in  pneumonia. 
The  effusion  may  be  very  much  larger  than  the  signs  indicate,  and  the  in- 
volvement of  the  adjacent  lung  and  pleura  is  confusing.  In  at  least  three 
cases  in  our  series  we  should  have  tapped  the  sac;  post  mortem  the  effusion 
was  more  than  a  litre. 

The  nature  of  the  fluid  can  not  positively  be  determined  without  aspira- 
tion; but  a  fairly  accurate  opinion  can  be  formed  from  the  nature  of  the 
primary  disease  and  the  general  condition  of  the  patient.  In  rheumatic  cases 
the  exudation  is  usually  sero-fibrinous ;  in  septic  and  tuberculous  cases  it  is 
often  purulent  from  the  outset;  in  senile,  nephritic,  and  tuberculous  cases  the 
exudate  may  be  haemorrhagic. 

Treatment. — The  patient  should  have  absolute  quiet,  mentally  and  bodily, 


PERICARDITIS  767 

so  as  to  reduce  to  a  minimum  the  heart's  action.  Drugs  given  for  this  pur- 
pose, such  as  aconite  or  digitalis,  are  of  doubtful  utility.  Local  bloodletting 
by  cupping  or  leeches  is  certainly  advantageous  in  robust  subjects,  particularly 
in  the  cases  of  extension  in  pleuro-pneumonia.  The  ice  bag  is  of  great  value. 
It  may  be  applied  to  the  praecordia  at  first  for  an  hour  or  more  at  a  time,  and 
then  continuously.  It  reduces  the  frequency  of  the  heart's  action  and  seems 
to  retard  the  progress  of  an  effusion.  Blisters  are  not  indicated  in  the  early 
stage. 

When  effusion  is  present,  the  following  measures  to  promote  absorption 
may  be  adopted:  Blisters  to  the  prascordia,  a  practice  not  so  much  in  vogue 
now  as  formerly.  It  is  surprising,  however,  in  some  instances,  how  quickly 
an  effusion  will  subside  on  their  application.  Purges  and  iodide  of  potassium 
are  of  doubtful  utility.  The  diet  should  be  light,  dry,  and  nutritious.  The 
action  of  the  kidneys  may  be  promoted  by  the  infusion  of  digitalis  and  potas- 
sium acetate. 

With  an  effusion,  so  soon  as  signs  of  serious  impairment  of  the  heart 
occur,  as  indicated  by  dyspnoea,  small,  rapid  pulse,  dusky,  anxious  coun- 
tenance, paracentesis,  or  incision  of  the  pericardium,  should  be  performed. 
With  the  sero-fibrinous  exudate,  such  as  commonly  occurs  after  rheumatism, 
aspiration  is  sufficient;  but  when  the  exudate  is  purulent,  the  pericardium 
should  be  freely  incised  and  freely  drained.  The  puncture  may  be  made  in 
the  fourth  or  fifth  interspace,  in  or  outside  the  nipple  line.  In  large  effusions 
the  pericardium  can  be  readily  reached  without  danger  by  thrusting  the  needle 
upward  and  backward  close  to  the  costal  margin  in  the  left  costo-xiphoid 
angle;  or  the  needle  may  be  introduced  outside  the  left  nipple  line.  The 
results  of  paracentesis  of  the  pericardium  have  so  far  not  been  satisfactory. 
With  an  earlier  operation  in  many  instances  and  a  more  radical  one  in  others 
— incision  and  free  drainage,  not  aspiration,  when  the  fluid  is  purulent — 
the  percentage  of  recoveries  will  be  greatly  increased.  Repeated  tapping  may 
be  needed.  One  case  of  tuberculous  effusion,  tapped  three  times,  recovered 
completely  and  was  alive  three  years  afterward. 


CHRONIC    ADHESIVE    PERICARDITIS 
(Adherent  Pericardium,  Indurative  Mediastinopericarditis) 

The  remote  prognosis  in  pericarditis  is  very  variable.  A  large  majority  of 
these  cases  get  well  and  have  no  further  trouble,  but  in  young  persons  serious 
results  sometimes  follow  adhesions  and  thickening  of  the  layers.  As  Sequira 
has  pointed  out,  the  danger  is  here  directly  in  proportion  to  the  amount  of 
dilatation  and  weakening  of  the  pericardium  in  consequence  of  the  inflamma- 
tion. The  loss  of  the  firm  support  afforded  to  the  heart  by  the  rigid  fibrous 
bag  in  which  it  is  inclosed  is  the  important  factor.  There  are  two  groups  of 
cases  of  adherent  pericardium. 

(a)  Simple  adhesion  of  the  peri-  and  epicardial  layers,  a  common  sequence 
of  pericarditis,  met  with  post  mortem  as  an  accidental  lesion.  It  is  not 
necessarily  associated  with  disturbance  in  the  function  of  the  heart,  which  in 
a  large  proportion  of  the  cases  is  neither  dilated  nor  hypertrophied. 

(&)   Adherent  pericardium  with  chronic  mediastinitis  and  union  of  the 


768  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

outer  layer  of  the  pericardium  to  the  pleura  and  to  the  chest  walls.  This 
constitutes  one  of  the  most  serious  forms  of  cardiac  disease,  particularly  in 
early  life,  and  may  lead  to  an  extreme  grade  of  hypertrophy  and  dilatation  of 
the  heart.  The  peritoneum  may  be  involved  with  perihepatitis,  cirrhosis,  and 
ascites  (Pick's  disease). 

Symptoms. — The  symptoms  of  adherent  pericardium  are  those  of  hyper- 
trophy and  dilatation  of  the  heart,  and  later  of  cardiac  insufficiency.  G.  D. 
Head  in  a  careful  study  of  59  cases  divides  them  into  (1)  a  small  silent  group 
with  no  symptoms,  (2)  a  larger  group  with  all  the  features  of  cardiac  disease, 
and  (3)  a  group  comprising  11  cases  in  his  series  in  which  the  features  were 
hepatic.  To  this  last  group  much  attention  has  been  paid  since  Pick's  descrip- 
tion. The  hepatic  features  dominate  the  picture  and  the  diagnosis  of  cirrhosis 
of  the  liver  is  usually  made.  Recurring  ascites  is  the  special  feature.  One  of 
my  patients  was  tapped  one  hundred  and  twenty-one  times.  There  is  chronic 
peritonitis,  with  great  thickening  of  the  capsule  of  the  liver  and  consequent 
contraction  of  the  organ. 

Diagnosis. — The  following  are  important  points  in  the  diagnosis :  Inspec- 
tion,— A  majority  of  the  signs  of  value  come  under  this  heading,  (a)  The 
prgecordia  is  prominent  and  there  may  be  marked  asymmetry,  owing  to  the 
enormous  enlargement  of  the  heart.  (&)  The  extent  of  the  cardiac  impulse 
is  greatly  increased,  and  may  sometimes  be  seen  from  the  third  to  the  sixth 
interspaces,  and  in  extreme  cases  from  the  right  parasternal  line  to  outside 
the  left  nipple,  (c)  The  character  of  the  cardiac  impulse.  It  is  undulatory, 
wavy,  and  in  the  apex  region  there  is  marked  systolic  retraction,  (d)  Dia- 
phragm phenomena.  Walter  Broadbent  has  called  attention  to  a  very  valuable 
sign  in  adherent  pericardium.  When  the  heart  is  adherent  over  a  large  area 
of  the  diaphragm  there  is  with  each  pulsation  a  systolic  tug,  which  may  be 
communicated  through  the  diaphragm  to  the  points  of  its  attachment  on  the 
wall,  causing  a  visible  retraction.  This  has  long  been  recognized  in  the  re- 
gion of  the  seventh  or  eighth  rib  in  the  left  parasternal  line,  but  Broadbent 
called  attention  to  the  fact  that  it  was  frequently  b'est  seen  on  the  left  side 
behind,  between  the  eleventh  and  twelfth  ribs.  This  is  a  very  valuable  and 
quite  common  sign,  and  may  sometimes  be  very  localized.  One  difficulty  is 
that,  as  A.  W.  Tallant  has  pointed  out,  it  may  occur  in  thin  chested  persons 
with  great  hypertrophy  of  the  heart.  Sir  William  Broadbent  called  atten- 
tion to  the  fact  that  owing  to  the  attachment  of  the  heart  to  the  central  ten- 
don of  the  diaphragm  this  part  does  not  descend  with  inspiration,  during 
which  act  there  is  not  the  visible  movement  in  the  epigastrium,  (e)  Dias- 
tolic  collapse  of  the  cervical  veins,  the  so-called  Friedreich's  sign.  This  is 
not  of  much  moment. 

Palpation. — The  apex  beat  is  fixed,  and  turning  the  patient  on  the  left 
side  does  not  alter  its  position.  On  placing  the  hand  over  the  heart  there  is 
felt  a  diastolic  shock  or  rebound,  which  some  have  regarded  as  the  most  re- 
liable of  all  signs  of  adherent  pericardium. 

Percussion. — The  area  of  cardiac  dulness  is  usually  much  increased.  In 
a  majority  of  instances  there  are  adhesions  between  the  pleura  and  the  peri- 
cardium, and  the  limit  of  cardiac  dulness  above  and  to  the  left  may  be  fixed 
and  is  uninfluenced  by  deep  inspiration.  This,  too,  is  an  uncertain  sign,  in- 
asmuch as  there  may  be  close  adhesions 'between  the  pleura  and  the  peri- 


OTHEE    AFFECTIONS    OF    THE    PEEICABDIUM  769 

cardium  and  between  the  pleura  and  the  chest  wall,  which  at  the  same  time 
allow  a  very  considerable  degree  of  mobility  to  the  edge  of  the  lung. 

Auscultation. — The  phenomena  are  variable  and  uncertain.  In  the  cases 
in  children  with  a  history  of  rheumatism  endocarditis  has  usually  been  pres- 
ent. Even  in  the  absence  of  chronic  endocarditis,  when  the  dilatation  reaches 
a  certain  grade,  there  are  murmurs  of  relative  insufficiency,  which,  as  in 
one  case  I  have  recorded,  may  be  present  not  only  at  the  mitral  but  also  at 
the  tricuspid  and  pulmonary  orifices.  Theodore  Fisher  has  called  attention 
to  the  fact  that  there  may  be  a  well-marked  presystolic  murmur  in  connection 
with  adherent  pericardium.  Occasionally  the  layers  of  the  pericardium  are 
united  in  places  by  strong  fibrous  bands,  5-7  mm.  long  by  3-5  mm.  wide. 
In  one  such  case  Drasche  heard  a  remarkable  whirring,  systolic  murmur  with 
a  twanging  quality. 

The  pulsus  paradoxus,  in  which  during  inspiration  the  pulse-wave  is 
small  and  feeble,  is  sometimes  present,  but  it  is  not  a  diagnostic  sign  of 
either  simple  pericardial  adhesion  or  of  the  cicatricial  mediastino-pericarditis. 

Cardiolysis,  Brauer's  operation,  has  been  proposed  for  this  condition  and 
has  been  helpful  in  a  few  cases.  Four  or  five  centimetres  of  the  fourth,  fifth, 
and  sixth  left  ribs  with  a  couple  of  centimetres  of  the  corresponding  cartilages 
are  resected,  by  which  means  the  heart's  action  is  less  embarrassed.  It  is  a 
justifiable  procedure  in  selected  cases — in,  for  example,  a  child  with  a  very 
large,  tumultuously  acting  heart,  with  much  bulging  of  the  chest. 


II.  OTHER  AFFECTIONS  OF  THE  PERICARDIUM 

Hydropericardium. — The  pericardial  sac  contains  post  mortem  a  few  cubic 
centimetres  of  clear,  citron  colored  fluid.  In  connection  with  general  dropsy, 
due  to  kidney  or  heart  disease,  more  commonly  the  former,  the  effusion 
may  be  excessive,  adding  to  the  embarrassment  of  the  heart  and  the  lungs, 
particularly  when  the  pleural  cavities  are  the  seat  of  similar  transudation. 
There  are  rare  instances  in  which  effusion  into  the  pericardium  occurs  after 
scarlet  fever  with  few,  if  any,  other  dropsical  symptoms.  Hydropericardium 
is  frequently  overlooked. 

In  rare  cases  the  serum  has  a  milky  character — chylopericardium. 

Hsemopericardium. — This  condition  is  met  with  in  aneurism  of  the  first 
part  of  the  aorta,  of  the  cardiac  wall,  or  of  the  coronary  arteries,  and  in 
rupture  and  wounds  of  the  heart.  Death  usually  follows  before  there  is  time 
for  the  production  of  symptoms  other  than  those  of  rapid  heart  failure  due  to 
compression.  In  rupture  of  the  heart  the  patient  may  live  for  many  hours 
or  even  days  with  symptoms  of  progressive  heart  failure,  dyspnoea,  and  the 
physical  signs  of  effusion. 

In  the  pericarditis  of  tuberculosis,  of  cancer,  of  Bright's  disease,  and  of 
old  people  the  inflammatory  exudate  is  often  blood  stained. 

Pneumopericardium. — This  is  an  excessively  rare  condition,  of  which 
Walter  James  was  able  to  collect  only  38  cases  in  1903.  I  have  met  with  but 
one  instance,  from  rupture  of  a  cancer  of  the  stomach.  Perforation  of  the 
sac  occurred  in  all  but  5,  in  which  the  gas  bacillus  was  the  possible  cause,  as 
in  Nicholl's  case  at  the  Eoyal  Victoria  Hospital,  Montreal,  this  organism 


770  DISEASES    OF   THE    CIRCULATORY   SYSTEM 

was  isolated.  Seven  cases  were  due  to  perforation  of  the  oesophagus  and  eight 
to  penetrating  wounds  from  without.  The  physical  signs  are  most  charac- 
teristic. A  tympany  replaces  the  normal  pericardial  flatness.  On  ausculta^ 
tion  there  is  a  splashing,  gurgling,  churning  sound,  called  hy  the  French 
bruit  de  moulin.  This  was  described  in  19  of  the  cases  collected  by  James. 
Of  the  38  cases,  26  died. 

Calcified  Pericardium. — This  remarkable  condition  may  follow  pericardi- 
tis, particularly  the  suppurative  and  tuberculous  forms;  occasionally  it  ex- 
tends from  the  calcined  valves.  It  may  be  partial  or  complete.  Of  59  cases 
collected  by  A.  E.  Jones,  in  38  there  were  no  cardiac  symptoms.  Adherent 
pericardium  was  diagnosed  in  one  case.  Jones's  careful  study  shows  that  the 
condition  is  usually  latent  and  unrecognized. 


B.    DISEASES    OF    THE    HEAET 
I.    FUNCTIONAL   AFFECTIONS   OF   THE   HEART 

1.     PALPITATION 

In  health  we  are  unconscious  of  the  action  of  the  heart.  One  of  the  first 
indications  of  debility  or  overwork  is  the  consciousness  of  the  cardiac  pulsa- 
tions,' which  may,  however,  be  perfectly  regular  and  orderly.  This  is  not 
palpitation.  The  term  is  properly  limited  to  irregular  or  forcible  action  of 
the  heart  perceptible  to  the  individual.  The  condition  of  extra-systole  de- 
scribed in  the  next  section  is  present  in  many  cases. 

Etiology. — The  expression  "perceptible  to  the  individual"  covers  the  es- 
sential element  in  palpitation  of  the  heart.  The  most  extreme  disturbance 
of  rhythm,  a  condition  even  of  what  is  termed  delitium  cordis,  may  be  unat- 
tended with  subjective  sensations  of  distress,  and  there  may  be  no  conscious- 
ness of  disturbed  action.  On  the  other  hand,  there  a>re  cases  in  which  com- 
plaint is  made  of  the  most  distressing  palpitation  and  sensations  of  throb- 
bing, in  which  the  physical  examination  reveals  a  regularly  acting  heart,  the 
sensations  being  entirely  subjective.  We  meet  with  this  symptom  in  a  large 
group  of  cases  in  which  there  is  increased  excitability  of  the  nervous  system. 
Palpitation  may  be  a  marked  feature  at  the  time  of  puberty,  at  the  climacteric, 
and  occasionally  during  menstruation.  It  is  a  very  common  symptom  in 
hysteria  and  neurasthenia,  particularly  in  the  form  of  the  latter  which  is 
associated  with  dyspepsia.  Emotions,  such  as  fright,  are  common  causes  of 
palpitation.  It  may  occur  as  a  sequence  of  the  acute  fevers.  Females  are 
more  liable  to  the  affection  than  males. 

In  a  second  group  the  palpitation  results  from  the  action  upon  the  heart 
of  certain  substances,  such  as  tobacco,  coffee,  tea,  and  alcohol.  And,  lastly, 
palpitation  may  be  associated  with  organic  disease  of  the  heart,  either  of  the 
myocardium  or  of  the  valves.  As  a  rule,  however,  it  is  a  purely  nervous  phe- 
nomenon— seldom  associated  with  organic  disease — in  which  the  most  violent 
action  and  the  most  extreme  irregularity  may  exist  without  that  subjective 
element  of  consciousness  of  the  disturbance  which  constitutes  the  essential 
feature  of  palpitation. 


FUNCTIONAL   AFFECTIONS    OF    THE    HEAET  771 

The  irritable  heart  described  by  Da  Costa,  which  was  so  common  among 
the  young  soldiers  during  the  civil  war,  is  a  neurosis  of  this  kind.  The  chief 
symptoms  were  palpitation  with  great  frequency  of  the  pulse  on  exertion,  a 
variable  amount  of  cardiac  pain,  and  dyspnoea.  The  factors  at  work  in  pro- 
ducing this  condition  appeared  to  be  the  mental  excitement,  the  unwonted 
muscular  exertion  associated  with  the  drill,  and  diarrhoea.  The  condition  is 
not  infrequent  in  civil  life  among  young  men,  and  when  persistent  it  may 
lead  to  hypertrophy  of  the  heart. 

Symptoms. — In  the  mildest  form,  such  as  occurs  during  a  dyspeptic  at- 
tack, there  are-  slight  fluttering  of  the  heart  and  a  sense  of  what  patients 
sometimes  call  "goneness/'  In  more  severe  attacks  the  heart  beats  violently, 
its  pulsations  against  the  chest  wall  are  visible,  the  rapidity  of  the  action  is 
much  increased,  the  arteries  throb  forcibly,  and  there  is  a  sense  of  great  dis- 
tress. In  some  instances  the  heart's  action  is  not  at  all  quickened.  The  most 
striking  cases  are  in  neurasthenic  women,  in  whom  the  mere  entrance  of  a 
person  into  the  room  may  cause  the  most  violent  action  of  the  heart  and 
throbbing  of  the  peripheral  arteries.  The  pulse  may  be  rapidly  increased 
until  it  reaches  150  or  160.  A  diffuse  flushing  of  the  skin  may  appear  at  the 
same  time.  After  such  attacks  there  may  be  the  passage  of  a  large  quantity 
of  pale  urine.  In  many  cases  of  palpitation,  particularly  in  young  men,  the 
condition  is  at  once  relieved  by  exertion.  A  patient  with  extreme  irregu- 
larity of  the  heart  may,  after  walking  quickly  100  yards  or  running  upstairs, 
return  with  the  pulse  perfectly  regular.  This  is  not  infrequently  seen,  too, 
in  the  irregular  action  of  the  heart  in  mitral  valve  disease. 

The  physical  examination  of  the  heart  is  usually  negative.  The  sounds, 
the  shock  of  which  may  be  very  palpable,  are  on  auscultation  clear,  ringing, 
and  metallic,  but  not  associated  with  murmurs.  The  second  sound  at  the 
base  may  be  greatly  accentuated.  A  murmur  may  sometimes  be  heard  over 
the  pulmonary  artery  or  even  at  the  apex  in  cases  of  rapid  action  in  neuras- 
thenia or  in  severe  anaemia.  The  attacks  may  be  transient,  lasting  only  for 
a  few  minutes,  or  may  persist  for  an  hour  or  more.  In  some  instances  any 
attempt  at  exertion  renews  the  attack.  Sometimes  in  vigorous  young  adults 
who  are  upset  nervously,  especially  after  exertion  or  during  excitement,  the 
signs  of  mitral  stenosis  are  simulated.  There  is  a  systolic  shock  preceded 
by  a  suggestion  of  a  thrill.  On  auscultation  it  may  be  difficult  to  decide 
whether  or  not  there  is  a  short  presystolic  murmur.  A  short  period  of  ob- 
servation usually  removes  the  uncertainty. 

The  prognosis  is  usually  good,  though  it  may  be  extremely  difficult  to 
remove  the  conditions  underlying  the  palpitation. 

2.     AEEHYTHMIA 

The  work  of  Gaskell  and  of  Engelmann  on  the  functions  of  the  heart 
muscle,  and  the  clinical  studies  of  James  Mackenzie,  Wenckebach,  and  oth- 
ers, have  modified  the  older  views  of  the  neurogenic  cardiac  mechanism  with 
its  musculo-motor  nerve  centres  upon  which  the  higher  centres  played  through 
the  vagi  and  the  sympathetic  nerves.  The  source  of  the  action  of  the  heart  is 
now  placed  in  the  muscle  itself — myogenic — and  Gaskell  describes  as  its  func- 
tions rhythmicity,  excitability,  contractility,  conductivity,  and  tonicity;  "that 


772  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

is  to  say,  the  muscular  fibres  of  the  heart  possess  the  power  of  rhythmically 
creating  a  stimulus,  of  being  able  to  receive  a  stimulus,  of  responding  to  a 
stimulus  by  contracting,  of  conveying  the  stimulus  from  muscle  fibre  to 
muscle  fibre,  and  of  maintaining  a  certain  ill-defined  condition  called  tone." 
Wenckebach  and  James  Mackenzie  have  studied  the  disturbances  of  these  func- 
tions of  the  heart  clinically,  and  have  endeavored  to  classify  them  in  harmony 
with  the  myogenic  theory.  I  am  indebted  to  Erlanger  for  the  following  classi- 
fication based  on  that  of  Wenckebach: 

I.  Arrhythmia   resulting  from    decreased  conductivity   in   the   auriculo- 
veniricular  junction — heart-block.      Characteristics:    Auricular   rhythm   per- 
fect, rate  normal  or  accelerated;  ventricular  rhythm  may  or  may  not  be  per- 
fect ;  if  perfect  its  rate  will  be  one  half  of  that  of  the  auricles,  or  less ;  if  not 
perfect  the  irregularities  will  bear  some  direct  relation  to  the  contractions 
of  the  auricles. 

A.  Partial  heart-block:  (1)  Occasional  ventricular  silence;  (2)  regularly 
recurring  ventricular  silence,  either  one  ventricular  beat  missed  in  7,  6,  5,  4, 
etc.,  auricular  beats,  or  a  2  :1,  3  :1,  4 :1  rhythm,  or  either  of  these  alternating. 

B.  Complete  heart-block:  Auricular  and  ventricular  rhythms  perfect  but 
independent. 

C.  Paroxysmal  bradycardia  (Stokes- Adams  disease)  affecting  the  ventricu- 
lar rate  alone. 

II.  Arrhythmia,  resulting  from  increased  irritability  of  the  heart. 

A.  Ventricular  extra-systoles,  characterized  by  an  early  systole,  which  is 
associated  with  the  phenomena  of  a  retrograde  impulse.     There  may  be  one 
or  more  extra-systoles  following  a  normal  systole;  when  regularly  recurring, 
one  or  more  extra-systoles  after  5,  4,  3,  2,  or  1  normal  systoles,  the  last  giving 
the  bigeminal  or  trigeminal  pulse,  or  there  may  be  irregularly  recurring  ex- 
tra-systoles causing  delirium  cordis. 

B.  Auricular  extra-systoles. 

C.  Nodal  extra-systoles,  causing  the  auricle  and  'ventricle  to  contract  at 
nearly  the  same  time. 

III.  Arrhythmia  resulting  from  a  deficiency  of  contractility  in  the  car- 
diac muscle. 

A.  Alternating  pulse. 

B.  Omissions  of  ventricular  systole,  e.  g.,  in  the  halved  rate  seen  after 
large  doses  of  digitalis. 

IV.  Arrhythmia  resulting  from   the  influence   of  extrinsic  nerves  upon 
the  heart-rate.      (1)    Vagus  effect,  and   (2)    accelerator  effects.     These  are 
seen  in  the  irregularities  synchronous  with  respiration  in  the  youthful  type 
of  irregularity,  in  "sinus"  irregularity,  and  in  certain  forms  of  paroxysmal 
tachycardia  (vagal).    Extra-systoles  seen  in  nervous  persons  are  probably  due 
to  a  slight  excess  of  accelerator  action. 

V.  Arrhythmia  resulting  from  disturbed  diastolic  filling  of  the  heart. 

A.  Disturbed  filling  resulting  from  violent  respiratory  movements:  may 
give  the  paradoxical  pulse. 

B.  Disturbed  filling  from  adherent  pericardium  or  mediastinal  tumor: 
may  give  the  paradoxical  pulse. 


FUNCTIONAL   AFFECTIONS    OF   THE   HEART 


773 


Intermittency ;  Extra-systoles. — The  commonest  type  of  arrhythmia  is 
that  now  known  as  the  extra-systole,  to  explain  which  it  must  be  remembered 
that  to  a  stimulus  strong  enough  to  set  up  a  contraction  the  heart  answers 
with  all  the  contractility  of  which  it  is  capable  at  the  moment  (Bowditch's  law 
of  maximal  contraction).  A  second  property  of  the  heart  muscle  is  that  it 
possesses  a  "refractory  phase"  in  which  normally  it  is  not  excitable,  or  answers 
only  to  very  strong  stimuli.  During  this  refractory  stage,  beginning  shortly 
before  the  systole  and  continuing  a  short  time  after  it,  the  heart  is  inexcitable. 
When  not  refractory  it  may  again  contract  during  this  phase  and  produce  an 


A,          1                       1                       1                      1 

1 

Vs 

FIG.   1. — A  "NODAL"  EXTRA- SYSTOLE. 
premature  and  simultaneous  (Mackenzie). 


The  auricular  and  ventricular  systoles  are 


extra-systole,  which  is  followed  by  a  long  pause.  Engelmann  explains  this 
long  pause  as  follows:  "In  consequence  of  the  extra-systole  the  ventricle  is 
still  in  the  refractory  stage  when  the  next  physiological  stimulus  reaches  it. 
This  stimulus,  therefore,  has  no  effect,  no  contraction  takes  place,  and  it  is 
not  till  the  next  stimulus  after  it  that  a  contraction  can  a^ain  be  produced. 
Thus  the  normal  systole  that  would  follow  the  extra-systole  is  missed;  then 
the  first  systole  that  comes  after  the  compensatory  pause  occurs  exactly  at  the 
moment  at  which  it  would  have  occurred  had  no  extra-systole  preceded  it" 
(Wenckebach).  The  irregularity,  inequality,  and  intermission  of  the  pulse  as 


FIG.  2. — EXTRA-SYSTOLES  OF  VENTRICULAR  TYPE  AT  cf  and  /  (Mackenzie). 

met  with  in  every  day  clinical  experience  are  largely  due  to  the  occurrence  of 
these  extra-systoles,  which  may  present  all  sorts  of  combinations  and  group- 
ings, bigeminal,  trigeminal,  etc.,  depending  upon  whether  the  extra  pulse 
beats  are  perceptible  or  not.  And  yet  in  spite  of  this  most  extreme  irregular- 
ity there  may  be  no  actual  pathological  change,  and  so  far  as  the  maintenance 
of  the  circulation  is  concerned  the  heart  may  be  acting  in  a  most  satisfactory 
manner.  Patients  may  feel  the  extra-systole  as  a  definite  thud,  and  the  com- 
pensatory pause  is  perceptible,  but  very  often  there  are  no  subjective  sensa- 
tions. 


774  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

Extra-systoles  occur  at  all  ages  and  under  the  most  varied  conditions  in 
health  and  disease.  Mackenzie  recognizes  a  youthful  and  an  adult  type  of 
arrhythmia,  which  in  the  latter  is  due  chiefly  to  the  presence  of  extra-systoles, 
There  are  several  classes  of  cases.  The  arrhythmia  may  be  a  life-long  con- 
dition. Without  any  recognizable  disease,  without  any  impairment  of  the 
action  of  the  heart,  there  is  permanent  irregularity.  This  may  be  a  peculiar- 
ity of  the  heart-muscle  of  the  individual,  who  has  extra-systole  for  the  same 
reason — physiological  but  not  well  understood — as  the  dog  and  horse,  in  which 
animals  this  phenomenon  is  common.  The  late  Chancellor  Ferrier,  of  McGill 
University,  who  died  at  the  age  of  eighty  seven,  had  an  extremely  irregular 
heart  action  for  the  last  fifty  years  of  his  life.  I  know  several  men  who  have 


FIG.  3. — EXTRA-SYSTOLES  (a')  FOLLOWED  BY  VENTRICULAR  CONTRACTIONS  (c',  /). 
The  arrows  in  the  diagram  represent  the  sinus  stimulation,  and  the  long  pauses  after 
the  extra-systoles  are  seen  to  be  due  to  the  fact  that  the  auricle  did  not  respond  to  the 
sinus  stimulation  after  the  extra-systole  (as,  auricular  systole  vs.  ventricular  systole) 
(Mackenzie). 

had  for  many  years  irregularity  without  the  slightest  discomfort.  In  debili- 
tated and  neurasthenic  persons  there  may  be  an  irritable  weakness  of  the  heart 
associated  with  extra-systole,  and  palpitation  of  a  most  distressing  character. 
In  a  second  group  toxic  agents,  as  tobacco,  tea,  coffee,  or  the  poisons  of  the 
infectious  diseases  or  those  originating  in  the  intestines  or  metabolic  poisons 
cause  arrhythmia.  Even  reflexly,  as  in  flatulent  dyspepsia,  extra-systoles  may 
arise.  Thirdly,  a  high  blood  pressure  can  set  up  extra-systoles;  also  change 
in  posture.  And,  lastly,  organic  disease  of  the  heart  itself,  "dilatation,  inflam- 
mation, poor  blood  supply  to  the  muscle,  overcxertion,  can  all  supply  stimuli 
to  set  up  extra-systoles  either  directly  or  reflexly"  (Wenckebach).  Too 
much  stress  should  not  be  laid  upon  arrhythmia  per  se  in  the  absence  of  or- 
ganic disease. 

3.     FIBEILLATION    OF    THE    HEAET 

(Cardiac  Flutter,  Nodal  Rhythm,   Pulsus   Irregularis  Perpetuus) 

This  common  manifestation  of  cardiac  irregularity  is  exceedingly  impor- 
tant to  recognize  clinically.  In  the  most  pronounced  form  it  is  seen  in  the 
last  stages  of  mitral  stenosis,  in  which  the  pulse  shows  extreme  irregularity, 
which,  when  once  established,  seldom  returns  to  normal.  A  study  of  its  fea- 
tures in  this  condition  gave  Mackenzie  the  clue  to  its  explanation.  He  found 
that  in  certain  cases  the  transition  from  regular  to  irregular  pulse  of  this 
type  occurred  with  suddenness,  and  that,  whereas  before  the  irregularity 
supervened  the  jugular  pulse  showed  the  normal  features  in  the  presence  of 
auricular  carotid  and  ventricular  waves,  with  a  marked  presystolic  murmur 
and  thrill  at  the  apex,  after  the  irregularity  was  established,  the  auricular 


FUNCTIONAL    AFFECTIONS    OF   THE    HEAET  775 

wave  disappeared  from  the  jugular  pulse  and  the  presystolic  muimur  from 
the  apex.  The  inference  drawn  from  these  facts  was  that  the  right  auricle 
of  the  heart  was  so  dilated  as  to  prevent  the  formation  of  a  normal  auricular 
contraction.  The  stimulus  normally  produced  at  or  near  the  superior  vena 
cava  was  prevented  from  passing  down  the  junctional  tissues  to  the  ventricle ; 
hence  the  stimulus  arose  in  another  and  slightly  less  excitable  part  of  the 
heart,  which  Mackenzie  supposed  to  be  the  auriculo-ventricular  node  of  Tawara 
on  the  right  side  of  the  auricular  septum.  Complete  proof  of  the  cause  of 
this  condition  has  been  supplied  by  Lewis,  who  found  that  patients  with  this 
irregularity  showed  in  galvanometric  tracings  from  the  auricle  numerous 
small  and  continuous  waves,  exactly  similar  to  those  obtained  in  the  dog 
after  fibrillati'on  of  the  auricle  has  been  induced  by  faradic  stimulation  of  the 
appendix,  of  the  right  auricle,  or  by  ligation  of  the  right  coronary  artery. 
Very  small  auricular  beats  are  occasionally  to  be  seen  in  the  jugular  tracings 
from  such  patients.  As  no  co-ordinated  contraction  of  the  auricle  is  present, 
the  arrival  of  the  stimuli  at  the  junctional  tissues  has  no  orderly  sequence, 
the  ventricle  is  stimulated  without  regularity,  and  in  consequence  the  pulse 
is  irregular. 

True  nodal  rhythm  is  a  comparatively  rare  condition,  in  which  the  stim- 
ulus production  arises  in  the  junctional  tissues;  the  diagnostic  feature  is  the 
simultaneous  contraction  of  auricle  and  ventricle  as  shown  by  the  superposi- 
tion of  the  a  and  c  waves  of  the  jugular  pulse.  The  radial  pulse  in  this  con- 
dition is  regular. 

Auricular  fibrillation  forms  a  large  proportion  of  the  cases  showing  cardiac 
irregularity.  Of  114  cases  of  all  forms  of  irregularity  studied  by  Lewis  57 
were  of  this  type.  Of  etiological  factors  the  most  important  are  mitral  steno- 
sis, whether  in  the  rheumatic  form  or  that  seen  in  women  with  no  history 
of  rheumatism  and  cardio-stenosis.  The  average  age  of  onset  in  those  with 
a  previous  history  of  rheumatism  is  30  to  40;  in  the  non-rheumatic  group  it 
is  between  50  and  60.  In  the  older  patients  it  may  show  a  paroxysmal  form 
or  at  least  prolonged  intermissions. 


FIG.  4. — PULSE  TRACING  FROM  A  CASE  OP  AURICULAR  FIBRILLATION. 

The  symptoms  due  to  the  fibrillation  itself  cannot  be  appreciated  in  the 
cases  of  mitral  stenosis,  but  may  be  seen  in  those  not  so  accompanied.  Here 
the  symptoms  may  be  absent,  or  consist  in  some  limitation  in  the  field 
of  cardiac  response:  the  patient  more  easily  becomes  breathless  on  exertion, 
and  there  may  be  a  tendency  to  much  greater  fatigue.  The  inception  of 
fibrillation  may  be  associated  with  great  dyspnoea,  orthopncea,  and  the  fea- 
tures of  right  heart  failure.  The  condition  may  last  for  many  years  when 
once  established,  and  the  patient  may  be  able  to  follow  an  arduous  occupa- 
tion. An  unduly  grave  view  must  not,  therefore,  be  taken,  unless  there  be 
marked  evidence  of  cardiac  failure.  The  patient  should  be  cautioned  against 
undue  exertion. 


?7G  DISEASES    OF    THE    CIRCULATORY    SYSTEM 


4.     RAPID    HEART— TACHYCARDIA 

The  rapid  action  may  be  perfectly  natural.  There  are  individuals  whose 
normal  heart  action  is  at  100  or  even  more  per  minute.  Emotional  causes, 
violent  exercise,  and  fevers  all  produce  great  increase  in  the  rapidity  of  the 
heart's  action.  The  extremely  rapid  action  which  follows  fright  may  persist 
for  days  or  even  weeks.  Traube  reports  an  instance  in  which,  after  violent 
exercise,  the  rapidity  of  the  heart  continued.  Cases  are  not  uncommon  at  the 
menopause. 

There  are  cases  again  in  which  the  condition  can  hardly  be  termed  a 
neurosis,  since  it  depends  upon  definite  changes  in  the  pncunrogastrics  or  in 
the  medulla.  Cases  have  been  reported  in  which  tumor  or  clot  in  or  about 
the  medulla  or  pressure  upon  the  vagi  has  been  associated  with  heart  hurry. 
Some  of  the  cases  of  frequent  action  of  the  heart  in  women  have  been  thought 
to  be  due  to  reflex  irritation  from  ovarian  or  uterine  disease.  Other  cases 
are  almost  certainly  due  to  lesions  of  the  heart  itself  and  are  now  and  then 
seen  subsequent  to  an  influenzal  attack;  young  and  old  persons  are  affected. 
The  tachycardia  may  persist  for  months  or  indefinitely,  and  there  is  serious 
interference  with  the  amount  of  muscular  exertion  such  persons  can  take;  in 
addition  there  is  a  sense  of  weakness  and  sometimes  fainting  attacks. 

Paroxysmal  Tachycardia. — Modern  methods  enable  us  to  subdivide  the 
cases  of  paroxysmal  tachycardia  into  three  groups,  corresponding  to  the  types 
of  extra-systole — the  auricular,  the  nodal,  and  the  ventricular.  In  the  auricu- 
lar type  there  is  a  well  marked  auricular  wave  in  the  venous  pulse  in  its 
normal  relation  to  the  carotid  wave;  in  the  nodal  type  the  auricular  and 
carotid  wave  occur  at  the  same  time,  giving  a  large  double  wave  in  the  venous 
tracing;  the  third  type  has  not  been  seen  in  man,  but  from  experimental  work 
on  the  dog  (Lewis)  it  may  be  predicted  that  it  will  be  found.  These  three 
types  are  due  to  an  irritable  focus  in  the  cardiac  musculature,  the  auricular 
in  the  auricular  muscle,  the  nodal  in  the  functional  (auriculo-ventricular) 
tissues  which  form  the  muscular  bridge  between  the  auricle  and  the  ventricle, 
and  the  ventricular  in  the  ventricular  muscle.  In  many  cases  it  may  be  due 
to  slight  or  transitory  ischemia  from  a  sclerosed  artery  or  one  whose  muscle 
is  liable  to  spasm,  for  Lewis  has  shown  that  on  tying  the  right  coronary 
artery  in  the  dog  attacks  of  ventricular  tachycardia  are  almost  invariably 
seen.  "A  hyper-excitability  of  some  focus  in  the  cardiac  musculature  as  the 
direct  exciting  cause  of  paroxysmal  tachycardia  is  a  probable  explanation  of 
its  production.  The  degree  of  response  to  stimulation  depends  not  only  on 
the  intensity  of  the  stimulus,  but  also  on  the  excitability  of  the  tissue  itself. 
In  the  known  increased  excitability  of  the  auricle  as  compared  to  the  ventricle 
may  possibly  be  found  an  explanation  of  the  increased  frequency  of  auricular 
over  other  forms  of  tachycardia"  (Lea). 

The  pulse  rate  may  reach  200  and  over.  The  cases  are  not  common.  The 
attack  may  be  quite  short  and  persist  only  for  an  hour  or  so.  A  patient  at 
the  Philadelphia  Infirmary  for  Nervous  Diseases  was  attacked  every  week  or 
two;  the  pulse  would  rise  to  220  or  230,  and  there  were  such  feelings  of  dis- 
tress and  uneasiness  that  the  patient  always  had  to  lie  down.  There  may  be, 
however,  no  subjective  disturbance,  and  in  another  case  the  patient  was  able 


FUNCTIONAL   AFFECTIONS    OF   THE    HEAET  777 

to  walk  about  during  the  paroxysm  and  had  no  dyspnoea.  One  of  the  most 
remarkable  cases  is  reported  by  H.  C.  Wood.  A  physician  in  his  eighty-sev- 
enth year  had  had  attacks  at  intervals  from  his  thirty-seventh  year.  The 
onset  was  abrupt  and  the  pulse  would  rapidly  rise  to  200  a  minute.  For  more 
than  twenty  years  the  taking  of  ice-water  or  strong  coffee  would  arrest  the 
attacks.  Bouveret,  who  has  analyzed  a  number  of  cases  of  this  essential  or 
idiopathic  form,  finds  that  a  permanent  cure  is  rare,  and  that  the  patients 
suffer  for  ten  or  more  years.  Four  instances  terminated  fatally  from  heart- 
failure.  One  of  the  most  remarkable  features  is  the  abruptness  of  onset  and 
the  abruptness  with  which  an  attack  may  end.  One  of  my  patients  had 
recurring  attacks  lasting  ten  to  thirty  days,  and  the  heart  would  suddenly 
"flop,"  as  she  expressed  it,  the  rate  falling  from  180  to  80  or  90  per  minute. 

5.     SLOW    HEAET— BRADYCAEDIA 

Slow  action  of  the  heart  is  sometimes  normal  and  may  be  a  family  pe- 
culiarity. Napoleon  is  stated  to  have  had  a  pulse  of  only  40  per  minute. 

In  any  case  of  slow  pulse  it  is  important  first  to  make  sure  that  the  num- 
ber of  heart  and  arterial  beats  correspond.  In  many  instances  this  is  not 
the  case,  and  with  a  radial  pulse  at  40  the  cardiac  pulsations  may  be  80,  half 
the  beats  not  reaching  the  wrist.  The  heart  contractions,  not  the  pulse  wave, 
should  be  taken  into  account. 

Physiological  Bradycardia. — As  age  advances  the  pulse  rate  becomes  slow. 
In  the  puerperal  state  the  pulse  may  beat  from  44  to  60  per  minute,  or  may 
even  be  as  low  as  34.  It  is  seen  in  premature  labor  as  well  as  at  term.  The 
explanation  of  its  occurrence  at  this  period  is  not  clear.  Slowness  of  the 
pulse  is  associated  with  hunger.  Bradycardia  depending  on  individual  pecu- 
liarity is  extremely  rare. 

Pathological  bradycardia,  which  is  met  with  under  the  following  con- 
ditions: (a)  In  convalescence  from  acute  fevers.  This  is  extremely  common, 
particularly  after  pneumonia,  typhoid  fever,  rheumatic  fever,  and  diphtheria. 
It  is  most  frequently  seen  in  young  persons  and  in  cases  which  have  run 
a  normal  course.  (&)  In  diseases  of  the  digestive  system,  such  as  chronic 
dyspepsia,  ulcer  or  cancer  of  the  stomach,  and  jaundice,  (c)  In  diseases  of 
the  respiratory  system.  Here  it  is  by  no  means  so  common,  but  it  is  seen  not 
infrequently  in  emphysema,  (d)  In  diseases  of  the  circulatory  system.  Ex- 
cluding all  cases  of  irregularity  of  the  heart,  bradycardia  is  not  common  in 
diseases  of  the  valves.  It  is  most  frequently  seen  in  fatty  and  fibroid  changes 
in  the  heart,  but  is  not  constant  in  them,  (e)  In  diseases  of  the  urinary 
organs.  It  occurs  occasionally  in  nephritis  and  may  be  a  feature  of  uraemia. 
(/)  From  the  action  of  toxic .  agents,  i i  occurs  in  uraemia,  poisoning  by 
lead,  alcohol,  and  follows  the  use  of  tobacco,  coffee,  and  digitalis,  (g)  In 
constitutional  disorders,  such  as  anaemia,  chlorosis,  and  diabetes,  (h)  In 
diseases  of  the  nervous  system.  Apoplexy,  epilepsy,  the  cerebral  tumors,  af- 
fections of  the  medulla,  and  diseases  and  injuries  of  the  cervical  cord  may 
be  associated  with  very  slow  pulse.  In  general  paresis,  mania,  and  melan- 
cholia it  is  not  infrequent,  (i)  P  occurs  occasionally  in  affections  of  the  skin 
and  sexual  organs,  and  in  sunstroke,  or  in  prolonged  exhaustion  from  any 

cause. 

51 


778 


DISEASES    OF   THE    CIRCULATORY    SYSTEM 


6.     HEAET-BLOCK.    STOKES-ADAMS    DISEASE 

The  impulse  causing  the  heart  to  beat  originates  at  the  venous  end  of  the 
heart  and  is  transmitted  in  such  a  way  that  the  auricles  contract  first,  the 
ventricles  a  moment  later,  the  impulse  being  propagated  like  a  peristaltic 
wave  through  the  heart  walls.  In  passing  from  the  auricle  to  the  ventricle 
the  stimulus  traverses  a  narrow  band  of  muscle,  the  only  demonstrable  mus- 
cular connection  between  the  venous  and  arterial  chambers.  In  the  adult 
heart  this  auriculo-ventricular  bundle  of  His  is  18  mm.  long,  2.5  mm.  broad, 
and  1.5  mm.  thick ;  it  arises  in  the  septum  of  the  auricles  below  the  foramen 
ovale  and  passes  downward  and  forward  through  the  trigonum  fibrosum  of 
the  auriculo-ventricular  junction,  where  it  comes  into  close  relation  with  the 
mesial  leaflet  of  the  tricuspid  valve.  Passing  along  the  upper  edge  of  the 


AURICULO- 

TAWAHA'S  VENTRICU- 
HODE  LAR  (HIS) 

BUNDLE 


TAWARA'S 

JJODE 


RIGHT 

BRANCH 


FIG.  5. — DIAGRAM  SHOWING  THE  SINO-AURICULAR  NODE  AND/  THE  AURICULAR  BUNDLE, 
A,  viewed  from  the  right;  B,  cross  section  of  the  heart,  viewed  from  the  front. 
(Kindness  of  A.  D.  Hirschf elder.) 

muscular  septum,  just  where  it  joins  with  the  posterior  edge  of  the  mem- 
branous septum,  it  radiates  from  this  point  throughout  the  heart  as  the  junc- 
tional  system  of  Tawara.  In  the  dog  destruction  of  the  bundle  prevents  the 
passage  from  the  auricle  to  the  ventricle  of  the  impulse  which  normally  causes 
the  ventricles  to  contract.  They  immediately  assume  a  rate  of  beating  which 
is  very  much  slower  than  that  of  the  auricles  and  is  totally  independent,  as 
they  possess  their  own  automatic  rhythmicity.  Under  ordinary  circumstances 
this  inherent  rhythmicity  can  not  manifest  itself  because  the  much  more  rap- 
idly beating  venous  end  of  the  heart  sets  the  pace  for  the  sluggish  arterial 
end.  But  if  the  auricular  impulse  is  blocked,  the  ventricles,  released  from 
the  control  of  their  normal  pace  maker,  assume  their  own  rate.  This  condi- 
tion has  been  called  complete  heart-block.  By  an  ingenious  contrivance  Er- 
langer  has  been  able  in  the  dog  gradually  to  compress  the  auriculo-ventricular 
bundle  and  produce  various  stages  of  this  condition,  namely,  one  ventricular 
silence  with  every  other  auricular  beat,  giving  a  2:1  rhythm,  and 
proceeding  to  a  3 :1  and  a  4 :1  rhythm.  Finally,  complete  block  may  result, 


FUNCTIONAL   AFFECTIONS   OF   THE   HEART  779 

in  which  no  impulses  pass  from  the  auricles,  but  the  ventricles  beat 
with  their  own  inherent  rate,  which  Erlanger  estimates  from  a  study 
of  cases  of  heart-block  in  my  wards,  to  be  about  23  to  28  beats  to  the 
minute  in  man.  The  explanation  of  the  phenomenon  is  based  upon  one 
suggested  by  Gaskell.  The  bundle  of  His,  like  all  muscle  tissue,  be- 
comes fatigued  when  it  is  made  to  contract  repeatedly.  Under  normal 
circumstances  sufficient  time  elapses  between  successive  beats  to  permit 
the  bundle  to  return  to  its  normal  state,  but  when  from  injury  or 
any  cause  the  irritability  of  the  bundle  is  greatly  reduced,  it  may  not  react 
to  the  auricular  stimulus,  which  thus  fails  to  reach  the  ventricles.  Occasion- 
ally while  compressing  the  auriculo-ventricular  bundle  in  the  dog,  the  ven- 
tricle alone  may  suddenly  stop  beating  for  as  long  as  twenty  seconds.  The 
explanation  is  here  to  be  sought  for  the  syncopal  attacks  in  Stokes-Adams 
disease.  In  this  condition  the  relaxed  ventricles  are  distended  rhythmically 
by  the  beats  of  the  auricles  until  the  distention  may  be  extreme.  The  veins 
•become  engorged  and  pulsate  synchronously  with  the  auricles.  Each  of  the 
infrequent  contractions  of  the  ventricles  relieves  the  condition  temporarily. 
When  the  heart-block  is  complete  the  vagi  still  exert  their  normal  control  over 
the  rate  of  the  auricles,  but  they  have  lost  almost  completely  their  influence 
over  the  ventricles,  and  in  Stokes-Adams  disease  we  find  the  pulse  rate  is  little 
influenced  by  conditions  which  normally  alter  it,  as  exercise,  posture,  etc. 

Clinically  Stokes-Adams  disease  presents  three  features:  (a)  slow  pulse, 
usually  permanent,  but  sometimes  paroxysmal,  falling  to  40,  20,  or  even  6 
per  minute;  (&)  cerebral  attacks — vertigo  of  a  transient  character,  syncope, 
pseudo-apoplectiform  attacks  or  epileptiform  seizures;  (c)  visible  auricular 
impulses  in  the  veins  of  the  neck,  as  noted  by  Stokes — the  beats  varying 
greatly;  a  2  :1  or  3  :1  rhythm  is  the  most  common.  There  are  several  groups 
of  cases.  It  is  usually  a  senile  manifestation  associated  with  arterio-sclerosis. 
The  cases  in  young  adults  and  middle  aged  men  are  often  myocardial  and  of 
syphilitic  origin.  There  is  a  neurotic  group  in  which  all  the  features  may 
be  present,  and  in  which  post  mortem  no  lesions  have  been  found  (Edes  and 
Councilman).  In  the  attacks  of  slow  pulse  in  this  group  the  auricular  as 
well  as  the  ventricular  rate  may  be  slow  and  equal,  the  normal  sequence  of 
events  being  preserved;  the  origin  of  the  condition  is  probably  vagal.  The 
outlook  in  this  class  of  cases  is  good;  in  the  others  it  is  a  serious  disease  and 
usually  fatal,  though  it  may  last  for  many  years.  The  cerebral  attacks  are 
due  to  anaemia  of  the  brain  or  of  the  medulla  in  consequence  of  the  imper- 
fect ventricular  action.  In  one  of  my  cases  Baetjer  could  see  with  the  fluoro- 
scope  the  more  frequent  contraction  of  the  auricles. 

TREATMENT    OF    PALPITATION    AND    AEEHYTHMIA 

An  important  element  in  many  cases  is  to  get  the  patient's  mind  quieted, 
and  he  can  be  assured  that  there  is  no  actual  danger.  The  mental  element  is 
often  very  strong.  In  palpitation,  before  using  medicines,  it  is  well  to  try 
the  effect  of  hygienic  measures.  As  a  rule,  moderate  exercise  may  be  taken 
with  advantage.  Eegular  hours  should  be  kept,  and  at  least  ten  hours  out  of 
the  twenty  four  should  be  spent  in  the  recumbent  posture.  A  tepid  bath 
may  be  taken  in  the  morning,  or,  if  the  patient  is  weakly  and  nervous,  in  the 


780  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

evening,  followed  by  a  thorough  rubbing.  Hot  baths  and  the  Turkish  bath 
should  be  avoided.  The  dietetic  management  is  most  important.  It  is  best 
to  prohibit  alcohol,  tea,  and  coffee  absolutely.  The  diet  should  be  light  and 
the  patient  should  avoid  taking  large  meals.  Articles  of  food  known  to  cause 
flatulency  should  not  be  used.  If  a  smoker,  the  patient  should  give  up  tobacco. 
Sexual  excitement  is  particularly  pernicious,  and  the  patient  should  be  warned 
specially  on  this  point.  For  the  distressing  attacks  of  palpitation  which  occur 
with  neurasthenia,  particularly  in  women,  a  rigid  Weir  Mitchell  course  is 
the  most  satisfactory.  It  is  in  these  cases  that  we  find  the  most  distressing 
throbbing  in  the  abdomen,  which  is  apt  to  come  on  after  meals,  and  is  very 
much  aggravated  by  flatulency.  The  cases  of  palpitation  due  to  excesses  or 
to  errors  in  diet  and  dyspepsia  are  readily  remedied  by  hygienic  measures. 

A  course  of  iron  is  often  useful.  Strychnia  is  particularly  valuable,  and 
is  perhaps  best  administered  as  the  tincture  of  nux  vomica  in  large  doses. 
Very  little  good  is  obtained  from  the  smaller  quantities.  It  should  be  given 
freely,  20  minims  (1.3  c.  c.)  three  times  a  day. 

If  there  is  great  rapidity  of  action,  aconite  may  be  tried.  There  are 
cases  associated  with  sleeplessness  and  restlessness  which  are  greatly  benefited 
by  bromide  of  potassium.  Digitalis  is  very  rarely  indicated,  but  in  obstinate 
cases  it  may  be  tried  with  the  nux  vomica.  Ammonium  bromide  is  very  effi- 
cacious in  the  tachycardias  and  arrythmias  of  nervous  people. 

Cases  of  heart  hurry  are  often  extremely  obstinate,  as  may  be  judged  from 
the  case  of  the  physician  reported  by  H.  C.  Wood,  in  whom  the  condition 
persisted  in  spite  of  all  measures  for  fifty  years.  The  bromides  are  sometimes 
useful;  the  general  condition  of  neurasthenia  should  be  treated,  and  during 
the  paroxysm  an  ice  bag  may  be  placed  upon  the  heart,  or  Leiter's  coil, 
through  which  ice  water  is  passed.  Electricity,  in  the  form  of  galvanism, 
is  sometimes  serviceable,  and  for  its  mental  effect  the  Franklinic  current.  For 
the  condition  of  slow  pulse  but  little  can  be  done.  A  great  majority  of  the 
cases  are  not  dangerous. 


H.    AFFECTIONS    OF   THE   MYOCARDIUM 

1.     HYPERTROPHY 

Varieties. — The  heart  enlarges  to  meet  a  demand  for  extra  work,  either 
general,  as  in  the  continuous  strain  of  athletics  (the  hypertrophy  of  work), 
or  special  to  combat  a  deficiency  of  cardiac  structure,  such  as  a  damaged  valve. 
There  are  two  forms,  one  in  which  the  cavity  or  cavities  are  of  normal  size, 
and  the  other  in  which  the  cavities  are  enlarged  and  the  walls  increased  in 
thickness  (eccentric  hypertrophy).  The  so-called  concentric  hypertrophy  in 
which  there  is  diminution  of  the  size  of  the  cavity  with  thickening  of  the 
walls  is,  as  a  rule,  a  post  mortem  change. 

The  enlargement  may  affect  the  entire  organ,  or  one  side,  or  only  one 
chamber.  Naturally,  as  the  left  ventricle  does  the  chief  work  the  change  is 
most  frequently  found  here.  Though  its  production  is  assisted  by  adequate 
nutrition,  hypertrophy  may  appear  even  under  conditions  of  starvation,  given 
otherwise  healthy  organs.  In  the  debilitated  the  limits  to  which  hypertrophy 


AFFECTIOXS    OF    THE    MYOCARDIUM  781 

may  progress  are  small.,  though  very  marked  hypertrophy  is  sometimes  seen 
in  the  aged. 

HYPERTROPHY  OF  THE  LEFT  VENTRICLE  ALONE,  or  with  general  enlarge- 
ment of  the  heart,  is  brought  about  by — 

Conditions  affecting  the  heart  itself:  (a)  Disease  of  the  aortic  valve;  (&) 
mitral  insufficiency;  (c)  pericardial  adhesions;  (d)  sclerotic  myocarditis;  (e) 
disturbed  innervation  with  overaction,  as  in  exophthalmic  goitre,  in  long-con- 
tinued nervous  palpitation,  and  as  a  result  of  the  action  of  certain  articles, 
such  as  tea,  coffee,  tobacco,  and  probably  alcohol,  as  in  the  Munich  beer  heart. 
In  all  of  these  the  work  of  the  heart  is  increased.  In  the  case  of  the  valve 
lesions  the  increase  is  due  to  the  increased  intraventricular  pressure;  in  the 
case  of  the  adherent  pericardium  and  myocarditis,  to  direct  interference  with 
the  symmetrical  and  orderly  contraction  of  the  chambers. 

Conditions  acting  upon  the  blood-vessels:  (a)  General  arterio-sclerosis, 
with  or  without  renal  disease,  especially  sclerosis  of  the  aorta,  the  renal  ar- 
teries, and  the  vessels  of  the  splanchnic  area;  (6)  all  states  of  increased  ar- 
terial tension  induced  by  the  contraction  of  the  smaller  arteries  under  the  in- 
fluence of  certain  toxic  substances,  which,  as  Bright  suggested,  "by  affecting 
the  minute  capillary  circulation,  render  great  action  necessary  to  send  the 
blood  through  the  distant  subdivisions  of  the  vascular  system";  (c)  prolonged 
muscular  exertion,  which  enormously  increases  the  blood  pressure  in  the  ar- 
teries; (d)  narrowing  of  the  aorta,  as  in  the  congenital  stenosis. 

HYPERTROPHY  OF  THE  RIGHT  VENTRICLE  is  met  with  under  the  following 
conditions — 

(a)  Lesions  of  the  mitral  valve,,  either  incompetence  or  stenosis,  which 
act  by  increasing  the  resistance  in  the  pulmonary  vessels.  (&)  Pulmonary 
lesions,  obliteration  of  any  number  of  blood  vessels  within  the  lungs,  such  as 
occurs  in  emphysema  or  cirrhosis,  is  followed  by  hypertrophy  of  the  right 
ventricle,  (c)  Valvular  lesions  on  the  right  side  occasionally  cause  hyper- 
trophy in  the  adult,  not  infrequently  in  the  fetus,  (d)  Chronic  valvular  dis- 
ease of  the  left  heart  and  pericardial  adhesions  are  sooner  or  later  associated 
with  hypertrophy  of  the  right  ventricle. 

In  the  auricles  simple  hypertrophy  is  never  seen;  there  is  always  dilata- 
tion with  hypertrophy.  In  the  left  auricle  the  condition  develops  in  lesions 
at  the  mitral  orifice,  particularly  stenosis.  The  right  auricle  hypertrophies 
when  there  is  greatly  increased  blood  pressure  in  the  lesser  circulation,  wheth- 
er due  to  mitral  stenosis  or  pulmonary  lesions.  Narrowing  of  the  tricuspid 
orifice  is  a  less  frequent  cause. 

Symptoms. — There  may  be  no  complaint  attributable  to  the  hypertrophy, 
and  if  associated  with  renal  disease  or  arterio-sclerosis  there  may  be  a  marked 
sense  of  well-being.  If,  however,  the  cardiac  defect  be  not  fully  compen- 
sated, the  patient  may  complain  of  slight  giddiness,  headache,  a  sense  of  pal- 
pitation in  the  thorax,  and  some  dyspnoea  on  exertion. 

In  hypertrophy  of  the  right  auricle  the  venous  pulsation  in  the  neck  may 
be  more  evident,  and  a  tracing  may  show  a  marked  increase  in  the  size  of  the 
auricular  wave.  An  increase  in  dulness  to  the  right  of  the  sternum  in  the 
third  and  fourth  interspaces  may  be  detected,  and  on  very  rare  occasions  a 
sound  preceding  that  of  the  ventricle  over  that  area.  Hypertrophy  of  the 
right  ventricle  causes  a  slight  bulging  of  the  costal  angle  with  a  positive 


782  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

instead  of  a  negative  pulsation  at  this  spot.  The  apex  beat  may  be  diffuse, 
as  the  enlarged  right  ventricle  prevents  the  left  ventricle  from  coming  into 
contact  with  the  chest  wall.  The  venous  pulsation  in  the  neck  is  usually 
marked,  and  the  first  sound  over  the  tricuspid  area  louder  than  normal.  Hy- 
pertrophy of  the  left  auricle,  which  is  seldom  marked  and  never  unassociated 
with  dilatation,  may  be  detected  occasionally  by  dulness  toward  the  base  of 
the  left  lung  behind;  it  is  easily  diagnosed  by  the  extension  backward  of  the 
cardiac  shadow  in  oblique  illumination  of  the  chest  by  the  X-rays.  Hyper- 
trophy of  the  left  ventricle  is  usually  easy  to  diagnose.  There  is  a  forcible 
impulse  at  the  apex  beat,  both  visible  and  palpable.  This  impulse  may  cause 
a  movement  of  a  large  area  of  the  chest  wall.  The  apex  beat,  if  there  be  only 
slight  dilatation,  is  usually  displaced  downward,  and  is  found  in  the  6th  and 
7th  spaces;  but  if  the  dilatation  be  marked,  the  apex  beat  becomes  more 
diffuse  and  is  found  well  outside  the  nipple  line  in  the  4th,  5th,  and  6th  spaces. 
The  first  sound  is  usually  marked  and  has  been  discribed  by  Michell  as  "L- 
lumb";  sometimes  it  has  a  distinct  booming  sound.  The  second  sound  at  the 
base  is  accentuated.  The  pulse  is  full  and  of  high  tension  at  the  height  of 
the  ventricular  impulse.  The  blood  pressure  is  raised. 

2.     DILATATION 

As  with  other  hollow  muscular  organs,  the  size  of  the  chambers  of  the 
heart  varies  greatly  within  normal  limits.  Dilatation  may  be  an  acute  process 
and  quite  transitory,  as  after  severe  muscular  effort,  or  it  may  be  chronic,  in 
which  case  it  is  associated  with  hypertrophy.  Not  always,  however;  there  is 
an  extraordinary  heart  in  the  McGill  College  Museum  showing  a  parchment 
like  thinning  of  the  walls  with  uniform  dilatation  of  all  the  chambers;  in 
places  in  the  right  auricle  and  ventricle  only  the  epicardium  remains.  Dila- 
tation is  pathological  only  when  permanent.  Increase  in  capacity  means  in- 
creased work  for  the  walls  and  in  consequence  hypertrophy  to  meet  the  de- 
mand. 

Etiology. — Two  important  causes  combine  to  produce  dilatation — in- 
creased pressure  within  the  cavities  and  impaired  resistance,  due  to  weakening 
of  the  muscular  wall — which  may  act  singly,  but  are  often  combined.  A 
normal  wall  may  yield  under  a  heightened  blood  pressure,  or  a  weakened  wall 
may  yield  to  a  normal  distending  force,  the  weakened  wall  being  due  either 
to  structural  change  in  the  cardiac  muscle,  or  to  a  diminution  of  its  natural 
tonus. 

(a)  HEIGHTENED  ENDOCAEDIAC  PRESSURE  results  either  from  an  increased 
quantity  of  blood  to  be  moved,  or  an  obstacle  to  be  overcome,  and  is  the  more 
frequent  cause  of  weakening.  It  does  not  necessarily  bring  about  dilatation; 
simple  hypertrophy  may  follow,  as  in  the  early  period  of  aortic  stenosis,  and 
in  the  hypertrophy  of  the  left  ventricle  in  Bright's  disease. 

The  size  of  the  cardiac  chambers  varies  in  health.  With  slow  action  of 
the  heart  the  dilatation  is  complete  and  fuller  than  it  is  with  rapid  action. 
Moderate  exertion  in  a  normal  heart,  or  even  prolonged  exertion  in  a  well- 
trained  heart,  lessens  the  heart  size,  but  in  conditions  of  ill  health  dilatation 
occurs.  Physiologically,  the  limits  of  dilatation  are  reached  when  the  cham- 
ber does  not  empty  itself  during  the  systole.  This  may  occur  as  an  acute. 


AFFECTIONS    OF   THE    MYOCARDIUM  ?83 

transient  condition  in  severe  exertion  in  an  untrained  or  feeble  condition — 
during,  for  example,  the  ascent  of  a  mountain. 

There  may  be  great  dilatation  of  the  right  heart,  as  shown  by  the  increased 
epigastric  pulsation,  and  even  increase  in  the  cardiac  dulness.  The  safety 
valve  action  of  the  tricuspid  valves  may  here  come  into  play,  relieving  the 
lungs  by  permitting  regurgitation  into  the  auricle.  With  rest  the  condition 
is  removed,  but,  if  it  has  been  extreme,  the  heart  may  suffer  a  strain  from 
which  it  may  recover  slowly,  or,  indeed,  the  individual  rrtny  never  be  able 
again  to  undertake  severe  exertion.  In  the  process  of  training  the  getting 
wind,  as  it  is  called,  is  largely  a  gradual  increase  in  the  capability  of  the 
heart,  particularly  of  the  right  chambers.  A  degree  of  exertion  can  be  safely 
maintained  in  full  training  which  would  be  quite  impossible  under  other 
circumstances,  because,  by  a  gradual  process  of  what  we  may  call  physical 
education,  the  heart  has  strengthened  its  reserve  force — widened  enormously 
its  limit  of  physiological  work.  Endurance  in  prolonged  contests  is  measured 
by  the  capabilities  of  the  heart,  which  by  increasing  its  tonus  has  increased 
its  resistance  to  dilatation.  We  have  no  positive  knowledge  of  the  nature  of 
the  changes  in  the  heart  which  occur  in  this  process,  but  it  must  be  in  the 
direction  of  increased  muscular  and  nervous  energy.  The  large  heart  of  ath- 
letes may  be  due  to  the  prolonged  use  of  their  muscles,  but  no  man  becomes 
a  great  runner  or  oarsman  who  has  not  naturally  a  capable  if  not  a  large 
heart.  Master  McGrath,  the  celebrated  greyhound,  and  Eclipse,  the  race 
horse,  both  famous  for  endurance  rather  than  speed,  had  very  large  hearts. 

Excessive  dilatation  during  severe  muscular  effort  results  in  heart-strain. 
A  man,  perhaps  in  poor  condition,  calls  upon  his  heart  for  extra  work  during 
the  ascent  of  a  high  mountain,  and  is  at  once  seized  with  pain  about  the 
heart  and  a  sense  of  distress  in  the  epigastrium.  He  breathes  rapidly  for 
some  time,  is  "puffed,"  as  we  say,  but  the  symptoms  pass  off  after  a  night's 
quiet.  An  attempt  to  repeat  the  exercise  is  followed  by  another  attack,  or, 
indeed,  an  attack  of  cardiac  dyspnoea  may  come  on  while  he  is  at  rest.  For 
months  such  a  man  may  be  unfitted  for  severe  exertion,  or  he  may  be  per- 
manently incapacitated.  In  some  way  he  has  overstrained  his  heart  and  be- 
come "broken-winded."  Exactly  what  has  taken  place  in  these  hearts  we  can 
not  say,  but  their  reserve  force  is  lost,  and  with  it  the  power  of  meeting  the 
demands  exacted  in  maintaining  the  circulation  during  severe  exertion.  The 
"heart-shock"  of  Latham  includes  cases  of  this  nature — sudden  cardiac  break- 
down during  exertion,  not  due  to  rupture  of  a  valve.  It  seems  probable  that 
sudden  death  in  men  during  long  continued  efforts,  as  in  a  race,  is  sometimes 
due  to  overdistention  and  paralysis  of  the  heart. 

Acute  dilatative  heart  weakness  is  seen  in  many  conditions,  as  in  Graves' 
disease,  in  paroxysmal  tachycardia,  in  old  myocardial  cases  following  exer- 
tion, and  in  angina  pectoris.  There  is  usually  a  striking  contrast  between 
the  wide  and  forcible  cardiac  impulse  and  the  small,  feeble,  irregular  pulse. 

Dilatation  occurs  in  all  forms  of  valve  lesions.  In  aortic  incompetency 
blood  enters  the  left  ventricle  during  diastole  from  the  unguarded  aorta  and 
from  the  left  auricle,  and  the  quantity  of  blood  at  the  termination  of  diastole 
subjects  the  walls  to  an  extreme  degree  of  pressure,  under  which  they  inevi- 
tably yield.  In  time  they  augment  in  thickness,  and  present  the  typical 
eccentric  hypertrophy  of  this  condition. 


784  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

In  mitral  insufficiency  blood  which  should  have  been  driven  into  the  aorta 
is  forced  into  and  dilates  the  auricle  from  which  it  came,  and  then  in  the 
diastole  of  the  ventricle  a  large  amount  is  returned  from  the  auricle,  and  with 
increased  force.  In  mitral  stenosis  the  left  auricle  is  the  seat  of  greatly  in- 
creased tension  during  diastole,  and  dilates  as  well  as  hypertrophies ;  the  dis- 
tention,  too,  may  be  enormous.  Dilatation  of  the  right  ventricle  is  produced 
by  a  number  of  conditions,  which  were  considered  under  hypertrophy.  All 
circumstances,  such  as  mitral  stenosis,  emphysema,  etc.,  which  permanently 
increase  the  tension  of  the  blood  in  the  pulmonary  vessels  cause  its  dilata- 
tion. 

The  idiopathic  dilatation  and  hypertrophy  of  beer  drinkers  also  comes  in 
this  group,  as  it  is  brought  about  gradually  by  increased  endocardial  pressure. 

(6)  IMPAIRED  NUTRITION  OF  THE  HEART  WALLS  may  lead  to  a  diminution 
of  the  resisting  power  so  that  dilatation  readily  occurs. 

The  loss  of  tone  due  to  parenchymatous  degeneration  or  myocarditis  in 
fevers  may  lead  to  a  fatal  condition  of  acute  dilatation.  It  is  a  recognized 
cause  of  death  in  scarlatinal  dropsy  (Goodhart),  and  may  occur  in  rheumatic 
fever,  typhus,  typhoid,  erysipelas,  etc.  The  changes  in  the  heart  muscle 
which  accompany  acute  endocarditis  or  pericarditis  may  lead  to  dilatation, 
especially  in  the  latter  disease.  In  anaemia,  leukaemia,  and  chlorosis  the  dila- 
tation may  be  considerable.  In  sclerosis  of  the  walls  the  yielding  is  always 
where  this  process  is  most  advanced,  as  at  the  left  apex.  Under  any  of  these 
circumstances  the  walls  may  yield  with  normal  blood  pressure. 

Pericardial  adhesions  are  a  cause  of  dilatation,  and  we  generally  find  in 
cases  with  extensive  and  firm  union  considerable  hypertrophy  and  dilatation. 
There  is  usually  here  some  impairment  as  well  of  the  superficial  layers  of 
muscle. 

3.     CAEDIAC    INSUFFICIENCY 

Etiology. — With  lessening  of  the  muscular  power' of  the  heart  the  rapidity 
with  which  the  blood  circulates  is  diminished,  and  the  tissues  fail  to  receive 
their  proper  supply  of  oxygen  and  food,  and  to  be  adequately  relieved  of  their 
waste  products — this  is  cardiac  failure.  The  same  effect  may  be  produced 
in  another  way.  The  amount  of  blood  in  the  body  is  much  less  than  the 
total  capacity  of  the  vascular  bed,  and  an  adequate  blood  supply  is  only  kept 
up  by  a  general  constriction  of  arterioles  which  dam  the  blood  in  the  arterial 
system,  but  if  by  any  chance  there  is  a  general  vaso-dilatation  of  the  arterioles, 
especially  those  in  the  splanchnic  area,  the  heart  does  not  receive  an  amount 
of  blood  sufficient  to  supply  the  bodily  needs,  with  the  same  effect  on  the 
organs  as  in  certain  forms  of  cardiac  failure.  This  condition,  which  is 
probably  the  essence  of  shock,  does  not  concern  us  here,  but  it  must  be  men- 
tioned to  avoid  the  impression  that  all  failure  of  the  circulation  means  fail- 
ure of  the  heart. 

The  failure  in  muscular  power  may  affect  any  cavity  singly  or  the  whole 
heart.  Weakness  of  the  left  ventricle  fails  to  give  proper  filling  of  the  ar- 
terial system  and  general  anaamia  of  the  tissues  results.  Failure  of  the  left 
auricle  means  stasis  in  the  lung  vessels  with  deficient  aeration  of  the  blood, 
and  a  tendency  to  cedema  of  the  lung  or  to  effusion  into  the  pleural  cavity. 


AFFECTIOXS    OF    THE    MYOCARDIUM  785 

Failure  of  the  right  auricle  and  ventricle  gives  cyanosis  of  the  organs,  dyspnoea 
at  rest  and  on  slight  exertion,  with  stasis  in  the  abdominal  organs  and  oedema. 

The  reserve  power  with  which  the  cardiac  muscle  is  endowed  disappears 
in  heart  failure.  This  reserve,  greatest  in  youth,  is  increased  by  adequate 
nutrition,  certain  congenital  endowments,  and,  'apart  from  other  defects,  by 
hypertrophy.  It  is  lessened  by  defects  in  the  cardiac  structure,  gross  or  mi- 
nute, by  defective  nutrition,  by  certain  bacterial  and  other  poisons,  and  with 
advancing  years.  We  have  at  present  no  means  of  gauging  this  reserve  power 
of  the  organ  as  a  -whole  or  in  its  different  parts. 

The  failure  may  be  sudden  or  slow,  according  to  the  kind  and  rapidity 
of  the  lesion  which  causes  it.  When  the  left  ventricle  fails  the  effect  may 
vary  from  immediate  death,  through  all  forms  of  fainting,  giddiness,  sense 
of  dissolution,  to  a  mild  sense  of  bodily  or  mental  fatigue;  when  the  right 
ventricle  fails  the  effect  varies  from  a  sudden  dyspnoea  to  a  dyspnoea  which 
comes  on  with  slight  exertion. 

As  to  the  actual  condition  in  cardiac  failure  generally,  it  is  by  no  means 
easy  in  all  cases  to  say  what  has  been  the  cause.  The  lesions  to  which  the 
cardiac  musculature  is  liable  are  described  further  on,  yet  there  is  a  propor- 
tion of  cases  in  which  neither  by  post  mortem  examination  nor  careful  mi- 
croscopic search  can  the  source  of  the  failure  be  even  suggested.  It  is  well  to 
bear  in  mind  a  suggestion  which  has  been  made  by  Aschoff,  namely,  that  in 
certain  cases  the  failure  is  due  not  so  much  to  the  implication  of  the  general 
musculature  as  to  an  affection  of  the  conducting  muscular  system  of  Tawara's 
node  in  the  inter-auricular  septum,  and  of  the  bundle  of  His  with  its  rami- 
fications which  stretch  to  all  parts  of  the  right  and  left  ventricles,  and  whose 
function  is  to  distribute  the  muscular  impulses  which  at  each  contraction 
spread  from  the  venous  to  the  arterial  end  of  the  heart. 

The  blood  pressure  in  cardiac  insufficiency  shows  no  uniform  figures.  The 
maximum  pressure,  which  is  that  usually  estimated,  may  be  high  even  in  a 
failing  heart.  In  serious  degrees  of  myocardial  affection,  such  as  fatty  de- 
generation or  chloroform  poisoning,  it  is  low.  In  cases  in  which  there  has 
been  a  raised  blood  pressure,  the  maximum  may  be  lower  or  higher  than  the 
normal  for  the  patient.  We  must  recognize  that  probably  in  early  stages  of 
failure  the  heart  is  stimulated  to  put  forth  increased  energy  at  each  beat, 
and  that  the  maximum  pressure  at  the  height  of  the  beat  slightly  over-com- 
pensates the  circulatory  defect. 

ACUTE  CARDIAC  INSUFFICIENCY. — Causes:  (a)  Wounds  of  the  heart,  (&) 
spontaneous  rupture  or  rupture  of  valves,  (c)  rapid  effusion  into  the  pericar- 
dium of  blood  or  serous  fluid,  (d)  access  of  air  to  the  chambers  of  the  heart, 
as  from  operations  at  the  root  of  the  neck  or  decomposition  after  exposure  to  a 
high  atmospheric  pressure,  (e)  large  thrombi  quickly  formed  in  a  heart  cavity, 
(/)  sudden  interference  with  the  coronary  circulation,  especially  the  left 
coronary  artery,  (g)  mechanical  interference  with  the  heart  from  obliteration 
of  the  trachea  or  larynx,  as  in  strangulation,  (7i)  acute  infections,  such  as 
diphtheria  or  pericarditis,  (i)  certain  poisons,  such  as  pilocarpin,  cocaine, 
phosphorus,  etc.,  (/)  stimulation  of  the  vagus  nerve,  its  centre  in  the  medulla, 
or  its  termination  in  the  heart. 

CHRONIC  CARDIAC  INSUFFICIENCY. — Causes:  (a)  Lesions  of  the  heart 
muscle,  which  will  be  described  in  more  detail  in  a  subsequent  paragraph. 


786  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

Essentially  all  cardiac  failure  is  muscular.  The  myocardium  may  be  insuffi- 
ciently nourished,  as  in  the  starvation  atrophy  of  new  growths  or  in  diabetes, 
or  there  may  be  recognizable  gross  or  microscopic  lesions.  One  or  more  of  the 
functions  of  the  cardiac  muscle  may  be  interfered  with  without  producing  any 
changes  that  can  be  detected  by  the  microscope,  such  as  the  failure  associated 
with  aortic  disease.  (6)  Lesions  of  the  valves,  (c)  Lesions  affecting  the  vas- 
cular fields  of  the  efferent  arteries.  Emphysema,  chronic  bronchitis,  asthma, 
sclerosis  of  the  lungs,  chest  deformities,  and  mitral  disease  produce  an  em- 
barrassment of  the  right  heart;  atheroma  of  the  aorta  and  arterio-sclerosis, 
especially  of  the  splanchnic  and  renal  area,  produce  failure  of  the  left  heart. 
(d)  Over-exertion,  (e)  Certain  poisons,  such  as  alcohol  (especially  beer)  and 
phosphorus.  (/)  Other  causes,  such  as  adherent  pericardium  and  exophthal- 
mic goitre. 

Anatomical  Basis  of  Cardiac  Insufficiency. — I.  LESIONS  DUE  TO  DISEASE 
or  THE  CORONARY  ARTERIES. — A  knowledge  of  the  changes  produced  in  the 
myocardium  by  disease  of  the  coronary  vessels  gives  a  key  to  the  understand- 
ing of  many  problems  in  cardiac  pathology.  The  terminal  branches  of  the 
coronary  vessels  are  end  arteries;  that  is,  the  communication  between  neigh- 
boring branches  is  through  capillaries  only.  J.  H.  Pratt  has  shown  that  the 
vessels  of  Thebesius,  which  open  from  the  ventricles  and  auricles  into  a  sys- 
tem of  fine  branches  and  thus  communicate  with  the  cardiac  capillaries  and 
coronary  veins,  may  be  capable  of  feeding  the  myocardium  sufficiently  to  keep 
it  alive  even  when  the  coronary  arteries  are  occluded.  The  blocking  of  one 
of  these  vessels  by  a  thrombus  or  an  embolus  leads  usually  to  a  condition 
which  is  known  as — 

(a)  Anaemic  necrosis,  or  white  infarct.  When  this  does  not  occur  the  rea- 
son may  be  sought  in  (1)  the  existence  of  abnormal  anastomoses,  which  by 
their  presence  take  the  coronary  system  out  of  the  group  of  end  arteries;  or 
(2)  the  vicarious  flow  through  the  vessels  of  Thebesius  and  the  coronary 
veins.  The  condition  is  most  commonly  seen  in  the  left  ventricle  and  in  the 
septum,  in  the  territory  of  distribution  of  the  anterior  coronary  artery.  The 
affected  area  has  a  yellowish  white  color,  sometimes  a  turbid,  parboiled  as- 
pect, at  other  times  a  grayish  red  tint.  It  may  be  somewhat  wedge-shaped, 
more  often  it  is  irregular  in  contour  and  projects  above  the  surface.  Micro- 
scopically the  changes  are  very  characteristic.  The  nuclei  either  disappear 
from  the  muscle  fibres  or  they  undergo  fragmentation.  Leucocytes  wander 
in  from  the  surrounding  tissue,  and  these  may  suffer  disintegration.  At  a 
later  stage  a  new  growth  of  fibrous  tissue  is  found  in  the  periphery  of  the 
infarct  which  ultimately  may  entirely  replace  the  dead  fibres.  The  fibres 
present  a  homogeneous,  hyaline  appearance.  In  some  instances  there  is  com- 
plete transformation,  and  even  to  the  naked  eye  a  firm  white  patch  of  hyaline 
degeneration  may  appear  in  the  centre  of  the  area.  Rupture  of  the  heart 
may  be  associated  with  anaemic  necrosis. 

(6)  The  second  important  effect  of  coronary-artery  disease  upon  the  myo- 
cardium is  seen  in  the  production  of  fibrous  myocarditis.  This  may  result 
from  the  gradual  transformation  of  areas  of  anaemic  necrosis.  More  common- 
ly it  is  caused  by  the  narrowing  of  a  coronary  branch  in  a  process  of  oblitera- 
tive  endarteritis.  Where  the  process  is  gradual  evidences  of  granulation 
tissue  are  often  wanting,  and  any  distinction  between  the  necrotic  muscle 


AFFECTIONS    OF    THE    MYOCARDIUM  787 

fibres  and  the  new  scar  tissue  is  difficult  to  establish.  J.  B.  MacCallum 
showed  that  the  muscle  fibres  undergo  a  change  the  reverse  of  that  of  their 
normal  development  and  lose  their  fibril  bundles  preliminary  to  their  com- 
plete replacement  by  connective  tissue.  The  sclerosis  is  most  frequently  seen 
at  the  apex  of  the  left  ventricle  and  in  the  septum,  but  it  may  occur  in  any 
portion.  In  the  septum  and  walls  there  are  often  streaks  and  patches  which 
are  only  seen  in  carefully  made  serial  sections.  Hypertrophy  of  the  heart  is 
commonly  associated  with  this  degeneration.  It  is  the  invariable  precursor 
of  aneurism  of  the  heart. 

(c)  Sudden  Death  in  Coronary  Artery  Disease. — Complete  obliteration 
of  one  coronary  artery,  if  produced  suddenly,  is  usually  fatal.     When  in- 
duced slowly,  either  by  arterio-sclerosis  at  the  orifice  of  the  artery  at  the  root 
of  the  aorta  or  by  an  obliterating  endarteritis  in  the  course  of  the  vessel,  the 
circulation  may  be  carried  on  through  the  other  vessel.     Sudden  death  is  not 
uncommon,  owing  to  thrombosis  of  a  vessel  which  has  become  narrowed  by 
sclerosis.     In  medico-legal  cases  it  is  a  point  of  primary  importance  to  remem- 
ber that  this  is  one  of  the  common  causes  of  sudden  death.    This  condition 
should  be  carefully  sought  for,  inasmuch  as  it  may  be  the  sole  lesion,  except 
a  general,  sometimes  slight,  arterio-sclerosis.     In  the  most  extreme  grade  one 
coronary  artery  may  be  entirely  blocked,  with  the  production  of  extensive 
fibroid  disease,  and  a  main  branch  of  the  other  also  may  be  occluded.    A  large, 
powerfully  built  imbecile,  aged  thirty  five,  at  the  Elwyn  Institution,  Pennsyl- 
vania, who  had  for  years  enjoyed  doing  the  heavy  work  about  the  place,  died 
suddenly,  without  any  preliminary  symptoms.     The  heart  weighed  over  600 
grams;  the  anterior  coronary  artery  was  practically  occluded  by  obliterating 
endarteritis,  and  of  the  posterior  artery  one  main  branch  was  blocked. 

(d)  Septic  Infarcts. — In  pyaemia  the  smaller  branches  of  the  coronary 
arteries  may  be  blocked  with  emboli  which  give  rise  to  infectious  or  septic 
infarcts  in  the  myocardium  in  the  form  of  abscesses,  varying  in  size  from  a 
pea  to  a  pin's  head.     These  may  not  cause  any  disturbance,  but  when  large 
they  may  perforate  into  the  ventricle  or  into  the  pericardium,  forming  what 
has  been  called  acute  ulcer  of  the  heart. 

II.  ACUTE  INTERSTITIAL  MYOCARDITIS. — In  some  infectious  diseases  and 
in  acute  pericarditis  the  intermuscular  connective  tissue  may  be  swollen  and 
infiltrated  with  small  round  cells  and  leucocytes,  the  blood  vessels  dilated,  and 
the  muscle  fibres  the  seat  of  granular,  fatty,  and  hyaline  degeneration.     Oc- 
casionally, in  pyaemia  the  infiltration  with  pus  cells  has  been  diffuse  and  con- 
fined chiefly  to  the  interstitial  tissue.     Councilman  has  described  this  condi- 
tion of  the  heart  wall  in  gonorrhoea,  and  succeeded  in  demonstrating  the 
gonococcus  in  the  diseased  areas.    The  commonest  examples  are  found  in  diph- 
theria, typhoid  fever,  and  acute  endocarditis,  as  shown  by  the  studies  of  Rom- 
berg.     The  foci  may  be  the  starting  points  of  patches  of  fibrous  myocarditis. 

III.  FRAGMENTATION  AND  SEGMENTATION. — This  condition  was  described 
by  Renaut  and  Landouzy  in  1877,  and  has  been  carefully  studied  by  differ- 
ent pathologists.     Two  forms  are  met  with:     1.  Segmentation.     The  muscle 
fibres  have  separated  at  the  cement  line.     2.  Fragmentation.     The  fracture 
has   been  across   the  fibre  itself,   and  perhaps   at  the   level  of  the  nucleus. 
Longitudinal  division  is  unusual.     Although  the  condition  doubtless  arises  in 
some  instances  during  the  death  agony,  as  in  cases  of  sudden  death  by  vio- 


788  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

lence,  in  others  it  would  seem  to  have  clinical  and  pathological  significance. 
It  is  found  associated  with  other  lesions,  fibrous  myocarditis,  infarction,  and 
fatty  degeneration.  J.  B.  MacCallum  distinguished  a  simple  from  a  degener- 
ative fragmentation.  The  first  takes  place  in  the  normal  fibre,  which,  how- 
ever, shows  irregular  extensions  and  contractions.  The  second  succeeds  degen- 
eration in  the  fibre.  Hearts  the  seat  of  marked  fragmentation  are  lax,  easily 
torn,  the  muscle  fibres  widely  separated,  and  often  pale  and  cloudy. 

IV.  PARENCHYMATOUS  DEGENERATION. — This  is  usually  met  with  in  fe- 
vers, or  in  connection  with  endocarditis  or  pericarditis,  and  in  infections  and 
intoxications  generally.     It  is  characterized  by  a  pale,  turbid  state  of  the 
cardiac  muscle,  which  is  general,  not  localized.     Turbidity  and  softness  are 
the  special  features.    It  is  the  softened  heart  of  Laennec  and  Louis.     Stokes 
speaks  of  an  instance  in  which  "so  great  was  the  softening  of  the  organ  that 
when  the  heart  was  grasped  by  the  great  vessels  and  held  with  the  apex  point- 
ing upward,  it  fell  down  over  the  hand,  covering  it  like  a  cap  of  a  large 
mushroom." 

Histologically,  there  is  a  degeneration  of  the  muscle  fibres,  which  are  in- 
filtrated to  a  various  extent  with  granules  which  resist  the  action  of  ether, 
but  are  dissolved  in  acetic  acid.  Sometimes  this  granular  change  in  the  fibres 
is  extreme,  and  no  trace  of  the  striae  can  be  detected.  It  is  probably  the  ef- 
fect of  a  toxic  agent,  and  is  seen  in  its  most  exquisite  form  in  the  lumbar 
muscles  in  cases  of  toxic  haemoglobinuria  in  the  horse.  It  is  met  with  in  cases 
of  typhoid,  typhus,  small-pox,  and  other  infectious  diseases,  particularly  when 
the  course  is  protracted.  There  is  no  definite  relation  between  it  and  the  high 
temperature. 

V.  FATTY  HEART. — Under  this  term  are  embraced  fatty  degeneration  and 
fatty  overgrowth. 

(a)  Fatty  degeneration  is  a  very  common  condition,  and  mild  grades  are 
met  with  in  many  diseases.  It  is  found  in  the  failing  nutrition  of  old  age, 
of  wasting  diseases,  and  of  cachectic  states;  in  prolonged  infectious  fevers,  in 
which  it  may  follow  or  accompany  the  parenchymatous  'change.  In  pernicious 
anaemia  and  in  phosphorus  poisoning  the  most  extreme  degrees  are  seen.  Peri- 
carditis is  usually  associated  with  fatty  or  parenchymatous  changes  in  the 
superficial  layers  of  the  myocardium.  Disease  of  the  coronary  arteries  is  a 
much  more  common  cause  of  fibroid  degeneration  than  of  fatty  heart.  Last- 
ly, in  the  hypertrophied  ventricular  wall  in  chronic  heart-disease  fatty  change 
is  by  no  means  infrequent.  This  degeneration  may  be  limited  to  the  heart  or 
it  may  be  more  or  less  general  in  the  solid  viscera.  The  diaphragm  may  also 
be  involved,  even  when  the  other  muscles  show  no  special  changes.  There 
appears  to  be  a  special  proneness  to  fatty  degeneration  in  the  heart  muscle, 
which  may  perhaps  be  connected  with  its  incessant  activity.  So  great  is  its 
need  of  an  abundant  oxygen  supply  that  it  feels  at  once  any  deficiency,  and 
is  in  consequence  the  first  muscle  to  show  nutritional  changes. 

Anatomically  the  condition  may  be  local  or  general.  The  left  ventricle  is 
most  frequently  affected.  If  the  process  is  advanced  and  general,  the  heart 
looks  large  and  is  flabby  and  relaxed.  It  has  a  light  yellowish  brown  tint, 
or,- as  it  is  called,  a  faded  leaf  color.  Its  consistence  is  reduced  and  the  sub- 
stance tears  easily.  In  the  left  ventricle  the  papillary  columns  and  the  muscle 
beneath  the  endocardium  show  a  streaked  or-  patchy  appearance.  Microscop- 


AFFECTIONS    OF   THE    MYOCAKDITJM  789 

ically,  the  fibres  are  seen  to  be  occupied  by  minute  globules  distributed  in 
rows  along  the  line  of  the  primitive  fibres  (Welch).  In  advanced  grades 
the  fibres  seem  completely  occupied  by  the  minute  globules. 

(6)  Fatty  Overgrowth. — This  is  usually  a  simple  excess  of  the  normal 
subpericardial  fat,  to  which  the  term  cor  adiposum  was  given  by  the  older 
writers.  In  pronounced  instances  the  fat  infiltrates  between  the  muscular 
substance  and,  separating  the  strands,  may  reach  even  to  the  endocardium. 
In  corpulent  persons  there  is  always  much  pericardial  fat.  It  forms  part  of 
the  general  obesity,  and  occasionally  leads  to  dangerous  or  even  fatal  impair- 
ment of  the  contractile  power  of  the  heart.  ^Of  122  cases  analyzed  by  Forch- 
heimer  there  were  88  males  and  34  females.  Over  80  per  cent,  occurred  be- 
tween the  fortieth  and  seventieth  years. 

The  entire  heart  may  be  enveloped  in  a  thick  sheeting  of  fat  through 
which  not  a  trace  of  muscle  substance  can  be  seen.  On  section  the  fat  infil- 
trates the  muscle,  separating  the  fibres,  and  in  extreme  cases — particularly 
in  the  right  ventricle — reaches  the  endocardium.  In  some  places  there  may 
be  even  complete  substitution  of  fat  for  the  muscle  substance.  In  rare  in- 
stances the  fat  may  be  in  the  papillary  muscles.  The  heart  is  usually  much 
relaxed  and  the  chambers  are  dilated.  Microscopically  the  muscle  fibres  may 
show,  in  addition  to  the  atrophy,  marked  fatty  degeneration. 

VI.  OTHER  DEGENERATIONS  OF  THE  MYOCARDIUM. — (a)  Brown  Atrophy. 
— This  is  a  common  change  in  the  heart  muscle,  particularly  in  chronic  val- 
vular lesions  and  in  the  senile  heart.  When  advanced  the  color  of  the  muscles 
is  a  dark  red  brown,  and  the  consistence  is  usually  increased.  The  fibres 
present  an  accumulation  of  yellow  brown  pigment  chiefly  about  the  nuclei. 
The  cement  substance  is  often  unusually  distinct,  but  seems  more  fragile  than 
in  healthy  muscle. 

(&)  Amyloid  degeneration  of  the  heart  is  occasionally  seen.  It  occurs  in 
the  intermuscular  connective  tissue  and  in  the  blood  vessels,  not  in  the  fibres. 

(c)  The  hyaline  transformation  of  Zenker  is  sometimes  met  with  in  pro- 
longed fevers.  The  affected  fibres  are  swollen,  homogeneous,  translucent,  and 
the  stria?  are  very  faint. 

'(d)  Calcareous  degeneration  occasionally  occurs  in  the  myocardium,  and 
the  muscle  fibres  may  be  infiltrated  with  lime  salts  and  yet  retain  their  ap- 
poarance. 

Symptoms  of  Cardiac  Insufficiency. — As  indicated  above,  the  symptoms  of 
left  sided  cardiac  failure  differ  from  those  of  the  right  side,  and  in  each  we 
may  distinguish  a  number  of  types,  which,  however,  merge  gradually  the 
one  into  the  other.  Failure  of  the  left  ventricle  is  seen  in  its  severest  forms 
in  the  abrupt  death  stroke  of  angina  pectoris,  in  the  sudden  faints  with  sweats 
and  heart  pain  of  fatty  or  fibroid  hearts,  or  in  the  fainting  and  convulsive  at- 
tacks of  Stokes-Adams  disease.  Less  severe  failure  may  be  seen  in  athletes 
after  a  hard  race,  when  vomiting  and  a  feeling  of  dissolution  are  present — 
a  type  which  is  sometimes  seen  in  angina,  when  it  is  liable  to  be  mistaken  for 
a  gastro-intestinal  upset.  The  milder  degrees  show  themselves  in  an  inability 
to  take  much  exercise  or  to  suffer  much  mental  work  without  the  sense  of 
great  fatigue.  Sudden  and  slow  typec  are  also  seen  in  failure  of  the  right 
side.  Subjected  to  a  slight  strain,  great  hyperpncea  and  distress  may  come 
on,  and  one  form  of  cardiac  dyspnoea  which  attacks  the  patient  at  night  is 


790  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

of  this  nature.  The  severer  forms  show  an  increasing  inability  to  undergo 
slight  extra  exertion,  such  as  mounting  stairs,  or  hyperpncea  even  when  at 
rest  in  bed,  in  both  of  which  there  is  usually  some  cedema  of  the  feet,  es- 
pecially at  night,  if  the  patient  is  on  his  feet  most  of  the  day. 

Grouped  under  their  special  systems  the  symptoms  complained  of  by  pa- 
tients with  cardiac  failure  are  as  follows:  (a)  Cardio-vascular  system:  Pain 
in  the  cardiac  area  or  extending  to  the  shoulders  and  down  the  arms,  a  sense 
of  weight  in  the  prsecordium;  palpitation  is  seldom  complained  of.  (&)  Res- 
piratory system :  Dyspnoea  at  rest  or  on  exertion,  or  orthopnooa,  Cheyne-Stokes 
respiration,  cough,  loss  of  voice  /rom  pressure  of  a  dilated  left  auricle  on  the 
left  recurrent  laryngeal  nerve,  hemoptysis  (as  resulting  from  lung  infarcts). 
(c)  Central  nervous  system;  in  addition  to  those  given  above  are  sleepless- 
ness, mental  symptoms,  delusions,  melancholia,  and  especially  toward  the  end 
stupor  and  drowsiness,  (d)  Cyanosis,  pallor,  cedema,  and  occasionally  pur- 
pura  in  the  lower  limbs,  (e)  Alimentary  system:  The  stasis  in  the  abdominal 
organs  in  right  heart  failure  produces  loss  of  appetite,  indigestion,  flatulence, 
vomiting,  constipation,  diarrhoea,  abdominal  pain,  hemorrhoids,  etc.  (/) 
Eenal  system :  The  urine  is  scanty,  high  colored,  and  contains  a  slight  amount 
of  albumin. 

Physical  examination  of  the  heart  may  reveal  an  apex-beat  which  is  feeble, 
outside  the  nipple  line,  diffuse,  and  whose  maximum  intensity  is  not  easily 
localized.  The  pulsation  may  be  marked  on  inspection  and  cover  a  very  wide 
area;  arterial  pulsation  in  the  neck  in  the  left  heart  failure  may  be  great; 
in  right  heart  failure  the  jugular  veins  may  be  very  dilated  and  their  pulsa- 
tions may  be  normal,  indicating  three  waves,  or  regurgitant.  On  percussion 
the  cardiac  area  may  be  much  increased  to  the  right  or  to  the  left,  or  both. 
On  auscultation  the  sounds  may  be  difficult  to  hear,  or  feebler  than  normal ; 
murmurs,  usually  soft,  may.  be  present  at  both  apex  and  base.  Gallop  rhythm 
may  be  present.  The  pulse  may  show  great  variations;  marked  failure  may 
exist  with  a  full  bounding  pulse;  more  usually  it  is  feeble  with  diminished 
tension;  it  may  be  irregular,  intermittent,  slow,  or  rapid.  No  one  sign  or 
combination  of  signs  is  significant  of  cardiac  failure.  A  heart  may  be  insuffi- 
cient and  yet  perhaps  nothing  can  be  detected  by  physical  examination  ex- 
cept feeble  sounds  and  a  low  tension  pulse. 

The  myocardial  lesion  is  not  always  proportionate  to  the  intensity  of  the 
symptoms.  A  patient  may  present  enfeebled,  irregular  action  and  signs  of 
dilatation — shortness  of  breath,  cedema,  and  the  general  symptoms  believed 
to  be  characteristic  of  cases  of  fibroid  and  fatty  heart — and  the  post  mortem 
show  little  or  no  change  in  the  myocardium. 

Cardio-sclerosis  or  fibroid  heart  is  in  some  cases  characterized  by  a  feeble, 
irregular,  slow  pulse,  with  dyspnoea  on  exertion  and  occasional  attacks  of 
angina.  Irregularity  is  present  in  many,  but  not  in  all  eases.  The  pulse 
may  be  very  slow,  even  30  or  40  per  minute,  and  the  features  those  of  Stokes- 
Adams  disease.  A  man  with  advanced  fibroid  myocarditis  may  die  suddenly 
while  at  work,  without  having  ever  complained  of  heart  trouble.  Ultimately 
the  cases  come  under  observation  with  the  symptoms  of  cardiac  insufficiency. 
The  arrhythmia,  which  may  have  been  present,  becomes  aggravated  and, 
according  to  Riegel,  may  not  only  precede,  but  also  persist  after  the  cardiac 
insufficiency  has  passed  away. 


AFFECTIONS    OF   THE    MYOCAKDIUM  791 

Fatty  degeneration  of  the  heart  presents  the  same  difficulties.  Extreme 
fatty  changes,  as  in  pernicious  anaemia,  may  be  present  with  a  full  pulse  and 
regularly  acting  heart.  The  fat  does  not  appear  to  interfere  seriously  with 
the  function  of  the  organ.  The  truth  is,  it  may  be  present  in  an  extreme 
grade  without  producing  symptoms,  so  long  as  great  dilatation  of  the  cham- 
bers does  not  occur.  The  cardiac  irregularity,  the  dyspncea,  palpitation  and 
small  pulse  are  in  reality  not  symptoms  of  the  fatty  degeneration,  but  of  dila- 
tation which  has  supervened.  The  fatty  arcus  senilis  is  of  no  moment  in  the 
diagnosis  of  fatty  heart.  The  heart  sounds  may  be  weak  and  the  action 
irregular. 

When  dilatation  occurs  there  is  gallop  rhythm,  shortening  of  the  long 
pause,  and  a  systolic  murmur  at  the  apex.  Shortness  of  breath  on  exertion 
is  an  early  feature  in  many  cases,  and  anginal  attacks  may  occur.  There  is 
sometimes  a  tendency  to  syncope,  and  in  both  fibroid  and  fatty  heart  there 
are  attacks  in  which  the  patient  feels  cold  and  depressed  and  the  pulse  sinks 
to  40  or  30,  or  even,  as  in  one  case  which  I  saw,  to  26.  The  patient  may 
wake  from  sleep  in  the  early  morning  with  an  attack  of  severe  "cardiac 
asthma."  These  "spells"  may  be  associated  with  nausea  and  may  alternate 
with  others  in  which  there  are  anginal  symptoms.  These  are  the  cases,  too, 
in  which  for  weeks  there  may  be  mental  symptoms.  The  patient  has  delusions 
and  may  even  become  maniacal.  Toward  the  close  the  type  of  breathing  known 
as  Cheyne-Stokes  may  occur.  It  was  described  in  the  following  terms  by  John 
Cheyne,  speaking  of  a  case  of  fatty  heart  (Dublin  Hospital  Reports,  vol.  ii, 
p.  221,  1818)  :  "For  several  days  his  breathing  was  irregular;  it  would  en- 
tirely cease  for  a  quarter  of  a  minute,  then  it  would  become  perceptible, 
though  very  low,  then  by  degrees  it  became  heaving  and  quick,  and  then  it 
would  gradually  cease  again :  this  revolution  in  the  state  of  his  breathing  lasted 
about  a  minute,  during  which  there  were  about  thirty  acts  of  respiration."  It 
is  seen  much  more  frequently  in  arterio-sclerosis  and  uraemic  states  than  in 
fatty  heart. 

Fatty  overgrowth  of  the  heart  is  a  condition  certain  to  exist  in  very  obese 
persons.  It  produces  no  symptoms  until  the  muscular  fibre  is  so  weakened 
that  dilatation  occurs.  These  patients  may  for  years  present  a  feeble  but 
regular  pulse ;  the  heart  sounds  are  weak  and  muffled,  and  a  murmur  may  be 
heard  at  the  apex.  Attacks  of  "cardiac  asthma"  are  not  uncommon,  and  the 
patient  may  suffer  from  bronchitis.  Dizziness  and  pseudo-apoplectic  seizures 
may  occur.  Sudden  death  may  result  from  syncope  or  from  rupture  of  the 
heart.  The  physical  examination  is  often  difficult  because  of  the  great  in- 
crease in  the  fat,  and  it  may  be  impossible  to  define  the  area  of  dulness. 

For  clinical  purposes  we  may  group  the  cases  of  failure  from  myocardial 
disease  as  follows: 

(1)  Those  in  which  sudden  death  occurs  with  or  without  previous  indi- 
cations of  heart-trouble.     Sclerosis  of  the  coronary  arteries  exists — in  some 
instances  with  recent  thrombus  and  white  inf arcts ;  in  others,  extensive  fibroid 
disease;  in  others  again,  fatty  degeneration.     Many  patients  never  complain 
of  cardiac  distress,  but,  as  in  the  case  of  Chalmers,  the  celebrated  Scottish 
divine,  enjoy  unusual  vigor  of  mind  and  body. 

(2)  Cases  in  which  there  are  cardiac  arrhythmia,  shortness  of  breath  on 
exertion,  attacks  of  dyspnoea,  sometimes  anginal  attacks,  collapse  symptoms 


DISEASES    OF   THE    CIRCULATORY    SYSTEM 

with  sweats  and  extremely  slow  pulse,  and  occasionally  marked  mental  symp- 
toms. 

(3)  Cases  with  general  arterio-sclerosis  and  hypertrophy  and  dilatation 
of  the  heart.  They  are  robust  men  of  middle  age  who  have  worked  hard 
and  lived  carelessly  Dyspnoea,  cough,  and  swelling  of  the  feet  are  the  early 
symptoms,  and  the  patient  comes  under  observation  either  with  a  gallop 
rhythm,  embryocardia,  or  an  irregular  heart  with  an  apex  systolic  murmur 
of  mitral  insufficiency.  Recovery  from  the  first  or  second  attack  is  the  rule. 
It  is  one  of  the  most  common  forms  of  heart-disease. 

Prognosis. — Each  case  must  be  judged  on  its  own  merits,  special  notice 
being  taken  of  the  age,  probable  origin,  and  anatomical  basis  of  the  insuffi- 
ciency. The  outlook  in  affections  of  the  myocardium  occurring  late  in  life  is 
extremely  grave.  Patients  recover,  however,  in  a  surprising  way  from  the 
most  serious  attacks,  particularly  those  of  the  third  group. 

Treatment. — Many  cases  never  come  under  treatment;  the  first  are  the 
final  symptoms.  Other  cases  with  well  marked  failure,  if  treated  on  general 
lines  according  to  the  routine  measures,  recover  quickly. 

Much  more  difficult  is  the  management  of  those  cases  in  which  there  is 
marked  cardiac  arrhythmia,  with  a  feeble,  irregular,  very  slow  pulse,  and 
syncope  or  angina.  Dropsy  is  not,  as  a  rule,  present;  the  heart  sounds  may 
be  clear  and  there  are  no  signs  of  dilatation. 

The  following  are  the  general  methods  to  be  observed  in  the  treatment  of 
cardiac  failure: 

(a)  REST. — Disturbed  compensation  may  be  completely  restored  by  rest 
of  the  body.  In  many  cases  with  cedema  of  the  ankles,  moderate  dilatation 
of  the  heart,  and  irregularity  of  the  pulse,  rest  in  bed,  a  few  doses  of  the 
compound  tincture  of  cardamon,  and  a  saline  purge  suffice,  within  a  week 
or  ten  days,  to  restore  the  compensation. 

(&)  DIET. — In  acute  conditions  it  is  usually  well  to  limit  this  in  amount, 
especially  the  fluids.  With  marked  passive  congestion  liquid  diet  may  be  ad- 
visable; otherwise  small  amounts  of  simple  food  ma'y  be  given  at  short  inter- 
vals. In  any  case  with  dilatation  it  is  well  to  limit  the  total  daily  intake  of 
fluids  to  1,500  c.  c.  A  "dry  diet"  for  a  few  days  is  sometimes  useful. 

(c)    THE  RELIEF  OF  THE  EMBARRASSED  CIRCULATION. 

(1)  By  Venesection. — In  cases  of  dilatation,  from  whatever  cause,  in 
mitral  or  aortic  lesions  or  distention  of  the  right  ventricle  in  emphysema, 
when  signs  of  venous  engorgement  are  marked  and  when  there  is  orthopnoea 
with  cyanosis,  the  abstraction  of  from  20  to  30  ounces  of  blood  is  indicated. 
This  is  the  occasion  in  which  timely  venesection  may  save  the  patient's  life. 
It  is  particularly  helpful  in  the  dilated  heart  of  arterio-sclerosis. 

(2)"  By  Depletion  through  the  Bowels. — This  is  particularly  valuable  when 
dropsy  is  present.  Of  the  various  purges  the  salines  are  to  be  preferred,  and 
may  be  given  by  Matthew  Hay's  method.  Half  an  hour  to  an  hour  before 
breakfast  from  half  an  ounce  to  an  ounce  and  a  half  of  Epsom  salts  may  be 
given  in  a  concentrated  form.  This  usually  produces  from  three  to  five  liquid 
evacuations.  The  compound  jalap  powder  in  half  drachm  doses,  or  elaterium, 
may  be  employed  for  the  same  purpose.  Even  when  the  pulse  is  very  feeble 
these  hydragogue  cathartics  are  well  borne,  and  they  deplete  the  portal  system, 
rapidly  and  efficiently. 


AFFECTIONS    OF    THE    MYOCARDIUM  793 

(3)  The  Use  of  Remedies  Which  Stimulate  the  Heart's  Action. — Of  these 
by  far  the  most  important  is  digitalis,  which  was  introduced  into  practice 
by  Withering.  The  indication  for  its  use  is  weakness  of  the  heart  muscle;  the 
centra-indication  is  a  perfectly  balanced  compensatory  hypertrophy,  such  as 
we  see  in  all  forms  of  valvular  disease.  Broken  compensation  in  valvular 
disease,  no  matter  what  the  lesion  may  be,  is  the  signal  for  its  use.  It  acts 
upon  the  heart,  slowing  and  at  the  same  time  increasing  the  force  of  the  con- 
tractions. It  acts  on  the  peripheral  arteries,  raising  their  tension,  so  that  a 
steady  and  equable  flow  of  blood  is  maintained  in  the  capillaries,  which,  after 
all,  is  the  prime  aim  and  object  of  the  circulation.  High  blood  pressure  is 
not  a  contra-indication  to  its  use.  The  beneficial  effects  are  best  seen  in  cases 
of  mitral  disease  with  small,  irregular  pulse  and  cardiac  dropsy.  Its  effects 
are  not  less  striking  in  the  dilatation  of  the  left  ventricle,  in  the  failing  com- 
pensation of  aortic  insufficiency  or  of  arterio-sclerosis.  On  theoretical  grounds 
it  has  been  urged  that  its  use  is  not  so  advantageous  in  aortic  insufficiency, 
since  it  prolongs  the  diastole  and  leads  to  greater  distention.  This  need  not 
be  considered,  and  digitalis  is  just  as  serviceable  in  this  as  in  any  other  con- 
dition associated  with  progressive  dilatation;  larger  doses  are  often  required. 
It  may  be  given  as  the  tincture  or  the  infusion.  In  cases  of  cardiac  dropsy, 
from  whatever  cause,  15  minims  (1  c.  c.)  of  the  tincture  or  half  an  ounce 
(15  c.  c.)  of  the  infusion  may  be  given  every  three  hours  for  two  days,  after 
which  the  dose  may  be  reduced.  Some  prefer  the  tincture,  others  the  infu- 
sion; it  is  a  matter  of  indifference  if  the  drug  is  good.  The  urine  of  a  patient 
taking  digitalis  should  be  carefully  estimated  each  day.  As  a  rule,  when  its 
action  is  beneficial,  there  is  within  twenty-four  hours  an  increase  in  the 
amount;  often  the  flow  is  very  great.  Under  its  use  the  dyspnoea  is  relieved, 
the  dropsy  gradually  disappears,  the  pulse  becomes  firmer,  fuller  in  volume, 
and  sometimes,  if  it  has  been  very  intermittent,  regular. 

Ill  effects  sometimes  follow  digitalis.  There  is  no  such  thing  as  a  cumu- 
lative action  of  the  drug  manifested  by  sudden  symptoms.  Toxic  effects  are 
seen  in  the  production  of  nausea  and  vomiting.  Digipuratum  is  less  disturb- 
ing to  the  stomach  and  may  be  given  when  there  is  gastric  irritability.  The 
pulse  becomes  irregular  and  small,  and  there  may  be  two  beats  of  the  heart 
to  one  of  the  pulse,  which,  as  pointed  out  by  Broadbent,  is  found  particularly 
in  cases  of  mitral  stenosis  when  they  are  under  the  influence  of  this  drug. 
The  urine  is  reduced  in  amount.  These  symptoms  subside  on  the  withdrawal 
of  the  digitalis,  and  are  rarely  serious.  There  are  patients  who  take  digitalis 
uninterruptedly  for  years,  and  feel  palpitation  and  distress  if  the  drug  is 
"omitted.  In  mitral  disease,  even  when  it  does  good,  it  does  not  always  steady 
the  pulse.  There  are  many  cases  in  which  the  irregularity  is  not  affected  by 
the  digitalis.  When  the  compensation  has  been  re-established  the  drug  may 
be  omitted.  When  there  is  dyspnrea  on  exertion  and  cardiac  distress,  from 
5  to  10  minims  (0.3  to  0.6  c.  c.)  three  times  a  day  may  be  advantageously 
given  for  prolonged  periods,  but  the  effects  should  be  carefully  watched.  In 
cardiac  dropsy  digitalis  should  be  used  at  the  outset  with  a  free  hand.  Small 
doses  should  not  be  given,  but  from  the  first  half-ounce  doses  of  the  infusion 
every  three  hours,  or  from  15  to  20  minims  of  the  tincture.  Digitalin,  hypo- 
dermically  (gr.  1/30,  0.002  gm.),  every  three  or  four  hours,  may  be  sub- 
stituted. 

52 


794  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

Of  other  remedies  strophanthus  alone  is  of  service,  but  as  its  effect  is 
uncertain  when  given  by  mouth  it  should  be  administered  by  intramuscular 
injection.  Doses  of  10  to  15  minims  (0.6  to  1  c.  c.)  of  the  tincture  or 
strophanthin  gr.  1/100  (0.0006£  gm.)  are  given  and  repeated  once  or  twice 
after  intervals  of  twenty-four  hours.  The  intramuscular  is  safer  than  the 
intravenous  administration.  It  certainly  will  sometimes  steady  the  inter- 
mittent heart  of  mitral  valve  disease  when  digitalis  fails  to  do  so.  Conval- 
laria,  citrate  of  caffeine,  and  adonis  vernalis  and  sparteine  are  warmly  recom- 
mended as  substitutes  for  digitalis,  but  their  inferiority  is  so  manifest  .that 
their  use  is  rarely  indicated. 

There  are  two  valuable  adjuncts  in  the  treatment  of  valvular  disease — iron 
and  strychnia.  When  anaemia  is  a  marked  feature  iron  should  be  given  in 
full  doses.  In  some  instances  of  failing  compensation  this  is  the  only  medi- 
cine needed  to  restore  the  balance.  Arsenic  is  occasionally  an  excellent  sub- 
stitute, and  one  or  other  of  them  should  be  administered  in  all  instances  of 
heart  trouble  when  pallor  is  present.  Strychnia  is  a  heart  tonic  of  very  great 
value.  It  may  be  given  alone  or  in  combination  with  the  digitalis  in  1  or  2 
drop  doses  of  the  1  per  cent,  solution,  or  hypodermically  in  doses  of  1/40- 
1/10  gr.  (0.0016  to  0.006  gm.).  Alcoholic  stimulants  in  moderation  are  oc- 
casionally useful,  especially  in  tiding  over  a  period  of  acute  cardiac  weakness. 

Treatment  of  Special  Symptoms.—  (a)  DROPSY. — The  increased  arterial 
tension  and  activity  of  the  capillary  circulation  under  the  influence  of  digitalis 
hasten  the  interstitial  lymph  flow  and  favor  resorption  of  the  fluid.  The 
hydragogue  cathartics,  by  rapidly  depleting  the  blood,  promote,  too,  the  ab- 
sorption of  the  fluid  from  the  lymph  spaces  and  the  lymph  sacs.  These  two 
measures  usually  suffice  to  rid  the  patient  of  the  dropsy.  In  some  cases,  how- 
ever, it  can  not  be  relieved,  arid  then  Southey's  tubes  may  be  used  or  the  legs 
punctured  by  ordinary  aspirating  needles  with  rubber  tubing  attached,  which 
may  be  inserted  and  left  for  hours;  they  often  drain  away  large  amounts.  If 
done  with  care,  after  a  thorough  washing  of  the  parts,  and  if  antiseptic  pre- 
cautions are  taken,  scarification  is  a  very  serviceable  measure,  and  should  be 
resorted  to  more  frequently  than  it  is.  Canton  flannel  bandages  may  be 
applied  on  the  cedematous  legs.  In  case  of  marked  hydrothorax  or  ascites 
tapping  is  advisable  before  digitalis  is  given. 

(&)  DYSPNCEA. — The  patients  are  usually  unable  to  lie  down.  A  com- 
fortable bed-rest  should  therefore  be  provided — if  possible,  one  with  lateral 
projections,  so  that  in  sleeping  the  head  can  be  supported  as  it  falls  over.  The 
shortness  of  breath  is  associated  with  dilatation,  chronic  bronchitis,  or  hydro- 
thorax.  The  chest  should  be  carefully  examined  in  all  these  cases,  as  hydro- 
thorax  of  one  side  or  of  both  is  a  common  cause  of  shortness  of  breath.  There 
are  cases  of  mitral  regurgitation  with  recurring  hydrothorax  usually  on  the 
right  side,  which  is  relieved,  week  by  week  or  month  by  month,  by  tapping. 
For  the  nocturnal  dyspnoea,  particularly  when  combined  with  restlessness, 
morphia  is  invaluable  and  may  be  given  without  hesitation.  The  value  of 
the  calming  influence  of  opium  in  all  conditions  of  cardiac  insufficiency  is 
not  sufficiently  recognized.  There  are  instances  of  cardiac  dyspnoea  unasso- 
ciated  with  dropsy,  particularly  in  mitral  valve  disease,  in  which  nitroglycerin 
is  of  great  service,  if  given  in  the  1  per  cent,  solution  in  increasing  doses.  It 
is  especially  serviceable  in  the  cases  in  which  tie  pulse  tension  is  high. 


AFFECTIONS    OF    THE    MYOCAKDIUM  795 

(c)  PALPITATION  AND  CARDIAC  DISTRESS. — In  instances  of  great  hyper- 
trophy and  in  the  throbbing  which  is  so  distressing  in  some  cases  of  aortic 
insufficiency,  aconite  is  of  service  in  doses  of  from  1  to  3  drops  every  two. 
or  three  hours.    An  ice  bag  over  the  heart  or  Leiter's  coil  is  also  of  service  in 
allaying  the  rapid  action  and  the  throbbing.     For  the  pains,  which  are  often 
so  marked  in  aortic  lesions,  iodide  of  potassium  in  10-grain  (0.6  gm.)  doses, 
three  times  a.  day,  or  nitroglycerin  may  be  tried.     Small  blisters  are  some- 
times advantageous.     It  must  be  remembered  that  an  important  cause  of  pal- 
pitation and  cardiac  distress  is  flatulent  distention  of  the  stomach  or  colon, 
against  which  suitable  measures  must  be  directed. 

(d)  GASTRIC   SYMPTOMS. — The   cases   of  cardiac  insufficiency  which  do 
badly  and  fail  to  respond  to  digitalis  are  most  often  those  in  which  nausea 
and  vomiting  are  prominent  features.     The  liver  is  often  greatly  enlarged  in 
these  cases;  there  is  more  or  less  stasis  in  the  hepatic  vessels,  and  but  little 
can  be  expected  of  drugs  until  the  venous  engorgement  is  relieved.     If  the 
vomiting  persists,  it  is  best  to  stop  the  food  and  give  small  bits  of  ice,  small 
quantities  of  milk  and  lime  water,  and  effervescing  drinks,  such  as  Apol- 
linaris  water  and  champagne.    The  bowels  should  be  freely  moved  and  drugs 
given  hypodermically,  if  possible. 

(e)  COUGH  AND  HAEMOPTYSIS. — The  former  is  almost  a  necessary  con- 
comitant of  cardiac  insufficiency,  owing  to  engorgement  of  the  pulmonary 
vessels  and  more  or  less  bronchitis.    It  is  allayed  by  measures  directed  rather 
to  the  heart  than  to  the  lungs.     Hemoptysis  in  chronic  valvular  disease  is 
sometimes  a  salutary  symptom.    An  army  surgeon,  who  was  invalided  during 
the  American  civil  war  on  account  of  hemoptysis,  supposed  to  be  due  to 
tuberculosis,  had  for  many  years,  in  association  with  mitral  insufficiency  and 
enlarged  heart,  many  attacks  of  haemoptysis.    He  assured  me  that  his  condi- 
tion was  invariably  better  after  the  attack.    It  is  rarely  fatal,  except  in  some 
cases  of  acute  dilatation,  and  seldom  calls  for  special  treatment. 

(/)  SLEEPLESSNESS. — One  of  the  most  distressing  features  of  valvular 
lesions,  even  in  the  stage  of  compensation,  is  disturbed  sleep.  Patients  may 
wake  suddenly  with  throbbing  of  the  heart,  often  in  an  attack  of  nightmare. 
Subsequently,  when  the  compensation  has  failed,  it  is  also  a  worrying  symp- 
tom. The  sleep  is  broken,  restless,  and  frequently  disturbed  by  frightful 
dreams.  Sometimes  a  dose  of  the  spirit  of  chloroform  or  of  ether,  with  half 
a  drachm  of  spirit  of  camphor,  given  in  a  little  hot  whisky,  will  give  a  quiet 
night.  The  compound  spirit  of  ether,  Hoffmann's  anodyne,  though  very  un- 
pleasant to  take,  is  frequently  a  great  boon  in  the  intermediate  period  when 
compensation  has  partially  failed  and  the  patients  suffer  from  restless  and 
sleepless  nights.  Paraldehyde  and  amylene  hydrate  are  sometimes  service- 
able, but  it  is  best,  after  a  few  trials,  particularly  if  the  paraldehyde  does 
not  answer,  to  resort  to  morphia.  It  may  be  given  in  combination  with 
atropine. 

(g)  EENAL  SYMPTOMS. — With  broken  compensation  and  lowering  of  the 
tension  in  the  aorta,  the  urinary  secretion  is  greatly  diminished,  and  the 
amount  may  sink  to  5  or  6  ounces  in  the  day.  Digitalis  and  strophanthus 
usually  increase  the  flow.  A  brisk  purge  may  be  followed  by  augmented  se- 
cretion. The  combination  in  pill  form  of  digitalis,  squill,  and  calomel  will 
sometimes  prove  effective  when  the  infusion  or  tincture  of  digitalis  alone  has 


796  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

failed.  Calomel  acts  well  in  some  cases,  given  in  3  grain  (0.2  gm.)  doses 
every  six  hours  for  three  or  four  days. 

The  DIET  in  chronic  valve  diseases  is  often  very  difficult  to  regulate. 
Widal  and  others  have  shown  that  retention  of  the  chlorides  is  an  important 
factor  in  cardiac  dropsy  and  heart  failure.  A  milk  diet,  2  litres  a  day,  favors 
their  elimination,  and  in  the  intervals  between  attacks  a  salt  free  diet  as  far 
as  possible  should  be  used.  Starchy  foods  and  all  articles  likely  to  cause 
flatulency  should  be  forbidden.  Stimulants  are  often  necessary,  either  whisky 
or  brandy. 

In  certain  cases  of  weak  heart,  particularly  when  it  is  due  to  fatty  over- 
growth, the  plans  recommended  by  Oertel  and  by  Schott  are  advantageous. 
They  "are  invaluable  methods  in  those  forms  of  heart  weakness  due  to  intem- 
perance in  eating  and  drinking  and  defective  bodily  exercise.  The  Oertel 
plan  consists  of  three  parts:  First,  the  reduction  in  the  amount  of  liquid. 
This  is  an  important  factor  in  reducing  the  fat  in  these  patients.  It  also 
slightly  increases  the  density  of  the  blood.  Oertel  allows  daily  about  36  ounces 
of  liquid,  which  includes  the  amount  taken  with  the  solid  food.  Free  per- 
spiration is  promoted  by  bathing  (if  advisable,  the  Turkish  bath),  or  even 
by  the  use  of  pilocarpine. 

The  second  important  point  in  his  treatment  is  the  diet,  which  should 
consist  largely  of  proteids. 

Morning. — Cup  of  coffee  or  tea,  with  a  little  milk,  about  6  ounces  alto- 
gether. Bread,  3  ounces. 

Noon. — Three  to  4  ounces  of  soup,  7  to  8  ounces  of  roast  beef,  veal,  game, 
or  poultry,  salad  or  a  light  vegetable,  a  little  fish ;  1  ounce  of  bread  or  farina- 
ceous pudding;  3  to  6  ounces  of  fruit  for  dessert.  No  liquids  at  this  meal,  as 
a  rule,  but  in  hot  weather  6  ounces  of  light  wine  may  be  taken. 

Afternoon. — Six  ounces  of  coffee  or  tea,  with  as  much  water.  As  an 
indulgence  an  ounce  of  bread. 

Evening. — One  or  2  soft-boiled  eggs,  an  ounce  of  bread,  perhaps  a  small 
slice  of  cheese,  salad,  and  fruit;  6  to  8  ounces  of  wine  with  4  or  5  ounces  of 
water  (Yeo). 

The  most  important  element  of  all  is  graduated  exercise,  not  on  the  level, 
but  up  hills  of  various  grades.  The  distance  walked  each  day  is  marked  off 
and  is  gradually  lengthened.  In  this  way  the  heart  is  systematically  exer- 
cised and  strengthened. 

The  Schott  Treatment. — This  consists  in  a  combination  of  baths  with  exer- 
cises at  Nauheim.  The  water  has  a  temperature  of  from  82°-95°  F.,  and 
is  very  richly  charged  with  C02.  The  good  effects  of  the  bath  are  claimed 
by  Schott  to  come  from  a  cutaneous  excitation,  induced  by  the  mineral  and 
gaseous  constituents  of  the  bath,  and  a  stimulation  of  the  sensory  nerves. 
There  is  no  question  that  the  bath,  in  suitable  cases,  will  alter  the  position 
of  the  apex  beat,  and  that  it  lessens  the  area  of  cardiac  dulness;  this  means 
that  it  diminishes  the  dilatation  of  the  heart.  Artificial  baths  are  used,  con- 
sisting of  forty  gallons  of  water,  with  various  strengths  of  sodium  chloride 
and  calcium  chloride.  The  exercises,  resistance  gymnastics,  consist  in  slow 
movements  executed  by  the  patient  and  resisted  by  the  operator.  The  best 
cases  for  the  Nauheim  treatment  are  those  with  myocardial  weakness  from 
whatever  cause.  For  valvular  heart  diseases  in  the  stage  of  broken  compensa- 


ENDOCAKDITIS  79? 

tion  with  dropsy,  etc.,  it  is  not  so  suitable.    The  neurotic  heart  is  often  much 
benefited. 

III.     ENDOCARDITIS 

Inflammation  of  the  lining  membrane  of  the  heart  is  'usually  confined  to 
the  valves,  so  that  the  term  is  practically  synonymous  with  valvular  endo- 
carditis. It  occurs  in  two  forms — acute,  characterized  by  the  presence  of 
vegetations  with  loss  of  continuity  or  of  substance  in  the  valve  tissues ;  chronic, 
a  slow  sclerotic  change,  resulting  in  thickening,  puckering,  and  deformity. 

ACU.TE    ENDOCARDITIS 

This  occurs  in  rare  instances  as  a  primary,  independent  affection;  but 
in  the  great  majority  of  cases  it  is  an  accident  in  various  infective  processes, 
so  that  in  reality  the  disease  does  not  constitute  an  etiological  entity. 

For  convenience  of  description  we  speak  of  a  simple  or  benign,  and  a 
malignant,  ulcerative,  or  infective  endocarditis,  between  which,  however, 
there  is  no  essential  anatomical  difference,  as  all  gradations  can  be  traced, 
and  they  represent  but  different  degrees  of  intensity  of  the  same  process. 

Etiology. — SIMPLE  ENDOCARDITIS  does  not  constitute  a  disease  of  itself, 
but  is  invariably  found  with  some  other  affection.  In  330  cases  of  rheumatic 
fever  at  the  Johns  Hopkins  Hospital  there  were  110  cases  of  endocarditis. 
Bouillaud  first  emphasized  the  frequency  of  the  association  of  simple  endo- 
carditis with  rheumatic  fever.  Before  him,  however,  the  association  had  been 
noticed.  Possibly  it  is  nothing  in  the  disease  itself,  but  simply  an  altered 
state  of  the  fluid  media — a  reduction  perhaps  of  the  lethal  influences  which 
they  normally  exert — permitting  the  invasion  of  the  blood  by  certain  micro- 
organisms. Tonsillitis,  which  in  some  forms  is  regarded  as  a  rheumatic  affec- 
tion, may  be  complicated  with  endocarditis.  Of  the  specific  diseases  of  child- 
hood it  is  not  uncommon  in  scarlet  fever,  while  it  is  rare  in  measles  and 
chicken-pox.  In  diphtheria  simple  endocarditis  is  rare.  In  small-pox  it  is  not 
common.  In  typhoid  fever  it  occurred  six  times  among  1,500  cases. 

In  pneumonia  both  simple  and  malignant  endocarditis  are  common.  In 
100  autopsies  in  this  disease  made  at  the  Montreal  General  Hospital  there  were 
5  instances  of  the  former.  Among  61  cases  of  endocarditis  studied  bacterio- 
logically  in  Welch's  laboratory,  pneumococci  were  found  in  21  (Marshall). 
Of  517  fatal  cases  of  acute  endocarditis,  115  were  in  connection  with  pneu- 
monia— 22.3  per  cent.  (E.  F.  Wells).  Acute  endocarditis  is  by  no  means 
rare  in  phthisis.  I  found  it  in  12  cases  in  216  post  mortems. 

In  chorea  simple  warty  vegetations  are  found  on  the  valves  in  a  large 
majority  of  all  fatal  cases,  in  62  of  73  cases  collected  by  me.  There  is  no 
disease  in  which,  post  mortem,  acute  endocarditis  has  been  so  frequently  found. 
And,  lastly,  simple  endocarditis  is  met  with  in  diseases  associated  with  loss 
of  flesh  and  progressive  debility,  as  cancer,  and  such  disorders  as  gout,  dia- 
betes, and  Bright's  disease. 

A  very  common  form  is  that  which  occurs  on  the  sclerotic  valves  in  old 
heart-disease — the  so-called  recurring  endocarditis. 

MALIGNANT  OR  INFECTIVE  ENDOCARDITIS  is  met  with:  (a)  As  a  primary 
disease  of  the  lining  membrane  of  the  heart  or  of  its  valves. 


798  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

(&)  As  a  secondary  affection  in  rheumatic  fever,  pneumonia,  in  various 
specific  fevers,  in  septic  processes  of  all  sorts,  and  most  frequently  of  all  as 
an  infection  on  old  sclerotic  valves.  In  a  majority  of  all  cases  it  is  a  local 
process  in  an  acute  infection.  Congenital  lesions  are  very  prone  to  the  severer 
types  of  endocarditis,  particularly  affections  of  the  orifice  of  the  pulmonary 
artery  and  the  margins  of  the  imperfect  ventricular  septum  (C.  Robinson). 

The  existence  of  a  primary  endocarditis  has  been  doubted;  but  there  are 
instances  in  which  persons  previously  in  good  health,  without  any  history  of 
affections  with  which  endocarditis  is  usually  associated,  have  been  attacked 
with  symptoms  resembling  severe  typhus  or  typhoid.  In  one  case  which  I  saw 
death  occurred  on  the  sixth  day  and  no  lesions  were  found  other  than  those  of 
malignant  endocarditis. 

The  simple  endocarditis  of  rheumatic  fever  or  of  chorea  rarely  progresses 
into  the  malignant  form.  In  only  24  of  209  cases  the  symptoms  of  severe  en- 
docarditis arose  in  the  progress  of  acute  rheumatism.  Of  all  acute  diseases 
complicated  with  severe  endocarditis  pneumonia  probably  heads  the  list. 
Gonorrhoea  is  a  much  more  common  cause  than  has  been  supposed.  There 
have  been  at  least  ten  instances  in  my  wards. 

The  affection  may  complicate  erysipelas,  septicaemia  (from  whatever 
cause),  and  puerperal  fever.  Malignant  endocarditis  is  very  rare  in  tuber- 
culosis, typhoid  fever,  and  diphtheria.  In  dysentery,  in  small-pox,  and  in 
scarlet  fever,  with  which  simple  endocarditis  is  not  infrequently  complicated, 
the  malignant  form  is  extremely  rare. 

Morbid  Anatomy  of  Simple  and  Malignant  Endocarditis. — SIMPLE  ENDO- 
CARDITIS is  characterized  by  the  presence  on  the  valves  or  on  the  lining  mem- 
brane of  the  chambers  of  minute  vegetations,  ranging  from  1  to  4  mm.  in 
diameter,  with  an  irregular  and  fissured  surface,  giving  to  them  a  warty  or 
verrucose  appearance.  Often  these  little  cauliflower-like  excrescences  are  at- 
tached by  very  narrow  pedicles.  They  are  more  common  on  the  left  side  of 
the  heart  than  the  right,  and  occur  on  the  mitral  more  often  than  on  the  aortic 
valves.  The  vegetations  are  upon  the  line  (of  closure  of  the  valves — i.  e.,  on 
the  auricular  face  of  the  auriculo-ventricular  valves,  a  little  distance  from  the 
margin,  and  on  the  ventricular  side  of  the  sigmoid  valves,  festooned  on  either 
half  of  the  valve  from  the  corpora  Arantii.  It  is  rare  to  see  any  swelling  or 
macroscopic  evidence  of  infiltration  of  the  endocardium  in  the  neighborhood 
of  even  the  smallest  of  the  granulations,  or  of  redness,  indicative  of  distention 
of  the  vessels,  even  when  they  occur  upon  valves  already  the  seat  of  sclerotic 
changes,  in  which  capillary  vessels  extend  to  the  edges.  With  time  the  vege- 
tations may  increase  greatly  in  size,  but  in  what  may  be  called  simple  endo- 
carditis the  size  rarely  exceeds  that  mentioned  above.  Hirschfelder  has 
shown  experimentally  that  they  may  form  with  great  rapidity,  even  in  a  few 
hours. 

The  earliest  vegetations  consist  of  elements  derived  from  the  blood,  and 
are  composed  of  blood  platelets,  leucocytes,  and  fibrin  in  varying  proportions. 
At  a  later  stage  they  appear  as  small  outgrowths  of  connective  tissue.  The 
transition  of  one  form  into  the  other  can  often  be  followed.  The  process  con- 
sists of  a  proliferation  of  the  endothelial  cells  and  the  cells  of  the  subendo- 
thelial  layer  which  gradually  invade  the  fresh  vegetation,  and  ultimately 
entirely  replace  it.  The  blood  cells  and  fibrin  undergo  disintegration  and 


ENDOCAEDITIS  799 

gradually  they  are  removed.  The  whole  process  has  received  the  name  of 
"organization."  Even  when  the  vegetation  has  been  entirely  converted  into 
connective  tissue  it  is  often  found  at  autopsy  to  be  capped  with  a  thin  layer 
of  fibrin  and  leucocytes. 

Micro-organisms  are  generally,  even  if  not  invariably,  found  associated 
with  the  vegetations.  They  tend  to  be  entangled  in  the  granular  and  fibril- 
lated  fibrin  or  in  the  older  ones  to  cap  the  apices. 

SUBSEQUENT  CHANGES. — (a)  The  vegetations  may  become  organized  and 
the  valve  restored  to  a  normal  state  ( ?).  (&)  The  process  may  extend,  and  a 
simple  may  become  an  ulcerative  endocarditis,  (c)  The  vegetations  may  be 
broken  off  and  carried  in  the  circulation  to  distant  parts,  (d)  The  vegeta- 
tions become  organized  and  disappear,  but  they  initiate  a  nutritive  change 
in  the  valve  tissue  which  ultimately  leads  to  sclerosis,  thickening,  and  de- 
formity. The  danger  in  any  case  of  simple  endocarditis  is  not  immediate, 
but  remote,  and  consists  in  this  perversion  of  the  normal  processes  of  nutri- 
tion which  results  in  sclerosis  of  the  valves. 

A  gradual  transition  from  the  simple  to  a  more  severe  affection,  to  which 
the  name  MALIGNANT  OR  ULCERATIVE  ENDOCARDITIS  has  been  given,  may  be 
traced.  Practically  in  every  case  of  ulcerative  endocarditis  vegetations  are 
present.  In  this  form  the  loss  of  substance  in  the  valve  is  more  pronounced, 
the  deposition — thrombus  formation — from  the  blood  is  more  extensive,  and 
the  micro-organisms  are  present  in  greater  number  and  often  show  increased 
virulence.  Ulcerative  endocarditis  is  often  found  in  connection  with  heart 
valves  already  the  seat  of  chronic  proliferative  and  sclerotic  changes. 

In  this  form  there  is  much  loss  of  substance,  which  may  be  superficial  and 
limited  to  the  endocardium,  or,  what  is  more  common,  it  involves  deeper 
structures,  and  not  very  infrequently  leads  to  perforation  of  a  valve,  the  sep- 
tum, or  even  of  the  heart  itself. 

Upon  microscopic  examination  the  affected  valve  shows  necrosis,  with  more 
or  less  loss  of  substance;  the  tissue  is  devoid  of  preserved  nuclei  and  presents 
a  coagulated  appearance.  Upon  it  a  mixture  of  blood  platelets,  fibrin — gran- 
ular or  fibrillated — and  leucocytes  enclosing  masses  of  micro-organisms  are 
met  with.  The  subjacent  tissue  often  shows  sclerotic  thickening  and  always 
infiltration  with  exuded  cells. 

PARTS  AFFECTED. — The  following  figures,  taken  from  my  Goulstonian  lec- 
tures, give  an  approximate  estimate  of  the  frequency  with  which  in  209  cases 
different  parts  of  the  heart  were  affected  in  malignant  endocarditis:  Aortic 
and  mitral  valves  together,  in  41;  aortic  valves  alone,  in  53;  mitral  valves 
alone,  in  77;  tricuspid  in  19;  the  pulmonary  valves  in  15;  and  the  heart  walls 
in  33.  In  9  instances  the  right  heart  alone  was  involved,  in  most  cases  the 
auriculo-ventricular  valves. 

Mural  endocarditis  is  seen  most  often  at  the  upper  part  of  the  septum 
of  the  left  ventricle.  Next  in  order  is  the  endocarditis  of  the  left  auricle  on 
the  postero-external  wall.  The  vegetations  may  extend,  as  in  a  case  in  my 
wards,  along  the  intima  of  the  pulmonary  artery  into  the  hilum  of  the  lung. 
A  common  result  of  the  ulceration  is  the  production  of  valvular  aneurism. 
In  three  fourths  of  the  cases  the  affected  valves  present  old  sclerotic  changes. 
The  process  may  extend  to  the  aorta,  producing,  as  in  one  of  my  cases,  exten- 
sive endarteritis  with  multiple  acute  aneurisms. 


800  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

ASSOCIATED  LESIONS. — The  associated  changes\  are  those  of  the  primary 
disease,  those  due  to  embolism,  and  the  changes  in  the  myocardium.  In  tho 
endocarditis  of  septic  processes  there  is  the  local  lesion — an  acute  necrosis,  & 
suppurative  wound,  or  puerperal  disease.  In  many  cases  the  lesions  are  those 
of  pneumonia,  rheumatism,  or  other  febrile  processes. 

The  changes  due  to  embolism  constitute  the  most  striking  features,  but  it 
is  remarkable  that  in  some  instances,  even  with  endocarditis  of  a  markedly 
ulcerative  character,  there  may  be  no  trace  of  embolic  processes.  The  infarcts 
may  be  few  in  number — only  one  or  two,  perhaps,  in  the  spleen  or  kidney — 
or  they  may  exist  in  hundreds  throughout  the  various  parts  of  the  body.  They 
may  present  the  ordinary  appearance  of  red  or  white  infarcts  of  a  suppurative 
character.  They  are  most  common  in  the  spleen  and  kidneys,  though  they  may 
be  numerous  in  the  brain,  and  in  many  cases  are  very  abundant  in  the  intes- 
tines. In  right  sided  endocarditis  there  may  be  infarcts  in  the  lungs.  In 
many  of  the  cases  there  are  innumerable  miliary  abscesses.  Acute  suppurative 
meningitis  was  met  with  in  5  of  23  of  the  Montreal  cases,  and  in  over  10  per 
cent,  of  the  209  cases  analyzed  in  the  literature.  Acute  suppurative  parotitis 
also  may  occur.  And,  lastly,  as  Romberg  has  pointed  out,  the  oft  accompany- 
ing myocarditis  plays  an  important  role.  The  valvular  insufficiency  in  an 
acute  endocarditis  is  probably  not  due  to  the  row  of  little  vegetations,  but 
to  the  associated  myocarditis,  which  interferes  with  the  proper  closure  of  the 
orifice. 

Bacteriology. — No  distinction  in  the  micro-organisms  found  in  the  two 
forms  of  endocarditis  can  be  made.  In  both  the  pyogenic  cocci — strepto- 
cocci, staphylococci,  pneumococci,  and  gonococci — are  the  most  frequent  bac- 
teria met  with.  More  rarely,  especially  in  the  simple  vegetative  endocarditis, 
the  bacilli  of  tuberculosis,  typhoid  fever,  and  anthrax  have  been  encountered. 
The  colon  bacillus  has  also  been  found,  and  Howard  has  described  a  case  of 
malignant  endocarditis  due  to  an  attenuated  form  of  the  diphtheria  bacillus. 
Marshall  in  61  cases  found  the  pneumococci  in  21,  streptococci  alone  or  with 
other  bacteria  in  26,  staphylococcus  pyogenes  aureus  in  12.  The  meningo- 
coccus  may  cause  endocarditis,  of  which  there  are  at  least  5  cases  in  the  litera- 
ture (Cecil  and  Soper)  ;  only  3  of  these  were  associated  with  meningitis. 
Combined  infections  are  not  uncommon.  In  the  chronic  infective  form  the 
Streptococcus  mitior  is  the  common  organism  (Libman). 

As  a  rule  no  organisms  are  found  in  the  simple  endocarditis  in  many 
chronic  diseases,  as  carcinoma,  tuberculosis,  nephritis,  etc.  They  may  have 
been  present  and  died  out,  or  the  lesions  may  be  caused  by  the  toxins. 

Symptoms. — Neither  the  clinical  course  nor  -the  physical  signs  of  SIMPLE 
'ENDOCARDITIS  are  in  any  respect  characteristic.  The  great  majority  of  the 
cases  are  latent  and  there  is  no  indication  whatever  of  cardiac  mischief. 
Experience  has  taught  us  that  endocarditis  is  frequently  found  post  mortem 
in  persons  in  whom  it  was  not  suspected  during  life.  There  are  certain  fea- 
tures, however,  by  which  its  presence  is  indicated  with  a  degree  of  probability, 
The  patient,  as  a  rule,  does  not  complain  of  any  pain  or  cardiac  distress.1  In 
a  case  of  rheumatic  fever,  for  example,  the  symptoms  to  excite  suspicion 
would  be  increased  rapidity  of  the  heart's  action,  perhaps  slight  irregularity, 
and  an  increase  in  the  fever,  without  aggravation  of  the  joint  trouble.  Rows 
of  tiny  vegetations  on  the  mitral  or  or-  the  aortic  segments  seem  a  trifling 


ENDOCARDITIS  •     801 

matter  to  excite  fever,  and  it  is  difficult  in  the  endocarditis  of  febrile  processes 
to  say  definitely  in  every  instance  that  an  increase  in  the  fever  depends  upon 
this  complication ;  but  a  study  of  the  recurring  endocarditis — which  is  of  the 
warty  variety,  consisting  of  minute  beads  on  old  sclerotic  valves — shows  that 
the  process  may  be  associated,  for  days  or  weeks  at  a  time,  with  slight  fever 
ranging  from  100°  to  1021/2 °.  Palpitation  may  be  a  marked  feature  and  is 
a  symptom  upon  which  certain  authors  lay  great  stress. 

The  diagnosis  of  the  condition  rests  upon  physical  signs,  which  are  no- 
toriously uncertain.  The  presence  of  a  murmur  at  one  or  other  of  the  car- 
diac areas  in  a  case  of  fever  is  often  taken  as  proof  of  the  existence  of  endo- 
carditis— a  common  mistake  which  has  arisen  from  the  fact  that  the  bruit 
de  souffle  or  bellows  murmur  is  common  to  it  and  to  a  number  of  other  con- 
ditions. At  first  there  may  be  only  a  slight  roughening  of  the  first  sound, 
which  may  gradually  increase  to  a  distinct  murmur.  The  apex  systolic  bruit 
is  probably  more  often  the  result  of  a  myocarditis.  It  may  not  be  present  in 
the  endocarditis  of  such  chronic  maladies  as  tuberculosis  and  carcinoma, 
since  in  them  the  muscle  involvement  is  less  common  (Krehl).  Eeduplication 
and  accentuation  of  the  pulmonic  second  sound  are  frequently  present. 

It  is  difficult  to  give  a  satisfactory  clinical  picture  of  MALIGNANT  ENDO- 
CARDITIS because  the  modes  of  onset  are  so  varied  and  the  symptoms  so  di- 
verse. Arising  in  the  course  of  some  other  disease,  there  may  be  simply  an 
intensification  of  the  fever  or  a  change  in  its  character.  In  a  majority  of  the 
cases  there  are  present  certain  general  features,  such  as  irregular  pyrexia, 
sweating,  delirium,  and  gradual  failure  of  strength. 

Embolic  processes  may  give  special  characters,  such  as  delirium,  coma,  or 
paralysis  from  involvement  of  the  brain  or  its  membranes,  pain  in  the  side 
and  local  peritonitis  from  infarction  of  the  spleen,  bloody  urine  from  implica- 
tion of  the  kidneys,  impaired  vision  from  retinal  haemorrhage  and  suppura- 
tion, and  even  gangrene  in  various  parts  from  the  distribution  of  the  emboli. 

Two  special  types  of  the  disease  have  been  recognized — the  septic  or  pyae- 
mic  and  the  typhoid.  In  some  the  cardiac  symptoms  are  most  prominent, 
while  in  others  again  the  main  symptoms  may  be  those  of  an  acute  affection 
of  the  cerebro-spinal  system. 

The  septic  type  is  met  with  usually  in  connection  with  an  external  wound, 
the  puerperal  process,  or  an  acute  necrosis  or  gonorrhoea.  There  are  rigors, 
sweats,  irregular  fever,  and  all  of  the  signs  of  septic  infection.  The  heart 
symptoms  may  be  completely  masked  by  the  general  condition,  and  attention 
called  to  them  only  on  the  occurrence  of  embolism.  In  many  cases  the  fea- 
tures are  those  of  a  severe  septicaemia,  and  the  organisms  may  be  isolated 
from  the  blood.  Optic  neuritis  is  not  uncommon,  and  was  present  in  15  cases 
of  chronic  septic  endocarditis  examined  by  Faulkner,  and  in  four  of  these 
recurrent  retinal  haemorrhages  were  present. 

The  typhoid  type  is  by  far  the  most  common  and  is  characterized  by  a 
less  irregular  temperature,  early  proitration,  delirium,  somnolence,  and  coma, 
relaxed  bowels,  sweating,  which  may  be  of  a  most  drenching  character, 
petechial  and  other  rashes,  and  occasionally  parotitis.  The  heart  symptoms 
may  be  completely  overlooked,  and  in  some  instances  the  most  careful  exam- 
ination has  failed  to  discover  a'  murmur. 

Under  the  cardiac  group,  as  suggested  by  Bramwell,  may  be  considered 


803  DISEASES   OF   THE   CIRCULATORY   SYSTEM 

those  cases  in  which  patients  with  chronic  valve  disease  are  attacked  with 
marked  fever  and  evidence  of  recent  endocarditis.  Many  such  cases  present 
symptoms  of  the  pyaemic  and  typhoid  character  and  run  a  most  acute  course. 
In  others  there  may  be  only  slight  fever  or  even  after  a  period  of  high  fever 
recovery  takes  place. 

In  what  may  be  termed  the  cerebral  group  of  cases  the  clinical  picture 
may  simulate  a  meningitis,  either  basilar  or  cerebro-spinal.  There  may  be 
acute  delirium  or,  as  in  three  of  the  Montreal  cases,  the  patient  may  be 
brought  into  the  hospital  unconscious.  Heineman  reports  an  instance,  with 
autopsy,  in  which  the  clinical  picture  was  that  of  an  acute  cerebro-spinal 
meningitis. 

Certain  special  symptoms  may  be  mentioned.  The  fever  is  not  always  of 
a  remittent  type,  but  may  be  high  and  continuous.  Petechial  rashes  are  very 
common  and  render  the  similarity  very  strong  to  certain  cases  of  typhoid  and 
cerebro-spinal  fever.  In  one  case  the  disease  wa"s  thought  to  be  haemorrhagic 
small-pox.  Erythematous  rashes  are  not  uncommon.  The  sweating  may  be 
most  profuse,  even  exceeding  that  which  occurs  in  phthisis  and  ague.  Diar- 
rhoea is  not  necessarily  associated  with  embolic  lesions  in  the  intestines. 
Jaundice  has  been  observed,  and  cases  are  on  record  which  were  mistaken  for 
acute  yellow  atrophy. 

The  heart  symptoms  may  be  entirely  latent  and  are  not  found  unless  a 
careful  search  be  made.  Even  on  examination  there  may  be  no  murmur 
present.  Instances  are  recorded  by  careful  observers  in  which  the  examina- 
tion of  the  heart  has  been  negative.  Cases  with  chronic  valve  disease  usually 
present  no  difficulty  in  diagnosis. 

The  course  of  the  disease  is  varied,  depending  largely  upon  the  nature  of 
the  primary  trouble.  Except  in  the  disease  grafted  upon  chronic  valvulitis  the 
course  is  rarely  extended  beyond  five  or  six  weeks.  The  most  rapidly  fatal  case 
on  record  is  described  by  Eberth,  the  duration  of  which  was  scarcely  two  days. 

CHRONIC  INFECTIVE  ENDOCARDITIS. — This  is  almost  always  engrafted  on 
an  old,  sometimes  an  unrecognized,  valve  lesion.  At  first  fever  is  the  only 
symptom;  in  a  few  cases  there  have  been  chills  at  onset  or  recurring  chills 
may  arouse  the  suspicion  of  malaria.  The  patient  may  keep  at  work  for 
months  with  a  daily  rise  of  temperature,  or  perhaps  an  occasional  sweat.  The 
heart  features  may  be  overlooked.  The  murmur  of  the  old  valve  lesion  may 
show  no  change,  and  even  with  the  most  extensive  disease  of  the  mitral  cusps 
the  heart's  action  may  be  very  little  disturbed.  For  months — six,  eight,  ten, 
even  thirteen ! — fever  and  progressive  weakness  may  be  the  only  symptoms. 
These  are  the  cases  in  which,  with  recurring  chills,  the  diagnosis  of  malaria 
is  made.  With  involvement  of  the  aortic  segments  the  signs  of  a  progressive 
lesion  are  more  common.  Embolic  features  are  not  common,  occurring  only 
toward  the  close.  Ephemeral  cutaneous  nodes,  red  raised  painful  spots  on  the 
skin  of  hands  or  feet  and  lasting  a  few  days,  rarely  occur  except  in  this  form. 
Post  mortem  there  has  been  found  in  my  cases  a  remarkable  vegetative  endo- 
carditis, involving  usually  the  mitral  valves,  sometimes  with  much- encrusting 
of  the  chordae  tendineae,  and  large  irregular  firm  vegetations  quite  different 
to  those  of  the  ordinary  ulcerative  form  of  the  disease.  In  some  cases  the 
aortic  and  tricuspid  segments  are  also  involved,  and  the  vegetations  may  ex- 
tend on  to  the  walls  of  the  heart. 


EKDOCAKDITIS  803 

Diagnosis. — In  many  cases  the  detection  of  the  disease  is  very  difficult; 
in  others,  with  marked  embolic  symptoms,  it  is  easy.  From  simple  endo- 
carditis it  is  readily  distinguished,  though  confusion  occasionally  occurs  in 
the  transitional  stage,  when  a  simple  is  developing  into  a  malignant  form. 
The  constitutional  symptoms  are  of  a  graver  type,  the  fever  is  higher,  rigors 
are  common,  and  septic  and  typhoid  symptoms  occur.  Perhaps  a  majority  of 
the  cases  not  associated  with  puerperal  processes  or  bone  disease  are  confound- 
ed with  typhoid  fever.  A  differential  diagnosis  may  even  be  impossible,  par- 
ticularly when  we  consider  that  in  typhoid  fever  infarctions  and  parotitis 
may  occur.  The  diarrhoea  and  abdominal  tenderness  may  also  be  present, 
which  with  the  stupor  and  progressive  asthenia  make  a  picture  not  to  be  dis- 
tinguished from  this  disease.  Points  which  may  guide  us  are:  The  more 
abrupt  onset  in  endocarditis,  the  absence  of  any  regularity  of  the  pyrexia  in 
the  early  stage  of  the  disease,  and  the  cardiac  pain.  Oppression  and  short- 
ness of  breath  may  be  early  symptoms  in  malignant  endocarditis.  Eigors,  too, 
are  not  uncommon.  There  is  a  marked  leucocytosis  in  infective  endocarditis. 
Between  pyaemia  and  malignant  endocarditis  there  are  practically  no  differ- 
ential features,  for  the  disease  really  constitutes  an  arterial  pycemia,  (Wilks). 
In  the  acute  cases  resembling  malignant  fevers  the  diagnosis  is  usually  made 
of  typhus,  typhoid,  cerebro-spinal  fever,  or  even  of  hasmorrhagic  small-pox. 
The  intermittent  pyrexia,  occurring  for  weeks  or  months,  has  led  in  some 
cases  to  the  diagnosis  of  malaria,  but  this  disease  can  be  positively  excluded 
by  the  blood  examination.  Blood  cultures  may  aid  greatly  in  the  diagnosis. 

The  cases  usually  terminate  fatally.  The  instances  of  recovery  are  those 
more  subacute  forms,  the  so-called  recurring  endocarditis  developing  on  old 
sclerotic  valves  in  cases  of  chronic  heart  disease. 

Treatment. — We  know  no  measures  by  which  in  rheumatic  fever,  chorea, 
or  the  eruptive  fevers  the  onset  of  endocarditis  can  be  prevented.  As  it  is 
probable  that  many  cases  arise,  particularly  in  children,  in  mild  forms  of 
these  diseases,  it  is  well  to  guard  the  patients  against  taking  cold  and  insist 
upon  rest  and  quiet,  and  to  bear  in  mind  that  of  all  complications  an  acute 
endocarditis,  though  in  its  immediate  effects  harmless,  is  perhaps  the  most 
serious.  This  statement  is  enforced  by  the  observations  of  Sibson  that  on  a 
system  of  absolute  rest  the  proportion  of  cases  of  rheumatic  fever  attacked 
by  endocarditis  was  less  than  of  those  who  were  not  so  treated.  It  is  doubt- 
ful whether  in  rheumatic  fever  the  salicylates  have  an  influence  in  reducing 
the  liability  to  endocarditis.  Considering  the  extremely  grave  after  results  of 
simple  endocarditis  in  children,  the  question  arises  whether  it  is  possible  to 
do  anything  to  avert  the  onset  of  progressive  sclerosis  of  the  affected  valve. 
Caton  recommends  a  systematic  plan  of  treatment:  (1)  Prolonged  rest  in 
bed,  three  months,  to  keep  the  heart  quiet;  (2)  a  series  of  small  blisters  over 
the  heart;  and  (3)  the  iodide  of  potassium  in  moderate  doses  for  many 
months.  If  there  is  much  vascular  excitement  aconite  may  be  given  and 
an  ice  bag  placed  over  the  heart.  The  salicylates  are  strongly  advised  by 
some  writers.  The  treatment  of  malignant  endocarditis  is  practically  that  of 
septicaemia — useless  and  hopeless  in  a  majority  of  the  cases.  Blood  cultures 
should  be  taken  as  soon  as  possible  and  a  vaccine  prepared.  Horder  and  others 
have  reported  good  results.  Personally  I  have  not  seen  a  successful  case. 


804 


CHRONIC    ENDOCARDITIS 


Definition. — A  sclerosis  of  the  valves  leading  to  shrinking,  thickening,  and 
adhesion  of  the  cusps,  often  with  the  deposition  of  lime  salts,  with  shortening 
and  thickening  of  the  chordae  tendineae,  leading  to  insufficiency  and  to  nar- 
rowing of  the  orifice.  It  may  be  primary,  but  is  oftener  secondary  to  acute 
endocarditis,  particularly  the  rheumatic  form. 

Etiology. — It  is  a  mistake  to  regard  every  case  of  sclerotic  valve  as  a  se- 
quel to  an  acute  endocarditis.  It  is  long  ago  since  Roy  and  Adami  called 
attention  to  the  possibility  that  sclerosis  of  the  valve  segments  might  be  a 
sequel  of  high  pressure.  The  preliminary  endocarditis  may  be  a  factor  in 
weakening  the  valve,  the  progressive  thickening  of  which  may  be  a  direct 
consequence  of  the  strain.  As  age  advances  the  valves  begin  to  lose  their 
pliancy,  show  slight  sclerotic  changes  and  foci  of  atheroma  and  calcification. 
Certain  poisons  appear  capable  of  initiating  the  change,  such  as  alcohol,  lead, 
syphilis,  and  gout,  though  we  are  at  present  ignorant  of  the  way  in  which 
they  act.  The  poisons  of  the  specific  fevers  may  initiate  the  change.  A  very 
important  factor,  particularly  in  the  case  of  the  aortic  valves,  is  the  strain 
of  prolonged  and  heavy  muscular  exertion.  In  no  other  way  can  be  explained 
the  occurrence  of  sclerosis  of  these  valves  in  young  and  middle  aged  men 
whose  occupations  necessitate  the  overuse  of  the  muscles.  In  the  aortic  seg- 
ments it  may  be  only  the  valvular  part  of  a  general  arterio-sclerosis. 

The  frequency  with  which  chronic  endocarditis  is  met  with  may  be  gath- 
ered from  the  following  figures :  In  the  statistics,  amounting  to  from  12,000 
to  14,000  autopsies,  reported  from  Dresden,  Wiirzburg,  and  Prague,  the  per- 
centage ranged  from  four  to  nine.  The  relative  frequency  of  involvement  of 
the  various  valves  is  thus  given  in  the  collected  statistics  of  Parrot:  The 
mitral  orifice  was  involved  in  621,  the  aortic  in  380,  the  tricuspid  in  46.  and 
the  pulmonary  in  11.  This  gives  57  instances  in  the  right  to  1,001  in  the 
left  heart. 

Morbid  Anatomy.  — Vegetations  in  the  form  in  'which  they  occur  in  acute 
endocarditis  are  not  present.  In  the  early  stage,  which  we  have  frequent  op- 
portunities of  seeing,  the  edge  of  the  valve  is  a  little  thickened  and  perhaps 
presents  a  few  small  nodular  prominences,  which  in  some  cases  may  represent 
the  healed  vegetations  of  the  acute  process.  In  the  aortic  valves  the  tissue 
about  the  corpora  Arantii  is  first  affected,  producing  a  slight  thickening  with 
an  increase  in  the  size  of  the  nodules.  The  substance  of  the  valve  may  lose 
its  translucency,  and  the  only  change  noticeable  be  a  grayish  opacity  and  a 
slight  loss  of  its  delicate  tenuity.  In  the  auriculo-ventricular  valves  these 
early  changes  are  seen  just  within  the  margin  and  here  it  is  not  uncommon 
to  find  swellings  of  a  grayish  red,  somewhat  infiltrated  appearance,  almost 
identical  with  the  similar  structures  on  the  intima  of  the  aorta  in  arterio- 
sclerosis. Even  early  there  may  be  seen  yellow  or  opaque  white  subintimal 
fatty  degenerated  areas.  As  the  sclerotic  changes  increase,  the  fibrous  tissue 
contracts  and  produces  thickening  and  deformity  of  the  segment,  the  edges 
of  which  become  round,  curled,  and  incapable  of  that  delicate  apposition  nec- 
essary for  perfect  closure.  A  sigmoid  valve,  for  instance,  may  be  narrowed 
one  fourth  or  even  one  third  across  its  face,  the  most  extreme  grade  of  in- 
sufficiency being  induced  without  any  special  deformity  and  without  any  nar- 


VALVULAR   DISEASE  805 

I 

rowing  of  the  arterial  orifice.  In  the  auriculo-ventricular  segments  a  simple 
process  of  thickening  and  curling  of  the  edges  of  the  valves,  inducing  a  failure 
to  close  without  forming  any  obstruction  to  the 'normal  course  of  the  blood- 
now,  is  less  common.  Still,  we  meet  with  instances  at  the  mitral  orifice,  par- 
ticularly in  children,  in  which  the  edges  of  the  valves  are  curled  and  thick- 
ened, so  that  there  is  extreme  insufficiency  without  any  material  narrowing  of 
the  orifice.  More  frequently,  as  the  disease  advances,  the  chords  tendinese 
become  thickened,  first  at  the  valvular  ends  and  then  along  their  course.  The 
edges  of  the  valves  at  their  angles  are  gradually  drawn  together  and  there  is 
a  narrowing  of  the  orifice,  leading  in  the  aorta  to  more  or  less  stenosis  and 
in  the  left  auriculo-ventricular  orifice — the  two  sites  most  frequently  involved 
— to  constriction.  Finally,  in  the  sclerotic  and  necrotic  tissues  lime  salts  are 
deposited  and  may  even  reach  the  deeper  structures  of  the  fibrous  rings,  so 
that  the  entire  valve  becomes  a  dense  calcareous  mass  with  scarcely  a  remnant. 
of  normal  tissue.  The  chordae  tendinea?  -may  gradually  become  shortened, 
greatly  thickened,  and  in  extreme  cases  the  papillary  muscles  are  implanted 
directly  upon  the  sclerotic  and  deformed  valve.  The  apices  of  the  papillary 
muscles  usually  show  marked  fibroid  change. 

In  all  stages  of  the  process  the  vegetations  of  simple  endocarditis  may 
be  present,  and  the  severer,  ulcerative  forms  are  very  apt  to  attack  these 
sclerotic  valves. 

Chronic  mural  endocarditis  produces  cicatrical  like  patches  of  a  grayish 
white  appearance  which  are  sometimes  seen  on  the  muscular  trabecula?  of 
the  ventricle  or  in  the  auricles.  It  often  occurs  in  association  with  myo- 
carditis. 

The  endocarditis  of  the  fetus  is  usually  of  the  sclerotic  form  and  involves 
the  valves  of  the  right  more  frequently  than  those  of  the  left  side. 


IV.     CHRONIC   VALVULAR   DISEASE 

GENERAL    INTRODUCTION 

Effects  of  Valve  Lesions. — The  general  influence  on  the  work  of  the  heart 
may  be  briefly  stated  as  follows:  The  sclerosis  induces  insufficiency  or  steno- 
sis, which  may  exist  separately  or  in  combination.  The  narrowing  retards  in 
a  measure  the  normal  outflow  and  the  insufficiency  permits  the  blood  current 
to  take  an  abnormal  course.  The  result  in  the  former  case  is  difficulty  in 
the  expulsion  of  the  normal  contents  of  the  chamber  through  the  narrow 
orifice;  in  the  other,  the  overfilling  of  a  chamber  by  blood  flowing  into  it 
from  an  improper  source  as,  for  instance,  in  mitral  insufficiency,  when  the 
left  auricle  receives  blood  both  from  the  pulmonary  veins  and  from  the  left 
ventricle.  In  both  instances  the  effect  is  dilatation  of  a  chamber,  and  to  expel 
the  normal  amount  of  blood  from  a  dilated  chamber  a  relatively  greater 
amount  of  mechanical  energy  is  required,  which  by  various  adjustments  the 
muscle  is  stimulated  to  do. 

The  cardiac  mechanism  is  fully  prepared  to  meet  ordinary  grades  of 
dilatation  which  constantly  occur  during  sudden  exertion.  A  man,  for  in- 
stance, at  the  end  of  a  hundred  yard  race  has  his  right  chambers  greatly 


806 


dilated  and  his,  reserve  cardiac  power  worked  to  its  full  capacity.  The  slow 
progress  of  the  sclerotic  changes  brings  about  a  gradual,  not  an  abrupt,  in- 
sufficiency, and  the  moderate  dilatation  which  follows  is  at  first  overcome  by 
the  exercise  of  the  ordinary  reserve  strength  of  the  heart  muscle.  Gradu- 
ally a  new  factor  is  introduced.  The  constant  increase  in  the  energy  put 
forth  by  the  heart  is  a  stimulus  to  the  muscle  fibres  to  increase  in  bulk  and 
probably  also  in  number ;  the  heart  hypertrophies,  and  the  effect  of  the  valve 
lesion  becomes,  as  we  say,  compensated.  The  equilibrium  of  the  circulation 
is  in  this  way  maintained. 

The  nature  of  the  process  with  which  we  have  to  deal  is  graphically  illus- 
trated in  the  accompanying  diagram,  from  Martius.  The  perpendicular  lines 
in  the  figures  represent  the  power  of  work  of  the  heart.  While  the  muscle 


Reserve-force— 
Accommodation- 
capacity 


Reserve-force  — 
Accommodation- 
capacity 


Power  of  work 
(body  at  rest) 


a 


\  Power  of  work 
(body  at  rest) 


Jotappower  of  heart 
^.  less  than  amount  needed 
when  the  body  is  at  rest. 
Insufficiency  of  the  heart) 


I.  Normal  heart 


II.  Heart  in  valvular  disease  in 
stage  of  compensation 


III.  Heart  in  uncompensated 
valvular  disease 


FlQ.  6. — DIAGRAMMATIC  PRESENTATION  SHOWING  THE  FOECE  OF  THE  HEART  FOR  WORK 
UNDER  NORMAL  CONDITIONS  AND  IN  VALVULAE  LESIONS. 

in  the  healthy  heart  (Diagram  I)  has  at  its  disposal  the  maximal  force,  a  c, 
it  carries  on  its  work  under  ordinary  circumstances  (when  the  body  is  at  rest) 
with  the  force  a  b  and  c  is  the  reserve  force  by  means  of  which  the  heart 
accommodates  itself  to  greater  exertion. 

If  now  there  be  a  gross  valvular  lesion,  the  force  required  to  do  the  ordi- 
nary work  of  the  heart  (at  rest)  becomes  very  much  increased  (Diagram 
II).  But  in  spite  of  this  enormous  call  for  force,  insufficiency  of  the  heart 
muscle  does  not  necessarily  result,  for  the  working  force  required  is  still 
within  the  limits  of  the  maximal  power  of  the  heart,  X  b1  being  less  than  ax  c^ 
The  muscle  accommodates  itself  to  the  new  conditions  by  making  its  reserve 
force  mobile.  If  nothing  further  occurred,  however,  this  condition  could  not 
be  permanently  maintained,  for  there  would  be  left  over  for  emergencies 
only  the  small  reserve  force,  b1  y.  Even  when  at  rest  the  heart  would  be  using 


807 

continuously  almost  its  entire  maximal  force.  Any  slight  exertion  requiring 
more  extra  force  than  that  represented  by  the  small  value  b±  y  (say  the  effort 
required  on  walking  or  on  going  upstairs)  would  bring  the  heart  to  the  limit 
of  its  working  power,  and  palpitation  and  dyspnoea  would  appear.  Such  a 
condition  does  not  last  long.  The  working  power  of  the  heart  gradually  in- 
creases. More  and  more  exertion  can  be  borne  without  causing  dyspnoea,  for 
the  heart  hypertrophies.  Finally,  a  new,  more  or  less  permanent  condition  is 
attained,  in  that  the  hypertropliied  heart  possesses  the  maximal  force,  at  cx. 
Owing  to  the  increase  in  volume  of  the  heart  muscle,  the  total  force  of  the 
heart  is  greater  absolutely  than  that  of  the  normal  heart  by  the  amount  y  c^. 
It  is,  however,  relatively  less  efficient,  for  its  reserve  force  is  much  less  than 
that  of  the  healthy  heart.  Its  capacity  for  accommodating  itself  to  unusual 
calls  upon  it  is  accordingly  permanently  diminished. 

Turning  now  to  the  disturbances  of  compensation,  it  is  to  be  distinctly 
borne  in  mind  that  any  heart,  normal  or  diseased,  can  become  insufficient 
whenever  a  call  upon  it  exceeds  its  maximal  working  capacity.  The  liability 
to  such  disturbance  will  depend,  above  all,  upon  the  accommodation  limits  of 
the  heart — the  less  the  width  of  the  latter,  the  easier  will  it  be  to  go  beyond 
the  heart's  efficiency.  A  comparison  of  Diagrams  I  and  II  will  immediately 
make  it  clear  that  the  heart  in  valvular  disease  will  much  earlier  become  in- 
sufficient than  the  heart  of  a  healthy  individual.  If  the  heart  muscle  is  com- 
pelled to  do  maximal  or  nearly  maximal  work  for  a  long  time,  it  becomes  ex- 
hausted. It  is  obvious  that  the  heart  in  valvular  disease,  on  account  of  its 
small  amount  of  reserve  force,  has  to  do  maximal  or  nearly  maximal  work 
far  more  frequently  than  does  the  normal  heart.  The  power  of  the  heart  may 
become  decreased  to  the  amount  necessary  simply  to  carry  on  the  work  of  the 
heart  when  the  body  is  at  rest,  or  it  may  cease  to  be  sufficient  even  for  this. 
The  reserve  force  gained  through  the  compensatory  process  may  be  entirely 
lost  (Diagram  III).  If  the  loss  be  only  temporary,  the  exhausted  heart 
muscle  quickly  recovering,  the  condition  is  spoken  of  as  a  "disturbance  of 
compensation."  The  term  "loss  of  compensation"  is  reserved  for  the  condi- 
tion in  which  the  disturbance  is  continuous. 

The  schema  of  Martius  (Fig.  7)  will  enable  the  student  to  understand 
the  relation  of  the  pathological  phenomena  to  the  normal  cardiac  cycle. 
The  contraction  of  the  ventricle  takes  an  appreciable  period  of  time,  seven- 
hundredths  of  a  second  (a-b)  to  overcome  the  strong  arterial  pressure  which 
keeps  the  aortic  (and  pulmonary)  doors  tightly  shut.  This  closure-time  is 
the  only  brief  period  in  the  cycle  in  which  both  the  auriculo-ventricular  valves 
and  the  semilunar  valves  are  shut,  the  former  as  a  result  of  the  beginning 
of  the  systole,  the  latter  until  the  intra-ventricular  has  overcome  the  aortic 
pressure.  With  this  closure-time  correspond  the  first  sound  and  the  heart 
beat.  In  the  second  period  of  the  ventricular  systole  the  blood  is  driven  into 
the  arteries — the  expulsion-time  (&-c) — and  this  corresponds  with  the  begin- 
ning of  the  aortic  pulse.  During  this  there  may  be  seen  at  the  apex  in  a 
forcibly  beating  heart  the  "back  stroke,"  as  Hope  called  it.  Following  the 
expulsion-time  there  is  a  brief  period — waiting-time  (c-d) — before  the  dias- 
tole begins.  Clinically  the  murmur  of  mitral  insufficiency  (A)  coincides,  at 
any  rate  in  its  beginning,  with  the  closure-time,  the  murmur  of  aortic  stenosis 
with  the  expulsion-time.  The  semiiunar  valves  close  at  the  moment  when 


808 


DISEASES    OF    THE    CIRCULATORY    SYSTEM 


the  ventricles  begin  to  relax  (d)  and  with  this  coincides  the  second  sound. 
At  the  same  moment  the  auriculo-ventricular  valves  open.  The  murmur  of 
aortic  insufficiency  (C)  is  heard  through  the  first  part  of  the  diastole,  some- 
times more,  while  the  murmur  of  mitral  stenosis  (D)  corresponds  with  the 
latter  part  of  the  diastole  of  the  ventricles  and  with  the  systole  of  the  auricles 
(D). 

The  incidence  of  valvular  lesions  may  be  gathered  from  the  following 
figures  compiled  by  Gillespie  from  the  records  of  the  Royal  Infirmary,  Edin- 
burgh: Of  2,368  cases  with  cardiac  lesions,  valvular  disease  occurred  in  80.8 
per  cent.;  endocarditis  and  pericarditis  in  5.3;  myocardial  lesions  in  11.9  per 
cent. :  66.2  per  cent,  of  the  cases  were  in  males. 


A 

B 

C 

D 

Mitral 

Aortfc  Stenosis 

Aortic  Insufficiency 

Mitral 

Insufficiency 

Stenosis 

Vent 

ricular  Systole 

Ventricular  Diastole 

0 

1 

H 

Closure-Time 

Expulsion  Time         be 

15 

"o 

* 

CO 

do 

js 

3 

B 

3 

I  Sound 

"Bad  Stroke" 

I 

I  Sound 

and 

Impulse 

a  6  c     d  ^  f 

Closure  of  Opening  of  Closure  of  the  Semilunar 

the  Auriculo-  the  Semilunar  and  Opening  of  the  Auriculo- 

ventricular  Valves  ventricular  Valves 

Valves  > 

FIG.  7. — SCHEMATIC  DIVISION  OF  THE  PHASES  OF  THE  HEART'S  ACTION  (Martius). 


ACETIC    INCOMPETENCY 

Incompetency  of  the  aortic  valves  arises  either  from  inability  of  the  valve 
segments  to  close  an  abnormally  large  orifice  or  more  commonly  from  disease 
of  the  segments  themselves.  This  best-defined  and  most  easily  recognized  of 
valvular  lesions  was  first  carefully  studied  by  Corrigan,  whose  name  it  some- 
times bears. 

Etiology  and  Morbid  Anatomy. — It  is  more  frequent  in  males  than  in 
females,  affecting  chiefly  able  bodied,  vigorous  men  at  the  middle  period  of 
life.  The  ratio  which  it  bears  to  other  valve  diseases  has  been  variously  given 
as  from  30  to  50  per  cent. 

There  are  five  groups  of  cases :  I,  Those  due  to  congenital  malformation, 
particularly  fusion  of  two  of  the  cusps — most  commonly  those  behind  which 
the  coronary  arteries  are  given  off.  It  is  probable  that  an  aortic  orifice  may 
be  competent  with  this  bicuspid  state  of  the  valves,  but  a  great  danger  is  the 
liability  of  these  malformed  segments  to  sclerotic  endocarditis.  Of  17  cases 


CHRONIC    VALVULAR    DISEASE  809 

which  I  have  reported  all  presented  sclerotic  changes,  and  the  majority  of 
them  had,  during  life,  the  clinical  features  of  chronic  heart-disease. 

II.  The  endocarditic  group.     Endocarditis  may  produce  an  acute  insuffi- 
ciency by  ulceration  and  destruction  of  the  valves;  in  one  case  the  aortic 
valves  were  completely  eroded  away.     The  valvulitis  of  rheumatism  and  of 
the  fevers,  while  more  rarely  aortic,  is  common  enough  in  children,  and  the 
insufficiency  is  caused  by  nodular  excrescences  at  the  margins  or  in  the  valves, 
which  may  ultimately  become  calcified;  more  often  it  induces  a  slow  sclerosis 
of  the  valves  with  adhesions,  causing  also  some  degree  of  narrowing. 

III.  The  arterio-sclerotic  group.     By  far  the  most  frequent  cause  of  in- 
sufficiency  is   a   slow,   progressive   sclerosis  of  the  segments,   resulting  in   a 
curling  of  the  edges,  which  lessens  the  working  surface  of  the  valve.     Most 
frequent  in  strong,  able  bodied  men,  there  are  three  main  factors  in  its  pro- 
duction :  First,  strain — not  a  sudden,  forcible  strain,  but  a  persistent  increase 
of  the  normal  tension  to  which  the  segments  are  subject  during  the  diastole 
of  the  ventricle.    Of  circumstances  increasing  this  tension,  repeated  and  exces- 
sive use  of  the  muscles  is  perhaps  the  most  important.     So  often  is  this  form 
of  heart  disease  found  in  persons  devoted  to  athletics  that  it  is  sometimes 
called  the  "athlete's  heart."     Secondly,  alcohol,  the  action  of  which  is  prob- 
ably direct  as  a  poison  to  the  vessel  wall  and  not,  as  we  have  supposed  here- 
tofore, in  keeping  up  a  high  blood  pressure.     Thirdly,  syphilis,  which  is  of 
importance  equal  to  alcohol  and  strain  combined.     The  Wassermann  reaction 
is  present  in  a  very  large  proportion  of  all  cases  of  aortic  insufficiency  in 
young  and  middle  aged  men. 

In  a  small  group,  usually  in  young  men,  syphilis  causes  a  localized  arterio- 
sclerosis at  the  root  of  the  aorta,  involving  the  valves  secondarily  or  causing 
dilatation  of  the  aortic  ring  with  relative  insufficiency.  The  endarteritis  may 
be  singularly  localized,  even  annular,  sometimes  patchy.  The  spirochsetes 
have  been  found  in  the  lesions. 

The  condition  of  the  valves  is  such  as  has  already  been  described  in 
chronic  endocarditis.  It  may  be  noted,  however,  how. slight  a  grade  of  curl- 
ing may  produce  serious  incompetency.  Associated  with  the  valve  disease  is, 
in  a  majority  of  cases,  a  more  or  less  advanced  arterio-sclerosis  of  the  arch  of 
the  aorta,  one  serious  effect  of  which  may  be  a  narrowing  of  the  orifices  of 
the  coronary  arteries.  The  sclerotic  changes  are  often  combined  with  athe- 
roma,  either  in  a  fatty  or  calcareous  stage.  This  may  exist  at  the  attached 
margin-  of  the  valves  without  inducing  insufficiency.  In  other  instances  in- 
sufficiency may  result  from  a  calcified  spike  projecting  from  the  aortic  a$- 
tachment  into  the  body  of  the  valve,  and  so  preventing  its  proper  closure. 
Some  writers  (Peter)  have  laid  great  stress  upon  the  extension  of  the  endar- 
teritis to  the  valve,  and  would  separate  the  instances  of  this  kind  from  those  of 
simple  valvular  endocarditis.  Anatomically  one  can  usually  recognize  the 
arterio-sclerotic  variety  by  the  smooth  surface,  the  rounded  edges,  and  the 
absence  of  excrescences. 

IV.  Insufficiency  may  be  induced  by  rupture  of  a  segment — a  very  rare 
event  in  healthy  valves,  but  not  uncommon  in  disease,  either  from  excessive 
effort  during  heavy  lifting  or  from  the  ordinary  endarterial  strain  on  a  valve 
eroded  and  weakened  by  ulcerative  endocarditis. 

V.  Relative  insufficiency,  due  to  dilatation  of  the  aortic  ring  and  adjacent 


810  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

arch,  is  not  very  frequent.  It  occurs  in  extensive  arterial  sclerosis  of  the 
ascending  portion  of  the  arch  with  great  dilatation  just  above  the  valves. 
The  valve  segments  are  usually  involved  with  the  arterial  coats,  but  the 
changes  in  them  may  be  very  slight.  In  aneurism  just  above  the  aortic  ring 
relative  insufficiency  of  the  valve  may  be  present. 

It  would  appear  from  the  careful  measurements  of  Beneke  that  the  aortic 
orifice,  which  at  birth  is  20  mm.,  increases  gradually  with  the  growth  of  the 
heart  until  at  one  and  twenty  it  is  about  60  mm.  At  this  it  remains  until  the 
age  of  forty,  beyond  which  date  there  is  a  gradual  increase  in  the  size  up 
to  the  age  of  eighty,  when  it  may  reach  from  68  to  70  mm.  There  is  thus 
at  the  very  period  of  life  in  which  sclerosis  of  the  valve  is  most  common  a 
physiological  tendency  toward  the  production  of  a  state  of  relative  insuf- 
ficiency. 

The  insufficiency  may  be  combined  with  various  grades  of  narrowing,  par- 
ticularly in  the  endocarditic  group.  In  a  majority  of  the  cases  of  the  arterio- 
sclerotic  form  there  is  no  stenosis.  On  the  other  hand,  aortic  stenosis  almost 
without  exception  ,is  associated  with  some  grade,  however  slight,  of  regurgi- 
tation. 

Non-valvular  incompetency  is  met  with  in  two  groups  of  cases,  in  one  of 
which  there  is  a  stretching  of  the  aortic  ring  in  connection  with  dilatation 
of  the  ascending  portion  of  the  arch.  Whether  insufficiency  occurs  apart 
from  this  in  cases  of  dilatation  of  the  left  ventricle  has  been  much  discussed 
— a  relative  incompetency  similar  to  that  which  occurs  at  the  pulmonary  ori- 
fice. Cases  are  reported  in  which  transient  diastolic  murmurs  have  occurred 
in  connection  with  dilatation  of  the  heart,  of  which  Anders  has  reported  and 
collected  corroborative  cases.  Some  years  ago  J.  B.  MacCallum,  whose  un- 
timely death  was  a  great  loss  to  science,  described  a  sphincter-like  band  of 
muscle  encircling  the  opening  of  the  left  ventricle  into  the  aorta,  and  in  these 
cases  the  relaxation  of  this  ring  muscle  may  be  associated  with  insufficiency 
of  the  valve. 

Effects. — The  direct  effect  of  aortic  insufficiency  is  the  regurgitation  of 
blood  from  the  artery  into  the  ventricle,  causing  an  overdistention  of  the 
cavity  and  a  reduction  of  the  blood  column ;  that  is,  a  relative  anaemia  in  the 
arterial  tree.  The  amount  returning  varies  with  the  size  of  the  opening.  The 
double  blood  flow  into  the  left  ventricle  causes  dilatation  of  the  chamber,  and 
finally  hypertrophy,  the  grade  depending  upon  the  lesion.  In  this  way  the 
valve  defect  is  compensated,  and,  as  with  each  ventricular  systole  a-  larger 
amount  of  blood  is  propelled  into  the  arterial  system,  the  regurgitation  of  a 
certain  amount  during  diastole  does  not,  for  a  time  at  least,  seriously  impair 
the  nutrition  of  the  peripheral  parts.  For  a  time  at  least  there  is  little  or 
no  resistance  offered  to  the  blood  flow  from  the  auricle — the  ventricle  accom- 
modates itself  readily  to  the  extra  amount,  and  there  is  no  disturbance  in  the 
lesser  circulation.  In  acute  cases,  on  the  other  hand,  with  rapid  destruction 
of  the  segments,  there  may  be  the  most  intense  dyspnoea  and  even  profuse 
haemoptysis.  In  this  lesion  dilatation  and  hypertrophy  reach  their  most  ex- 
treme limit.  The  heaviest  hearts  on  record  are  described  in  connection  with 
this  affection.  The  so-called  bovine  heart,  cor  bovinum,  may  weigh  35  or  40 
ounces,  or  even,  as  in  a  case  of  Dulles's,  48  ounces.  The  dilatation  is  usually 
extreme  and  is  in  marked  contrast  to  the  condition  of  the  chamber  in  cases  of 


CHRONIC    VALVULAR    DISEASE  811 

pure  aortic  stenosis.  The  papillary  muscles  may  be  greatly  flattened.  The 
mitral  valves  are  usually  not  seriously  affected,  though  the  edges  may  present 
slight  sclerosis,  and  there  is  often  relative  incompetency,  owing  to  distention 
of  the  mitral  ring.  Dilatation  and  hypertrophy  of  the  left  auricle  are  com- 
mon, and  secondary  enlargement  of  the  right  heart  occurs  in  all  cases  of 
long  standing.  In  the  arterio-sclerotic  group  there  is  an  ever  present  pos- 
sibility of  narrowing  of  the  orifices  of  the  coronary  arteries  or  an  extension  of 
the  sclerosis  to  their  branches,  leading  to  fibroid  myocarditis.  In  the  endo- 
carditis cases,  particularly  those  following  rheumatism,  the  intima  is  perfectly 
smooth,  and  the  arch  with  its  main  branches  not  dilated.  A  normal  aorta  may 
be  found  post  mortem  when  during  life  there  have  been  the  most  character- 
istic signs  of  enlargement  of  the  arch  and  of  dilatation  of  the  innominate  and 
right  carotid.  The  so-called  dynamic  dilatation  of  the  arch  is  best  seen  in 
-these  cases.  A  young  girl,  whose  case  had  been  reported  as  one  of  aneurism, 
had  forcible  pulsation  and  a  tumor  which  could  be  grasped  above  the  sternum 
—post  mortem  the  innominate  artery  did  not  admit  the  little  finger  and  the 
arch  was  not  dilated ! 

Although  the  coronary  arteries,  as  shown  by  Martin  and  Sedgwick,  are 
filled  during  the  ventricular  systole,  the  circulation  in  them  must  be  embar- 
rassed in  aortic  incompetency.  They  must  miss  the  effect  of  the  blood  pres- 
sure in  the  sinuses  of  Valsalva  during  the  elastic  recoil  of  the  arteries,  which 
surely  aids  in  keeping  the  coronary  vessels  full.  The  arteries  of  the  body 
usually  present  more  or  less  sclerosis  consequent  upon  the  strain  which  they 
undergo  during  the  forcible  ventricular  systole. 

Symptoms. — The  condition  is  often  discovered  accidentally  in  persons  who 
have  not  presented  any  features  of  cardiac  disease. 

Headache,  dizziness,  flashes  of  light,  and  a  feeling  of  faintness  on  rising 
quickly  are  among  the  earliest  symptoms.  Palpitation  and  cardiac  distress  on 
slight  exertion  are  common.  Long  before  any  signs  of  failing  compensation 
pain  may  become  a  marked  and  troublesome  feature.  It  is  extremely  variable 
in  its  manifestations.  It  may  be  of  a  dull,  aching  character  confined  to  the 
prascordia.  More  frequently,  however,  it  is  sharp  and  radiating,  and  is  trans- 
mitted up  the  neck  and  down  the  arms,  particularly  the  left.  Attacks  of  true 
angina  pectoris  are  more  frequent  in  this  than  in  any  other  valvular  disease. 
Anaemia  is  also  common,  much  more  so  than  in  aortic  stenosis  or  in  mitral 
affections. 

As  compensation  fails  more  serious  symptoms  are  shortness  of  breath 
and  cedema  of  the  feet.  The  attacks  of  dyspnoea  are  liable  to  come  on  at 
night,  and  the  patient  has  to  sleep  with  his  head  high  or  even  in  a  chair. 
Cyanosis  is  rare.  It  is  most  commonly  due  to  complicating  valve  disease,  or 
it  is  stated  that  it  may  result  from  bulging  of  the  septum  ventriculorum  and 
encroachment  upon  the  right  ventricle.  Of  respiratory  symptoms  cough  is 
common,  due  to  the  congestion  of  the  lungs  or  oedema.  Haemoptysis  is  less 
frequent  than  in  mitral  disease.  I  have  reported  a  case  in  which  it  was  pro- 
fuse and  believed  to  be  due  to  tuberculosis  of  the  lungs,  inasmuch  as  the 
patient  was  admitted  in  a  state  of  emaciation  and  profound  exhaustion. 
General  dropsy  is  not  common,  but  cedema  of  the  feet  may  occur  early  and  is 
sometimes  due  to  the  anaemia,  sometimes  to  the  venous  stasis,  at  times  to  both. 
Unless  there  is  coexisting  disease  of  the  mitral  valve,  it  is  rare  in  aortic  in- 


812  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

competency  for  the  patient  to  die  with  general  anasarca.  Sudden  death  is 
frequent;  more  so  in  this  than  in  other  valvular  diseases.  As  compensation 
fails  the  patient  takes  to  bed  and  slight  irregular  fever,  associated  usually 
with  a  recurring  endocarditis,  is  not  uncommon  toward  the  close.  Embolic 
symptoms"  are  not  infrequent — pain  in  the  splenic  region  with  enlargement  of 
the  organ,  hagmaturia,  and  in  some  cases  paralysis.  Distressing  dreams  and 
disturbed  sleep  are  more  common '  in  this  than  in  other  forms  of  valvular 
disease. 

Mental  symptoms  are  often  seen  with  this  lesion;  toward  the  close  there 
may  be  delirium,  hallucinations,  and  morbid  impulses.  It  is  important  to  bear 
this  in  mind,  for  patients  occasionally  display  suicidal  tendencies.  I  have 
twice  had  patients  throw  themselves  from  a  window  of  the  ward. 

PHYSICAL  SIGNS. — Inspection  shows  a  wide  and  forcible  area  of  cardiac 
impulse  with  the  apex  beat  in  the  sixth  or  seventh  interspace,  and  perhaps. 
as  far  out  as  the  anterior  axillary  line.  In  young  subjects  the  pracordia 
may  bulge.  There  may  be  slight  visible  pulsation  in  the  second  right  inter- 
space, or,  in  some  acute  cases  of  insufficiency  or  ulcerative  endocarditis,  a 
couple  of  inches  from  the  sternal  margin.  In  very  slight  insufficiency  there 
may  be  little  or  no  enlargement  to  be  determined  clinically.  On  palpation  a 
thrill,  diastolic  in  time,  is  occasionally  felt,  but  is  not  common.  The  impulse 
is  usually  strong  and  heaving,  unless  in  conditions  of  extreme  dilatation, 
when  it  is  wavy  and  indefinite.  Occasionally  two  or  'three  interspaces  be- 
tween the  nipple  line  and  sternum  will  be  depressed  with  the  systole  as  the 
result  of  atmospheric  pressure.  Percussion  shows  a  greater  increase  in  the 
arefl,  of  heart  dulness  than  is  found  in  any  other  valvular  lesion.  It  extends 
chiefly  downward  and  to  the  left. 

Auscultation. — A  murmur  is  heard  during  the  diastole  of  the  ventricles 
at  the  base  of  the  heart  and  propagated  down  the  sternum.  It  may  be  feeble 
or  inaudible  at  the  aortic  cartilage,  and  is  usually  heard  best  at  midsternum 
opposite  the  third  costal  cartilage  or  along  the  left  border  of  the  sternum 
as  low  as  the  ensiform  cartilage.  It  is  usually  soft;  blowing  in  quality,  and 
is  prolonged,  or  "long  drawn,"  as  the  phrase  is.  It  is  produced  by  the  reflux 
of  blood  into  the  ventricle.  In  some  cases  it  is  loudly  transmitted  to  the 
axilla  at  the  level  of  the 'fourth  interspace,  not  by  way  of  the  apex.  The 
second  sound  may  be  well  heard  or  it  may  be  replaced  by  the  murmur,  or 
with  a  dilated  and  calcified  arch  the  second  sound  may  have  a  ringing  metal- 
lic or  booming  quality,  and  the  diastolic  murmur  is  well  heard,  or  even  loud- 
est, over  the  manubrium. 

The  first  sound  may  be  clear  at  the  base;  more  commonly  there  is  a  soft, 
short,  systolic  murmur.  In  the  arterio-sclerotic  group  the  systolic  bruit  is,  as 
a  rule,  short  and  soft,  while  in  the  endocarditic  group,  in  which  the  valve  seg- 
ments are  united  and  often  covered  with  calcified  vegetations  and  excrescences, 
the  systolic  murmur  is  rough  and  may  be  accompanied  by  a  thrill. 

At  the  apex,  or  toward  it,  the  diastolic  murmur  may  be  faintly  heard  propa- 
gated from  the  base.  With  full  compensation  the  first  sound  is  usually  clear 
at  the  apex;  with  dilatation  there  is  a  loud  systolic  murmur  of  relative  mitral 
insufficiency,  which  may  disappear  under  observation  as  the  dilatation  lessens. 

A  second  murmur  at  the  apex,  probably  produced  at  the  mitral  orifice, 
is  not  uncommon.  Attention  was  called  to  this  by  the  late  Austin  Flint,  and 


CHEOXIC    VALVULAE    DISEASE  813 

the  murmur  usually  goes  by  his  name.  It  is  of  a  rumbling,  echoing  charac- 
ter, occurring  in  the  middle  or  latter  part  of  diastole,  usually  presystolic  in 
time,  and  limited  to  the  apex  region.  It  is  similar  to,  though  less  intense 
than,  the  louder  presystolic  murmurs  of  mitral  stenosis,  and  is  often  associated 
with  a  palpable  thrill.  It  is  probably  caused  by  the  impinging  of  the  regur- 
gitant  current  from  the  aortic  orifice  on  the  large,  anterior  flap  of  the  mitral 
valve,  so  as  to  cause  interference  with  the  entrance  of  blood  at  the  time  of 
auricular  contraction.  The  condition  is  thus  essentially  the  same  as  in  a 
moderate  mitral  stenosis.  This  late  diastolic  echoing  or  rumbling  murmur 
is  present  in  about  half  of  the  cases  of  uncomplicated  aortic  insufficiency 
(Thayer).  It  is  very  variable,  disappearing  and  reappearing  again  without 
apparent  cause.  The  sharp,  valvular  first  sound  and  abrupt  systolic  shock, 
so  common  in  true  mitral  stenosis,  are  rarely  present,  while  the  pulse  is  char- 
acteristic of  uncomplicated  aortic  insufficiency. 

Arteries. — The  examination  of  the  arteries  in  aortic  insufficiency  is  of 
great  value.  Visible  pulsation  is  more  commonly  seen  in  the  peripheral  vessels 
in  this  than  in  any  other  condition.  The  carotids  may  be  seen  to  throb  for- 
cibly, the  temporals  to  dilate,  and  the  brachials  and  radials  to  expand  with 
each  heart-beat.  With  the  ophthalmoscope  the  retinal  arteries  are  seen  to 
pulsate.  Xot  only  is  the  pulsation  evident,  but  the  characteristic  jerking  qual- 
ity is  apparent.  In  the  throat  the  throbbing  carotids  may  lead  to  the  diag- 
nosis of  aneurism.  In  many  cases  the  pulsation  can  be  seen  in  the  supra- 
sternal  notch,  and  prominent,  forcibly  throbbing  vessels  beneath  the  right 
sterno-mastoid  muscle.  The  abdominal  aorta  may  lift  the  epigastrium  with 
each  systole.  In  severe  cases  with  great  hypertrophy,  particularly  if  anemia 
is  present,  the  vascular  throbbing  may  be  of  an  extraordinary  character, 


FIG.  8. — PULSE  TRACING  IN  AORTIC  INSUFFICIENCY;  AN  EXTRA-SYSTOLE  Is  SHOWN. 

jarring  the  whole  front  of  the  chest,  causing  the  head  to  nod,  the  pulsation 
may  lift  the  foot  when  the  knees  are  crossed,  and  even  the  tongue  may  throb 
rhythmically.  To  be  mentioned  with  this  is  the  capillary  pulse,  met  very 
often  in  the  aortic  insufficiency,  and  best  seen  in  the  finger  nails  or  by  draw- 
ing a  line  upon  the  forehead,  when  the  margin  of  hypersemia  on  either  side 
alternately  blushes  and  pales.  In  extreme  grades  the  face  or  the  hand  may 
blush  visibly  at  each  systole.  It  is  met  with  also  in  profound  anasmia,  occa- 
sionally in  neurasthenia,  and  in  health  in  conditions  of  great  relaxation  of 
the  peripheral  arteries.  Pulsation  may  also  be  present  in  the  peripheral 
veins.  On  palpation  the  characteristic  water-hammer  or  Corrigan  pulse  is 
felt.  In  the  majority  of  instances  the  pulse  wave  strikes  the  finger  forcibly 
with  a  quick  jerking  impulse,  and  immediately  recedes  or ,  collapses.  The 
characters  of  this  are  sometimes  best  appreciated  by  grasping  the  arm  above 
the  wrist  and  holding  it  up.  Moreover,  the  pulse  of  aortic  regurgitation  is 
usually  retarded  or  delayed — i.  e.,  there  is  an  appreciable  interval  between  the 


814  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

beat  of  the  heart  and  the  pulsation  in  the  radial  artery,  which  varies  accord- 
ing to  the  extent  of  the  incompetence.  Occasionally  in  the  carotid  artery  the 
second  sound  is  distinctly  audible  when  absent  at  the  aortic  cartilage.  In- 
deed, according  to  Broadbent,  it  is  at  the  carotid  that  we  must  listen  for  the 
second  aortic  sound,  for  when  heard  it  indicates  that  the  regurgitation  is 
small  in  amount,  and  is  consequently  a  very  favorable  prognostic  element. 
In  the  larger  arteries  a  systolic  thud  or  shock  may  be  heard  and  sometimes  a 
double  murmur,  as  pointed  out  by  Duroziez.  The'  systolic  pressure  is  high 
and  the  diastolic  much  decreased.  The  sphygmographic  tracing  is  very  char- 
acteristic. The  high  ascent,  the  sharp  top,  the  quick  drop  in  which  the 
dicrotic  notch  and  wave  are  very  slightly  marked. 

The  recent  studies  of  Stewart  and  of  W.  G.  MacCallum  have  shown  that 
in  aortic  insufficiency  the  low  position  of  the  dicrotic  notch  in  the  descending 
arm  of  the  pulse  wave  and  the  characteristic  collapsing  character  of  the  pulse 
are  not  due,  as  was  formerly  supposed,  to  the  regurgitation  in  the  left  ven- 
tricle, but  to  the  dilatation  of  the  peripheral  arteries,  which  is  a  sort  of  pro- 
tective adaptation  under  the  vaso-motor  influences. 

Aortic  insufficiency  may  for  years  be  fully  compensated.  Persons  do  not 
necessarily  suffer  any  inconvenience,  and  the  condition  is  often  found  acci- 
dentally. So  long  as  the  hypertrophy  just  equalizes  the  valvular  defect  there 
may  be  no  symptoms  and  the  individual  may  even  take  moderately  heavy 
exercise  without  experiencing  sensations  of  distress  about  the  heart.  The 
cases  which  last  the  longest  are  those  in  which  the  insufficiency  follows  endo- 
carditis and  is  not  a  part  of  a  general  arterio-sclerosis.  The  age  of  the  patient, 
too,  at  the  time  of  onset,  is  a  most  important  consideration,  as  in  youth  the 
lesion  is  not  often  from  sclerosis,  and  the  coronary  arteries  are  unaffected. 
Coexistent  lesions  of  the  mitral  valves  tend  early  to  disturb  the  compensation. 
Pure  aortic  insufficiency  is  consistent  with  years  of  average  health  and  with 
a  tolerably  active  life. 

With  the  onset  of  myocardial  changes,  with  increasing  degeneration  of 
the  arteries,  particularly  with  a  progressive  sclerosis  of  the  arch  and  involve- 
ment of  the  orifices  of  the  coronary  arteries,  the  compensation  becomes  dis- 
turbed. The  insufficiency  of  the  circulation  is  seen  first  on  the  arterial  side 
in  occasional  faintings,  giddiness,  or  mental  irritability  and  enfeeblement ; 
later  there  may  be  mitral  regurgitation  and  embarrassment  of  the  right  side 
of  the  heart  with  its  usual  features.  '  In  advanced  cases  the  changes  about  the 
aortic  ring  may  be  associated  with  alterations  in  the  cardiac  nerves  and, 
ganglia,  and  so  introduce  an  important  factor. 

ACETIC   STENOSIS 

Narrowing  or  stricture  of  the  aortic  orifice  is  not  nearly  so  common  ac 
insufficiency.  The  two  conditions,  as  already  stated,  may  occur  together,  how- 
ever, and  probably  in  almost  every  case  of  stenosis  there  is  some  leakage. 

Etiology  and  Morbid  Anatomy. — In  the  milder  grades  there  is  adhesion 
between  the  segments,  which  are  so  stiffened  that  during  systole  they  can  not 
be  pressed  back  against  the  aortic  wall.  The  process  of  cohesion  between  the 
segments  may  go  on  without  great  thickening,  and  produce  a  condition  in 
which  the  orifice  is  guarded  by  a  comparatively  thin  membrane,  on  the  aortic 


CHRONIC    VALVULAR   DISEASE  815 

face  of  which  may  be  seen  the  primitive  raphes  separating  the  sinuses  of 
Valsalva.  In  some  instances  this  membrane  is  so  thin  and  presents  so  few 
traces  of  atheromatous  or  sclerotic  changes  that  the  condition  looks  as  if  it 
had  originated  during  fetal  life.  More  commonly  the  valve  segments  are 
thickened  and  rigid,  and  have  a  cartilaginous  hardness.  In  advanced  cases 
they  may  be  represented  by  stiff,  calcined  masses  obstructing  the  orifice, 
through  which  a  circular  or  slit  like  passage  can  be  seen.  The  older  the 
patient  the  more  likely  it  is  that  the  valves  will  be  rigid  and  calcified. 

We  may  speak  of  a  relative  stenosis  of  the  aortic  orifice  when  with  normal 
valves  and  ring  the  aorta  immediately  beyond  is  greatly  dilated.  A  stenosis 
due  to  involvement  of  the  aortic  ring  in  sclerotic  and  calcareous  changes  with- 
out lesion  of  the  valves  is  referred  to  by  some  authors.  I  have  never  met  with 
an  instance  of  this  kind.  A  subvalvular  stenosis,  the  result  of  endocarditis 
in  the  mitro-sigmoidean  sinus,  usually  occurs  as  the  result  of  fetal  endocar- 
ditis. In  comparison  with  aortic  insufficiency,  stenosis  is  a  rare  disease.  It 
is  usually  met  with  at  a  more  advanced  period  of  life  than  insufficiency,  and 
the  most  typical  cases  of  it  are  found  associated  with  extensive  calcareous 
changes  in  the  arterial  system  in  old  men. 

Owing  to  the  impeded  blood  flow  the  ventricle  has  to  work  against  an 
increased  resistance  and  its  walls  become  hypertrophied,  usually  at  first  with 
little  or  no  dilatation.  We  see  in  this  condition  the  most  typical  instances  of 
what  is  called  concentric  hypertrophy,  in  which,  without  much,  if  any,  en- 
largement of  the  cavity,  the  walls  are  greatly  thickened,  in  contradistinction 
to  the  so-called  eccentric  hypertrophy,  in  which,  with  the  increase  in  the  thick- 
ness of  the  walls,  the  chamber  itself  is  greatly  dilated.  The  systole  is  pro- 
longed, even  as  much  as  twenty-five  per  cent.  There  may  be  no  changes  in 
the  other  cardiac  cavities  if  compensation  is  well  maintained;  but  with  its 
failure  come  dilatation,  impeded  auricular  discharge,  pulmonary  congestion, 
and  increased  work  for  the  right  heart.  The  arterial  changes  are,  as  a  rule, 
not  so  marked  as  in  aortic  insufficiency,  for  the  walls  have  not  to  withstand 
the  impulse  of  greatly  increased  blood-wave  with  each  systole.  On  the  con- 
trary, the  amount  of  blood  propelled  through  the  narrow  orifice  may  be  smaller 
than  normal,  though  when  compensation  is  fully  established  the  pulse  wave 
may  be  of  medium  volume. 

Symptoms. — PHYSICAL  SIGNS. — Inspection  may  fail  to  reveal  any  area  of 
cardiac  impulse.  Particularly  is  this  the  case  in  old  men  with  rigid  chest 
walls  and  large  emphysematous  lungs.  Under  these  circumstances  there  may 
be  a  high  grade  of  hypertrophy  without  any  visible  impulse.  Even  when  the 
apex  beat  is  visible,  it  may  be,  as  Traube  pointed  out,  feeble  and  indefinite. 
In  many  cases  the  apex. is  seen  displaced  downward  and  outward,  and  the 
impulse  looks  strong  and  forcible. 

Palpation  reveals  in  many  cases  a  thrill  at  the  base  of  the  heart  of  maxi- 
mum force  in  the  aortic  region.  With  no  other  condition  do  we  meet  with 
thrills  of  greater  intensity.  The  apex  beat  may  not  be  palpable  under  the 
conditions  above  mentioned,  or  there  may  be  a  slow,  heaving,  forcible  impulse. 

Percussion  never  gives  the  same  wide  area  of  dulness  as  in  aortic  insuf- 
ficiency. The  extent  of  it  depends  largely  on  the  state  of  the  lungs,  whether 
emphysematous  or  not. 

Auscultation. — A  rough  systolic  murmur,  of  maximum  intensity  at  the 


816  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

aortic  cartilage,  and  propagated  into  the  great  vessels,  is  the  most  constant 
physical  sign  in  aortic  stenosis.  One  of  the  last  lessons  learned  by  the  student 
of  physical  diagnosis  is  io  recognize  that  the  systolic  murmur  at  the  aortic 
area  does  not  necessarily  mean  obstruction  at  the  orifice.  Roughening  of  the 
valves,  or  of  the  intima  of  the  aorta,  and  hsemic  states  are  much  more  frequent 
causes.  In  aortic  stenosis  the  murmur  often  has  a  much  harsher  quality,  is 
louder,  and  is  more  frequently  musical  than  in  the  conditions  just  mentioned. 
When  compensation  fails  and  the  ventric.le  is  dilated  and  feeble,  the  murmur 
may  be  soft  and  distant.  The  second  sound  is  rarely  heard  at  the  aortic 
cartilage,  owing  to  the  thickening  and  stiffness  of  the  valve.  A  diastolic 
murmur  is  not  uncommon,  but  in  many  cases  it  can  not  be  heard.  Occasion- 
all}',  as  noted  by  W.  H.  Dickinson,  there  is  a  musical  murmur  of  greatest  in- 
tensity in  the  region  of  the  apex,  due  probably  to  a  slight  regurgitation  at  high 
pressure  through  the  mitral  valves.  The  pulse  in  pure  aortic  stenosis  is  small, 
usually  of  good  tension,  well  sustained,  regular,  and  perhaps  slower  than 
normal. 


FIG.  9. — PULSE  TRACING  IN  AORTIC  STENOSIS. 

The  condition  may  be  latent  for  an  indefinite  period,  as  long  as  the  hy- 
pertrophy is  maintained.  Early  symptoms  are  those  due  to  defective  blood 
supply  to  the  brain,  dizziness,  and  fainting.  Palpitation,  pain  about  the 
heart,  and  anginal  symptoms  are  not  so  marked  as  in  insufficiency.  With 
degeneration  of  the  heart-muscle  and  dilatation  relative  insufficiency  of  the 
mitral  valve  is  established,  and  the  patient  may  present  all  the  features  of 
engorgement  in  the  lesser  and  systemic  circulations,  with  dyspnoea,  cough, 
rusty  expectoration,  and  the  signs  of  anasarca  in  the  lower  part  of  the  body. 
Many  of  the  cases  in  old  people,  without  presenting  any  dropsy,  have  symp- 
toms pointing  rather  to  general  arterial  disease.  Cheyne-Stokes  breathing 
is  not  uncommon  with  or  without  signs  of  uraemia. 

Diagnosis. — With  an  extremely  rough  or  musical  murmur  of  maximum 
intensity  at  the  aortic  region  and  signs  of  hypertrophy  of  the  left  ventricle,  a 
thrill,  and  especially  a  hard,  slow  pulse  of  moderate  volume  and  fairly  good 
tension,  which  in  a  sphygmographic  tracing  gives  a  curve  of  slow  rise,  a 
broad,  well  sustained  summit  -and  slow  decline,  a  diagnosis  of  aortic  stenosis 
can  be  made  with  some  degree  of  certainty,  particularly  if  the  subject  is  an 
old  man.  Mistakes  are  common,  however,  and  a  roughened  or  calcified  valve 
segment,  or,  in  some  instances,  a  very  roughened  and  prominent  calcified 
plate  in  the  aorta,  and  hypertrophy  associated  with  renal  disease,  may  produce 
similar  symptoms.  Seldom  is  there  difficulty  in  distinguishing  the  murmur 
due  to  anemia,  since  it  is  rarely  so  intense  and  is  not  associated  with  thrill 
or  with  marked  hypertrophy  of  the  left  ventricle.  In  aortic  insufficiency  a 


CHRONIC    VALVULAR    DISEASE  817 

systolic  murmur  is  usually  present,  but  has  neither  the  intensity  nor  the 
musical  quality,  nor  is  it  accompanied  with  a  thrill.  With  roughening  and 
dilatation  of  the  ascending  aorta  the  murmur  may  be  very  harsh  or  musical; 
but  the  existence  of  a  second  sound,  accentuated  and  ringing  in  quality,  is 
usually  sufficient  to  differentiate  this  condition. 

MITEAL    INCOMPETENCY 

Etiology. — Insufficiency  of  the  mitral  valve  ensues:  (a)  From  changes  in 
the  segments  whereby  they  are  contracted  and  shortened,  usually  combined 
with  changes  in  the  chords  tendineae,  or  with  more  or  less  narrowing  of  the 
orifice.  (&)  As  a  result  of  changes  in  the  muscular  walls  of  the  ventricle, 
either  dilatation,  so  that  the  valve  segments  fail  to  close  an  enlarged  orifice, 
or  changes  in  the  muscular  substance,  so  that  the  segments  are  imperfectly 
coapted  during  the  systole — muscular  incompetency.  The  common  lesions 
producing  insufficiency  result  from  endocarditis,  which  causes  a  gradual  thick- 
ening at  the  edges  of  the  valves,  contraction  of  the  chordae  tendineaa,  and 
union  of  the  edges  of  the  segments,  so  that  in  a  majority  of  the  instances  there 
is  not  only  insufficiency,  but  some  grade  of  narrowing  as  well.  Except  in 
children,  we  rarely  see  the  mitral  leaflets  curled  and  puckered  without  narrow- 
ing of  the  orifice.  Calcareous  plates  at  the  base  of  the  valve  may  prevent 
perfect  closure  of  one  of  the  segments.  In  long-standing  cases  the  entire 
mitral  structures  are  converted  into  a  firm  calcareous  ring.  From  this  val- 
vular insufficiency  the  other  condition  of  muscular  incompetency  must  be 
carefully  distinguished.  It  is  met  with  in  all  conditions  of  extreme  dilata- 
tion of  the  left  ventricle,  and  also  in  weakening  of  the  muscles  in  prolonged 
fevers  and  in  anaemia. 

Morbid  Anatomy. — The  effects  of  incompetency  of  the  mitral  segment 
upon  the  heart  and  circulation  are  as  follows :  (a)  The  imperfect  closure  allows 
a  certain  amount  of  blood  to  regurgitate  from  the  ventricle  into  the  auricle, 
so  that  at  the  end  of  auricular  diastole  this  chamber  contains  not  only  the 
blood  which  it  has  received  from  the  lungs,  but  also  that  which  has  regur- 
gitated from  the  left  ventricle.  This  necessitates  dilatation,  and,  as  increased 
work  is  thrown  upon  it  in  expelling  the  augmented  contents,  hypertrophy  as 
well. 

(&)  With  each  systole  of  the  left  auricle  a  larger  volume  of  blood  is  forced 
into  the  left  ventricle,  which  also  dilates  and  subsequently  becomes  hyper- 
trophied. 

(c)  During  the  diastole  of  the  left  auricle,  as  blood  is  regurgitated  into 
it  from  the  left  ventricle,  the  pulmonary  veins  are  less  readily  emptied.     In 
consequence  the  right  ventricle  expels  its  contents  less  freely,  and  in  turn 
becomes  dilated  and  hypertrophied. 

(d)  Finally,  the  right  auricle  also  is  involved,  its  chamber  is  enlarged, 
and  its  walls  are  increased  in  thickness. 

(e)  The  effect  upon  the  pulmonary  vessels  is  to  produce  dilatation  both 
of  the  arteries  and  veins — often  in  long-standing  cases,  atheromatous  change's ; 
the  capillaries  are  distended,  and  ultimately  the  condition  of  brown  induration 
is  produced.    Perfect  compensation  may  be  effected,  chiefly  through  the  hyper- 
trophy of  both  ventricles,  and  the  effect  upon  the  peripheral  circulation  may 


818  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

not  be  manifested  for  years,  as  a  normal  volume  of  blood  is  discharged  from 
the  left  heart  at  each  systole.  The  time  comes,  however,  when,  owing  either 
to  increase  in  the  grade  of  the  incompetency  or  to  failure  of  the  compensa- 
tion, the  left  ventricle  is  unable  to  send  out  its  normal  volume  into  the  aorta. 
Then  there  are  overfilling  of  the  left  auricle,  engorgement  in  the  lesser  cir- 
culation, embarrassed  action  cf  the  right  heart,  and  congestion  in  the  sys- 
temic veins.  For  years  this  somewhat  congested  condition  may  be  limited  to 
the  lesser  circulation,  but  finally  the  right  auricle  becomes  dilated,  the  tri- 
cuspid  valves  incompetent,  and  the  systemic  veins  are  engorged.  This  grad- 
ually leads  to  the  condition  of  cyanotic  induration  in  the  viscera  and,  when 
extreme,  to  dropsical  effusion. 

Muscular  incompetency,  due  to  impaired  nutrition  of  the  mitral  and  papil- 
lary muscles,  is  rarely  followed  by  such  perfect  compensation.  There  may  be 
in  acute  destruction  of  the  aortic  segments  an  acute  dilatation  of  the  left 
ventricle  with  relative  incompetency  of  the  mitral  segments,  great  dilatation 
of  the  left  auricle,  and  intense  engorgement  of  the  lungs,  under  which  circum- 
stances profuse  haemorrhage  may  result.  In  these  cases  there  is  little  chance 
for  the  establishment  of  compensation.  In  cases  of  hypertrophy  and  dilatation 
of  the  heart,  without  valvular  lesions,  but  associated  with  heavy  work  and 
alcohol,  the  insufficiency  of  the  mitral  valve  may  be  extreme  and  lead  to  great 
pulmonary  congestion,  engorgement  of  the  systemic  veins,  and  a  condition 
of  cardiac  dropsy,  which  can  not  be  distinguished  by  any  feature  from  that 
of  mitral  incpmpetency  due  to  lesion  of  the  valve  itself.  In  chronic  Bright's 
disease  the  hypertrophy  of  the  left  ventricle  may  gradually  fail,  leading,  in 
the  later  stages,  to  relative  insufficiency  of  the  mitral  valve,  and  the  produc- 
tion of  a  condition  of  pulmonary  and  systemic  congestion,  similar  to  that  in- 
duced by  the  most  extreme  grade  of  lesion  of  the  valve  itself.  Adherent  peri- 
cardium, especially  in  children,  may  lead  to  like  results. 

Symptoms. — During  the  development  of  the  lesion,  unless  the  incom- 
petency comes  on  acutely  in  consequence  of  rupture  of  the  valve  segment  or 
of  ulceration,  the  compensatory  changes  go  hand  in  hand  with  the  defect,  and 
there  are  no  subjective  symptoms.  So,  also,  in  the  stage  of  perfect  compensa- 
tion, there  may  be  the  most  extreme  grade  of  mitral  insufficiency  with  enor- 
mous hypertrophy  of  the  heart,  yet  the  patient  may  not  be  aware  of  the  exis- 
tence of  heart  trouble,  and  may  suffer  no  inconvenience  except  perhaps  a  little 
shortness  of  breath  on  exertion  or  on  going  upstairs.  It  is  only  when  from 
any  cause  the  compensation  has  not  been  perfectly  effected,  or,  having  been 
,so,  is  broken  abruptly  or  gradually,  that  the  patients  begin  to  be  troubled.  The 
symptoms  may  be  divided  into  two  groups : 

(a)  The  minor  manifestations  while  compensation  is  still  good.  Patients 
with  extreme  incompetency  often  have  a  congested  appearance  of  the  face, 
the  lips  and  ears  have  a  bluish  tint,  and  the  venules  on  the  cheeks  may  be 
enlarged — signs  in  many  cases  very  suggestive.  In  long  standing  cases,  par- 
ticularly in  children,  the  fingers  may  be  clubbed,  and  there  is  shortness  of 
breath  on  exertion.  This  is  one  of  the  most  constant  features  in  mitral  in- 
sufficiency and  may  exist  for  years,  even  when  the  compensation  is  perfect. 
Owing  to  the  somewhat  congested  condition  of  the  lungs  these  patients  have 
a  tendency  to  attacks  of  bronchitis  or  haemoptysis.  There  may  also  be  palpi- 
tation of  the  heart.  As  a  rule,  however,  in  well  balanced  lesions-  in  adults, 


CHRONIC   VALVULAR   DISEASE  819 

this  period  of  full  compensation  or  latent  stage  is  not  associated  with  symp- 
toms which  call  the  attention  to  an  affection  of  the  heart,  and  with  care  the 
patient  may  reach  old  age  in  comparative  comfort  without  being  compelled 
to  curtail  seriously  his  pleasures  or  his  work. 

(&)  Sooner  or  later  comes  a  period  of  disturbed  or  broken  compensation, 
in  which  the  most  intense  symptoms  are  those  of  venous  engorgement.  There 
are  palpitation,  weak,  irregular  action  of  the  heart,  and  signs  of  dilatation. 
Dyspnoea  is  an  especial  feature,  and  there  may  be  cough.  A  distressing  synlp- 
tom  is  the  cardiac  "sleep-start,"  in  which,  just  as  the  patient  falls  asleep,  he 
wakes  gasping  and  feeling  as  if  the  heart  were  stopping.  There  is  usually  a 
slight  cyanosis,  and  even  a  jaundiced  tint  to  the  skin.  The  most  marked 
symptoms,  however,  are  those  of  venous  stasis.  The  overfilling  of  the  pul- 
monary vessels  accounts  in  part  for  the  dyspnoea.  There  is  cough,  often  with 
bloody  or  watery  expectoration,  and  the  alveolar  epithelium  containing  brown 
pigment-grains  is  abundant.  Dropsical  effusion  usually  sets  in,  beginning  in 
the  feet  and  extending  to  the  body  and  the  serous  sacs.  Right  sided  hydro- 
thorax  may  recur  and  require  repeated  tapping.  The  urine  is  usually  scanty 
and  albuminous,  and  contains  tube  casts  and  sometimes  blood  corpuscles. 
With  judicious  treatment  the  compensation  may  be  restored  and  all  the  serious 
symptoms  may  pass  away.  Patients, usually  have  recurring  attacks  of  this 
kind,  and  die  of  a  general  dropsy;  or  there  is  progressive  dilatation  of  the 
heart,  and  death  from  asystole.  Sudden  death  in  these  cases  is  rare.  Some 
cases  of  mitral  disease — stenosis  and  insufficiency — reach  what  may  be  called 
the  hepatic  stage,  when  all  the  symptoms  are  due  to  the  secondary  changes  in 
the  liver. 

PHYSICAL  SIGNS. — Inspection. — In  children  the  prsecordia  may  bulge  and 
there  may  be  a  large  area  of  visible  pulsation.  The  apex  beat  is  to  the  left 
of  the  nipple,  in  some  cases  in  the  sixth  interspace,  in  the  anterior  axillary 
line.  A  localized  right  ventricle  impulse  may  sometimes  be  seen  below  the 
right  costal  border  in  the  parasternal  line.  There  may  be  a  wavy  impulse  in 
the  cervical  veins,  which  are  often  full,  particularly  when  th.fi  patient  is 
recumbent. 

Palpation. — A  thrill  is  rare;  when  present  it  is  felt  at  the  apex,  often  in 
a  limited  area.  The  force  of  the  impulse  may  depend  largely  upon  the  stage 
in  which  the  case  is  examined.  In  full  compensation  it  is  forcible  and  heav- 
ing; when  the  compensation  is  disturbed,  usually  wavy  and  feeble. 

Percussion. — The  dulness  is  increased,  particularly  in  a  lateral  direction. 
There  is  no  disease  of  the  valves  which  produces,  in  long  standing  cases,  a 
more  extensive  transverse  area  of  heart  dulness.  It  does  not  extend  so  much 
upward  along  the  left  margin  of  the  sternum  as  beyond  the  right  margin  and 
to  the  left  of  the  nipple  line. 

Auscultation. — At  the  apex  there  is  a  systolic  murmur  which  wholly  or 
partly  obliterates  the  first  sound.  It  is  loudest  here,  and  has  a  blowing,  some- 
times musical  character,  particularly  toward  the  latter  part.  The  murmur  is 
transmitted  to  the  axilla  and  may  be  heard  at  the  back,  in  some  instances 
over  the  entire  chest.  There  are  cases  in  which,  as  pointed  out  by  Naunyn, 
the  murmur  is  heard  best  along  the  left  border  of  the  sternum.  Usually  in 
diastole  at  the  apex  the  loudly  transmitted  second  sound  may  be  heard.  Occa- 
sionally there  is  also  a  soft,  sometimes  a  rough  or  rumbling  presystolic  mur- 


820  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

mur.  As  a  rule,  in  cases  of  extreme  mitral  insufficiency  from  valvular  lesion 
with  great  hypertrophy  of  both  ventricles,  there  is  heard  only  a  loud  blowing 
murmur  during  systole.  A  murmur  of  mitral  insufficiency  may  vary  a  great 
deal  according  to  the  position  of  the  patient.  It  may  be  present  in  the  recum- 
bent and  absent  in  the  erect  posture.  In  cases  of  dilatation,  particularly  when 
dropsy  is  present,  there  may  be  heard  at  the  ensiform  cartilage  and  in  the 
lower  sternal  region  a  soft  systolic  murmur  due  to  tricuspid  regurgitation. 
An  important  sign  on  auscultation  is  the  accentuated  pulmonary  second  sound. 
This  is  heard  to  the  left  of  the  sternum  in  the  second  interspace,  or  over  the 
third  left  costal  cartilage. 

The  pulse  in  mitral  insufficiency,  during  the  period  of  full  compensation, 
may  be  full  and  regular,  often  of  low  tension.  Usually  with  the  first  onset 
of  the  symptoms  the  pulse  becomes  irregular,  a  feature  which  then  dominates 
the  case  throughout.  There  may  be  no  two  beats  of  equal  force  or  volume. 
Often  after  the  disappearance  of  the  symptoms  of  failure  of  compensation  the 
irregularity  of  the  pulse  persists. 

The  three  important  physical  signs  then  of  mitral  regurgitation  are :  (a) 
Systolic  murmur  of  maximum  intensity  at  the  apex,  which  is  propagated  to 
the  axilla  and  heard  at  the  angle  of  the  scapula;  (6)  accentuation  of  the  pul- 
monary second  sound;  (c)  evidence  of  enlargement  of  the  heart,  particularly 
the  increase  in  the  transverse  diameter,  due  to  hypertrophy  of  both  right  and 
left  ventricles. 

Diagnosis. — There  is  rarely  any  difficulty  in  the  diagnosis  of  mitral  insuf- 
ficiency. The  physical  signs  just  referred  to  are  quite  characteristic  and 
distinctive.  Two  points  are  to  be  borne  in  mind.  First,  a  murmur,  systolic 
in  character,  and  of  maximum  intensity  at  the  apex,  and  propagated  even  to 
the  axilla,  does  not  necessarily  indicate  incompetency  of  the  mitral  valve. 
There  is  heard  in  this  region  a  large  group  of  what  are  termed  accidental 
murmurs,  the  precise  nature  of  which  is  still  doubtful.  They  are  probably 
formed,  however,  in  the  ventricle,  and  are  not  associated  with  hypertrophy, 
or  accentuation  of  the  pulmonary  second  sound. 

Second,  it  is  not  always  possible  to  say  whether  the  insufficiency  is  due 
to  lesion  of  the  valve  segment  or  to  dilatation  of  the  mitral  ring  and  rela- 
tive incompetency.  Here  neither  the  character  of  the  murmur,  the  propa- 
gation, the  accentuation  of  the  pulmonary  second  sound,  nor  the  hypertrophy 
assists  in  the  differentiation.  The  history  is  sometimes  of  greater  value  in  this 
matter  than  the  physical  examination.  The  cases  most  likely  to  lead  to  error 
are  those  of  the  so-called  idiopathic  dilatation  and  hypertrophy  of  the  heart 
(in  which  the  systolic  murmur  may  be  of  the  greatest  intensity),  and  the 
instances  of  arterio-sclerosis  with  dilated  heart.  Balfour  and  others,  however, 
maintain  that  organic  disease  of  the  mitral  leaflets  sufficient  to  produce  in- 
competency is  always  accompanied  with  a  certain  degree  of  narrowing  of  the 
orifice,  so  that  the  only  unequivocal  proof  of  the  actual  disease  of  the  mitral 
valve  is  the  presence  of  a  presystolic  murmur. 

MITEAL   STENOSIS 

Etiology. — There  are  two  groups  of  cases,  one  following  an  acute  endo- 
carditis, the  other  the  result  of  a  slow  sclerosis  of  the  valves  without  any 


CHRONIC    VALVULAR    DISEASE  821 

history  of  rheumatic  fever  or  other  infection.  It  is  very  much  more  common 
in  women  than  in  men — in  63  of  /80  cases  noted  by  Duckworth,  while  in  4,791 
autopsies  at  Guy's  Hospital  during  ten  years  there  were  196  cases,  of  which 
107  were  females  and  89  males  (Samways).  This  is  not  easy  to  explain,  but 
there  are  at  least  two  factors  to  be  considered.  Rheumatism  prevails  more  in 
girls  than  in  boys,  and,  as  is  well  known,  endocarditis  of  the  mitral  valve  is 
more  common  in  rheumatism.  Chorea,  also,  as  suggested  by  Barlow,  has  an 
important  influence,  occurring  more  frequently  in  girls  and  being  often  asso- 
ciated with  endocarditis.  Anaemia  and  chlorosis,  which  are  prevalent  in  girls, 
have  been  regarded  as  possible  factors.  In  a  surprising  number  of  cases  of 
what  the  French  call  pure  mitral  stenosis  no  recognizable  etiological  factor 
can  be  discovered.  This  has  been  regarded  by  some  writers  as  favoring  the 
view  that  they  may  be  of  congenital  origin,  but  congenital  affections  of  the 
mitral  valve  are  notoriously  rare.  Whooping-cough,  with  its  terrible  strain 
on  the  heart-valves,  may  be  accountable  for  certain  cases.  While  met  with  at 
all  ages,  stenosis  is  certainly  most  frequent  in  young  adult  women. 

Morbid  Anatomy. — The  valve  segments  and  chordae  may  be  fused  together, 
the  result  of  repeated  attacks  of  endocarditis.  The  condition  varies  a  good 
deal,  according  to  the  amount  of  atheromatous  change.  In  many  cases  the 
curtains  are  so  welded  together  and  the  whole  valvular  region  so  thickened 
that  the  orifice  is  reduced  to  a  mere  chink — Corrigan's  button-hole  contrac- 
tion. In  non-endocarditic  cases  the  curtains  are  not  much  thickened,  but 
narrowing  has  resulted  from  gradual  adhesion  at  the  edges,  and  thickening  of 
the  chordae  tendineae,  so  that  from  the  auricle  it  looks  cone  like — the  so-called 
funnel  shaped  variety  of  stenosis.  The  instances  in  which  the  valve  segments 
are  very  slightly  deformed,  but  in  which  the  orifice  is  considerably  narrowed, 
are  regarded  by  some  as  possibly  of  congenital  origin.  Occasionally  the  cur- 
tains are  in  great  part  free  from  disease,  but  the  narrowing  results  from 
large  calcareous  masses,  which  project  into  them  from  the  ring.  The  in- 
volvement of  the  chordae  tendineae  is  usually  extreme,  and  the  papillary 
muscles  may  be  inserted-  directly  upon  the  valve.  In  moderate  grades  of  con- 
striction the  orifice  will  admit  the  tip  of  the  index  finger;  in  more  extreme 
forms  the  tip  of  the  little  finger;  and  occasionally  one  meets  with  a  specimen 
in  which  the  orifice  seems  almost  obliterated,  admitting  only  a  medium  sized 
probe.  The  heart  is  not  greatly  enlarged,  rarely  weighing  more  than  14  or 
15  ounces.  Occasionally,  in  an  elderly  person,  it  may  seem  only  slightly,  if 
at  all,  enlarged,  and  again  there  are  instances  in  which  the  weight  may  reach 
as  much  as  20  ounces.  The  left  ventricle  is  usually  small,  and  may  look  very 
small  in  comparison  with  the  right  ventricle,  which  forms  the  greater  portion 
of  the  apex.  In  cases  in  which  with  the  narrowing  there  is  very  considerable 
incompetency  the  left  ventricle  may  be  moderately  dilated  and  hypertrophied. 

It  is  not  uncommon  at  the  examination  to  find  white  thrombi  in  the 
appendix  of  the  left  auricle.  Occasionally  a  large  part  of  the  auricle  is  occu- 
pied by  an  ante-mortem  thrombus.  Still  more  rarely  the  remarkable  ball 
thrombus  is  found,  in  which  a  globular  concretion,  varying  in  size  from  a 
walnut  to  a  small  egg,  lies  free  in  the  auricle,  two  examples  of  which  have 
come  under  my  observation. 

The  left  auricle  discharges  its  blood  with  greater  difficulty  and  in  conse- 
quence dilates,  and  its  walls  reach  three  or  four  times  their  normal  thickness. 


822  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

| 

Although  the  auricle  is  by  structure  unfitted  to  compensate  an  extreme  lesion, 
the  probability  is  that  for  some  time  during  |he  gradual  production  of  stenosis 
the  increasing  muscular  power  of  the  walls  is  sufficient  to  counterbalance  the 
defect.  In  36  cases  of  well-marked  stenosis  Samways  found  the  auricle  hyper- 
trophied  in  26,  dilatation  coexisting  in  14.  Eventually  the  tension  is  increased 
in  the  pulmonary  circulation,  owing  to  impeded  outflow  from  the  veins  and 
this  to  heightened  pressure  in  the  pulmonary  artery.  Extra  work  is  thus 
thrown  on  the  right  ventricle,  which  gradually  hypertrophies.  Relative  incom- 
petency  of  the  tricuspid  and  congestion  of  the  systemic  veins  at  last  supervene. 

Symptoms. — PHYSICAL  SIGNS. — Inspection. — In  children  the  lower  ster- 
num and  the  fifth  and  sixth  left  costal  cartilages  are  often  prominent,  owing 
to  hypertrophy  of  the  right  ventricle.  The  apex  beat  may  be  ill  defined.  Usu- 
ally it  is  not  dislocated  far  beyond  the  nipple  line,  and  the  chief  impulse  is 
over  the  lower  sternum  and  adjacent  costal  cartilages.  Often  in  thin  chested 
persons  there  is  pulsation  in  the  third  and  fourth  left  interspaces  close  to 
the  sternum.  When  compensation  fails,  the  prsecordial  impulse  is  much 
feebler,  and  in  the  veins  of  the  neck  there  may  be  marked  systolic  regurgi- 
tation  or  the  right' jugular  near  the  clavicle  may  stand  out  as  a  prominent 
tumor.  In  the  later  stage  there  is  great  enlargement  with  pulsation  of  the 
liver  or  pulmonary  pulsation  seen  in  the  intercostal  spaces. 

Palpation  reveals  in  a  majority  of  the  cases  a  characteristic,  well  defined 
fremitus  or  thrill,  which  is  best  felt,  as  a  rule,  in  the  fourth  or  fifth  inter- 
space within  the  nipple  line.  It  is  of  a  rough,  grating  quality,  often  pecu- 
liarly limited  in  area,  most  marked  during  expiration,  and  can  be  felt  to  ter- 
minate in  a  sharp,  sudden  shock,  synchronous  with  the  impulse.  This  most 
characteristic  of  physical  signs  is  pathognomonic  of  narrowing  of  the  mitral 
orifice,  and  is,  perhaps  the  only  instance  in  which  the  diagnosis  of  a  valvular 
lesion  can  be  made  by  palpation  alone.  The  cardiac  impulse  is  felt  most 
forcibly  in  the  lower  sternum  and  in  the  fourth  and  fifth  left  interspaces.  The 
impulse  is  felt  very  high  in  the  third  and  fourth  interspaces,  or  in  rare  cases 
even  in  the  second,  and  it  has  been  thought  that  in  the  latter  interspace  the 
impulse  is  due  to  pulsation  of  the  auricle.  It  is  always  the  impulse  of  the 
conus  arteriosus  of  the  right  ventricle;  even  in  the  most  extreme  grades  of 
mitral  stenosis  there  is  never  such  tilting  forward  of  the  auricle  or  its  appen- 
dix as  would  enable  it  to  produce  an  impression  on  the  chest  wall. 

Percussion  gives  an  increase  in  the  cardiac  dulness  to  the  right  of  the 
sternum  and  along  the  left  margin;  not  usually  a  great  increase  beyond  the 
nipple  line,  except  in  extreme  cases,  when  the  transverse  dulness  may  reach 
from  5  cm.  beyond  the  right  margin  of  the  sternum  to  10  cm.  beyond  the 
nipple  line. 

Auscultation. — To  the  inner  side  of  the  apex  beat,  often  in  a  very  limited 
region,  there  is  heard  a  rough,  vibratory  or  purring  murmur,  cumulative  or 
crescendo  in  character,  which  terminates  abruptly  in  the  first  sound.  By 
combining  palpation  and  auscultation  the  purring  murmur  is  found  to  be  syn- 
chronous with  the  thrill  and  the  loud  shock  with  the  first  sound.  The  mur- 
mur is  auricular  systolic,  due  to  the  blood  passing  through  the  narrow  orifice. 
Some  have  thought  it  to  be  early  systolic  in  time,  but  the  majority  of  ob- 
. servers  hold  to  the  former  view  with  Gairdner.  The  presystolic  murmur  may 
occupy  the  entire  period  of  the  diastole,  or  the  middle  or  only  the  latter  half, 


CHRONIC    VALVULAR   DISEASE  823 

corresponding  to  the  auricular  systole.  The  difference  may  sometimes  be 
noted  between  the  first  and  second  portions  of  the  murmur,  when  it  occupies 
the  entire  time.  Often  there  is  a  peculiar  rumbling  or  echoing  quality,  which 
in  some  instances  is  very  limited  and  may  be  heard  only  over  a  single  bell- 
space  of  the  stethoscope.  A  rumbling,  echoing  presystolic  murmur  at  the  apex 
is  heard  in  some  cases  of  aortic  insufficiency  (Flint  murmur),  occasionally 
in  adherent  pericardium  with  great  dilatation  of  the  heart,  and  in  upward 
dislocation  of  the  organ. 

A  systolic  murmur  may  be  heard  at  the  apex  or  along  the  left  sternal 
border,  often  of  extreme  softness  and  audible  only  when  the  breath  is  held. 
Sometimes  the  systolic  murmur  is  loud  and  distinct  and  is  transmitted  to 
the  axilla.  The  second  sound  in  the  second  left  interspace  is  loudly  accentu- 
ated, and  often  reduplicated.  It  may  be  transmitted  far  to  the  left  and  be 
heard  with  great  clearness  beyond  the  apex.  In  uncomplicated  cases  of  mitral 
stenosis  there  are  usually  no  murmurs  audible  at  the  aortic  region,  at  which 
spot  the  second  sound  is  less  intense  than  at  the  pulmonary  area.  In  advanced 
cases  at  the  lower  sternum  and  to  the  right  a  systolic  tricuspid  murmur  is 
1  sometimes  heard.  Other  points  to  be  noted  are  the  following :  The  unusually 
sharp,  clear  first  sound  which  follows  the  presystolic  murmur,  the  cause  of 
which  is  by  no  means  easy  to  explain.  It  can  scarcely  be  a  valvular  sound 
produced  chiefly  at  the  mitral  orifice,  since  it  may  be  heard  with  great  intensity 
in  cases  in  which  the  valves  are  rigid  and  calcified.  It  has  been  suggested  by 
A.  E.  Sansom  and  others  that  it  is  a  loud  "snap"  of  the  tricuspid  valves 
caused  by  the  powerful  contraction  of  the  greatly  hypertrophied  right  ven- 
tricle. Broadbent  thinks  it  may  be  due  to  the  abrupt  contraction  of  a  partially 
filled  left  ventricle.  The  valvular  sound  may  be  audible  at  a  distance,  as  one 
sits  at  the  bedside  of  the  patient  (Graves).  In  a  patient  I  saw  with  C.  J. 
Blake  the  first  sound  was  audible  six  feet,  by  measurement,  from  the  chest 
wall. 

These  physical  signs,  it  is  to  be  borne  in  mind,  are  characteristic  only 
of  the  stage  in  which  compensation  is  maintained.  The  murmur  may  be 
soft,  almost  inaudible,  and  only  brought  out  after  exertion.  Finally  there 
comes  a  period  in  which,  with  the  establishment  of  auricular  fibrillation,  the 
presystolic  murmur  disappears  and  there  is  heard  in  the  apex  region  a  sharp 
first  sound,  or  sometimes  a  gallop  rhythm.  The  marked  systolic  shock  may 
be  present  after  the  disappearance  of  the  thrill  and  the  characteristic  mur- 
mur. Under  treatment,  with  gradual  recovery  of  compensation,  probably 
with  increasing  vigor  of  contraction  of  the  right  ventricle  and  left  auricle, 
the  presystolic  murmur  reappears.  In  cases  seen  at  this  stage  of  the  disease 
the  nature  of  the  valve  lesion  may  be  entirely  overlooked.  As  Mackenzie  and 
Lewis  have  shown,  auricular  fibrillation  is  the  rule  in  the  arrhythmia  of 
mitral  stenosis. 

Stenosis  of  the  mitral  valve  may,  for  years  be  efficiently  compensated  by 
the  hypertrophy  of  the  right  ventricle.  Many  persons  with  the  characteristic 
physical  signs  of  this  lesion  present  no  symptoms.  They  may 'for  years  per- 
haps be  short  of  breath  on  going  upstairs,  but  are  able  to  pass  through  the 
ordinary  duties  of  life  without  discomfort.  The  pulse  is  smaller  in  volume 
than  normal,  and  very  often  irregular.  A  special  danger  of  this  stage  is  the 
recurring  endocarditis.  Vegetations  may  be  whipped  off  into  the  circulation 


824  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

and,  blocking  a  cerebral  vessel,  may  cause  hemiplegia  or  aphasia,  or  both. 
This,  unfortunately,  is  not  an  uncommon  sequence  in  women.  Patients  with 
mitral  stenosis  may  survive  this  accident  for  an  indefinite  period.  A  woman, 
above  seventy  years  of  age,  died  in  one  of  my  wards  at  the  Philadelphia  Hos- 
pital, who  had  been  in  the  almshouse,  hemiplegic,  for  more  than  thirty  years. 
The  heart  presented  an  extreme  grade  of  mitral  stenosis  which  had  probably 
existed  at  the  time  of  the  hemiplegic  attack. 

Pressure  of  the  enlarged  auricle  on  the  left  recurrent  laryngeal  nerve1, 
causing  paralysis  of  the  vocal  cord  on  the  corresponding  side,  has  been  de- 
scribed by  Ortner  and  by  Herrick.  It  is  a  point  to  be  borne  in  mind,  as  the 
diagnosis  of  aneurism  of  the  arch  of  the  aorta  may  be  made.  On  the  other 
hand,  Fetterolf  and  Norris  conclude  that  it  is  not  the  pressure  of  the  left 
auricle  directly,  but  the  squeezing  of  the  nerve  between  the  pulmonary  artery 
and  the  aortic  arch,  and  that  the  paralysis  is  due  to  the  neuritis  so  excited. 

Failure  of  compensation  brings  in  its  train  the  group  of  symptoms  which 
have  been  discussed  under  cardiac  insufficiency.  Briefly  enumerated,  they  are : 
Rapid  and  irregular  action  of  the  heart,  shortness  of  breath,  cough,  signs  of 
pulmonary  engorgement,  and  very  frequently  hemoptysis.  Attacks  of  this- 
kind  may  recur  for  years.  Bronchitis  or  a  febrile  attack  may  cause  shortness 
of  breath  or  slight  blueness.  Inflammatory  affections  of  the  lungs  or  pleura 
seriously  disturb  the  right  heart,  and  these  patients  stand  pneumonia  very 
badly.  -  Many,  perhaps  a  majority  of,  cases  of  mitral  stenosis  do  not  have 
dropsy.  The  liver  may  be  greatly  enlarged,  and  in  the  late  stages  ascites  is 
not  uncommon,  particularly  in  children.  General  anasarca  is  most  frequently 
met  with  in  those  cases  in  which  there  is  secondary  narrowing  of  the  tricuspid 
orifice  (Broadbent). 

TRICUSPID    VALVE    DISEASE 

Tricuspid  Regurgitation. — Occasionally  this  results  from  acute  or  chronic 
endocarditis  with  puckering;  more  commonly  the  condition  is  one  of  rela- 
tive insufficiency,  and  is  secondary  to  lesions  of  the  valves  on  the  left  side, 
particularly  of  the  mitral.  It  is  met  with  also  in  all  conditions  of  the  lungs 
which  cause  obstruction  to  the  circulation,  such  as  cirrhosis  and  emphysema, 
particularly  in  combination  with  chronc  bronchitis.  The  symptoms  are  those 
of  obstruction  in  the  lesser  circulation  with  venous  congestion  in  the  systemic 
veins,  such  as  has  already  been  described  in  connection  with  mitral  insuffi- 
ciency. The  signs  of  this  condition  are: 

(a)  Systolic  regurgitation  of  the  blood  into  the  right  auricle  and  the 
transmission  of  the  .pulse  wave  into  the  veins  of  the  neck.  If  the  regurgita- 
tion is  slight  or  the  contraction  of  the  ventricle  is  feeble  there  may  be  no 
venous  throbbing,  but  in  other  cases  there  is  marked  systolic  pulsation  in  the 
cervical  veins.  That  in  the  right  jugular  is  more  forcible  than  that  in  the 
left.  It  may  be  seen  both  in  the  internal  and  the  external  vein,  particularly 
in  the  latter.  Marked  pulsation  in  these  veins  occurs  only  when  the  valves 
guarding  them  become  incompetent.  Slight  oscillations  are  by  no  means  un- 
common, even  when  the  valves  are  intact.  The  distention  is  sometimes  enor- 
mous, particularly  in  the  act  of  coughing,  when  the  right  jugular  at  the  root 
of  the  neck  may  stand  out,  forming  an  extraordinarily  prominent  ovoid  mass. 
Occasionally  the  regurgitant  pulse  wave  may  be  widely  transmitted  and  be 


CHRONIC    VALVULAR    DISEASE  825 

seen  in  the  subclavian  and  axillary  veins,  and  even  in  the  subcutaneous  veins 
over  the  shoulder,  or  in  the  superficial  mammary  veins. 

Regurgitant  pulsation  through  the  tricuspid  orifice  may  be  transmitted 
to  the  inferior  cava,  and  so  to  the  hepatic  veins,  causing  a  systolic  distention 
of  the  liver.  This  is  best  appreciated  by  bimanual  palpation,  placing  one  hand 
over  the  fifth  and  sixth  costal  cartilages  and  the  other  in  the  lateral  region 
of  the  liver  in  the  mid-axillary  line.  The  rhythmical  expansile  pulsation  may 
be  readily  distinguished,  as  a  rule,  from  the  systolic  depression  of  the  liver 
due  to  communicated  pulsation  from  the  left  ventricle. 

(6)  The  second  important  sign  of  tricuspid  regurgitation  is  the  occur- 
rence of  a  systolic  murmur  of  maximum  intensity  in  the  lower  sternum.  It 
is  usually  a  soft,  low  murmur,  often  to  be  distinguished  from  a  coexisting 
mitral  murmur  by  differences  in  quality  and  pitch,  and  may  be  heard  to  the 
right  as  far  as  the  axilla.  Sometimes  it  is  very  limited  in  its  distribution. 

Together  these  two  signs  positively  indicate  tricuspid  regurgitation.  In 
addition,  the  percussion  usually  shows  increase  in  the  area  of  dulness  to  the 
right  of  the  sternum,  and  the  impulse  in  the  lower  sternal  region  is  forcible. 
In  the  great  majority  of  cases  the  symptoms  are  those  of  the  associated  lesions. 
In  cirrhosis  of  the  lung  and  in  chronic  emphysema  the  failure  of  compensation 
of  the  right  ventricle  with  insufficiency  of  the  tricuspid  not  infrequently  leads 
either  to  acute  asystole  or  to  gradual  failure  with  cardiac  dropsy. 

Tricuspid  Stenosis. — The  condition  is  rare  both  clinically  and  anatomi- 
cally, and  it  is  not  often  recognized  during  life.  Of  26,000  medical  admissions 
in  the  Johns  Hopkins  Hospital  there  were  only  8  with  either  clinical  or  post 
mortem  diagnosis  of  this  condition;  and  in  a  total  of  3,500  autopsies,  only  5 
cases  were  found,  all  in  females.  Of  a  total  of  195  collected  cases,  there  were 
141  females,  38  males,  16  sex  unknown.  In  a  majority  of  the  cases — 104 — the 
mitral  and  tricuspid  were  affected  together,  in  14  the  tricuspid  alone,  in  64 
the  tricuspid  and  aortic.  A  definite  history  of  rheumatism  was  present  in  only 
66  cases  (Futcher). 

The  diagnosis  is  not  often  made;  extreme  cyanosis  and  dyspnoea  are 
common,  and  toward  the  end  the  ordinary  signs  of  cardiac  failure.  Among 
the  important  physical  signs  are  presystolic  pulsation  in  the  jugular  veins 
and  in  the  enlarged  liver.  A  presystolic  thrill  may  be  felt  at  the  tricuspid 
area  with  a  marked  systolic  shock.  The  cardiac  dulness  is  greatly  increased 
to  the  right,  a  rumbling  presystolic  murmur  may  be  present  over  the  lower 
sternum  with  an  extension  to  the  right  border.  This,  with  a  very  snappy 
first  sound,  great  increase  of  dulness  to  the  right,  and  chronic  breathless- 
ness  with  cyanosis,  are  the  important  features. 

PULMONARY    VALVE    DISEASE 

MURMURS  in  the  region  of  the  pulmonary  valves  are  extremely  common; 
lesions  of  the  valves  are  exceedingly  rare.  Balfour  has  well  called  the  pul- 
monic  area  the  region  of  auscultatory  romance.  A  systolic  murmur  is  heard 
here  under  many  conditions — (1)  very  often  in  health,  in  thin  chested  per- 
sons, particularly  in  children,  during  expiration  and  in  the  recumbent  pos- 
ture; (2)  when  the  heart  is  acting  rapidly,  as  in  fever  and  after  exertion; 
(3)  it  is  a  favorite  situation  of  the  cardio-respiratory  murmur;  (4)  in  anaemic 
54 


826  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

states;  and  (5),  as  mentioned  previously,  the  systolic  murmur  of  mitral  in- 
sufficiency may  be  transmitted  along  the  left  sternal  margin.  Actual  lesions 
of  the  valves  of  the  pulmonary  artery  are  rare. 

Stenosis  is  almost  invariably  a  congenital  anomaly.  It  constitutes  one 
of  the  most  important  of  the  congenital  cardiac  affections.  The  valve  seg- 
ments are  usually  united,  leaving  a  small,  narrow  orifice.  In  adults  cases 
occasionally  occur.  The  congenital  lesion  is  commonly  associated  with  patency 
of  the  ductus  Botalli  and  imperfection  of  the  ventricular  septum.  There 
may  also  be  tricuspid  stenosis.  Acute  endocarditis  not  infrequently  attacks 
the  sclerotic  valves. 

The  physical  signs  are  extremely  uncertain.  There  may  be  a  systolic  mur- 
mur with  a  thrill  heard  best  to  the  left  of  the  sternum  in  the  second  inter- 
costal space.  This  murmur  may  be  very  like  a  murmur  of  aortic  stenosis,  but 
is  not  transmitted  into  the  vessels.  Naturally  the  pulmonary  second  sound  is 
weak  or  obliterated,  or  may  be  replaced  by  a  diastolic  murmur.  Usually  there 
is  hypertrophy  of  the  right  heart. 

Pulmonary  Insufficiency. — This  rare  affection  is  occasionally  due  to  con- 
genital malformation,  particularly  fusion  of  two  of  the  segments.  It  is  some- 
times present,  as  Bramwell  has  shown,  in  cases  of  malignant  endocarditis. 
Barie  has  collected  58  cases. 

The  physical  signs  are  those  of  regurgitation  into  the  right  ventricle, 
but,  as  a  rule,  it  is  difficult  to  differentiate  the  murmur  from  that  of  aortic 
insufficiency,  though  the  maximum  intensity  may  be  in  the  pulmonary  area. 
The  absence  of  the  vascular  features  of  aortic  insufficiency  is  the  most  sug- 
gestive feature.  Both  Gibson  and  Graham  Steell  have  called  attention  to  the 
possibility  of  leakage  through  these  valves  in  cases  of  great  increase  of  pres- 
sure in  the  pulmonary  artery,  and  to  a  soft  diastolic  murmur  heard  under  these 
circumstances,  which  Steell  calls  "the  murmur  of  high  pressure  in  the  pul- 
monary artery." 

COMBINED    VALVULAE   LESl'ONS 

Valvular  lesions  are  seldom  single  or  pure;  combined  lesions  are  more 
common.  This  is  particularly  the  case  in  congenital  disease.  In  young  chil- 
dren mitral  and  aortic  lesions,  the  result  of  rheumatic  fever,  are  common. 
Pure  mitral  insufficiency  and  pure  mitral  stenosis  may  exist  for  years,  but 
in  time  the  tricuspid  becomes  involved,  at  first  in  sclerosis  and  later  narrow- 
ing of  the  orifice.  Aortic  valve  lesions  are  more  commonly  uncombined  than 
mitral  lesions.  The  added  lesion  may  be  hurtful  or  helpful.  The  stenosis 
which  so  often  accompanies  the  endocarditic  variety  may  lessen  the  regurgi- 
tation in  aortic  insufficiency ;  and  a  progressive  narrowing  of  the  mitral  orifice 
may  be  beneficial  in  mitral  regurgitation. 

Prognosis  in  Valvular  Disease. — The  question  is  entirely  one  of  efficient 
compensation.  So  long  as  this  is  maintained  the  patient  may  suffer  no  incon- 
venience, and  even  with  the  most  serious  forms  of  valve  lesion  the  function 
of  the  heart  may  be  little,  if  at  all,  disturbed. 

Practitioners  who  are  not  adepts  in  auscultation  and  feel  unable  to  esti- 
mate the  value  of  the  various  heart  murmurs  should  remember  that  the  best 
judgment  of  the  conditions  may  be  gathered  from  inspection  and  palpation. 


CHRONIC    VALVULAK    DISEASE  827 

With  an  apex  beat  in  the  normal  situation  and  regular  in  rhythm  the  ausculta- 
tory  phenomena  may  be  practically  disregarded. 

A  murmur  per  se  is  of  little  or  no  moment  in  determining  the  prognosis 
in  any  given  case.  There  is  a  large  group  of  patients  who  present  no  other 
symptoms  than  a  systolic  murmur  heard  over  the  body  of  the  heart,  or  over 
the  apex,  in  whom  the  left  ventricle  is  not  hypertrophied,  the  heart  rhythm 
is  normal,  and  who  may  not  have  had  rheumatism.  Indeed,  the  condition  is 
accidentally  discovered,  often  during  examination  for  life  insurance.  Among 
the  conditions  influencing  prognosis  are : 

(a)  AGE. — Children  under  ten  are  bad  subjects.  Compensation  is  well 
effected,  and  they  are  free  from  many  of  the  influences  which  disturb  com- 
pensation in  adults.  The  coronary  arteries  are  healthy,  and  nutrition  of  the 
heart  muscle  can  be  readily  maintained.  Yet,  in  spite  of  this,  the  outlook  in 
cardiac  lesions  developing  in  very  young  children  is  usually  bad.  One  reason 
is  that  the  valve  lesion  itself  is  apt  to  be  rapidly  progressive,  and  the  limit  of 
cardiac  reserve  force  is  in  such  cases  early  reached.  There  seems  to  be  pro- 
portionately a  greater  degree  of  hypertrophy  and  dilatation.  Among  other 
causes  of  the  risks  of  this  period  are  to  be  mentioned  insufficient  food  in  the 
poorer  classes,  the  recurrence  of  rheumatic  attacks,  and  the  existence  of  peri- 
cardial  adhesions.  The  outlook  in  a  child  who  can  be  carefully  supervised 
and  prevented  from  damaging  himself  by  overexertion  is  naturally  better  than 
in  one  who  is  constantly  overtasking  his  muscles.  The  valvular  lesions  which 
occur  at,  or  subsequent  to,  the  period  of  puberty  are  more  likely  to  be  per- 
manently and  efficiently  compensated.  Sudden  death  from  heart  disease  is 
very  rare  in  children. 

(6)  SEX. — Women  bear  valve  lesions,  as  a  rule,  better  than  men,  owing 
partly  to  the  fact  that  they  live  quieter  lives,  partly  to  the  less  common  in- 
volvement of  the  coronary  arteries,  and  to  the  greater  frequency  of  mitral 
lesions.  Pregnancy  and  parturition  are  disturbing  factors,  but  are,  I  think, 
less  serious  than  some  writers  would  have  us  believe. 

(c)  VALVE  AFFECTED. — The  relative  prognosis  of  the  different  valve  le- 
sions is  very  difficult  to  estimate.  Each  case  must,  therefore,  be  judged  on  its 
own  merits.  Aortic  insufficiency  is  unquestionably  the  most  serious;  yet  for 
years  it  may  be  perfectly  compensated.  Favorable  circumstances  in  any  case 
are  the  moderate  grade  of  hypertrophy  and  dilatation,  the  absence  of  all 
symptoms  of  cardiac  distress,  and  the  absence  of  extensive  arterio-sclerosis 
and  of  angina.  The  prognosis  rests  in  reality  with  the  condition  of  the 
coronary  arteries.  Eheumatic  lesions  of  the  valves,  inducing  insufficiency, 
are  less  apt  to  be  associated  with  endarteritis  at  the  root  of  the  aorta;  and 
in  such  cases  the  coronary  arteries  may  escape  for  years.  On  the  other  hand, 
when  the  aortic  insufficiency  is  only  a  part  of  an  extensive  arterio-sclerosis  at 
the  root  of  the  aorta,  the  coronary  arteries  are  almost  invariably  involved,  and 
the  outlook  in  such  cases  is  much  more  serious.  Sudden  death  is  not  un- 
common, either  from  acute  dilatation  during  some  exertion,  or,  more  fre- 
quently, from  blocking  of  one  of  the  branches  of  the  coronary  arteries.  The 
liability  of  this  form  to  be  associated  with  angina  pectoris  also  adds  to  its 
severity.  Aortic  stenosis  is  a  comparatively  rare  lesion,  most  commonly  met 
with  in  middle  aged  or  elderly  men,  and  is,  as  a  rule,  well  compensated.  In 
Broadbent's  series  of  cases,  in  which  autopsy  showed  definite  aortic  narrowing, 


828  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

forty  years  was  the  average  age  at  death,  and  the  oldest  was  but  fifty- 
three. 

In  mitral  lesions  the  outlook  on  the  whole  is  much  more  favorable  than 
in  aortic  insufficiency.  Mitral  insufficiency,  when  well  compensated,  carries 
with  it  a  better  prognosis  than  mitral  stenosis.  Except  aortic  stenosis,  it  is 
the  only  lesion  commonly  met  with  in  patients  over  three-score  years.  It 
must  be  borne  in  mind  that  the  cases  which  last  the  longest  are  those  in  which 
the  valve  orifice  is  more  or  less  narrowed,  as  well  as  incompetent.  There  is, 
in  reality,  no  valve  lesion  so  poorly  compensated  and  so  rapidly  fatal  as  that 
in  which  the  mitral  segments  are  gradually  curled  and  puckered  until  they 
form  a  narrow  strip  around  a  wide  mitral  ring — a  condition  specially  seen  in 
children.  There  are  many  cases  of  mitral  insufficiency  in  which  the  defect 
is  thoroughly  balanced  for  thirty  or  even  forty  years,  without  distress  or 
inconvenience.  Even  with  great  hypertrophy  and  the  apex  beat  almost  in 
the  mid-axillary  line,  there  may  be  little  or  no  distress,  and  the  compensation 
may  be  most  effective.  Women  may  pass  safely  through  repeated  pregnancies, 
though  here  they  are  liable  to  accidents  associated  with  the  severe  strain.  I 
have  had  under  observation  for  many  years  a  patient  who  had  her  first  attack 
of  rheumatism  at  the  age  of  fifteen,  when  she  already  had  a  well  marked  mitral 
murmur.  She  first  came  under  my  observation  over  thirty  years  ago,  with 
signs  of  hypertrophy  of  the  left  ventricle  and  a  loud  systolic  murmur.  She 
has  lived  a  very  active  life,  has  been  unusually  vigorous,  has  borne  eleven 
children,  and  has  passed  through  three  subsequent  attacks  of  rheumatism. 
The  loud  mitral  systolic  murmur  persists,  but  she  is  very  well,  only  a  little 
short  of  breath  on  exertion. 

In  mitral  stenosis  the  prognosis  is  usually  regarded  as  less  favorable.  My 
own  experience  has  led  me,  however,  to  place  this  lesion  almost  on  a  level, 
particularly  in  women,  with  the  mitral  insufficiency.  It  is  found  very  often 
in  persons  in  perfect  health,  who  have  had  neither  palpitation  nor  signs  of 
heart-failure,  and  who  have  lived  laborious  lives.  The  figures  given,  too,  by 
Broadbent  indicate  that  the  date  of  death  in  mitral  stenosis  is  comparatively 
advanced.  Of  53  cases  abstracted  from  the  post  mortem  records  of  St. 
Mary's  Hospital,  thirty  three  was  the  age  for  males,  and  thirty  seven  or  thirty 
eight  for  females.  These  women,  too,  pass  through  repeated  pregnancies  with 
safety.  There  are,  of  course,  those  too  common  accidents,  the  result  of  cerebral 
embolism,  which  are  more  likely  to  occur  in  this  than  in  other  forms. 

Hard  and  fast  lines  can  not  be  drawn  in  the  question  of  prognosis  in 
valvular  disease.  Every  case  must  be  judged  separately,  and  all  the  circum- 
stances carefully  balanced.  There  is  no  question  which  requires  greater  ex- 
perience and  more  mature  judgment,  and  even  the  most  experienced  are  some- 
times at  fault. 

The  following  conditions  justify  a  favorable  prognosis:  Good  general 
health  and  good  habits;  no  exceptional  liability  to  rheumatic  or  catarrhal 
affections;  origin  of  the  valvular  lesion  independently  of  degeneration:  exis- 
tence of  the  valvular  lesion  without  change  for  over  three  years;  sound  ven- 
tricles, of  moderate  frequency,  and  general  regularity  of  action;  sound  ar- 
teries, with  a  normal  amount  of  blood  and  tension  in  the  smaller  vessels ;  and, 
lastly,  freedom  from  pulmonary,  hepatic,  and  renal  congestion. 

Treatment  of  Valvular  Lesions. — (a)  STAGE  OF  COMPENSATION. — Medici- 


SPECIAL    PATHOLOGICAL    CONDITIONS  829 

nal  treatment  at  this  period  is  not  necessary  and  is  often  hurtful.  A  very 
common  error  is  to  administer  cardiac  drugs,  such  as  digitalis,  on  the  discov- 
ery of  a  murmur  or  of  hypertrophy.  If  the  lesion  has  been  found  accidental- 
ly, it  may  be  best  not  to  tell  the  patient,  but  rather  an  intimate  friend.  Often 
it  is  necessary,  however,  to  be  perfectly  frank  in  order  that  the  patient  may 
take  certain  preventive  measures.  He  should  lead  a  quiet,  regulated,  orderly 
life,  free  from  excitement  and  worry,  and  the  risk  of  sudden  death  makes  it 
imperative  that  the  patient  suffering  from  aortic  disease  should  be  specially 
warned  against  overexertion  and  hurry.  An  ordinary  wholesome  diet  in  mod- 
erate quantities  should  be  taken;  tobacco  may  be  allowed  in  moderation,  but 
stimulants  should  be  interdicted  or  used  in  very  small  amount.  Exercise 
should  be  regulated  entirely  by  the  feelings  of  the  patient.  So  long  as  no 
cardiac  distress  or  palpitation  follows,  moderate  exercise  will  prove  very  bene- 
ficial. The  skin  should  be  kept  active  by  a  daily  bath.  Hot  baths  should  be 
avoided  and  the  Turkish  bath  should  be  interdicted.  In  the  case  of  full- 
blooded,  somewhat  corpulent  individuals,  an  occasional  saline  purge  should  be 
taken.  Patients  with  valvular  lesions  should  not  go  into  very  high  altitudes. 
The  act  of  coition  has  serious  risks,  particularly  in  aortic  insufficiency.  Know- 
ing that  the  causes  which  most  surely  and  powerfully  disturb  the  compensation 
are  overexertion,  mental  worry,  and  malnutrition,  the  physician  should  give 
suitable  instructions  in  each  case.  As  it  is  always  better  to  have  the  coopera- 
tion of  an  intelligent  patient,  he  should,  as  a  rule,  be  told  of  the  condition, 
but  in  this  matter  the  physician  must  be  guided  by  circumstances,  and  there 
are  cases  in  which  reticence  is  the  wiser  policy. 

(&)  STAGE  OF  BROKEN  COMPENSATION. — The  break  may  be  immediate  and 
final,  as  when  sudden  death  results  from  acute  dilatation  or  from  blocking  of 
a  branch  of  the  coronary  artery,  or  it  may  be  gradual.  Among  the  first  indi- 
cations are  shortness  of  breath  on  exertion  or  attacks  of  nocturnal  dyspnoea. 
These  are  often  associated  with  impaired  nutrition,  particularly  with  anemia, 
and  a  course  of  iron  or  change  of  air  may  suffice  to  relieve  the  symptoms. 

Irregularity  of  the  action  of  the  heart  can  not  always  be  termed  an  in- 
dication of  failing  compensation,  particularly  in  instances  of  mitral  disease. 
It  has  greater  significance  in  aortic  lesions.  Serious  failure  of  compensation 
is  indicated  by  signs  of  dilatation  of  the  heart,  marked  cyanosis,  the  gallop 
rhythm,  or  various  forms  of  arrhythmia,  with  or  without  the  existence  of 
dropsy.  LTnder  these  circumstances  the  same  measures  are  to  be  carried  out 
as  are  indicated  under  treatment  in  cardiac  insufficiency. 

V.    SPECIAL   PATHOLOGICAL   CONDITIONS 

1.     ANETJKISM    OF    THE    HEART 

Aneurism  of  a  valve  results  from  acute  endocarditis,  which  produces  soft- 
ening or  erosion  and  may  lead  either  to  perforation  of  the  segment  or  to 
gradual  dilatation  of  a  limited  area  under  the  influence  of  the  blood  pressure. 
The  aneurisms  are  usually  spheroidal  and  project  from  the  ventricular  face 
of  a  sigmoid  valve.  They  are  much  less  common  on  the  mitral  segments. 
They  frequently  rupture  and  produce  extensive  destruction  and  incompetencj 
of  the  valves. 


830  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

Aneurism  of  the  walls  results  from  the  weakening  induced  by  chronic 
myocarditis,  or  occasionally  it  follows  acute  mural  endocarditis,  which  more 
commonly,  however,  leads  to  perforation.  It  has  followed  a  stab  wound,  a 
gumma  of  the  ventricle,  and,  according  to  some  authors,  pcricardial  adhesions. 
The  left  ventricle  near  the  apex  is  usually  the  seat,  this  being  the  situation 
in  which  fibrous  degeneration  is  most  common.  Fifty  nine  of  the  60  cases 
collected  by  Legg  were  situated  here.  In  the  early  stages  the  anterior  wall 
of  the  ventricle,  near  the  septum,  sometimes  even  the  septum  itself,  is  slightly 
dilated,  the  endocardium  opaque,  and  the  muscular  tissue  sclerotic.  In  a 
more  advanced  stage  the  dilatation  is  pronounced  and  layers  of  thrombi  occupy 
the  sac.  Ultimately  a  large  rounded  tumor  may  project  from  the  ventricle 
and  may  attain  a  size  equal  to  that  of  the  heart.  Occasionally  the  aneurism 
is  sacculated  and  communicates  with  the  ventricle  through  a  very  small  orifice. 
The  sac  may  be  double,  as  in  the  cases  of  Janeway  and  Sailer.  In  the  museum 
of  Guy's  Hospital  there  is  a  specimen  showing  the  wall  of  the  ventricle  cov- 
ered with  aneurismal  bulgings.  Rupture  occurred  in  7  of  the  90  cases  col- 
lected by  Legg. 

The  symptoms  produced  by  aneurism  of  the  heart  are  indefinite.  Occa- 
sionally there  is  marked  bulging  in  the  apex  region  and  the  tumor  may 
perforate  the  chest  wall.  In  mitral  stenosis  the  right  ventricle  may  bulge 
and  produce  a  visible  pulsating  tumor  below  the  left  costal  border,  which  I 
have  known  to  be  mistaken  for  cardiac  aneurism.  When  the  sac  is  large  and 
produces  pressure  upon  the  heart  itself,  there  may  be  a  marked  disproportion 
between  the  strong  cardiac  impulse  and  the  feeble  pulsation  in  the  peripheral 
arteries. 

2.     EUPTUEE    OF    THE    HEAET 

This  rare  event  is  usually  associated  with  fatty  infiltration  or  degenera- 
tion of  the  heart-muscle.  In  some  instances  acute  softening  in  consequence 
of  embolism  of  a  branch  of  the  coronary  artery,  Suppurative  myocarditis,  or 
a  gummatous  growth  has  been  the  cause.  Of  100  cases  collected  by  Quain, 
fatty  degeneration  was  noted  in  77.  Two  thirds  of  the  patients  were  over 
sixty  years  of  age.  It  may  occur  in  infants.  Schaps  reports  a  case  in  an 
infant  of  four  months  associated  with  an  embolic  infarct  of  the  left  ventricle. 
Harvey,  in  his  second  letter  to  Riolan  (1649),  described  the  case  of  Sir  Rob- 
ert Darcy,  who  had  distressing  pain  in  the  chest  and  syncopal  attacks  with 
suffocation,  and  finally  cachexia  and  dropsy.  Death  occurred  in  one  of  the 
paroxysms.  The  wall  of  the  left  ventricle  of  the  heart  was  ruptured,  "hav- 
ing a  rent  in  it  of  size  sufficient  to  admit  any  of  my  fingers,  although  the  wall 
itself  appeared  sufficiently  thick  and  strong." 

The  rent  may  occur  in  any  of  the  chambers,  but  is  found  most  frequently 
in  the  left  ventricle  on  the  anterior  wall,  not  far  from  the  septum.  The 
accident  usually  takes  place  during  exertion.  There  may  be  no  preliminary 
symptoms,  but  without  any  warning  the  patient  may  fall  and  die  in  a  few 
moments.  Sudden  death  occurred  in  71  per  cent,  of  Quain's  cases.  In  other 
instances  there  may  be  in  the  cardiac  region  a  sense  of  anguish  and  suffoca- 
tion, and  life  may  be  prolonged  for  several  hours.  In  a  Montreal  case,  which 
I  examined,  the  patient  walked  up  a  steep  hill  after  the  onset  of  the  symptoms, 


SPECIAL    PATHOLOGICAL    CONDITIONS  831 

and  lived  for  thirteen  hours.     A  case  is  on  record  in  which  the  patient  lived 
for  eleven  days. 

3.     NEW    GEOWTHS    AND    PARASITES 

Tubercle  and  syphilis  have  already  been  considered.  Primary  cancer  or 
sarcoma  is  extremely  rare.  Secondary  tumors  may  be  single  or  multiple,  and 
are  usually  unattended  with  symptoms,  even  when  the  disease  is  most  exten- 
sive. In  one  case  I  found  in  the  wall  of  the  right  ventricle  a  mass  which 
involved  the  anterior  segment  of  the  tricuspid  valve  and  partly  blocked  the 
orifice.  The  surface  was  eroded  and  there  were  numerous  cancerous  emboli 
in  the  pulmonary  artery.  In  another  instance  the  heart  was  greatly  enlarged, 
owing  to  the  presence  of  innumerable  masses  of  colloid  cancer  the  size  of 
cherries.  The  mediastinal  sarcoma  may  penetrate  the  heart,  though  it  is 
remarkable  how  extensive  the  disease  of  the  mediastinal  glands  may  be 
without  involvement  of  the  heart  or  vessels. 

Cysts  in  the  heart  are  rare.  They  are  found  in  different  parts,  and  are 
filled  either  with  a  brownish  or  a  clear  fluid.  Blood  cysts  occasionally  occur. 

The  parasites  have  been  discussed  under  the  appropriate  section,  but  it 
may  be  mentioned  here  that  both  the  cysticercus  celluloses  and  the  echinococcus 
cysts  occur  occasionally. 

4.     WOUNDS    AND    FOEEIGN    BODIES 

Wounds  of  the  heart  may  be  caused  by  external  injuries,  as  stabs  and 
bullet  wounds,  by  foreign  bodies  passing  from  the  gullet  or  oesophagus,  or  by 
puncture  for  therapeutic  purposes. 

(a)  Bullet  wounds  of  the  heart  are  common.  Eecovery  may  take  place, 
and  bullets  have  been  found  encysted  in  the  organ.  Stab  wounds  are  still 
more  common.  A  medical  student,  while  on  a  spree,  passed  a  pin  into  his 
heart.  The  pericardium  was  opened,  and  the  head  of  the  pin  was  found  out- 
side of  the  right  ventricle.  It  was  grasped  and  an  attempt  made  to  remove 
it,  but  it  was  withdrawn  into  the  heart  and,  it  is  said,  caused  the  patient  no 
further  trouble  (Moxon).  In  recent  stab  wounds  the  practice  now  is  to 
expose  the  heart  and  attempt  to  suture  the  wound.  The  results  have  been 
progressively  improving.  In  a  case  of  stab  wound  Pagenstecher  tied  the  left 
coronary  artery,  which  had  been  divided. 

(&)  Hysterical  girls  sometimes  swallow  pins  and  needles,  which,  passing 
through  the  oesophagus  and  stomach,  are  found  in  various  parts  of  the  body. 
A  remarkable  case  is  reported  by  Allen  J.  Smith  of  a  girl  from  whom  several 
dozen  needles  and  pins  were  removed,  chiefly  from  subcutaneous  abscesses. 
Several  years  later  she  developed  symptoms  of  chronic  heart  disease.  At  the 
post  mortem  needles  were  found  in  the  tissues  of  the  adherent  pericardium, 
and  between  thirty  and  forty  were  embedded  in  the  thickened  pleural  mem- 
branes of  the  left  side. 

(c)  Puncture  of  the  heart  (cardiocentesis)  has  been  recommended  as  a 
therapeutic  procedure,  as  in  chloroform  narcosis,  and  experimental  evidence 
has  been  brought  forward  by  B.  A.  Watson  in  favor  of  the  operation.  He 
advises  abstraction  of  blood  in  combination  with  the  puncture — cardiocentesis. 
The  proceeding  is  not  without  risk.  Hemorrhage  may  take  place  from  the 


832  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

puncture,  though  it  is  not  often  extensive.  Sloane  has  recently  urged  its  use 
in  all  cases  of  asphyxia  and  in  suffocation  by  drowning  and  from  coal  gas. 
The  successful  case  which  he  reports  illustrates  forcibly  its  stimulating  action. 

VI.     CONGENITAL   AFFECTIONS    OF    THE    HEART 

These  have  only  a  limited  clinical  interest,  as  in  a  large  proportion  of  the 
cases  the  anomaly  is  not  compatible  with  life,  and  in  others  nothing  can  be 
done  to  remedy  the  defect  or  even  to  relieve  the  symptoms. 

The  congenital  affections  result  from  interruption  of  the  normal  course 
of  development  or  from  inflammatory  processes — endocarditis;  sometimes 
from  a  combination  of  both. 

General  Anomalies. — Of  general  anomalies  of  development  the  following 
conditions  may  be  mentioned:  Acardia,  absence  of  the  heart,  which  has 
been  met  with  in  the  monstrosity  known  by  the  same  name;  double  heart, 
which  has  occasionally  been  found  in  extreme  grades  of  fetal  deformity; 
dextrocardia,  in  which  the  heart  is  on  the  right  side,  either  alone  or  as  part 
of  a  general  transportation  of  the  viscera ;  ectopia  cordis,  a  condition  associated 
with  fission  of  the  chest  wall  and  of  the  abdomen.  The  heart  may  be  situ- 
ated in  the  cervical,  pectoral,  or  abdominal  regions.  Except  in  the  abdominal 
variety,  the  condition  is  very  rarely  compatible  with  extra-uterine  life.  Occa- 
sionally, as  in  a  case  reported  by  Holt,  the  child  lives  for  some  months,  and 
the  heart  may  be  seen  and  felt  beating  beneath  the  skin  in  the  epigastric 
region.  This  infant  was  five  months  old  at  the  date  of  examination. 

Anomalies  of  the  Cardiac  Septa. — The  septa  of  both  auricles  and  ventricles 
may  be  defective,  in  which  case  the  heart  consists  of  but  two  chambers, 
the  cor  biloculare  or  reptilian  heart.  In  the  septum  of  the  auricles  there  is 
a  very  common  defect,  owing  to  the  fact  that  the  membrane  closing  the  fora- 
men ovale  has  failed  at  one  point  to  become  attached  to  the  ring,  and  leaves 
a  valvular  slit  which  may  be  large  enough  to  admit  the  handle  of  a  scalpel. 
Neither  this  nor  the  small  cribriform  perforations  of  the  membrane  are  of 
any  significance. 

The  foramen  ovale  may  be  patent  without  a  trace  of  membrane  closing 
it.  In  some  instances  this  exists  with  other  serious  defects,  such  as  stenosis 
of  the  pulmonary  artery,  or  imperfection  of  the  ventricular  septum.  In 
others  the  patent  foramen  ovale  is  the  only  anomaly,  and  in  many  instances 
it  does  not  appear  to  have  caused  any  embarrassment,  as  the  condition  has 
been  found  in  persons  who  have  died  of  various  affections.  The  ventricular 
septum  may  be  absent,  the  condition  known  as  trilocular  heart.  Much  more 
frequently  there  is  a  small  defect  in  the  upper  portion  of  the  septum,  either 
in  the  situation  of  the  membranous  portion  known  as  the  "undefended  space" 
or  in  the  region  situated  just  anterior  to  this.  The  anomaly  is  very  frequently 
asoociated  with  narrowing  of  the  pulmonary  orifice  or  of  the  conus  arteriosus 
of  the  right  ventricle. 

Apart  from  the  instances  in  association  with  narrowing  of  the  orifice  of 
the  pulmonary  artery,  or  of  the  conus,  there  are  cases  in  which  defect  of  the 
membranous  septum  is  the  only  lesion,  a  condition  not  incompatible  with 
long  and  fairly  active  life.  The  late  Professor  Brooks  of  the  Johns  Hopkins 
University  knew  from  early  manhood  that  he  had  heart  trouble,  but  he  ac- 


CONGENITAL   AFFECTIONS    OF    THE    HEART  833 

complished  an  extraordinary  amount  of  work,  and  lived  to  be  about  60.  Im- 
perfect septum  was  the  only  lesion.  The  physical  signs  are  fairly  distinctive, 
with  usually  some  enlargement  of  the  heart,  and  a  murmur  first  describe^, 
by  Roger  in  the  following  terms:  "It  is  a  loud  murmur,  audible  over  a 
large  area,  and,  commencing  with  systole,  is  prolonged  so  as  to  cover  the 
normal  tic-tac.  It  has  its  maximum,  not  at  the  base  to  the  right,  as  in  aortic 
stenosis,  or  to  the  left,  as  in  pulmonary  stenosis,  but  at  the  upper  third  of 
the  prsecordial  region.  It  is  central,  like  the  septum,  and  from  this  central 
point  gradually  diminishes  in  intensity  in  every  direction.  The  murmur 
does  not  vary  at  any  time,  and  it  is  not  conducted  into  the  vessels."  In  sev- 
eral of  my  cases  there  has  been  a  distinct  systolic  intensification  of  this 
loud  continuous  murmur. 

Anomalies  and  Lesions  of  the  Valves. — Numerical  anomalies  of  the  valves 
are  not  uncommon.  The  semilunar  segments  at  the  arterial  orifices  are  not 
infrequently  increased  or  diminished  in  number.  Supernumerary  segments 
are  more  frequent  in  the  pulmonary  artery  than  in  the  aorta.  Four,  or 
sometimes  five,  valves  have  been  found.  The  segments  may  be  of  equal  size, 
but,  as  a  rule,  the  supernumerary  valve  is  small. 

Instead  of  three  there  may  be  only  two  semilunar  valves,  or,  as  it  is 
termed,  the  bicuspid  condition.  In  my  experience  this  is  more  frequent  in 
the  aortic  valve.  Of  21  instances  only  2  occurred  at  the  pulmonary  orifice. 
Two  of  the  valves  have  united,  and  from  the  ventricular  face  show  either  no 
trace  of  division  or  else  a  slight  depression  indicating  where  the  union  has 
occurred.  From  the  aortic  side  there  is  usually  to  be  seen  some  trace  of  divi- 
sion into  two  sinuses  of  Valsalva.  There  has  been  a  discussion  as  to  the  origin 
of  this  condition,  whether  it  is  really  an  anomaly  or  whether  it  is  not  due  to 
endocarditis,  fetal  or  post-natal.  The  combined  segment  is  usually  thickened, 
but  the  fact  that  this  anomaly  is  met  with  in  the  fetus  without  a  trace  of 
sclerosis  or  endocarditis  shows  that  it  may,  in  some  cases  at  least,  result  from 
a  developmental  error. 

Clinically  this  is  a  very  important  congenital  defect,  owing  to  the  liability 
of  the  combined  valve  to  sclerotic  changes.  Except  two  fetal  specimens,  all 
of  my  cases  showed  thickening  and  deformity,  and  in  15  of  those  which  I 
have  reported  death  resulted  directly  or  indirectly  from  the  lesion. 

The  little  fenestrations  at  the  margins  of  the  sigmoid  valves  have  no  sig- 
nificance; they  occur  in  a  considerable  proportion  of  all  bodies. 

Anomalies  of  the  auriculo-ventricular  valves  are  not  often  met  with. 

FETAL  ENDOCARDITIS  may  occur  either  at  the  arterial  or  auriculo-ven- 
tricular orifices.  It  is  nearly  always  of  the  chronic  or  sclerotic  variety.  Very 
rarely,  indeed,  is  it  of  the  warty  or  verrucose  form.  There  are  little  nodular 
bodies,  sometimes  six  or  eight  in  number,  on  the  mitral  and  tricuspid  seg- 
ments— the  nodules  of  Albini — which  represent  the  remains  of  fetal  struc- 
tures, and  must  not  be  mistaken  for  endocardial  outgrowths.  The  little 
rounded,  bead  like  haemorrhages  of  a  deep  purple  color,  which  are  very  com- 
mon on  the  heart  valves  of  children,  are  also  not  to  be  mistaken  for  the  prod- 
ucts of  endocarditis.  In  fetal  endocarditis  the  segments  are  usually  thickened 
at  the  edges,  shrunken,  and  smooth.  In  the  mitral  and  tricuspid  valves  the 
cusps  are  found  united  and  the  chords  tendineae  are  thickened  and  shortened. 
In  the  semilunar  valves  all  trace  of  the  segments  has  disappeared,  leaving  a 


834  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

stiff  membranous  diaphragm  perforated  by  an  oval  or  rounded  orifice.  It 
is  sometimes  very  difficult  to  say  whether  this  condition  has  resulted  from 
fetal  endocarditis  or  whether  it  is  an  error  in  development.  In  very  many 
instances  the  processes  are  combined;  an  anomalous  valve  becomes  the  seat 
of  chronic  sclerotic  changes,  and,  according  to  Rauchfuss,  endocarditis  is  more 
common  on  the  right  side  of  the  heart  only  because  the  valves  are  here  more 
often  the  seat  of  developmental  errors. 

LESIONS  AT  THE  PULMONARY  ORIFICE. — Stenosis  of  this  orifice  is  one  of 
the  commonest  and  most  important  of  congenital  heart  affections.  A  slow 
endocarditis  causes  gradual  union  of  the  segments  and  narrowing  of  the  orifice 
to  such  a  degree  that  it  admits  only  the  smallest  sized  probe.  In  some  of  the 
cases  the  smooth  membranous  condition  of  the  combined  segments  is  such  that 
it  would  appear  to  be  the  result  of  faulty  development.  In  some  instances 
vegetations  occur.  The  condition  is  compatible  with  life  for  many  years, 
and  in  a  considerable  proportion  of  the  cases  of  congenital  heart  disease  above 
the  tenth  year  this  lesion  is  present.  With  it  there  may  be  defect  of  the  ven- 
tricular septum.  Pulmonary  tuberculosis  is  a  very  common  cause  of  death. 
Obliteration  or  atresia  of  the  pulmonary  orifice  is  a  less  frequent  but  more 
serious  condition  than  stenosis.  It  is  associated  with  persistence  of  the  ductus 
arteriosus,  together  with  patency  of  the  foramen  ovale  or  defect  of  the  ven- 
tricular septum  with  hypertrophy  of  the  right  heart.  Stenosis  of  the  conus 
arteriosus  of  the  right  ventricle  exists  in  a  considerable  proportion  of  the 
cases  of  obstruction  at  the  pulmonary  orifice.  At  the  outset  a  developmental 
error,  it  may  be  combined  with  sclerotic  changes.  The  ventricular  septum  is 
imperfect,  the  foramen  ovale  is  usually  open,  and  the  ductus  arteriosus  pat- 
ent. These  three  lesions  at  the  pulmonary  orifice  constitute  the  most  impor- 
tant group  of  all  congenital' cardiac  affections.  Of  181  instances  of  various 
congenital  anomalies  collected  by  Peacock,  119  cases  came  under  this  category, 
and,  according  to  this  author,  in  86  per  cent,  of  the  patients  living  beyond  the 
twelfth  year  the  lesion  is  at  this  orifice. 

CONGENITAL  LESIONS  OF  THE  AORTIC  ORIFICE  are  not  very  frequent. 
Rauchfuss  has  collected  24  cases  of  stenosis  and  atresia;  stenosis  of  the  left 
conus  arteriosus  may  also  occur,  a  condition  which  is  not  incompatible  with 
prolonged  life.  Ten  of  the  16  cases  tabulated  by  Dilg  were  over  thirty  years 
of  age. 

TRANSPOSITION  OF  THE  LARGE  ARTERIAL  TRUNKS  is  a  not  uncommon 
anomaly.  There  may  be  neither  hypertrophy,  cyanosis,  nor  heart  murmur. 

Symptoms  of  Congenital  Heart  Disease. — Cyanosis  occurs  in  over  90  per 
cent,  of  the  cases,  and  forms  so  distinctive  a  feature  that  the  terms  "blue  dis- 
ease" and  "morbus  caeruleus"  are  practically  synonyms  for  congenital  heart- 
disease.  The  lividity  in  a  majority  of  cases  appears  only  within  the  first 
week  of  life,  and  may  be  general  or  confined  to  the  lips,  nose,  and  ears,  and 
to  the  fingers  and  toes.  In  some  instances  there  is  in  addition  a  general  dusky 
suffusion,  and  in  the  most  extreme  grades  the  skin  is  almost  purple.  It  may 
vary  a  good  deal  and  may  be  intense  only  on  exertion.  The  external  temper- 
ature is  low.  Dyspnoea  on  exertion  and  cough  are  common  symptoms.  A 
great  increase  in  the  number  of  the  red  corpuscles  has  been  noted  by  Gibson 
and  by  Vaquez.  In  a  case  of  Gibson's  there  were  above  eight  millions  of  red 
blood  corpuscles  to  the  cubic  millimetre.  The  children  rarely  thrive,  and  often 


CONGENITAL   AFFECTIONS    OF    THE    HEART  835 

display  a  lethargy  of  both  mind  and  body.  The  fingers  and  toes  are  clubbed 
to  a  degree  rarely  met  with  in  any  other  affection.  The  cause  of  the  cyanosis 
has  been  much  discussed.  Morgagni  referred  it  to  the  general  congestion  of 
the  venous  system  due  to  obstruction,  and  this  view  was  supported  in  a  paper, 
one  of  the  ablest  that  has  been  written  on  the  subject,  by  Moreton  Stille. 
Morrison's  analysis  of  75  cases  of  congenital  heart  disease  shows  that  closure 
of  the  pulmonary  orifice  with  patency  of  the  foramen  ovale  and  the  ventricular 
septum  is  the  condition  most  frequently  associated  with  cyanosis,  and  he  con- 
cludes that  the  deficient  aeration  of  the  blood  owing  to  diminished  lung  func- 
tion is  the  most  important  factor.  Another  view,  often  attributed  erroneously 
to  William  Hunter,  was  that  the  discoloration  was  due  to  the  admixture  in  the 
heart  of  venous  and  arterial  blood ;  but  lesions  may  exist  which  permit  of  very 
free  mixture  without  producing  cyanosis.  The  question  of  the  cause  of  cyano- 
sis really  can  not  be  considered  as  settled.  Variot  has  recently  made  the  sug- 
gestion that  the  cause  is  not  entirely  cardiac,  but  is  associated  with  disturbance 
throughout  the  whole  circulatory  system,  and  particularly  a  vaso-motor  paresis 
and  malaeration  of  the  red  blood  corpuscles. 

Diagnosis. — In  the  case  of  children,  cyanosis,  with  or  without  enlargement 
of  the  heart,  and  the  existence  of  a  murmur,  are  sufficient,  as  a  rule,  to  de- 
termine the  presence  of  a  congenital  heart  lesion.  The  cyanosis  gives  us  no 
clew  to  the  precise  nature  of  the  trouble,  as  it  is  a  symptom  common  to  many 
lesions  and  it  may  be  absent  in  certain  conditions.  The  murmur  is  usually 
systolic  in  character.  It  is,  however,  not  always  present,  and  there  are  in- 
stances on  record  of  complicated  congenital  lesions  in  which  the  examination 
showed  normal  heart  sounds.  In  two  or  three  instances  fetal  endocarditis  has 
been  diagnosed  in  gravida  by  the  presence  of  a  rough  systolic  murmur,  and 
the  condition  has  been  corroborated  subsequent  to  the  birth  of  the  child. 
Hypertrophy  is  present  in  a  majority  of  the  cases  of  congenital  defect.  The 
fatal  event  may  be  caused  by  abscess  of  the  brain.  For  a  full  discussion  of 
the  subject  the  senior  student  is  referred  to  the  exhaustive  monograph  of  Dr. 
Maude  Abbott  in  Vol.  IV  of  my  "System  of  Medicine/'  I  here  abstract  the 
conclusions  of  Hochsinger: 

"(1)  In  childhood,  loud,  rough,  musical  heart  murmurs,  with  normal  or 
only  slight  increase  in  the  heart  dulness,  occur  only  in  congenital  heart  dis- 
ease. The  acquired  endocardial  defects  with  loud  heart  murmurs  in  young 
children  are  almost  always  associated  with  great  increase  in  the  heart  dul- 
ness. In  the  transposition  of  the  large  arterial  trunks  there  may  be  no  cyano- 
sis, no  heart  murmur,  and  an  absence  of  hypertrophy. 

"(2)  In  young  children  heart  murmurs  with  great  increase  in  the  cardiac 
dulness.  and  feeble  apex  beat  suggest  congenital  changes.  The  increased 
dulness  is  chiefly  of  the  right  heart,  whereas  the  left  is  only  slightly  altered. 
On  the  other  hand,  in  the  acquired  endocarditis  in  children,  the  left  heart  is 
chiefly  affected  and  the  apex  beat  is  visible ;  the  dilatation  of  the  right  heart 
comes  late  and  does  not  materially  change  the  increased  strength  of  the  apex 
beat. 

"(3)  The  entire  absence  of  murmurs  at  the  apex,  with  their  evident  pres- 
ence in  the  region  of  the  auricles  and  over  the  pulmonary  orifice,  is"  always  an 
important  element  in  differential  diagnosis,  and  points  rather  to  septum  defect 
or  pulmonary  stenosis  than  to  endocarditis. 


836  DISEASES    OF    THE    CIRCULATOKY    SYSTEM 

"(4)  An  abnormally  weak  second  pulmonic  sound  associated  with  a  dis- 
tinct systolic  murmur  is  a  symptom  which  in  early  childhood  is  only  to  be 
explained  by  the  assumption  of  a  congenital  pulmonary  stenosis,  and  possesses 
therefore  an  importance  from  a  point  of  differential  diagnosis  which  is  not  to 
be  underestimated. 

"(5)  Absence  of  a  palpable  thrill,  despite  loud  murmurs  which  are  heard 
over  the  whole  praecordial  region,  is  rare  except  with  congenital  defects  in 
the  septum,  and  it  speaks,  therefore,  against  an  acquired  cardiac  affection. 

"(6)  Loud,  especially  vibratory,  systolic  murmurs,  with  the  point  of 
maximum  intensity  over  the  upper  third  of  the  sternum,  associated  with  a 
lack  of  marked  symptoms  of  hypertrophy  of  the  left  ventricle,  are  very  im- 
portant for  the  diagnosis  of  a  persistence  of  the  ductus  Botalli,  and  can  not 
be  explained  by  the  assumption  of  an  endocarditis  of  the  aortic  valve." 

Escherich  suggests  that  the  systolic  basic  murmur  heard  sometimes  in  the 
newborn,  particularly  if  premature,  may  originate  in  the  ductus  Botalli  before 
its  closure. 

Treatment. — The  child  should  be  warmly  clad  and  guarded  from  all  cir- 
cumstances liable  to  excite  bronchitis.  In  the  attacks  of  urgent  dyspnoea 
with  lividity  blood  should  be  freely  let.  Saline  cathartics  are  also  useful. 
Digitalis  must  be  used  with  care ;  it  is  sometimes  beneficial  in  the  later  stages. 
When  the  compensation  fails,  the  indications  for  treatment  are  those  of  valvu- 
lar disease  in  adults. 

VH.    ANGINA  PECTORIS 

(Stenocardia,  Breast  Pang} 

Definition. — A  disease  characterized  by  paroxysmal  attacks  of  pain,  usual- 
ly pectoral,  associated  with  changes  in  the  vascular  walls,  organic  or  func- 
tional. 

History. — In  1768  Heberden  described  a  "disorder  of  the  breast,"  to  which 
he  gave  the  -name  of  "Angina  Pectoris."  Beforfe  this  date  Morgagni  and 
Rougnon  had  described  cases.  The  association  with  coronary  artery  disease 
was  early  shown  by  Jenner.  John  Hunter  died  in  an  attack.  The  connection 
with  aortitis  as  demonstrated  by  Corrigan  and  Allbutt,  the  recognition 
of  extra-pectoral  forms,  and  the  introduction  of  nitrites  in  treatment  by 
Lauder  Brunton  are  the  important  contributions  of  the  nineteenth  century. 

Etiology.  — The  disease  is  not  uncommon,  about  700  dying  yearly  of  it  in 
England  and  Wales.  In  the  United  States  it  is  more  common,  the  average 
number  of  deaths  per  million  of  the  population  being  more  than  double  that 
of  England. 

It  is  a  rare  disease  in  hospitals;  a  case  a  year  is  about  the  average,  even 
in  the  large  metropolitan  hospitals.  It  is  a  disease  of  the  better  classes,  and 
a  consultant  in  active  work  may  see  a  dozen  or  more  cases  a  year. 

AGE.— In  my  series  of  268  cases  there  were,  under  30,  9  cases;  between 
30  and  40,  41 ;  between  40  and  50,  59 ;  between  50  and  60,  81 ;  between  60 
and  70,  62 ;  between  70  and  80,  13 ;  above  80,  3.  The  fifth  and  sixth  decades 
are  the  fatal  periods,  as  shown  by  the  Registrar  General's  statistics. 

SEX. — Women  are  rarely  attacked.  Of  my  cases  231  were  men  and  37 
women. 


ANGINA    PECTOEIS  837 

EACE. — As  mentioned,  the  disease  seems  to  be  relatively  more  frequent 
in  the  United  States.  Jews  are  particularly  prone,  37  of  my  268  cases. 

OCCUPATION. — It  is  not  an  affection  of  the  working  classes.  The  life 
of  stress  and  strain,  particularly  of  worry,  seems  to  predispose  to  it,  and  this 
is  perhaps  why  it  is  so  common  in  our  profession.  In  my  series  of  268 
cases  there  were  33  physicians,  a  very  large  proportion.  From  John  Hunter 
onward  a  long  list  of  distinguished  physicians  have  heen  its  victims,  among 
whom  may  be  mentioned  in  recent  years  Charcot,  Nothnagel,  and  William 
Pepper. 

CARDIO-VASCULAR  DISEASE. — In  persons  under  forty  syphilis  is  an  im- 
portant feature,  causing  an  aortitis,  often  limited  to  the  root  of  the  vessel. 
Whatever  the  cause,  arterio-sclerosis  predisposes  to  angina.  A  majority  of 
the  patients  have  sclerosis,  many  high  blood  pressure.  Business  men  lead- 
ing lives  of  great  strain,  and  eating,  drinking,  and  smoking  to  excess,  form 
the  large  contingent  of  angina  cases.  Slight  attacks  may  occur  with  high 
blood  pressure  alone. 

HEREDITY. — The  disease  may  occur  in  members  of  three  generations,  as 
in  the  Arnold  family. 

Imitative  Features. — Outbreaks  of  angina-like  attacks  have  been  described. 
After  the  death  of  one  member  of  a  family  from  the  disease,  another  may 
have  somewhat  similar  attacks.  Two  of  his  physicians  had  angina  after 
Senator  Sumner's  fatal  attack.  One  of  them  died  within  two  weeks;  the 
other,  a  young  man,  recovered  completely. 

Symptoms. — Gaged  by  the  severity  of  the  attacks,  cases  may  be  grouped 
in  three  categories : 

(a)  MILDEST  FORM  ("Les  Formes  Frustes"  of  the  French). — There  is 
a  feeling  of  substernal  tension,  uneasiness,  or  distress,  rising  at  times  to  posir 
tive  pain,  usually  associated  with  emotion,  sometimes  with  exertion,  but  soon 
passing  off.  There  may  be  slight  pallor,  or  a  feeling  of  faintness.  When 
rising  to  speak  in  public  there  may  be  a  feeling  of  substernal  tension — it 
is  a  common  experience — which  passes  off.  Muscular  effort,  as  in  climbing 
a  hill  or  a  stair,  may  bring  on  the  sensation.  In  the  high  pressure  life  a 
man  may  experience  for  weeks  or  months  this  sense  of  substernal  tension, 
not  pain,  and  without  accurate  localization  or  radiation,  and  not  increased 
by  exercise  or  emotion.  It  is,  as  one  patient  expressed  it,  a  "hot-box"  in- 
dicating too  great  pressure  and  too  high  speed.  It  is  away  after  the  night's 
rest,  and  may  disappear  entirely  when  the  "harness"  is  taken  off. 

(6)  MILD  FORM  (Angina  Minor). — Pain  in  the  heart  of  moderate  se- 
verity with  radiation  to  the  arm  is  met  with  in  many  nervous  and  hysterical 
persons,  in  tobacco  smokers,  sometimes  following  the  acute  infections,  par- 
ticularly influenza,  The  attacks  are  rarely  prolonged,  are  brought  on  by 
emotion,  are  more  frequent  in  women,  and  are  never  fatal.  Often  called 
pseudo,  false,  functional,  or  toxic  angina,  the  difference  in  the  character  of 
the  attacks  may  be  one  of  degree  only.  The  conditions  under  which  the 
attacks  come  on  are  of  greater  importance  than  the  nature  of  the  attack 
itself.  There  may  be  marked  vaso-motor  disturbance,  with  cold,  numb,  and 
blue  extremities,  followed  by  praecordial  pain  and  a  feeling  of  faintness.  In 
persons  addicted  to  tea,  coffee,  and  tobacco  heart  pain  is  not  infrequent, 
sharp  and  shooting,  associated  with  palpitation,  or  severe  and  truly  anginal. 


838  DISEASES    OP    THE    CIRCULATORY    SYSTEM 

(c)  SEVERE  ANGINA  (Angina  Major). — The  two  special  features  in  this 
group  are  the  existence  in  a  large  proportion  of  all  the  cases  of  organic  dis- 
ease of  heart  or  vessels  and  the  liability  to  sudden  death.  An  exciting  cause 
of  the  attack  can  usually  be  traced;  muscular  effort  is  the  most  common. 
Mental  emotion  is  a  second  potent  cause.  John  Hunter  used  to  say  that 
"his  life  was  in  the  hands  of  any  rascal  who  chose  to  worry  him,"  and  his 
fatal  attack  occurred  in  a  fit  of  anger.  A  third  very  common  excitant  is 
flatulent  distention  of  the  stomach.  Many  patients  are  very  sensitive  to  cold, 
and  the  chill  of  getting  out  of  bed  or  of  the  bath  may  bring  on  a  paroxysm. 

PHENOMENA  OF  THE  ATTACK. — During  exertion  or  intense  mental  emo- 
tion the  patient  is  seized  with  an  agonizing  pain  in  the  region  of  the  heart 
and  a  sense  of  constriction,  as  if  the  heart  had  been  seized  in  a  vice.  The 
pains  radiate  to  the  neck  and  down  the  arm,  and  there  may  be  numbness  of 
the  fingers  or  in  the  cardiac  region.  The  face  is  usually  pallid  and  may  as- 
sume an  ashy  gray  tint,  and  not  infrequently  a  profuse  sweat  breaks  out  over 
the  surface.  The  paroxysm  lasts  from  several  seconds  to  a  minute  or  two, 
during  which,  in  severe  attacks,  the  patient  feels  as  if  death  were  imminent. 
As  pointed  out  by  Latham,  there  are  two  elements  in  it,  the  pain — dolor  pec- 
toris — and  the  indescribable  feeling  of  anguish  and  sense  of  imminent  dis- 
solution— angor  animi.  There  are  great  restlessness  and  anxiety,  and  the 
patient  may  drop  dead  at  the  height  of  the  attack  or  faint  and  pass  away 
in  syncope.  The  condition  of  the  heart  during  the  attack  is  variable;  the 
pulsations  may  be  uniform  and  regular.  The  pulse  tension,  however,  is 
usually  increased,  but  it  is  surprising,  even  in  the  cases  of  extreme  severity, 
how  slightly  the  character  of  the  pulse  may  be  altered.  After  the  attack 
there  may  be  eructations,  or  the  passage  of  a  large  quantity  of  clear  urine. 
The  patient  usually  feels  exhausted,  and  for  a  day  or  two  may  be  badly 
shaken;  in  other  instances  in  an  hour  or  two  the  patient  feels  himself  again. 
While  dyspnoea  is  not  a  constant  feature,  the  paroxysm  is  not  infrequently 
associated  with  a  form  of  asthma;  there  is  wheezing  in  the  bronchial  tubes, 
which  may  come  on  very  rapidly,  and  the  patient  gets  short  of  breath. 

Death  may  occur  in  the  first  attack,  as  in  the  well  known  case  of  Thomas 
Arnold;  or  at  the  end  of  a  series  of  attacks,  the  so-called  status  angiosus. 
Paroxysms  may  occur  at  intervals  of  a  few  weeks  for  a  year  or  more  before 
the  fatal  attack. 

There  is  a  chronic  form  represented  by  ten  cases  in  my  series,  in  which 
attacks  occur  irregularly.  John  Hunter's  first  seizure  was  in  1773,  and 
he  had  many  in  4he  20  years  before  his  death.  Sometimes  life  is  a  terrible 
burden,  as  any  emotion  or  effort  may  bring  on  an  attack.  And,  lastly,  after 
paroxysms  of  great  severity  recurring  for  months,  or  even  for  so  long  as 
two  years,  as  in  one  of  my  cases,  complete  recovery  takes  place. 

EXTRA-PECTORAL  FEATURES  OF  ANGINA. — In  the  attack  the  pain  usually 
radiates  up  the  neck  and  down  the  left  arm.  As  the  studies  of  Mackenzie 
and  Head  have  shown  in  disease  of  the  heart  and  of  the  aorta,  the  pain  is 
referred  to  the  1st,  2d,  3d,  and  4th  dorsal  areas;  and  in  angina  it  may  be 
also  in  areas  of  the  distribution  of  the  5th  to  the  9th  dorsal  nerves.  The  pain 
may  begin  in  the  left  arm,  or  in  the  jaw,  even  in  the  front  teeth,  or  in  one 
testis.  Sometimes  the  pain  remains  in  these  distant  parts,  and  yet  the  attack 
presents,  as  noted  by  Heberden,  all  the  features  of  angina.  I  have  known 


ANGINA    PECTOEIS  839 

the  attack  to  begin  with  agonizing  pain  in  the  left  leg;  in  another  case  in  the 
left  pectoral  muscle.  The  entire  features  of  the  attack  may  be  sub-dia- 
phragmatic— the  so-called  angina  dbdominis.  In  at  least  ten  of  my  series 
the  pains  were  abdominal,  and,  as  first  pointed  out  by  Leared,  gastralgia  may 
be  diagnosed. 

The  pulmonary  features  of  angina  are  remarkable.  A  condition  like  acute 
emphysema  may  come  on,  with  wheezing  and  an  inflated  state  of  the  lungs. 
Acute  cedema  may  follow  with  the  expectoration  of  large  quantities  of  a 
thin,  bloody  fluid.  The  blood  pressure  may  be  extraordinarily  high — 340 
mm.  Hg.  in  one  case.  Cerebral  features  are  not  common,  but  unconscious- 
ness may  occur.  Transient  monoplegia,  or  hemiplegia  and  aphasia,  occurred 
in  three  of  my  cases. 

Morbid  Anatomy  and  Pathology. — The  17  post  mortems  in  my  series 
illustrate  the  usual  lesions: 

(a)  Coronary  artery  disease  was  present  in  13  cases.  The  orifices  only 
may  be  involved  in  a  sclerotic  aortitis.  In  one  case  they  were  narrowed  to 
admit  only  a  bristle,  while  the  vessels  beyond  were  normal.  Blocking  of  a 
branch  with  a  fresh  thrombus,  or  with  an  embolus,  is  not  uncommon.  Dur- 
ing an  attack  an  infarct  may  soften,  with  perforation  of  the  ventricular  wall. 
Obliterative  endarteritis,  the  lesion  of  the  disease,  was  present  in  9  of  my 
cases.  In  elderly  subjects  the  coronary  vessels  may  be  calcified — the  condi- 
tion found  by  Jenner  in  John  Hunter. 

(6)  Aortitis  was  present  in  four  of  my  cases,  in  syphilitic  subjects,  all 
under  40  years  of  age.  Corrigan  first  called  attention  to  this  lesion  in  angina, 
the  great  importance  of  which  has  been  emphasized  by  Clifford  Allbutt.  It 
is  usually  limited  to  the  supra-sigmoidal  area,  and  has  the  characteristic 
features  of  the  syphilitic  aortitis. 

(c)  In  a  few  instances  no  lesions  have  been  found.  In  one  case  of  my 
list  a  man  aged  26  had  attacks,  which  were  regarded  as  functional,  on  and  off 
for  two  years.  Death  occurred  after  a  series  of  paroxysms.  The  aorta  was 
small,  otherwise  there  were  no  changes. 

No  completely  satisfactory  explanation  of  the  phenomena  of  the  angina 
attack  has  yet  been  offered.  It  has  been  regarded  as  a  neuralgia  of  the  car- 
diac nerves,  a  cramp  of  the  heart  muscle,  or  of  certain  parts  of  it,  or  an 
expression  of  tension  of  the  ventricular  walls  in  extreme  dilatation.  In 
some  ways  the  intermittent  claudication  theory  of  Allan  Burns  meets  the 
case.  This  may  be  defined  as  a  state  in  which  an  artery  admits  enough  blood 
to  a  muscular  structure  for  quiet  work,  but  not  enough  for  increased  work, 
so  that  the  contractile  function  of  the  muscle  is  disturbed  and  pain  results. 
Burns  remarked  that  "...  If  we  can  call  into  vigorous  action  a  limb 
around  which  we  have  with  moderate  tightness  applied  a  ligature,  we  find 
that  then  the  member  can  only  support  its  action  for  a  very  short  time,  for 
now  the  supply -of  energy  and  its  expenditure  do  not  balance  each  other.  .  .  . 
A  heart,  the  coronary  arteries  of  which  are  cartilaginous  or  ossified,  is  nearly 
in  a  similar  condition;  it  can,  like  the  limb  begirt  with  a  moderately  tight 
ligature,  discharge  its  functions  so  long  as  its  action  is  moderate  and  equal. 
Increase,  however,  the  action  of  the  whole  body,  and  along  with  the  rest  that 
of  the  heart,  and  you  will  soon  see  exemplified  the  truth  of  what  has  been 
said." 


840  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

Angina  results  from  an  alteration  in  the  working  of  the  muscle  fibres 
of  any  part  of  the  cardio-vascular  system,  whereby  painful  afferent  stimuli 
are  excited.  Cold,  emotion,  or  toxic  agents  interfering  with  the  orderly 
action  of  the  peripheral  circulation  increase  the  tension  in  the  heart  walls 
or  in  the  larger  central  mains,  causing  strain  and  a  type  of  contraction 
capable  of  exciting  in  the  involuntary  muscles  painful  afferent  stimuli.  In 
disturbance  of  this  all-important  Gaskellian  function,  in  the  stretching,  in 
the  alteration  of  the  wall  tension  at  any  point,  sufficient  to  excite  a  pain- 
producing  resistance  to  this  by  the  muscle  elements,  are  to  be  sought  an 
explanation  of  the  phenomenon  of  the  attack.  Spasm,  or  narrowing  of  a 
coronary  artery,  or  of  one  branch,  may  so  modify  the  action  of  a  section 
of  the  heart  that  it  works  with  disturbed  tension,  and  with  stretching  and 
strain  sufficient  to  rouse  painful  sensations.  Or  the  heart  may  be  in  the 
same  state  as  the  leg  muscles  of  a  man  with  intermittent  claudication,  work- 
ing smoothly  when  quiet,  but  the  instant  an  effort  is  made,  or  if  a  wave  of 
emotion  touches  the  peripheral  vessels,  the  normal  contraction  is  dist'urbed 
and  a  crisis  of  pain  excited. 

There  are  three  modes  of  dying  in  angina — one,  as  Walshe  says,  "is  sud- 
den, instantaneous,  coeval  with  a  single  pang."  The  functions  of  life  stop 
abruptly,  and  with  a  gasp  all  is  over.  In  a  second  mode,  following  a  series 
of  attacks,  the  heart  grows  weaker  and  the  patient  dies  in  a  progressive 
asthenia;  while  in  a  third  there  is  a  gradually  induced  cardiac  insufficiency 
with  dyspnoea. 

Prognosis. — In  men  under  40  syphilis  must  be  suspected,  and  with  appro- 
priate treatment  recovery  may  be  complete  (see  my  Lumleian  Lectures, 
Lancet,  1910,  I).  In  men  in  the  5th  and  6th  decades  who  have  lived  the 
high  pressure  life  a  change  of  habits  may  bring  relief;  but,  as  Walshe  re- 
marked, "the  cardinal  fact  in  real  angina  is  its  uncertainty."  Even  after 
attacks  of  the  greatest  severity  recovery  is  possible.  The  circumstances  that 
briag  on  an  attack  are  important.  Emotion  is  of  the  least  importance.  The 
angina  of  effort  that  follows  any  slight  exertion  is',  as  a  rule,  more  serious 
than  that  which  comes  on  spontaneously,  or  is  excited  by  emotion;  yet  one 
of  my  patients  who  could  never  dress  without  having  what  he  called  "angor 
de  toilette"  lived  for  11  years.  The  cardio-vascular  condition  is  of  the  first 
importance  in  prognosis.  Very  high  blood  pressure,  advanced  arterio-sclero- 
sia,  valvular  disease,  signs  of  myocardial  weakness  are  of  serious  import.  It 
is  to  be  remembered  that  a  large  proportion  of  all  cases  have  no  obvious  signs 
of  cardiac  disease;  and  the  coronary  arteries  may  be  extensively  diseased 
with  clear  heart  sounds  and  a  good  pulse.  In  women  the  forms  of  angina 
with  marked  vaso-motor  disturbance  as  a  rule  do  well,  and  when  neurotic  or 
hysterical  manifestations  are  prominent  the  outlook  is  good. 

Treatment- — Syphilitic  cases  require  active  treatment — salvarsan  in  the 
subjects  under  40,  mercury  and  iodide  of  potassium  in  older  persons.  In 
the  neurotic  cases  with  a  recognition  of  the  basic  disturbance  in  the  vaso- 
motor  system  a  Weir  Mitchell  cure  and  hydrotherapy  are  indicated.  A  per- 
sistent course  of  wet  packs  I  have  often  seen  helpful.  When  high  tension  is 
present,  as  is  not  infrequently  the  case  in  neurasthenia,  the  nitrites  may  be 
given;  and  ergotin  grs.  ii  (0.13  gm.)  three  times  a  day  has  a  definite  value  in 
vaso-motor  instability.  In  the  severer  types  of  the  disease  the  treatment  is 


ARTERIO-SCLEROSIS  841 

concerned  with  the  attack  and  with  the  general  condition  afterward.  In 
the  attack  inhalation  of  nitrite  of  amyl,  introduced  by  Lauder  Brunton,  may 
give  instant  relief.  We  see  its  benefit  particularly  in  cases  with  widespread 
arterial  constriction.  In  the  recurring  terrible  paroxysms  it  may  lose  its 
effect,  but  many  milder  forms  are  relieved  promptly,  and  it  gives  great  com- 
fort and  confidence  to  the  patient  to  carry  the  perles.  Morphia  should  be 
used  freely  when  amyl  nitrite  fails  and  when  the  attacks  recur  with  great 
frequency.  As  Burney  Yeo  pointed  out,  angina  patients  are  very  resistant 
to  this  drug,  and  between  10  p.  m.  and  1  p.  m.  the  next  day  I  have  known 
five  grains  administered  with  relief  to  the  pain,  but  without  causing  sleep. 
Chloroform  may  have  to  be  used,  and  my  experience  coincides  with  that  of 
the  late  George  Balfour  of  Edinburgh,  that  it  is  always  helpful,  never  harm- 
ful. With  a  dusky  cyanosis  and  asthma  like  breathing  oxygen  inhalations 
may  be  given. 

For  the  general  condition,  if  high  tension  is  present,  iodide  of  potassium 
and  the  nitrites  in  all  forms  are  useful.  The  use  of  theobromine  has  been 
warmly  advocated  by  Marchiafava,  grs.  xv  (1  gm.)  three  times  a  day,  and 
I  have  tried  it  in  a  few  cases  with  benefit,  particularly  in  two  cases  of  the 
angina  of  effort. 


C.    DISEASES  OF  THE  ARTERIES 
I.    ARTERIO-SCLEROSIS 

(Arterio-capillary  Fibrosis) 

The  conception  of  arterio-sclerosis  as  an  independent  affection — a  general 
disease  of  the  vascular  system — is  due  to  Gull  and  Sutton. 

Definition. — A  condition  of  thickening  of  the  arterial  coats,  with  degen- 
eration, diffuse  or  circumscribed.  The  process  leads,  in  the  larger  arteries,  to 
what  is  known  as  atheroma  and  to  endarteritis  deformans,  and  seriously  in- 
terferes with  the  normal  functions  of  various  organs. 

Etiology.  —Among  the  important  factors  in  causing  arterio-sclerosis  the 
following  may  be  considered: 

(a)  HYPERTENSION. — The  blood  pressure,  the  tension  or  force  with  which 
the  blood  circulates,  depends  upon  five  factors:  The  heart  pump  supplies 
the  force;  the  elastic  coats  of  the  large  arteries  store  and  convert  an  inter- 
mittent into  a  continuous  stream;  the  small  arteries  act  as  sluices  or  taps 
regulating  the  control  to  different  parts;  the  capillary  bed  is  the  irrigation 
field  over  which  the  nutritive  fluid  is' distributed;  and  the  drainage  system 
is  represented  by  the  veins  and  lymph  channels. 

Galen  first  grasped  the  fact  that  life  depends  upon  the  maintenance  of 
a  due  pressure  in  these  irrigation  fields :  "Many  canals  dispersed  throughout 
all  the  parts  of  the  body  convey  to  them  blood  as  those  of  a  garden  convey 
moisture,  and  the  intervals  separating  those  canals  are  wonderfully  disposed 
by  nature  in  such  a  way  that  they  should  neither  lack  a  sufficient  quantity 
of  blood  for  absorption,  nor  be  overloaded  at  any  time  with  an  excessive 

supply." 

55 


842  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

The  blood  pressure  varies  greatly  in  different  individuals,  and  in  the 
same  individual  under  varying  conditions.  The  normal  blood  pressure  is 
from  120  to  130  mm.  of  mercury,  but  in  persons  over  50  it  is  very  often  from 
140  to  160  mm.  A  permanent  pressure  above  the  latter  figure  may  be  called 
high,  but  there  are  great  regional  variations.  Permanently  low  blood  pres- 
sure may  be  met  with  in  asthenia  from  any  cause,  in  the  various  toxaemias  of 
the  infectious  diseases,  and  there  are  persons  in  apparently  good  health  with 
chronic  hypotension. 

High  tension  is  met  with  in  many  chronic  diseases,  in  various  forms  of 
cardiac  and  renal  disease,  in  lead  poisoning,  and,  above  all,  in  connection 
with  general  arterio-sclerosis.  The  relation  to  artcrio-sclcrosis  has  been 
much  discussed.  Briefly,  there  are  three  groups  of  cases:  (1)  First,  the 
simple  high  tension  without  signs  of  arterial  or  renal  disease — what  Clifford 
Allbutt  calls  hyperpyesis.  In  this  well  recognized  condition,  met  with  in 
individuals  otherwise  healthy,  the  blood  pressure  is  permanently  high — 
above  180 — but,  so  far  as  can  be  ascertained,  there  are  no  arterial,  car- 
diac, or  renal  changes.  It  is  difficult,  of  course,  to  exclude  internal,  not 
discernible  alterations  in  the  splanchnic  and  other  vessels,  since,  as  is 
well  known,  vascular  disease  may  be  very  localized.  But  clinically  the 
group  is  well  defined  and  very  important.  The  condition  is  met  with  most 
frequently  in  keen  business  men,  who  work  hard,  drink  hard,  and  smoke 
hard. 

The  exact  cause  of  this  high  tension  we  do  not  know.  Some  have  at- 
tributed it  to  over-activity  of  the  adrenals,  but  it.  is  much  more  likely  that 
the  primary  difficulty  is  somewhere  in  the  capillary  bed — in  that  short  space 
in  which  the  real  business  of  life  is  transacted.  However  produced,  the  im- 
portant point  here  is  that  this  hypertension  itself  leads  to  arterio-sclerosis, 
which  can  be  produced  experimentally  by  the  injection  of  adrenalin  and  other 
hypertensive  substances. 

(2)  In  the  second  group  of  cases  the  high  tension  is  associated  with  an 
arterio-sclerosis  with  consecutive  cardiac  and  renal  disease. 

(3)  In  the  third  group  the  high  tension  is  secondary  to  forms  of  chronic 
nephritis  in  association  with  cardio-vascular  disease. 

(&)  As  an  INVOLUTION  PROCESS  arterio-sclerosis  is  an  accompaniment  of 
old  age,  and  is  the  expression  of  the  natural  wear  and  tear  to  which  the  tubes 
are  subjected.  Longevity  is  a  vascular  question,  which  has  been  well  ex- 
pressed in  the  axiom  that  "a  man  is  only  as  old  as  his  arteries."  To  a  ma- 
jority of  men  death  comes  primarily  or  secondarily  through  this  portal.  The 
onset  of  what  may  be  called  physiological  arterio-sclerosis  depends,  in  the  first 
place,  upon  the  quality  of  arterial  tissue  (vital  rubber)  which  the  individual 
has  inherited,  and  secondly  upon  the  amount  of  wear  and  tear  to  which  he 
has  subjected  it.  That  the  former  plays  a  most  important  role  is  shown  in 
tho  cases  in  which  arterio-sclerosis  sets  in  early  in  life  in  individuals  in 
whom  none  of  the  recognized  etiological  factors  can  be  found.  Thus,  for 
instance,  a  man  of  twenty  eight  or  twenty  nine  may  have  the  arteries  of  a 
man  of  sixty,  and  a  man  of  forty  may  present  vessels  as  much  degenerated 
as  they  should  be  at  eighty.  Entire  families  sometimes  show  this  tendency 
to  early  arterio-sclerosis — a  tendency  which  can  not  be  explained  in  any  other 
way  than  that  in  the  makeup  of  the  machine  bad  material  was  used  for  the 


ARTERIO-SCLEROSIS  843 

tubing.     More  commonly  the  arterio-sclerosis  results  from  the  bad  use  of 
good  vessels. 

(c)  CHRONIC  INTOXICATIONS. — Alcohol,  lead,  and  gout  play  an  important 
role  in  the  causation  of  arterio-sclerosis,  although  the  precise  mode  of  their 
action  is  not  yet  very  clear.    They  may  act,  as  Traube  suggests,  by  increasing 
the  peripheral  resistance  in  the  smaller  vessels  and  in  this  way  raising  the 
blood  tension,  or  possibly,  as  Bright  taught,  they  alter  the  quality  of  the 
blood  and  render  more  difficult  its   passage  through  the  capillaries.     The 
observations  of  Cabot  have  thrown  doubt  on  the  importance  of  alcohol  as  a 
factor. 

The  poisons  of  the  acute  infections  may  produce  degenerative  changes  in 
the  media  and  adventitia.  Thayer  has  recently  called  attention  to  the  fre- 
quency of  arterial  changes  as  a  sequence  of  typhoid  fever. 

(d)  SYPHILIS,  one  of  the  most  important  single  causes,  will  be  spoken  of 
under  morbid  anatomy. 

(e)  OVEREATING. — I  am  more  and  more  impressed  with  the  part  played 
by  overeating  in  inducing  arterio-sclerosis.     There  are  many  cases  in  which 
there  is  no  other  factor.     George  Cheyne's  advice,  quoted  at  page  451,  was 
never  more  needed  than  by  the  present  generation. 

(/)  THE  STRESS  AND  STRAIN  OF  MODERN  LIFE. — There  are  men  in  the 
fifth  decade  who  have  not  had  syphilis  or  gout,  who  have  eaten  and  drunk 
with  discretion,  and  in  whom  none  of  the  ordinary  factors  are  present — men 
in  whom  the  arterio-sclerosis  seems  to  come  on  as  a  direct  result  of  a  high 
pressure  life.  • 

(g)  OVERWORK  OF  THE  MUSCLES,  which  acts  by  increasing  the  peripheral 
resistance  and  by  raising  the  blood  pressure. 

(h)  RENAL  DISEASE. — The  relation  between  the  arterial  and  kidney 
lesions  has  been  much  discussed,  some  regarding  the  arterial  degeneration  as 
secondary,  others  as  primary.  There  are  two  groups  of  cases,  one  in  which 
the  arterio-sclerosis  is  the  first  change,  'and  the  other  in  which  it  is  secon- 
dary to  a  primary  affection  of  the  kidneys. 

Morbid  Anatomy. — The  affection  is  met  with  most  frequently  in  the  aorta 
and  its  main  branches.  It  is  comparatively  less  frequent  in  the  mesenteric 
and  rare  in  the  pulmonary  arteries.  Several  different  forms  may  be  recog- 
nized : 

(a)  NODULAR. — The  aorta  presents  in  the  early  stages,  from  the  ring  to 
the  bifurcation,  numerous  flat  projections,  yellowish  or  yellowish  white  in 
color,  and  situated  particularly  about  the  orifices  of  the  branches.  In  the 
early  stage  these  patches  are  scattered  and  do  not  involve  the  entire  intima. 
In  more  advanced  stages  the  patches  undergo  atheromatous  changes.  The 
material  constituting  the  button  undergoes  softening  and  breaks  up  into 
granular  material,  consisting  of  molecular  debris — the  so-called  atheromatous 
abscess. 

(&)  DIFFUSE  ARTERIO-SCLEROSIS. — In  this  form,  met  with  usually  in 
middle-aged  men,  or  younger  persons,  the  affection  is  widespread  through- 
out the  arteries.  In  the  aorta  the  media  shows  necrotic  and  hyaline  changes, 
while  the  intima  may  be  smooth  or  show  very  slight  thickenings — scattered 
elevated  areas  of  an  opaque  white  color,  some  of  which  undergo  atheromatous 
changes.  The  smaller  arteries  show  thickening  of  the  walls,  due  particularly 


844  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

to  increase  in  the  sub-endothelial  connective  tissue.  The  muscular  coat  may 
be  at  first  hypertrophied,  but  later  undergoes  hyaline  and  calcareous  changes. 
In  this  group  of  cases  the  heart  hypertrophies  and  later  fibrous  myocarditis  is 
often  present.  The  semilunar  valves  are  opaque  and  sclerotic.  The  kidneys 
are  sclerotic  and  may  be  increased  in  size,  and  are  usually  very  firm.  In 
places  the  surface  may  be  rough,  or  present  atrophied  depressed  areas  of  a 
deep  red  color. 

(c)  SENILE  ARTERIO-SCLEROSIS. — In  this  the  larger  arteries  are  dilated 
and  tortuous,  the  walls  thin  and  stiff,  and  the  smaller  vessels,  as  the  radials, 
converted  into  rigid  tubes  like  pipe-stems.  The  intima  of  the  aorta  may  be 
occupied  by  rough,  calcareous  plaques,  with  here  and  there  fissures  and  loss 
of  substance.  There  may  be  sub-endothelial  softening  with  the  formation 
of  atheromatous  ulcers  on  which  thrombi  may  deposit;  though,  as  a  rule, 
there  may  be  the  most  extreme  calcification  and  roughness  with  erosions 
of  the  aorta  without  thrombus  formation.  In  the  smaller  vessels,  as  the 
radicals,  there  are  degeneration  and  calcification  of  the  media — the  so-called 
Monckeberg  type. 

The  SYPHILITIC  ARTERIO-SCLEROSIS  is  usually  a  mesaortitis  with  definite 
characteristics.  Microscopically  it  may  be  limited  in  extent,  localized  at  the 
root  of  the  aorta,  or  about  the  orifice  of  an  aneurism,  or  there  is  a  band  of 
an  inch  in  width  on  some  portion  of  the  tube,  while  other  parts  of  the  aorta 
and  its  branches  are  normal.  In  other  instances  the  intima  is  involved,  not 
with  the  usual  plaque-like  areas  of  atheroma,  but  there  are  shallow  depressions 
of  a  bluish  tint,  and  short  transverse  or  longitudinal  puckerings,  sometimes 
with  a  stellate  arrangement;  or  the  intima  is  pitted  and  scarred  with  small 
depressions  and  linear  sulci.  Microscopically  the  most  important  changes 
are  found  in  the  media  and  adventitia:  (a)  peri  vascular  infiltration  of  the 
vasa  vasorum;  (&)  small-celled  infiltration  in  areas  of  the  media,  with  (c) 
splitting,  separation,  and  destruction  of  elastic  fibres  and  the  muscle  cells. 
The  intima  over  these  areas  may  be  perfectly  normal,  but  it  often  shows 
signs  of  thickening  with  fatty  degeneration  and  th6  production  of  hyaline. 
Similar  changes  have  been  described  by  Klotz  in  the  larger  blood  vessels  in 
cases  of  congenital  syphilis.  And,  lastly,  the  specific  nature  of  this  mesaorti- 
tis has  been  determined  by  the  detection  of  the  spirochaetes.  Other  forms  af- 
fecting the  smaller  vessels  have  been  referred  to  under  syphilis. 

SCLEROSIS  or  THE  PULMONARY  ARTERY  is  met  with  in  all  conditions  which 
for  a  long  time  increase  the  tension  in  the  lesser  circulation,  particularly  in 
mitral  valve  disease  and  in  emphysema.  Sometimes  the  sclerosis  reaches  a 
high  grade  and  is  accompanied  with  aneurismal  dilatation  of  the  primary 
and  secondary  branches,  more  rarely  with  insufficiency  of  the  pulmonary 
valve.  Leonard  Rogers  has  shown  that  in  India  it  is  not  uncommon  as  a 
primary  affection.  In  a  remarkable  case  of  a  young  man  of  twenty  four,  re- 
ported by  Romberg  from  Curschmann's  clinic,  the  pulmonary  arteries  were 
involved  in  most  extensive  arterio-sclerosis ;  the  main  branches  were  dilated, 
and  the  smaller  branches  were  the  seat  of  the  most  extreme  sclerotic  changes. 
On  the  other  hand,  the  aorta  and  its  branches  were  normal. 

In  many  cases  of  arterio-sclerosis  the  condition  is  not  confined  to  the 
arteries,  but  extends  not  only  to  the  capillaries  but  also  to  the  veins,  and 
may  properly  be  termed  an  angio-sderosis. 


ARTEBIO-SCLEROSIS  845 

SCLEROSIS  OF  THE  VEINS — phlebo-sclerosis — is  not  at  all  an  uncommon 
accompaniment  of  arterio-sclerosis.  It  is  seen  in  conditions  of  heightened 
blood  pressure,  as  in  the  portal  system  in  cirrhosis  of  the  liver  and  in  the 
pulmonary  veins  in  mitral  stenosis.  The  affected  vessels  are  usually  dilated, 
and  the  intima  shows,  as  in  the  arteries,  a  compensatory  thickening,  which  is 
particularly  marked  in  those  regions  in  which  the  media  is  thinned.  The 
new-formed  tissue  in  the  endophlebitis  may  undergo  hyaline  degeneration, 
and  is  sometimes  extensively  calcified.  Without  existing  arterio-sclerosis  the 
peripheral  veins  may  be  sclerotic,  usually  in  conditions  of  debility,  but  not 
infrequently  in  young  persons. 

Symptoms. — INCREASED  TENSION. — The  pressure  with  which  the  blood 
flows  in  the  arteries  depends  upon  the  degree  of  peripheral  resistance  and  the 
force  of  the  ventricular  contraction.  A  high-tension  pulse  may  exist  with 
very  little  arterio-sclerosis;  but,  as  a  rule,  when  the  condition  has  been  per- 
sistent, the  sclerosis  and  high  tension  are  found  together.  On  the  other  hand, 
a  very  low  or  normal  tension  may  be  present  in  extremely  sclerotic  vessels. 

GENERAL  SYMPTOMS. — The  early  symptoms  are  interesting.  Stengel  has 
called  attention  to  the  pallor,  and  there  may  be  dyspeptic  symptoms.  It  is 
remarkable  with  what  rapidity  the  disease  may  progress.  I  have  known  the 
peripheral  arteries  to  stiffen  and  grow  old  in  a  couple  of  years. 

The  combination  of  heightened  blood  pressure,  a  palpable  thickening  of 
the  arteries,  hypertrophy  of  the  left  ventricle,  and  accentuation  of  the  aortic 
second  sound  are  signs  pathognomonic  of  arterio-sclerosis.  From  this  period 
of  establishment  the  course  of  the  disease  may  be  very  varied.  For  years 
the  patient  may  have  good  health,  and  be  in  a  condition  analogous  to  that 
of  a  person  with  a  well  compensated  valvular  lesion.  There  may  be  no  renal 
symptoms,  or  there  may  be  the  passage  of  a  larger  amount  of  urine  than 
normal,  with  transient  albuminuria,  and  now  and  then  hyaline  tube  casts. 
The  subsequent  history  is  extraordinarily  diverse,  depending  upon  the  vas- 
cular territory  in  which  the  sclerosis  is  most  advanced,  or  upon  the  accidents 
which  are  so  liable  to  happen,  and  the  symptoms  may  be  cardiac,  cerebral, 
renal,  etc. 

(a)  Cardiac. — The  involvement  of  the  coronary  arteries  may  lead  to  the 
various  symptoms  already  referred  to  under  that  section — thrombosis  with 
sudden  death,  fibroid  degeneration  of  the  heart,  aneurism  of  the  heart,  rup- 
ture, and  angina  pectoris.  Angina  pectoris  is  not  uncommon,  and  the  or- 
ganic variety  is  almost  always  associated  with  arterio-sclerosis.  A  second  im- 
portant group  of  cardiac  symptoms  results  from  the  dilatation  which  finally 
gets  the  better  of  the  hypertrophy.  The  patient  then  presents  all  the  symp- 
toms of  cardiac  insufficiency— dyspnoea,  scanty  urine,  and  very  often  serous 
effusions.  If  the  case  has  come  under  observation  for  the  first  time  the  clin- 
ical picture  is  that  of  chronic  valvular  disease,  and  the  existence  of  a  loud 
blowing  murmur  at  the  apex  may  throw  the  practitioner  off  his  guard.  Many 
cases  terminate  in  this  way. 

(&)  The  cerebral  symptoms  of  arterio-sclerosis  are  varied  and  important, 
and  embrace  those  of  many  degenerative  diseases,  acute  and  chronic  (which 
follow  sclerosis  of  the  smaller  branches),  and  cerebral  hemorrhage. 

Transient  hemiplegia,  monoplegia,  or  aphasia  may  occur  in  advanced  ar- 
terio-sclerosis. The  attacks  are  very  characteristic,  often  brief,  lasting  twenty 


846  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

four  hours  or  less.  Recovery  may  be  perfect.  Recurrence  is  the  rule,  and  a 
patient  may  have  a  score  or  more  attacks  of  aphasia,  or  in  the  course  of  a 
couple  of  years  there  may  be  half  a  dozen  transient  hemiplcgic  attacks  or  one 
or  two  monoplegias,  or  paraplegia  for  a  day  or  two.  Much  attention  has  of 
late  been  given  to  these  cases,  which  seem  best  explained  on  the  view  of  tran- 
sient spasm  as  originally  suggested  by  Peabody.  Vertigo  occurs  frequently, 
and  may  be  either  simple,  or  is  associated  with  slow  pulse  and  syncopal  or 
epileptiform  attacks — the  Stokes-Adams  syndrome. 

(c)  Renal  symptoms  supervene  in  a  large  number  of  the  cases.    A  sclero- 
sis, patchy  or  diffuse,  is  present  in  a  majority  of  the  cases  at  the  time  of 
autopsy,  and  the  condition  is  practically  that  of  contracted  kidney.     It  is 
seen  in  a  typical  manner  in  the  senile  form,  and  not  infrequently  develops 
early  in  life  as  a  direct  sequence  of  the  diffuse  variety.    It  is  often  difficult  to 
decide  clinically  (and  the  question  is  one  upon  which  good  observers  might 
not  agree  in  a  given  case)  whether  the  arterial  or  the  renal  disease  has  been 
primary. 

(d)  Abdominal  Arterio-sclerosis. — It  is  believed  to  be  associated  particu- 
larly with  overeating  and  chronic  overtaxing  of  the  stomach  and  intestines 
with  work.     The  condition  is  by  no  means  uncommon,  and  the  sclerosis  of 
the  splanchnic  vessels  may  be  advanced  out  of  all  proportion  to  that  else- 
where.    The  symptoms  are   indefinite,  sometimes   resembling  those   of  the 
ordinary  neurosis  with  marked  constipation,  features  that  are  by  no  means 
certainly  associated  with  sclerosis;  on  the  other  hand,  there  is  much  more 
reason  to  connect  the  attacks  of  severe  abdominal  pain,  the  gastric  crises  of 
lead  and  of  tabes  with  spasm  of  the  vessels  in  this  condition.     There  are 
cases  of  angina  pectoris  with  abdominal  pain  which  may  be  due  to  angio- 
spasm  of  the  sclerotic  vessels. 

(e)  Among  other  events  in  arterio-sclerosis  may  be  mentioned  gangrene 
of  the  extremities,  due  either  directly  to  endarteritis  or  to  the  dislodgment 
of  thrombi.     Sudden  transient  paralysis  may  occur. 

(/)  Intermittent  lameness  or  claudication,  the  dySbasia  angio-sclerotica  of 
Erb,  the  crural  angina  of  Walton,  is  seen  most  frequently  in  connection  with 
arterio-sclerosis.  In  the  horse,  in  which  the  intermittent  lameness  was  first 
described  by  Bouley,  verminous  aneurisms  are  present  in  the  iliac  arteries.  In 
man  Charcot  described  the  condition  in  1856  in  an  old  soldier  who  was  not 
able  to  walk  for  more  than  a  quarter  of  an  hour  without  severe  cramps  in  the 
legs.  The  post  mortem  showed  a  traumatic  aneurism  of  one  iliac  artery.  The 
loss  of  function  and  the  pain  in  the  muscles  were  due  to  the  relative  ischemia. 
Erb  has  shown  that  intermittent  lameness  is  not  at  all  infrequent,  particular- 
ly among  private  patients,  only  2  of  his  45  cases  not  coming  in  this  class.  Of 
127  cases  there  were  only  7  in  women.  Hebrews  seem  more  frequently  af- 
fected. Syphilis,  alcohol,  and  tobacco  are  common  factors.  Muscular  weak- 
ness after  exertion  or  complete  disability,  numbness,  tingling,  and  parasthesia 
of  various  forms  are  the  common  symptoms.  Pulsation  may  be  absent  in  the 
dorsal  arteries  of  the  feet  and  the  vessels  are  sclerotic.  Vaso-motor  changes 
may  be  present,  and  in  the  dependent  position  the  feet  and  legs  become  deeply 
congested. 

Treatment. — In  the  late  stages  the  conditions  must  be  treated  as  they 
arise  in  connection  with  the  various  viscera;  In  the  early  stages,  before  any 


ANEURISM  847 

local  symptoms  are  manifest,  the  patient  should  be  enjoined  to  live  a  quiet, 
well  regulated  life,  avoiding  excesses  in  food  and  drink.  It  is  usually  best  to 
explain  frankly  the  condition  of  affairs,  and  so  gain  his  intelligent  coopera- 
tion. Special  attention  should  be  paid  to  the  state  of  the  bowels  and  urine, 
and  the  secretion  of  the  skin  should  be  kept  active  by  daily  baths.  Alcohol 
in  all  forms  should  be  prohibited,  and  the  food  should  be  restricted  to  plain, 
wholesome  articles.  The  use  of  mineral  waters  or  a  residence  every  year  at 
one  of  the  mineral  springs  is  usually  serviceable.  If  there  has  been  a  syph- 
ilitic history  the  persistent  use  of  iodide  of  potassium  is  indicated;  indeed, 
even  in  the  non-syphilitic  cases  it  seems  to  do  good.  It  is  best  given  in  small 
doses,  grains  v  to  x  (0.3  to  0.6  gm.).  Whenever  the  blood  pressure  is  high 
nitroglycerin  or  the  sodium  nitrite  may  be  given  to  relieve  symptoms  rather 
than  with  any  hope  of  essentially  influencing  the  disease. 

In  cases  which  come  under  observation  for  the  first  time  with  dyspnoea, 
slight  lividity,  and  signs  of  cardiac  insufficiency,  venesection  is  indicated.  In 
some  instances,  with  very  high  tension,  striking  relief  is  afforded  by  the 
abstraction  of  10  to  20  ounces  of  blood.  Cardiac  failure,  renal  symptoms, 
etc.,  require  the  usual  treatment. 

H.    ANEURISM 

Definition.  — A  tumor  containing  fluid  or  solid  blood  in  direct  communica- 
tion with  the  cavity  of  the  heart,  the  surface  of  a  valve,  or  the  lumen  of  an 
artery. 

History. — Galen  knew  external  aneurism  well,  and  in  the  second  century 
A.  D.,  Antyllos  devised  his  operation  of  incising  and  emptying  the  sac  in- 
closed between  ligatures.  Internal  aneurism  was  recognized  by  Fernelius 
in  the  16th  century,  and  Vesalius  was  very  familiar  with  the  disease.  Am- 
broise  Pare  suggested  the  relation  of  aneurism  to  syphilis,  which  was  insisted 
upon  in  the  great  monograph  of  Lancisi  in  1728.  Morgagni  in  1761  de- 
scribed very  fully  the  symptoms  and  morbid  anatomy.  The  modern  views 
date  from  the  studies  of  Helmstedter  and  Koster,  who  showed  that  the  pri- 
mary change  was  in  the  media.  The  researches  of  Eppinger,  Thoma,  and 
Welch  emphasized  the  importance  of  these  changes  in  the  media,  particularly 
as  brought  about  by  syphilis. 

Classification. — For  practical  purposes  the  following  classification  may  be 
adopted : 

I.  TRUE  ANEURISM    (aneurisma   verum   or  aneurisma   spontaneum),   in 
which  one  or  more  of  the  coats  of  the  vessel  form  the  wall  of  the  tumor: 
(a)    Dilatation-aneurism — (1)    Limited  to. a  certain  portion  of  the  vessel, 
fusiform,  cylindroid;  (2)  extending  over  a  whole  artery  and  its  branches — 
cirsoid  aneurism.     (b)   Circumscribed  saccular  aneurism,  which  is  the  com- 
mon form  of  aneurism  of  the  aorta,     (c)  Dissecting  aneurism,  with  splitting 
of  the  media,  and  occasionally  with  the  formation  of  a  new  tube  lined  with 
intimal  endothelium. 

II.  FALSE  ANEURISM,  following  a  wound  or  the  rupture  of  an  artery,  or 
of  a  true  aneurism,  causing  a  diffuse,  or  circumscribed,  hamatoma. 

III.  ARTERIO-VENOUS  ANEURISM,  either  with  direct  communication  be- 
tween an  artery  and  vein,  or  with  the  intervention  of  a  sac,  varicose  aneurism. 


848 

IV.  SPECIAL  FORMS,  such  as  the  parasitic,  the  erosion,  the  traction,  the 
mycotic. 

Etiology. — PREDISPOSING  CAUSES. — Age. — Nearly  one  half  of  the  deaths 
in  England  and  Wales  from  aneurism  in  males  occur  between  the  ages  of 
30  and  45.  In  the  young  and  in  the  very  old  the  disease  is  rare,  but  it  may 
occur  at  any  age.  Congenital  aneurism  has  been  described. 

Sex. — Males  are  attacked  much  more  frequently  than  females — in  a  ratio 
of  5  to  1. 

Race  and  Locality. — The  disease  is  more  common  in  Great  Britain  than 
on  the  Continent.  Among  about  19,000  post  mortems  at  Vienna  there  were 
230  cases  of  aneurism,  while  among  18,678  at  Guy's  Hospital  there  were  325 
cases.  It  is  more  common  in  the  negroes  of  the  Southern  States  of  America 
than  among  the  whites.  Of  345  admissions  for  aneurism  to  my  wards  at  the 
Johns  Hopkins  Hospital  132  were  in  colored  and  213  in  white  patients — a 
ratio  of  1  to  1.6,  while  the  ratio  of  white  to  colored  in  the  hospital  at  large 
was  5  to  1.  In  India  aneurism  is  rare,  though  syphilis  and  arterial  disease 
are  common.  Possibly,  as  Eogers  suggests,  the  low  blood  pressure  in  the 
natives  may  have  something  to  do  with  this  comparative  immunity. 

Occupation. — Soldiers,  sailors,  draymen,  iron  and  steel  workers,  and  dock 
workers  are  particularly  prone.  In  soldiers  and  sailors,  who  are  peculiarly 
liable,  the  disease  appears  to  be  in  direct  proportion  to  the  prevalence  of 
syphilis. 

DETERMINING  CAUSES. — These  are  three  in  number: 

I.  The  Acute  Infections. — In  the  specific  fevers  areas  of  degeneration  are 
common  in  the  aorta.     Fortunately  in  most  instances  they  are  confined  to 
the  intima,  but  occasionally,  as  Thayer  has  pointed  out  in  typhoid  fever, 
the  changes  may  be  in  the  media.     The  infection  with  which  aneurism  is 
especially  connected  is  syphilis — a  fact  recognized  in  the  eighteenth  century 
by  Lancisi  and  by  Morgagni,  and  dwelt  upon  specially  in  1876  by  Francis 
H.  Welch,  of  the  British  Army.     All  recent  figures  show  a  very  high  per- 
centage of  syphilis  in  the  subjects  of  aneurism — as  high  as  80  or  85  per  cent. ; 
and  nowadays  it  is  rare  not  to  find  a  positive  Wassermann  reaction  in  an 
aneurismal  patient  under  fifty.    The  lesion,  a  mesaortitis,  has  been  described 
under  arterio-sclerosis. 

Other  infections  play  a  very  minor  role  in  the  disease.  With  rheumatic 
fever,  pneumonia,  and  septicaemia,  the  mycotic  aneurism  may  be  associated. 

The  various  toxic  factors  which  favor  arterial  degeneration,  such  as  al- 
cohol, lead,  tobacco,  and  the  chronic  endogenous  toxaemias,  as  gout  and 
Bright's  disease,  are  rare  determining  causes. 

II.  The  second   determining  factor  is  strain,   particularly  the  internal 
strain  associated  with  sudden  and  violent  muscular  effort.     The  media  is 
the  protecting  coat  of  the  artery,  and  during  a  violent  effort,  as^  in  lifting  or 
jumping,  laceration  or  splitting  of  the  intima  may  occur  over  a  weak  spot. 
If  small  this  leads  to  a  local  bulging  of  the  media  and  the  gradual  produc- 
tion of  a  sac,  or  the  tear  of  the  intima  may  heal  completely,  or  a  dissecting 
aneurism  may  form.    In  other  instances  a  widespread  mesaortitis  leads  to  a 
gradual,  diffuse  distention  of  the  artery.     This  type  of  aneurism,  frequently 
seen  in  the  aged,  may  follow  ordinary  chronic  atheroma. 

III.  Occasional   Causes. —  (a)    Embolism:     The    emboli  may  consist   of 


ANEUKISM  849 

vegetations  or  calcified  fragments  from  the  valves.  This  form  of  aneurism, 
often  multiple,  is  met  with  in  infective  endocarditis,  as  in  the  remarkable 
case  which  was  described  by  me  in  1888.  In  infective  endocarditis  the 
emboli  probably  pass  to  the  vasa  vasorum,  causing  mesaortitis  with  weaken- 
ing of  the  wall;  but  in  the  smaller  vessels  the  aneurisms  are  caused  by  the 
direct  lodgment  of  the  emboli  which  infect  and  weaken  the  wall.  (&)  Exter- 
nal Injury:  A  blow  on  the  chest,  a  sudden  fall,  or  the  jar  of  an  accident 
may  cause  a  rupture  of  the  intima  over  a  weak  spot  in  the  aorta,  with  the 
production  of  a  dissecting  or  sacculated  aneurism,  (c)  External  Erosion: 
A  tuberculous  focus  may  involve  the  wall  of  the  aorta;  or  a  bullet  lodged 
near  the  wall  of  an  artery  may  weaken  it  and  be  followed  by  aneurism,  (d) 
In  the  horse  there  is  a  parasitic  aneurism  common  in  the  mesenteric  vessels, 
due  to  growth  in  them  of  the  Strongylus  armatus.  (e)  Thoma  has  described 
a  "traction"  aneurism  at  the  concavity  of  the  arch  at  the  point  of  insertion 
of  the  ductus  Botalli. 

Morbid  Anatomy  and  Pathology. — NUMBER. — Usually  there  is  one  aneu- 
rism, but  three  or  four  or  even  a  dozen  may  be  present.  Multiple  cup- 
shaped  tumors  in  the  aorta  are  always  syphilitic.  The  mycotic  are  usually 
multiple,  and  in  the  peripheral  vessels  there  may  be  a  dozen  or  more. 

FORM. — There  are  two  great  types — one  in  which  the  lumen  of  the  ves- 
sel is  dilated,  and  the  other  in  which  a  limited  section  of  the  wall  gives  way 
with  the  formation  of  a  sac.  Typical  cylindrical  and  spindle  shaped  aneurisms 
are  seen  in  the  aorta  and  in  the  vessels  of  the  second  and  third  dimensions. 
The  sacculated  form  is  the  more  common.  They  are  either  flat,  saucer-shaped, 
or  cup-shaped,  or  sometimes  beyond  a  very  narrow  orifice  is  a  cylindrical  tu- 
mor of  variable  size,  from  a  pin's  head  in  the  smaller  vessels,  as  in  the  brain, 
to  a  huge  sac  which  may  fill  one  half  of  the  chest. 

VESSELS  AFFECTED. — Of  a  series  of  551  cases  studied  by  Crisp,  the  tho- 
racic aorta  was  involved  in  175,  the  abdominal  aorta  in  59,  the  femoral-iliac 
in  66,  the  popliteal  in  137,  the  innominate  in  20,  the  carotids  in  25,  sub- 
clavians  in  23,  axillary  in  18.  The  other  smaller  vessels  are  rarely  attacked. 
Of  late  years  aneurism  of  the  external  vessels  appears  to  have  become  much 
less  frequent. 

ANEURISM  OF  THE  THOEACIC  AOETA 

I.  Dilatation  Aneurism. — New  interest  has  been  attached  to  this  .form 
since  the  introduction  of  the  X-rays  in  diagnosis.  Formerly  it  was  very  often 
overlooked.  The  shape  may  be  a  single  fusiform,  or  tent-shaped,  or  there 
may  be  multiple  spindles.  The  condition  was  accurately  noted  by  Hodgson, 
who  called  it  "a  preternatural  permanent  enlargement  of  the  cavity  of  an 
artery,"  and  distinguished  it  clearly  from  ordinary  aneurism.  It  is  very 
often  associated  with  insufficiency  of  the  aortic  valves — a  combination  to 
which  the  French  gave  the  name  "Maladie  de  Hodgson."  It  is  more  com- 
mon in  elderly  people,  and  may  follow  diffuse  arterio-sclerosis  from  any 
cause.  In  syphilitic  subjects  it  may  be  limited  to  the  ascending  portion  of 
the  arch,  or  may  involve  the  entire  arch. 

SYMPTOMS. The  cases  are  often  latent,  met  with  accidentally  in  medico- 
legal  work,  and  the  dilatation  may  reach  an  extreme  grade  without  any  symp- 
toms. In 'other  cases,  particularly  in  the  syphilitic  aortitis  in  men,  angina 


850  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

pectoris  is  an  early  symptom.,  and  dilatation  may  be  present  in  the  senile 
form.  In  a  third  group  the  features  are  those  of  organic  disease  of  the 
heart,  usually  of  aortic  insufficiency.  Of  60  cases  analyzed  by  T.  McCrae 
there  were  18  patients  under  40;  the  majority  of  the  cases  were  in  elderly 
persons.  Pressure  effects  are  not  uncommon;  the  trachea  may  be  flattened 
and  the  resophagus  compressed.  Erosion  of  the  bones  is  rare. 

The  PHYSICAL  SIGNS  are  often  characteristic.  Visible  pulsation  in  the 
episternal  notch  is  usually  present,  and  it  may  even  extend  to  the  right  sterno- 
clavicular  articulation.  Pulsation  may  sometimes  be  seen  in  the  first  and 
second  right  interspaces.  In  about  one  half  of  the  cases  a  diffuse  pulsation 
over  the  manubrium  is  present,  but  in  old  persons  with  rigid  chest  walls 
there  may  be  extreme  dilatation  without  any  visible  impulse.  A  rough  thrill 
is  not  infrequently  present,  or  a  diastolic  thrill  when  the  valves  are  insuffi- 
cient. A  sharp  diastolic  shock  may  be  felt. 

Dulness  over  the  manubrium  is  the  most  constant  single  sign.  The  sec- 
ond sound  may  be  of  a  clanging,  metallic,  or  even  amphoric  quality.  When 
a  diastolic  murmur  is  present  it  may  be  heard  loudly  over  the  manubrium 
and  perhaps  transmitted  into  the  vessels  of  the  neck.  The  blood  pressure  is 
often  low — below  140  mm.  in  35  of  40  cases  studied  by  McCrae.  Examina- 
tion with  the  X-rays  in  skilled  hands  is  the  most  satisfactory  means  of  diag- 
nosis, as  the  dilated  aorta  casts  a  very  definite  shadow  much  larger  than  the 
normal  aorta,  and  showing  very  little  difference  in  extent  during  systole  and 
diastole. 

II.  Dissecting  Aneurism.  • — The  majority  of  aneurisms  of  the  aorta  begin 
with  a  split  or  crack  of  the  intima  over  a  spot  of  syphilitic  mesaortitis.  Once 
this  split  has  started  the  aorta  may  rupture  in  all  its  coats,  or  an  aneurism, 
may  form  at  the  site,  or  the  fracture  of  the  intima,  though  large  and  often 
circumferential,  may  heal;  or  the  blood  may  extend  between  the  coats,  sep- 
arating them  for  many  inches,  or  in  the  entire  extent,  forming  a  dissecting 
aneurism;  and,  lastly,  such  a  dissecting  aneurism  may  heal  perfectly. 

RUPTURE  or  THE  AORTA  is  not  very  infrequent,  as  medico-legal  work  in- 
dicates. Usually  there  is  agonizing  pain  with  features  of  shock,  and  death 
may  take  place  instantly;  but  in  fully  half  of  the  cases  there  are  two  very 
characteristic  stages,  the  first  corresponding  to  the  rupture  of  the  inner 
coats,  the  second  eight  to  ten  hours,  or  as  long  as  fifteen  or  sixteen  days  later, 
to  fatal  rupture  of  the  external  layer. 

Dissecting  aneurism  is  not  very  common.  There  were  only  two  cases  in 
16  years  at  the  Johns  Hopkins  Hospital,  where  aneurism  may  be  said  to  be 
exceptionally  frequent.  The  primary  split  is  most  frequently  in  the  arch, 
not  far  above  the  valves,  and  is  in  the  form  of  a  transverse,  or  vertical,  clean 
cut  incision,  as  if  made  with  a  razor.  The  extent  of  the  separation  of  the 
coats  is  variable.  If  the  adventitia  is  reached,  rupture  is  certain  to  take 
place,  as  only  the  structures  of  the  middle  coat  can  resist  for  any  time  the 
pressure  of  the  blood.  The  blood  may  pass  for  three  or  four  or  more  inches, 
separating  the  media,  and  then  burst  internally  or  externally.  In  other 
cases  the  dissection  reaches  from  the  ascending  arch  to  the  bifurcation  of  the 
aorta,  even  passing  down  the  iliac  and  femorals  into  the  smaller  vessels  of 
the  leg.  The  splitting  of  the  coats  may,  indeed,  as  in  a  case  described  by 
Eokitansky,  reach  to  all  the  subdivisions  of  the  aorta.  The  symptoms  are 


AtfETJBISM  851 

those  spoken  of  under  rupture;  but  a  very  remarkable  condition  may  follow, 
leading  to : 

HEALED  DISSECTING  ANEURISM. — The  earlier  observers  of  this  remark- 
able condition  regarded  it  as  an  anatomical  anomaly  of  a  double  aorta.  Adami 
has  collected  39  cases,  in  a  majority  of  which  there  was  no  advanced  disease 
of  the  aorta  itself.  The  outer  tube  formed  by  the  dissecting  aneurism  may 
extend  the  entire  length  of  the  aorta,  occupying  the  full  extent  of  the  circum- 
ference. The  most  extraordinary  feature  is  that  the  outer  tube  may  present 
a  perfectly  smooth  and  natural  appearance,  and  be  lined  with  a  new  intima. 
The  condition  may  last  for  many  years. 

III.  Sacculated  Aneurism  of  the  Aorta:  Aneurism  of  the  Arch. — For 
purposes  of  discussion  this  part  of  the  vessel  may  be  divided  into  the  sinuses  of 
Valsalva,  ascending,  transverse,  and  descending  portions. 

(a)  ANEURISM  OF  THE  SINUSES  OF  VALSALVA,  a  common  and  important 
variety,  is  met  with  most  frequently  in  young  syphilitic  subjects.  There  may 
be  pouching  of  one  or  of  all  three  sinuses ;  the  aortic  ring  is  apt  to  be  involved 
and  one  or  more  of  the  valves  rendered  incompetent.  The  special  features 
may  be  thus  summarized:  (1)  It  is  often  latent,  causing  sudden  death  by 
perforation  into  the  pericardium.  (2)  It  is  a  medico-legal  aneurism  met 
with  most  frequently  in  coroner's  cases.  (3)  Angina  pectoris  is  not  un- 
common and  may  be  the  only  symptom.  (4)  Aortic  insufficiency  is  often 
associated  with  it.  (5)  In  a  majority  of  all  cases  syphilitic  mesaortitis  is 
present. 

(&)  ANEURISM  OF  THE  ASCENDING  ARCH. — Along  the  convex  border 
aneurism  frequently  arises  and  may  grow  to  a  large  size,  either  passing  out 
into  the  right  pleura  or  forward,  pointing  at  the  second  or  third  interspace, 
eroding  the  ribs  and  sternum,  and  producing  large  external  tumors.  In  this 
pituation  the  sac  may  compress  the  superior  vena  cava,  causing  engorge- 
ment of  the  vessels  of  the  head  and  arm;  sometimes  it  compresses  only  the 
subclavian  vein,  and  causes  enlargement  and  cedema  of  the  right  arm.  Per- 
foration may  take  place  into  the  superior  vena  cava,  of  which  accident  Pepper 
and  Griffith  have  collected  29  cases.  In  rare  instances,  when  the  aneurism 
springs  from  the  concave  side  of  the  vessels,  the  tumor  may  appear  to  the 
left  of  the  sternum.  Large  aneurisms  in  this  situation  may  cause  much 
dislocation  of  the  heart,  pushing  it  down  and  to  the  left,  and  sometimes  com- 
pressing the  inferior  vena  cava,  and  causing  swelling  of  the  feet  and  ascites. 
The  right  recurrent  laryngeal  nerve  is  often  compressed.  The  innominate 
artery  is  rarely  involved.  Death  commonly  follows  from  rupture  into  the 
pericardium,  the  pleura,  or  into  the  superior  cava;  less  commonly  from  rup- 
ture externally,  sometimes  from  syncope. 

(c)  ANEURISM  OF  THE  TRANSVERSE  ARCH. — The  direction  of  growth  is 
most  commonly  backward,  but  the  sac  may  grow  forward,  erode  the  sternum, 
and  form  a  large  tumor.  The  sac  presents  in  the  middle  line  and  to  the 
right  of  the  sternum  much  more  often  than  to  the  left,  which  occurred  in 
only  4  of  35  aneurisms  in  this  situation  (0.  A.  Browne).  Even  when  small 
and  producing  no  external  tumor  it  may  cause  marked  pressure  signs  in  its 
growth  backward  toward  the  spine,  involving  the  trachea  and  the  oesophagus, 
and  giving  rise  to  cough,  which  is  often  of  a  paroxysmal  character,  and 
dysphagia.  The  left  recurrent  laryngeal  is  often  involved  in  its  course  round 


852  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

the  arch.  A  small  aneurism  from  the  lower  or  posterior  wall  of  the  arch  may 
compress  a  bronchus,  inducing  bronchorrhoaa,  gradual  bronchiectasis,  and 
suppuration  in  the  lung — a  process  which  by  no  means  infrequently  causes 
death  in  aneurism,  and  a  condition  which  at  the  Montreal  General  Hospital 
we  were  in  the  habit  of  terming  aneurismal  phthisis.  Occasionally  enormous 
aneurisms  arise  in  this  situation,  and  grow  into  both  pleurae,  extending  be- 
tween the  manubrium  and  the  vertebra?;  they  may  persist  for  years.  The 
sac  may  be  evident  at  the  sternal  notch.  The  innominate  artery,  less  com- 
monly the  left  carotid  and  subclavian,  may  be  involved  in  the  sac,  and  the 
radial  or  carotid  pulse  may  be  absent  or  retarded.  Pressure  on  the  sym- 
pathetic may  at  first  cause  dilatation  and  subsequently  contraction  of  the 
pupil.  Sometimes  the  thoracic  duct  is  compressed. 

The  ascending  and  transverse  portions  of  the  arch  are  not  infrequently 
involved  together,  usually  without  the  branches;  the  tumor  grows  upward, 
or  upward  and  to  the  right. 

(d)  ANEURISM  OF  THE  DESCENDING  PORTION  OF  THE  ARCH. — It  is  not 
infrequently  the  traction  aneurism  of  Thoma.     The  sac  projects  to  the  left 
and  backward,  and  often  erodes  the  vertebra?  from  the  third  to  the  sixth 
dorsal,  causing  great  pain  and  sometimes  compression  of  the  spinal  cord. 
Dysphagia  is  common.     Pressure  on  a  bronchus  may  induce  bronchiectasis, 
with  retention  of  secretions,  and  fever.     A  tumor  may  appear  externally  in 
the  region  of  the  scapula,  and  here  attain  an  enormous  size.     Death  not  in- 
frequently occurs  from  rupture  into  the  pleura,  or  the  sac  may  grow  into 
the  lung  and  cause  haemoptysis. 

(e)  ANEURISM  OF  THE  DESCENDING  THORACIC  AORTA. — This  is  the  least 
common  situation  of  aortic  aneurism.     The  larger  number  occur  close  to 
the  diaphragm,  the  sac  lying  upon  or  to  the  left  of  the  bodies  of  the  lower 
dorsal  vertebrae,  which  are  often  eroded.     It  is  frequently  latent,  in  3  of  14 
cases  reported  by  me,  and  is  often  overlooked;  pulmonary  and  pleural  symp- 
toms are  common.    Pain  in  the  back  is  severe;  dysphagia  is  not  infrequent. 
The  sac  may  reach  an  enormous  size  and  form  a  subcutaneous  tumor  in  the 
left  back. 

Physical  Signs. — INSPECTION. — A  good  light  is  essential;  cases  are  often 
overlooked  owing  to  a  hasty  inspection.  The  face  is  often  suffused,  the  con- 
junctivae  injected,  and  veins  of  the  chest  and  of  one  arm  engorged.  One 
pupil  may  be  enlarged.  In  many  instances  inspection  is  negative.  On  either 
side  of  the  sternum  there  may  be  abnormal  pulsation,  due  to  dislocation  of 
the  heart,  to  deformity  of  the  thorax,  or  to  retraction  of  the  lung.  Three 
sorts  of  pulsation  may  be  seen  in  the  chest:  (!)  A  general  shock,  such  as  is 
seen  in  the  violent  throbbing  of  the  heart  or  of  an  aneurism.  In  anaemia,  in 
neurasthenia,  and  in  great  hypertrophy  this  widespread  shock  may  suggest 
aneurism.  (2)  A  diffuse  impulse  localized  in  a  certain  part  of  the  chest, 
which  may  be  caused  by  a  deep-seated  aneurism  but  which  is  met  with  also 
in  tumors,  in  pulsating  pleurisy,  and  in  a  few  cases  without  evident  cause 
(see  "Modern  Medicine/'  Vol.  IV,  p.  474).  (3)  The  punctate,  heaving  true 
aneurismal  impulse  which  when  of  any  extent  is  visibly  expansile.  It  is  seen 
most  frequently  above  the  level  of  the  third  rib  to  the  right  of  the  sternum, 
in  the  second  left  interspace,  over  the  manubrium,  and  behind  in  the  left 
irterscapular  region.  When  the  innominate  is  involved  the  throbbing  may 


ANEURISM  853 

be  seen  at  the  right  sterno-clavicular  joint  and  above  it.  An  external  tumor 
is  present  in  many  eases,  projecting  either  through  the  upper  part  of  the 
sternum  or  to  the  right,  sometimes  involving  the  sternum  and  costal  cartilages 
on  both  sides,  forming  a  swelling  the  size  of  a  cocoanut  or  even  larger.  The 
skin  is  thin,  often  blood  stained,  or  it  may  have  ruptured,  exposing  the  lam- 
ina of  the  sac.  The  apex  beat  may  be  much  dislocated,  particularly  when 
.the  sac  is  large.  It  is  more  commonly  a  dislocation  from  pressure  than  from 
enlargement  of  the  heart  itself. 

PALPATION. — The  area  and  degree  of  pulsation  are  best  determined  by 
palpation.  When  the  aneurism  is  deep  seated  and  not  apparent  externally, 
the  bimanual  method  should  be  used,  one  hand  upon  the  spine  and  the  other 
on  the  sternum.  There  may  be  only  a  diffuse  impulse.  When  the  sac  has 
perforated  the  chest  wall  the  impulse  is,  as  a  rule,  forcible,  slow,  heaving, 
and  expansile,  and  has  the  same  qualities  as  a  forcible  apex  beat.  The  re- 
sistance may  be  very  great  if  there  are  thick  lamina  beneath  the  skin ;  more 
rarely  the  sac  is  soft  and  fluctuating.  The  hand  upon  the  sac,  or  on  the 
region  in  which  it  is  in/  contact  with  the  chest  wall,  may  feel  a  diastolic 
shock,  often  of  great  intensity,  which  forms  one  of  the  valuable  physical  signs 
of  aneurism.  A  systolic  thrill  is  sometimes  present,  not  so  often  in  saccular 
aneurisms  as  in  the  dilatation  of  the  arch.  The  pulsation  may  sometimes  be 
felt  in  the  suprasternal  notch. 

PERCUSSION. — The  small  and  deep  seated  aneurisms  are  in  this  respect 
negative.  In  the  larger  tumors,  as  soon  as  the  sac  reaches  the  chest  wall, 
there  is  produced  an  area  of  abnormal  dulness,  the  position  of  which  depends 
upon  the  part  of  the  aorta  affected.  Aneurisms  of  the  ascending  arch  grow 
forward  and  to  the  right,  producing  dulness  on  one  side  of  the  manubrium; 
those  from  the  transverse  arch  produce  dulness  in  the  middle  line,  extending 
toward  the  left  of  the  sternum,  while  aneurisms  of  the  descending  portion 
most  commonly  produce  dulness  in  the  left  interscapular  and  scapular  regions. 
The  percussion  note  is  flat  and  gives  a  feeling  of  increased  resistance. 

AUSCULTATION. — Adventitious  sounds  are  not  always  to  be  heard.  Even 
in  a  large  sac  there  may  be  no  murmur.  Much  depends  upon  the  thick- 
ness of  the  lamina  of  fibrin.  An  important  sign,  particularly  if  heard  over 
a  dull  region,  is  a  ringing,  accentuated  second  sound,  a  phenomenon  rarely 
missed  in  large  aneurisms  of  the  aortic  arch.  A  systolic  murmur  may  be 
present ;  sometimes  a  double  murmur,  in  which  case  the  diastolic  bruit  is  usu- 
ally due  to  associated  aortic  insufficiency.  The  systolic  murmur  alone  is  of 
little  moment  in  the  diagnosis  of  an  aneurismal  sac.  A  continuous  humming 
top  murmur  with  systolic  intensification  is  heard  when  the  aneurism  com- 
municates with  the  vena  cava  or  the  pulmonary  artery.  With  the  single 
stethoscope  the  shock  of  the  impulse  with  the  first  sound  is  sometimes  very 
marked. 

Among  OTHER  PHYSICAL  SIGNS  of  importance  are  retardation  of  the  pulse 
in  the  arteries  beyond  the  aneurism,  or  in  those  involved  in  the  sac.  There 
may,  for  instance,  be  a  marked  difference  between  the  right  and  left  radial, 
both  in  volume  and  time.  The  blood  pressure  on  the  two  sides  may  be  un- 
equal. A  physical  sign  of  large  thoracic  aneurism,  which  I  have  not  seen 
referred  to,  is  obliteration  of  the  pulse  in  the  abdominal  aorta  and  its  branch- 
es. My  attention  was  called  to  this  in  a  patient  who  was  stated  to  have 


854  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

aortic  insufficiency.  There  was  a  well-marked  diastolic  murmur,  but  in  the 
femorals  and  in  the  aorta  I  was  surprised  to  find  no  trace  of  pulsation,  and 
not  the  slightest  throbbing  in  the  abdominal  aorta  or  in  the  peripheral  ar- 
teries of  the  leg.  The  circulation  was,  however,  unimpaired  in  them  and  there 
was  no  dilatation  of  the  veins.  Attracted  by  this,  I  then  made  a  careful 
examination  of  the  patient's  back,  when  .the  circumstance  was  discovered, 
which  neither  the  patient  himself  nor  any  of  his  physicians  had  noticed,  that 
he  had  a  very  large  area  of  pulsation  in  the  left  scapular  region.  The  sac 
probably  was  large  enough  to  act  as  a  reservoir  annihilating  the  ventricular 
systole,  and  converting  the  intermittent  into  a  continuous  stream. 

A  remarkable  condition  suggestive  of  pneumothorax  may  be  caused  by 
compression  of  one  bronchus  by  the  sac  (Newton  Pitt).  The  air  is  inspired 
beyond  the  obstruction,  but  has  difficulty  in  getting  out,  so  that  the  lung  is 
gradually  distended,  causing  enlargement  of  the  side  with  a  hyperresonant 
note  on  percussion,  and  on  auscultation  absence  of  breath  sounds.  The  X-ray 
picture  may  alone  decide  the  diagnosis. 

The  tracheal  tugging,  a  valuable  sign  in  deep-seated  aneurisms,  was  de- 
scribed by  Surgeon-Major  Oliver,  and  was  specially  studied  by  my  colleagues 
Ross  and  MacDonnell  at  the  Montreal  General  Hospital.  Oliver  gives  the 
following  directions:  "Place  the  patient  in  the  erect  position,  and  direct  him 
to  close  his  mouth  and  elevate  his  chin  to  almost  the  full  extent ;  then  grasp 
the  cricoid  cartilage  between  the  finger  and  thumb,  and  use  steady  and  gentle 
upward  pressure  on  it,  when,  if  dilatation  or  aneurism  exists,  the  pulsation 
of  the  aorta  will  be  distinctly  felt  transmitted  through  the  trachea  to  the 
hand."  The  tug  is  sometimes  felt  more  easily  if  the  chin  is  held  down.  This 
is  a  sign  of  great  value  in  the  diagnosis  of  deep-seated  aneurisms,  though 
it  may  occasionally  be  felt  in  tumors  and  in  the  extreme  dynamic  dilatation 
of  aortic  insufficiency.  It  may  be  visible  in  the  thyroid  cartilage.  The 
trachea  may  be  pushed  to  one  side. 

Occasionally  a  systolic  murmur  may  be  heard  in  the  trachea,  as  pointed 
out  by  David  Drummond,  or  even  at  the  patient's  mduth,  when  opened.  This 
is  either  the  sound  conveyed  from  the  sac,  or  is  produced  by  the  air  as  it  is 
driven  out  of  the  wind  pipe  during  the  systole.  Feeble  respiration  in  one 
lung  is  a  common  effect  of  pressure. 

Symptoms. — Broadbent  made  the  useful  division  of  aneurisms  of  symp- 
toms and  aneurisms  of  physical  signs;  the  former  is  more  commonly  seen 
when  the  transverse  arch  is  involved,  the  latter  when  the  ascending  portion. 
There  may  be  no  symptoms.  A  man  may  present  a  tumor  which  has  eroded 
the  chest  wall  without  pain  or  any  discomfort.  On  the  other  hand,  every 
physical  sign  may  be  present  without  a  single  symptom. 

An  important  but  variable  feature  in  thoracic  aneurism  is  pain,  which  is 
particularly  marked  in  deep  seated  tumors.  It  is  usually  paroxysmal,  sharp, 
and  lancinating,  often  very  severe  when  the  tumor  is  eroding  the  vertebras,  or 
perforating  the  chest  wall.  In  the  latter  case  after  perforation  the  pain  may 
cease.  Anginal  attacks  are  not  uncommon,  particularly  in  aneurisms  at  the 
root  of  the  aorta.  Frequently  the  pain  radiates  down  the  left  arm  or  up  the 
neck,  sometimes  along  the  upper  intercostal  nerves.  Superficial  tenderness 
may  be  felt  in  the  skin  over  the  heart  or  over  the  left  sternomastoid  muscle. 
Cough  results  either  from  the  direct  pressure  on  the  trachea,  or  is  associated 


ANEURISM  855 

with  bronchitis.  The  expectoration  in  these  instances  is  abundant,  thin,  and 
watery;  subsequently  it  becomes  thick  and  turbid.  Paroxysmal  cough  of  a 
peculiar  brazen,  ringing  character  is  a  characteristic  symptom  in  some  cases, 
particularly  when  there  is  pressure  on  the  recurrent  laryngeal  nerves,  or  the 
cough  may  have  a  peculiar  wheezy  quality — the  "goose  cough." 

Dyspnoea,  which  is  common  in  cases  of  aneurism  of  the  transverse  por- 
tion, is  not  necessarily  associated  with  pressure  on  the  recurrent  laryngeal 
nerves,  but  may  be  due  directly  to  compression  of  the  trachea  or  the  left 
bronchus.  It  may  occur  with  marked  stridor.  Loss  of  voice  and  hoarseness 
are  consequences  of  pressure  on  the  recurrent  laryngeal,  usually  the  left, 
inducing  either  a  spasm  in  the  muscles  of  the  left  vocal  cord  or  paralysis. 

Paralysis  of  an  abductor  on  one  side  may  be  present  without  any  symp- 
toms. It  is  more  particularly,  as  Semon  states,  when  the  paralytic  contrac- 
tures  supervene  that  the  attention  is  called  to  laryngeal  symptoms. 

Hcemorrhage  in  thoracic  aneurism  may  come  from  (a)  the  soft  granula- 
tions in  the  trachea  at  the  point  of  compression,  in  which  case  the  sputum  is 
blood  tinged,  but  large  quantities  of  blood  are  not  lost;  (&)  from  rupture 
of  the  sac  into  the  trachea  or  a  bronchus;  (c)  from  perforation  into  the  lung 
or  erosion  of  the  lung  tissue.  The  bleeding  may  be  profuse,  rapidly  proving 
fatal,  and  is  a  common  cause  of  death.  It  may  persist  for  weeks  or  months, 
in  which  case  it  is  simply  haemorrhagic  weeping  through  the  sac,  which  is 
exposed  in  the  trachea.  In  some  instances,  even  after  a  very  profuse  hemor- 
rhage, the  patient  recovers  and  may  live  for  years.  A  man  with  well-marked 
thoracic  aneurism,  whom  I  showed  to  my  class  at  the  University  of  Pennsyl- 
vania and  who  had  had  several  brisk  hemorrhages,  died  four  years  after, 
having  in  the  meantime  enjoyed  average  health.  Death  from  haemorrhage  is 
relatively  more  common  in  aneurism  of  the  third  portion  of  the  arch  and  of 
the  descending  aorta. 

Difficulty  of  swallowing  is  a  comparatively  rare  symptom,  and  may  be 
due  either  to  spasm  or  to  direct  compression.  The  sound  should  never  be 
passed  in  these  cases,  as  the  oesophagus  may  be  almost  eroded  and  perforation 
of  the  sac  has  taken  place. 

Heart  Symptoms. — Pain  has  been  referred  to;  it  is  often  anginal  in  char- 
acter, and  is  most  common  when  the  root  of  the  aorta  is  involved.  The  heart 
is  hypertrophied  in  less  than  one  half  the  cases.  The  aortic  valves  are 
Fometimes  incompetent,  either  from  disease  of  the  segments  or  from  stretch- 
ing of  the  aortic  ring. 

Among  other  signs  and  symptoms,  venous  compression,  which  has  already 
been  mentioned,  may  involve  one  subclavian  or  the  superior  vena  cava.  A 
curious  phenomenon  in  intrathoracic  aneurism  is  the  clubbing  of  the  fingers 
and  incurving  of  the  nails  of  one  hand,  of  which  two  examples  have  been 
under  my  care,  both  without  any  special  distention  or  signs  of  venous  en- 
gorgement. Tumors  of  the  arch  may  involve  the  pulmonary  artery,  pro- 
ducing compression,  or  in  some  instances  adhesion  of  the  pulmonary  seg- 
ments and  insufficiency  of  the  valve;  or  the  sac  may  rupture  into  the  artery, 
an  accident  which  happened  in  two  of  nay  cases,  producing  instantaneous 
death. 

Pupil  Symptoms. — These  may  be  due  to,  first,  pressure  on  the  sympa- 
thetic, which  may  cause  dilatation  of  one  pupil  when  the  cord  is  irritated^ 


856  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

contraction  when  the  nerve  is  paralyzed.  Flushing  of  the  side  of  the  face 
and  ear,  increased  temperature,  and  sweating  may  be  present.  Secondly,  as 
Ainley  Walker  and  Wall  have  shown,  the  anisocoria  is  most  frequently  due  to 
vascular  conditions — with  low  blood  pressure  in  one  carotid  the  pupil  on  that 
side  is  dilated,  with  high  pressure  contracted,  and  in  26  cases  of  aneurism 
they  found  a  relation  between  the  state  of  the  pupil  and  the  arteries  on  the 
same  side.  Thirdly,  in  a  few  cases  the  anisocoria  is  a  parasyphilitic  mani- 
festation associated  with  the  Argyll-Robertson  phenomenon  and  absent  knee- 
jerks — the  Babinski  syndrome. 

An  X-ray  examination  should  be  made  in  all  doubtful  cases.  The  fluoro- 
scope  gives  an  accurate  picture  of  the  situation,  the  size,  and  the  relation  to 
the  heart.  Even  a  small  sac  may  be  seen.  In  several  cases  I  have  known  the 
diagnosis  to  rest  upon  it  alone  in  cases  in  which  scarcely  a  physical  sign  was 
present.  Sailer,  jand  Pf abler  have  shown  that  a  condition  of  tortuosity  of  the 
aorta,  due  to  afrterio-sclerosis,  may  exist,  suggesting  very  strongly  the  pres- 
ence of  aneurism,  particularly  on  examination  with  the  fluoroscope. 

The  clinical  picture  of  aneurism  of  the  aorta  is  extremely  varied.  Many 
cases  present  characteristic  symptoms  and  no  physical  signs,  while  others 
have  well-marked  physical  signs  and  no  s}rmptoms. 

Diagnosis. — Aneurism  of  the  aorta  may  be  confounded  with:  (a)  The 
violent  throbbing  impulse  of  the  arch  in  aortic  insufficiency.  I  have  already 
referred  to  a  case  of  this  kind  in  which  the  diagnosis  of  aneurism  was  made 
by  several  good  observers. 

(b)  Simple  Dynamic  Pulsation. — This  is  common  in  the  abdominal  aorta, 
but  is  rare  in  the  arch.    A  case  which  came  under  the  care  of  William  Mur- 
ray and  Bramwell  presented,  without  any  pain  or  pressure  symptoms,  pulsa- 
tion and  dulness  over  the  aorta.     The  condition  gradually  disappeared  and 
was  thought  to  be  neurotic. 

(c)  Dislocation  of  the  heart  in  curvature  of  the  spine  may  cause  great 
displacement  of  the  aorta,  so  that  it  has  been  known  to  pulsate  forcibly  to 
the  right  of  the  sternum. 

(d)  Solid  Tumors. — When  the  tumor  projects  externally  and  pulsates  the 
difficulty  may  be  considerable.    In  tumor  the  heaving,  expansile  pulsation  is 
absent,  and  there  is  not  that  sense  of  force  and  power  which  is  so  striking 
in  the  throbbing  of  a  perforating  aneurism.     There  is  not  to  be  felt,  as  in 
aortic  aneurism,  the  shock  of  the  heart  sounds,  particularly  the  diastolic 
shock.     Auscultatory  sounds  are  less  definite,  as  large  aneurisms  may  occur 
without  murmurs;  and,  on  the  other  hand,  murmurs  may  be  heard  over  tu- 
mors.   The  greatest  difficulty  is  in  the  deep  seated  thoracic  tumors,  and  here 
the  diagnosis  may  be  impossible.    The  physical  signs  may  be  indefinite.    The 
ringing  aortic  second  sound  is  of  great  importance  and  is  rarely,  if  ever, 
heard  over  tumor.     Tracheal  tugging  is  here  a  valuable  sign.     Pressure  phe- 
nomena are  less  common  in  tumor,  whereas  pain  is  more  frequent.     The 
general  appearance  of  the  patient  in  aneurism  is  much  better  than  in  tumor, 
in  which  there  may  be  cachexia  and  enlargement  of  the  glands  in  the  axilla 
or  in  the  neck.    Healthy,  strong  males  who  have  worked  hard  and  have  had 
syphilis  are  the  most  common  subjects  of  aneurism.     Occasionally  cancer  of 
the    oesophagus   may    simulate    aneurism,    producing    pressure    on    the    left 
bronchus. 


ANEURISM  857 

(e)  Pulsating  Pleurisy. — In  cases  of  empyema  necessitatis,  if  the  pro- 
jecting tumor  is  in  the  neighborhood  of  the  heart  and  pulsates,  the  condi- 
tion may  readily  be  mistaken  for  aneurism.  The  absence  of  the  heaving,  firm 
distention  and  of  the  diastolic  shock  would,  together  with  the  history  and 
the  existence  of  pleural  effusion,  determine  the  nature  of  the  case.  If  neces- 
sary, puncture  may  be  made  with  a  fine  hypodermic  needle.  In  a  majority 
of  the  cases  of  pulsating  pleurisy  the  throbbing  is  diffuse  and  widespread, 
moving  the  whole  side. 

Prognosis. — The  outlook  in  thoracic  aneurism  is  always  grave.  Life  may 
be  prolonged  for  some  years,  but  the  patients  are  in  constant  jeopardy.  Spon- 
taneous cure  is  not  very  infrequent  in  the  small  sacculated  tumors  of  the 
ascending  and  thoracic  portions.  The  cavity  becomes  filled  with  laminae  of 
firm  fibrin,  which  become  more  and  more  dense  and  hard,  the  sac  shrinks 
considerably,  and  finally  lime  salts  are  deposited  in  the  old  fibrin.  The  laminae 
of  fibrin  may  be  on  a  level  with  the  lumen  of  the  vessel,  causing  complete 
obliteration  of  the  sac.  The  cases  which  rupture  externally,  as  a  rule,  run  a 
rapid  course,  although  to  this  there  are  exceptions;  the  sac  may  contract, 
become  firm  and  hard,  and  the  patient  may  live  for  five,  or  even  for  ten  or 
twenty  years.  The  cases  which  have  lasted  longest  in  my  experience  have 
been  those  in  which  a  saccular  aneurism  has  projected  from  the  ascending 
arch.  One  patient  in  Montreal  had  been  known  to  have  aneurism  for  eleven 
years.  The  aneurism  may  be  enormous,  occupying  a  large  area  of  the  chest, 
and  yet  life  be  prolonged  for  many  years.  One  of  the  most  remarkable  in- 
stances is  the  case  of  dissecting  aneurism  reported  by  Graham.  The  patient 
was  invalided  after  the  Crimean  War  with  aneurism  of  the  aorta,  and  for 
years  was  under  the  observation  of  J.  H.  Richardson,  of  Toronto,  under  whose 
care  he  died  in  1885.  The  autopsy  showed  a  healed  aneurism  of  the  arch, 
with  a  dissecting  aneurism  extending  the  whole  length  of  the  aorta,  which 
formed  a  double  tube. 

Treatment. — In  a  large  proportion  of  the  cases  this  can  only  be  PALLIATIVE. 
Still  in  every  instance  measures  should  be  taken  which  are  known  to  promote 
clotting  and  consolidation  within  the  sac. «  In  any  large  series  of  cured  aneu- 
risms a  considerable  majority  of  the  patients  have  not  been  known  to  be 
subjects  of  the  disease,  but  the  obliterated  sac  has  been  found  accidentally  at 
the  post  mortem. 

The  most  satisfactory  plan  in  early  cases,  when  it  can  be  carried  out  thor- 
oughly, is  the  modified  Valsalva  method  advised  by  the  late  Mr.  Tufnell,  of 
Dublin,  the  essentials  of  which  are  rest  and  a  restricted  diet.  The  rest  should, 
as  far  as  possible,  be  absolute.  The  reduction  of  the  daily  number  of  heart 
beats,  when  a  patient  is  recumbent  and  without  exertion,  amounts  to  many 
thousands,  and  is  one  of  the  principal  advantages  of  this  plan.  Mental  quiet 
should  also  be  enjoined.  The  diet  advised  by  Tufnell  is  extremely  rigid— 
for  breakfast,  2  ounces  of  bread  and  butter  and  2  ounces  of  milk  or  tea; 
dinner,  3  ounces  of  mutton  and  3  of  potatoes  or  bread  and  4  ounces  of  claret ; 
supper',  2  ounces  of  bread  and  butter  and  2  ounces  of  tea.  This  low  diet 
diminishes  the  blood  volume  and  is  thought  also  to  render  the  blood  more 
fibrinous.  "Total  per  diem,  10  ounces  of  solid  food  and  8  ounces  of  fluid, 
and  no  more."  This  treatment  should  be  pursued  for  several  months,  but, 
except  iu  persons  of  a  good  deal  of  mental  stamina,  it  is  impossible  to  carry 
56 


858  DISEASES    OF   THE    CIRCULATORY    SYSTEM 

it  out  for  more  than  a  few  weeks  at  a  time.  It  is  a  form  of  treatment  adapted 
only  to  the  saccular  form  of  aneurism,  and  in  cases  of  large  sacs  communi- 
cating with  the  aorta  by  a  comparatively  small  orifice  the  chances  of  con- 
solidation are  fairly  good.  Unquestionably  rest  and  the  restriction  of  the 
liquids  are  the  important  parts  of  the  treatment,  and  a  greater  variety  and 
quantity  of  food  may  be  allowed  with  advantage.  If  this  plan  can  not  be 
thoroughly  carried  out,  the  patient  should  at  any  rate  be  advised  to  live  a 
*ery  quiet  life,  moving  about  with  deliberation  and  avoiding  all  sudden  men- 
tal or  bodily  excitement.  The  bowels  should  be  kept  regular,  and  constipa- 
tion and  straining  should  be  carefully  avoided.  Of  medicines,  iodide  of 
potassium,  as  advised  by  Balfour,  is  of  great  value.  It  may  be  given  in  doses 
of  from  10  to  20  grains  (0.6  to  1.3  gm.)  three  times  a  day.  Larger  doses  are 
not  necessary.  The  mode  of  action  is  not  well  understood.  It  may  act  by 
increasing  the  secretions  and  so  inspissating  the  blood,  by  lowering  the  blood 
pressure,  or,  as  Balfour  thinks,  by  causing  thickening  and  contraction  of 
the  sac.  The  most  striking  effect  of  the  iodide  in  my  experience  has  been  the 
relief  of  the  pain.  The  evidence  is  conclusive  that  the  syphilitic  cases  are 
more  benefited  by  it  than  the  non-syphilitic.  All  these  measures  have  little 
value  unless  the  sac  is  of  a  suitable  form  and  size.  The  large  tumors  with 
wide  mouths  communicating  with  the  ascending  portion  of  the  aorta  may  be 
treated  on  the  most  approved  plans  for  months  without  the  slightest  influ- 
ence other  than  reduction  in  the  intensity  of  the  throbbing.  A  patient  with 
a  tumor  projecting  into  the  right  pleura  remained  on  the  most  rigid  Tufnell 
treatment  for  more  than  one  hundred  days,  during  which  time  he  also  took 
iodide  of  potassium  faithfully.  The  pulsations  were  greatly  reduced  and 
the  area  of  dulness  diminished,  and  we  congratulated  ourselves  that  the  sac 
was  probably  consolidating.  Sudden  death  followed  rupture  into  the  pleura, 
and  the  sac  contained  only  fluid  blood,  not  a  shred  of  fibrin.  In  cases  in 
which  the  tumor  is  large,  or  in  which  there  seems  to  be  very  little  prospect  of 
consolidation,  it  is  perhaps  better  to  advise  a  man  to  go  on  quietly  with  his 
occupation,  avoiding  excitement  and  worry.  Our  profession  has  offered  many 
examples  of  good  work,  thoroughly  and  conscientiously  carried  out,  by  men 
with  aneurism  of  the  aorta,  who  wisely,  I  think,  preferred,  as  did  the  late 
Hilton  Fagge,  to  die  in  harness. 

SURGICAL  MEASURES. — In  a  few  cases  consolidation  may  be  promoted  in 
the  sac  by  the  introduction  of  a  foreign  body,  such  as  wire,  horse-hair,  or 
by  the  combination  of  wiring  and  electrolysis.  Moore,  in  1864,  first  wired 
a  sac,  putting  in  78  feet  of  fine  wire.  Death  occurred  on  the  fifth  day.  Cor- 
radi  proposed  the  combined  method  of  wiring  with  electrolysis,  which  was 
first  used  by  Burresi  in  1879.  His  patient  lived  for  three  and  a  half  months. 
Horse-hair,  watch-spring  wire,  catgut,  and  Florence  silk  have  been  used. 
Hunner  reports  the  statistical  results  of  both  methods  up«to  October,  1900. 
With  Moore's  method  (wiring)  14  cases  were  treated,  8  of  thoracic  aneurism, 
all  fatal ;  6  aneurisms  of  the  abdominal  aorta,  3  of  which  were  successful. 
Of  23  cases  treated  by  wiring  and  electrolysis  (Moore-Corradi  method)  17 
were  thoracic  and  6  abdominal.  The  thoracic  cases  of  Rosenstirn,  Stewart, 
and  Kerr,  and  the  abdominal  cases  of  Noble  and  Finney  (Case  V),  were 
successful.  In  8  of  the  23  cases  there  were  amelioration  of  symptoms  and 
probable  prolongation  of  life.  The  most  favorable  cases  are  those  in  which 


ANEURISM  859 

the  aneurism  is  sacculated,  but  this  is  a  point  not  easily  determined,  and 
often  from  a  sac  particularly  favorable  for  wiring  there  may  be  secondary 
projections  of  great  thinness.  The  sudden  filling  by  clot  of  an  aneurism  of 
the  cceliac  axis  of  the  superior  mesenteric  artery  may  result  fatally  from 
infarct  of  the  intestine. 

OTHER  CONDITIONS  REQUIRING  TREATMENT. — Pressure  on  veins  causing 
engorgement,  particularly  of  the  head  and  arms,  is  sometimes  promptly  re- 
lieved by  free  venesection,  and,  at  any  time  during  the  course,  of  a  thoracic 
aneurism,  if  attacks  of  dyspnoea  with  lividity  supervene,  bleeding  may  be  re- 
sorted to  with  great  benefit.  It  has  the  advantage  also  of  promptly  checking 
the  pain,  for  which  symptom,  as  already  mentioned,  the  iodide  of  potassium 
often  gives  relief.  In  the  final  stages  morphia  is,  as  a  rule,  necessary.  Dysp- 
noea, if  associated  with  cyanosis,  is  best  relieved  by  bleeding.  Chloroform 
inhalations  may  be  necessary.  The  question  sometimes  comes  up  with  refer- 
ence to  tracheotomy  in  these  cases  of  urgent  dyspnoea.  If  it  can.  be  shown 
by  laryngoscopic  examination  that  it  is  due  to  bilateral  abductor  paralysis 
the  trachea  may  be  opened,  but  this  is  extremely  rare,  and  in  nearly  every 
instance  the  urgent  dyspnoea  is  caused  by  pressure  about  the  bifurcation. 
When  the  sac  appears  externally  and  grows  large,  an  ice  bag  or  a  belladonna 
plaster  may  be  applied  to  allay  the  pain. ,  In  some  instances  an  elastic  sup- 
port may  be  used  with  advantage,  and  I  saw  a  physician  with  an  enormous 
external  aneurism  in  the  right  mammary  region  who  for  many  months  had 
obtained  great  relief  by  an  elastic  support,  passing  over  the  shoulder  and  un- 
der the  arm  of  the  opposite  side. 

The  calcium  salts  may  be  given  to  influence  coagulation,  and  the  nitrites 
if  the  blood  pressure  is  high,  but  rest  and  diet,  restriction  of  the  fluids,  and 
free  purgation  are  usually  more  effectual  than  drugs  in  reducing  blood 
pressure. 

ANETJKISM     OF     THE     ABDOMINAL     AOKTA 

Of  233  cases  collected  by  Nixon,  207  were  in  males,  26  in  females;  121 
were  between  the  ages  of  twenty-five  and  forty-five.  Nixon  reports  a  case 
in  a  syphilitic  girl  of  twenty.  Sixteen  cases  occurred  among  16,000  ad- 
missions at  the  Johns  Hopkins  Hospital. 

Pathology. — The  sac  is  most  common  just  below  the  diaphragm  in  the 
neighborhood  of  the  cceliac  axis.  The  tumor  may  be  fusiform  or  sacculated, 
and  it  is  sometimes  multiple.  Projecting  backward,  it  erodes  the  vertebra?  and 
may  cause  numbness  and  tingling  in  the  legs  and  finally  paraplegia,  or  it  may 
pass  into  the  thorax  and  burst  into  the  pleura.  More  commonly  the  sac  is 
on  the  anterior  wall  and  projects  forward  as  a  definite  tumor,  which  may  be 
either  in  the  middle  line  or  a  little  to  the  left.  The  tumor  may  project  in 
the  epigastric  region  (which  is  most  common),  in  the  left  hypochondrium, 
in  the  left  flank,  or  in  the  lumbar  region.  When  high  up  beneath  the  pillar 
of  the  diaphragm  it  may  attain  considerable  size  without  being  very  apparent 
on  palpation.  When  it  ruptures  into  the  retro-peritoneal  tissues  a  tumor  in  . 
the  flank  may  be  formed  gradually,  which  enlarges  with  very  little  pulsation. 
It  may  be  mistaken  for  a  rapidly  growing  sarcoma  or  for  appendicitis,  and 
an  operation  may  be  performed. 

The  symptoms  are  chiefly  pain,  very  often  of  a  neuralgic  nature,  passing 


860  DISEASES    OF    THE    CIRCULATORY    SYSTEM 

round  to  the  sides  or  localized  in. the  back,  and  more  persistent  and  intense 
than  in  any  other  variety  of  aneurism.  Gastric  symptoms,  particularly  vom- 
iting, may  be  early  and  deceptive  features.  Retardation  of  the  pulse  in  the 
femoral  artery  is  a  very  common  symptom. 

Diagnosis  and  Physical  Signs. — Inspection  may  show  marked  pulsation  in 
the  epigastric  region,  sometimes  a  definite  tumor.  A  thrill  is  not  uncommon. 
The  pulsation  is  forcible,  expansile,  and  sometimes  double  when  the  sac  is 
large  and  in  contact  with  the  pericardium.  On  palpation  a  definite  tumor 
can  be  felt.  If  large,  there  is  some  degree  of  dulness  on  percussion,  which 
usually  merges  with  that  of  the  left  lobe  of  the  liver.  On  auscultation,  a 
systolic  murmur  is,  as  a  rule,  audible,  and  is  sometimes  best  heard  at  the 
back.  A  diastolic  murmur  is  occasionally  present,  usually  very  soft  in  qual- 
ity. One  of  the  commonest  of  clinical  errors  is  to  mistake  a  throbbing  aorta 
for  an  aneurism.  It  is  to  be  remembered  that  no  pulsation,  however  forcible, 
or  the  presence  of  a  thrill  or  a  systolic  murmur,  justifies  the  diagnosis  of 
abdominal  aneurism  unless  there  is  a  definite  tumor  which  can  be  grasped 
and  which  has  an  expansile  pulsation.  Attention  to  this  rule  will  save  many 
errors.  The  throbbing  aorta — the  "preternatural  pulsation  in  the  epigas- 
trium/' as  Allan  Burns  calls  it — is  met  with  in  all  neurasthenic  conditions, 
particularly  in  women.  In  anaemia,  particularly  in  some  instances  of  trau- 
matic anaemia,  the  throbbing  may  be  very  great.  Very  frequently  a  tumor 
of  the  pylorus,  of  the  pancreas,  or  of  the  left  lobe  of  the  liver  is  lifted  with 
each  impulse  of  the  aorta  and  may  be  confounded  with  aneurism.  The  ab- 
sence of  the  forcible  expansile  impulse  and  the  examination  in  the  knee  elbow 
position,  in  which  the  tumor,  as  a  rule,  falls  forward,  and  the  pulsation  is 
not  then  communicated,  suffice  for  differentiation.  The  tumor  of  abdominal 
aneurism,  though  usually  fixed,  may  be  very  freely  movable. 

Prognosis. — The  outlook  in  abdominal  aneurism  is  bad.  A  few  cases  heal 
spontaneously.  Death  may  result  from  (a)  complete  obliteration  of  the  lu- 
men by  clots;  (6)  compression  paraplegia;  (c)  rupture  (which  occurred  in 
152  of  the  233  cases  in  Nixon's  series)  either  into'the  pleura,  retroperitoneal 
tissues,  peritoneum,  or  the  intestines,  most  commonly  into  the  duodenum;  (d) 
embolism  of  the  superior  mesenteric  artery,  producing  infarction  of  the  intes- 
tines. 

The  treatment  is  such  as  already  advised  in  thoracic  aneurism.  When 
the  aneurism  is  low  down  pressure  has  been  successfully  applied  in  a  case 
by  Murray,  of  Newcastle.  It  must  be  kept  up  for  many  hours  under  chloro- 
form. The  plan  is  not  without  risk,  as  patients  have  died  from  bruising  and 
injury  of  the  sac.  Nine  cases  in  my  series  were  treated  surgically.  In  two 
the  wiring  and  electrolysis  were  followed  by  great  improvement;  one  man 
lived  for  three  years. 

ANEUEISM  OF  THE  BEANCHES  OF  THE  ABDOMINAL  AOETA 

The  coeliac  axis  is  itself  not  infrequently  involved  in  aneurism  of  the 
first  portion  of  the  abdominal  aorta.  Of  its  branches,  the  splenic  artery  is 
occasionally  the  seat  of  aneurism.  This  rarely  causes  a  tumor  large  enough 
to  be  felt;  sometimes,  however,  the  tumor  is  of  large  size.  I  have  reported 
a  case  in  a  man,  aged  thirty,  who  had .  an  illness  of  several  months'  dura- 


ANEURISM  861 

tion,  severe  epigastric  pain  and  vomiting,  which  led  his  physicians  in  New 
York  to  diagnose  gastric  ulcer.  There  was  a  deep  seated  tumor  in  the  left 
hypochondriac  region,  the  dulness  of  which  merged  with  that  of  the  spleen. 
There  was  no  pulsation,  but  it  was  thought  on  one  occasion  that  a  bruit  was 
heard.  The  chief  symptoms  while  under  observation  were  vomiting,  severe 
epigastric  pain,  occasional  haematemesis,  and  finally  severe  haemorrhage  from 
the  bowels.  An  aneurism  of  the  splenic  artery  the  size  of  a  cocoanut  was 
situated  between  the  stomach  above  and  the  transverse  colon  below,  and  ex- 
tended to  the  right  as  far  as  the  level  of  the  navel.  The  sac  contained  densely 
laminated  fibrin.  It  had  perforated  the  colon.  I  have  twice  seen  small 
aneurisms  on  the  splenic  artery.  Of  39  instances  of  aneurism  on  the  branches 
of  the  abdominal  aorta  collected  by  Lebert,  10  were  of  the  splenic  artery. 

Of  aneurism  of  the  hepatic  artery  Holland  has  collected  40  cases  (1908), 
of  which  24  were  extra-hepatic.  In  Holland's  case  there  were  three  sacs — all 
intra-hepatic.  Eupture  took  place  in  32  cases — in  16  into  the  peritoneal  cav- 
ity, in  13  into  the  bile  passages.  The  sac  is  rarely  large,  but  in  the  case  of 
Wollmann's  it  was  as  large  as  a  child's  head.  No  case  has  been  diagnosed. 
Cholelithiasis  and  duodenal  ulcer  are  the  conditions  for  which  it  is  most 
likely  to  be  mistaken.  In  Eoss  and  Osier's  case  the  liver  was  enlarged,  with 
symptoms  of  pyaemia. 

Aneurism  of  the  superior  mesenteric  artery  is  not  very  uncommon.  The 
diagnosis  is  scarcely  possible  from  aneurism  of  the  arch.  Plugging  of  the 
branches  or  of  the  main  stem  may  cause  infarction  of  the  bowel. 

Renal  Artery. — Henry  Morris  has  collected  21  instances  of  aneurism,  12 
of  which  arose  from  injury.  Many  of  them  were  false.  Pulsation  and  a  bruit 
are  not  always  present.  Four  cases  were  operated  upon;  three  recovered.  In 
a  case  of  Keen's  the  tumor  and  the  kidney  were  removed  together. 

Pulmonary  Artery.  — Primary  aneurism  of  the  trunk  is  very  rare.  Of 
the  branches  there  are  two  varieties:  (a)  The  acute  embolic,  which  may  be 
multiple,  arising  in  connection  with  thrombi  in  the  veins  or  a  septic  endo- 
carditis in  the  right  heart.  (&)  The  small  aneurisms  in  the  walls  of  pul- 
monary cavities,  already  considered. 

AETEEIO-VENOUS    ANEUEISM 

In  this  form,  known  to  Galen,  but  first  accurately  described  by  the  great 
William  Hunter,  there  is  abnormal  communication  between  an  artery  and  a 
vein.  When  a  tumor  lies  between  the  two  it  is  known  as  varicose  aneurism; 
when  there  is  a  direct  communication  without  tumor  the  vein  is  chiefly  dis- 
tended and  the  condition  is  known  as  aneurismal  varix. 

While  it  may  occur  in  the  aorta,  it  is  much  more  common  in  the  periph- 
eral arteries  as  a  result  of  stab  or  gunshot  wounds. 

An  aneurism  of  the  ascending  portion  of  the  arch  may  open  directly  into 
the  vena  cava.  Twenty-nine  cases  of  this  lesion  have  been  analyzed  by  Pepper 
and  Griffith.  Cyanosis,  oedema,  and  great  distention  of  the  veins  of  the  upper 
part  of  the  body  are  the  most  frequent  symptoms,  and  develop,  as  a  rule, 
with  suddenness.  Of  the  physical  signs  a  thrill  is  present  in  some  cases.  A 
continuous  murmur  with  systolic  intensification  is  of  great  diagnostic  value. 
Thurnam  (Medico-Chirurgical  Transactions,  1840)  gave  the  first  accurate 


862  DISEASES    OF   THE    CIRCULATORY   SYSTEM 

account  of  this  murmur  and  of  this  characteristic  type  of  cyanosis.  There  is 
only  one  condition  with  which  it  could  be  confounded,  viz.,  the  remarkable 
cyanosis  of  the  upper  part  of  the  body  which  follows  crushing  accidents  to 
the  thorax.  Perforation  between  the  aorta  and  pulmonary  artery  causes  very 
much  the  same  symptoms.  In  a  few  cases  an  aneurism  of  the  abdominal  aorta 
perforates  the  inferior  vena  cava — oedema  and  cyanosis  of  the  legs  and  lower 
half  of  the  body,  and  the  distinctive  thrill  and  murmur  are  present. 

In  the  arterio-venous  aneurisms  which  follow  stab  and  bullet  wounds  of 
the  subclavian,  axillary,  carotid,  femoral,  and  popliteal  arteries  the  clinical 
features  are  most  characteristic.  First,  the  veins  enlarge  as  the  arterial  blood 
flows  under  high  pressure  into  them.  The  affected  limb  may  be  greatly 
swollen  and  in  a  young  person  may  lengthen,  and  the  growth  of  hair  is  in- 
creased. Secondly,  a  strong  thrill  is  felt,  of  maximum  intensity  at  the  site  of 
the  aneurism,  but  sometimes  to  be  felt  at  the  most  distant  parts  of  a  limb. 
Thirdly,  the  characteristic  continuous  murmur  with  systolic  intensification 
is  heard.  In  the  external  arteries  the  condition  may  persist  for  years  before 
disability  is  caused  by  enlargement  of  the  veins  and  swelling  of  the  limb. 

POLYAETEEITIS    ACUTA    NODOSA 
(Periarteritis  Nodosa) 

A.  series  of  cases  has  been  described  in  which  small  aneurisms  occur  on 
the  arteries  of  the  muscles  and  viscera.  The  first  case  was  reported  by  Kuss- 
maul  and  Maier,  and  about  19  cases  in  all  have  been  described  (Dickson). 
A  case,  agreeing  clinically  with  the  others,  has  occurred  in  my  wards.  No 
autopsy  was  permitted,  but  the  nodules  were  felt  in  the  abdominal  wall  before 
death.  The  case  is  reported  by  Sabin  (J.  H.  H.  Bulletin,  1901).  There  are 
marked  thickening  of  the  intima  and  infiltration  of  the  other  coats,  with  a 
nuclear  growth  almost  sarcomatous.  There  are  two  theories:  one,  that  the 
nodules  are  aneurisms  due  to  syphilis  or  to  congenital  weakening  of  the 
arteries;  the  other,  that  they  are  aneurisms  secondary  to  an  inflammatory 
process  like  the  infectious  granulomata. 

The  cases  have  occurred  chiefly  in  men  between  the  ages  of  twenty  seven 
and  fifty  two;  the  course  is  from  eight  to  twelve  weeks.  The  patients  com- 
plain of  weakness.  The  symptoms  correspond  with  the  situation  of  the  le- 
sions; thus  their  presence  in  the  muscles  is  associated  with  pain,  weakness, 
and  sometimes  paralysis  and  atrophy.  The  nodules  are  abundant  in  the  ali- 
mentary tract.  The  severest  symptom  is  epigastric  pain;  there  is  loss  of 
appetite,  thirst,  vomiting,  constipation,  or  diarrhoea.  The  disease  is  febrile 
at  first,  but  the  temperature  sinks  to  subnormal,  while  the  pulse  remains 
rapid.  When  the  cerebral  vessels  are  involved  there  are  headache,  excitement, 
convulsions,  and  -optic  neuritis,  and  the  diagnosis  of  meningitis  is  made.  The 
anaemia  is  extreme.  In  our  case  the  haemoglobin  was  21  per  cent.,  the  red 
blood-cells  1,704,000.  The  leucocytes  reached  116,000,  of  which  91  per  cent, 
were  polymorphonuclear  forms.  The  urine  is  scanty,  of  low  specific  gravity, 
with  albumin  and  casts.  Urea  is  excreted  in  small  quantities,  but  the  mind 
is  clear. 


SECTION   X 

DISEASES    OF    THE    DUCTLESS    GLANDS 
I.    DISEASES    OF    THE    SUPRARENAL    BODIES 

1.     ADDISON'S    DISEASE 

Definition. — A  disease  characterized  by  muscular  and  vascular  asthenia, 
irritation  of  the  stomach,  and  pigmentation  of  the  skin ;  due  either  to  tubercu- 
losis or  atrophy  of  the  adrenals,  or  to  degenerative  changes  in  the  chromaffin 
system  generally. 

The  recognition  of  the  disease  is  due  to  Addison  of  Guy's  Hospital,  whose 
monograph  on  "The  Constitutional  and  Local  Effects  of  Disease  of  the  Supra- 
renal Capsules"  was  published,  in  1855. 

Etiology. — The  disease  is  rare.  Only  17  cases  came  under  my  observation 
in  the  United  States.  In  large  clinics  a  year  or  more  may  pass  without  a 
case.  Males  are  more  frequently  attacked  than  females.  In  Greenhow's  analy- 
sis of  183  cases,  119  were  males  and  64  females.  The  majority  of  cases  occur 
between  the  twentieth  and  fortieth  years.  A  congenital  case  has  been  de- 
scribed, in  which  the  child  lived  for  eight  weeks,  and  post  mortem  the  adrenals 
were  found  to  be  large  and  cystic.  In  a  few  cases  a  blow  on  the  abdomen  or 
back  has  preceded  the  onset.  A  certain  number  of  cases  have  been  associated 
with  Pott's  disease. 

Pathology. — To  understand  the  remarkable  character  of  Addison's  disease 
it  is  necessary  to  have  an  idea  of  the  structure  and  function  of  the  supra- 
renal bodies.  The  cortex  of  the  gland  is  an  epithelial  structure,  the  medulla 
consists  of  an  irregular  meshwork  of  consecutive  tissue,  including  large  multi- 
nucleated  cells,  non-medullated  nerve  fibres  and  nerve  cells,  and  in  addition 
large  polymorphous  cells,  which  in  chromic  acid  solution  take  on  a  brownish 
pigmentation,  and  are  spoken  of  as  chromaffin  cells.  Extra-adrenal  chromaffin 
cells  are  found  in  the  ganglia  of  the  abdominal  sympathetic  system  and  in 
certain  structures  situated  along  the  course  of  the  aorta  and  are  known  as 
paraganglia  or  Zuckerkandl's  bodies.  These  chromaffin  cells  have  also  been 
found  in  the  carotid  glands  and,  according  to  some  authors,  in  the  coccygeal 
gland,  the  parovarium  and  the  epidydimis.  Collectively  these  structures  are 
spoken  of  as  the  "chromaffin  system." 

Removal  of  the  suprarenal  causes  death  in  animals  by  progressive  weakness 
and  toxasmia. 

The  specific  function  of  the  medullary  portion  of  the  gland  and  of  the 
chromaffin  system  is  to  furnish  an  internal  secretion  known  as  epinephrin, 
which  controls  blood  pressure,  acting  on  peripheral  neuro-muscular  elements 

863 


864  DISEASES    OF    THE    DUCTLESS    GLANDS 

in  the  arterioles,  promotes  the  activity  of  the  skeletal  muscles,  and  in  some  way 
controls  the  metabolism  of  the  pigment  of  the  skin.  The  remarkable  discovery 
of  Schafer  and  Oliver  of  the  blood  pressure  raising  property  of  these  glands 
is  almost  the  only  positive  fact  we  know  in  connection  with  their  functions. 

Glycosuria  is  also  caused  by  the  injection  of  epinephrin,  and  in  animals  a 
form  of  arterio-sclerosis,  probably  due  to  the  high  blood  pressure.  Following 
this  discovery  many  theoretical  conceptions  have  been  entertained  of  the  rela- 
tion between  a  defect  of  the  adrenal  secretion  and  asthenic  affections,  and  it 
is  suggested  that  adrenal  insufficiency  itself  plays  an  important  role  in  acute 
infections,  in  tuberculosis,  and  many  wasting  diseases,  with  which  it  is  inter- 
esting to  note  that  increased  pigmentation  may  be  associated. 

Epinephrin  has  been  shown  to  be  present  in  the  chromaffin  bodies,  so  that 
we  may  take  it  that  the  chromaffin  system  has  everywhere  the  special  function 
of  providing  a  material  which  keeps  up  the  vascular  tone. 

In  some  way,  too,  it  controls  the  pigment  metabolism.  Abolition  of  the 
function  of  the  suprarenals,  or  marked  irritation  in  the  chromaffin  tissues 
in  the  abdomen,  as  in  tuberculous  peritonitis  or  in  aneurism,  is  associated  with 
a  great  increase  in  the  pigmentation  of  the  skin. 

We  have  no  positive  knowledge  as  to  the  function  of  the  cortex  of  the 
glands.  Apparently  it  has  some  influence  upon  sexual  activity  and  pregnancy. 
This  portion  of  the  capsules  becomes  twice  its  normal  thickness  in  pregnant 
rabbits.  Hyperplasia  of  the  cortex  or  tumor  formations  may  be  associated  with 
precocious  sexual  development,  and  hypoplasia  of  this  part  with  infantilism. 
It  is  also  suggested  that  the  cortex  produces  bodies  which  neutralize  the  poison- 
ous products  of  nitrogenous  metabolism  and  in  this  way  prevent  auto-intoxi- 
cation. 

Morbid  Anatomy. — There  is  rarely  emaciation  or  anaemia.  Eolleston  thus 
summarizes  the  condition  of  the  suprarenal  bodies  in  Addison's  disease: 

"1.  The  fibro-caseous  lesion  due  to  tuberculosis — far  the  commonest  condi- 
tion found.  2.  Simple  atrophy.  3.  Chronic  interstitial  inflammation  leading 
to  atrophy.  4.  Malignant  disease  invading  the  capsules,  including  Addison's 
case  of  malignant  nodule  compressing  the  suprarenal  vein.  5.  Blood  extravas- 
ated  into  the  suprarenal  bodies.  6.  No  lesion  of  the  suprarenal  bodies  them- 
selves, but  pressure  or  inflammation  involving  the  semilunar  ganglia. 

"The  first  is  the  only  common  cause  of  Addison's  disease.  The  others, 
with  the  exception  of  simple  atrophy,  may  be  considered  as  very  rare." 

The  nerve-cells  of  the  semilunar  ganglia  have  been  found  degenerated  and 
deeply  pigmented,  and  the  nerves  sclerotic.  The  ganglia  are  not  uncommonly 
entangled  in  the  cicatricial  tissue  about  the  adrenals.  The  chromaffin  cells 
in  the  sympathetic  ganglia  and  in  the  abdominal  plexuses  generally  disappear, 
The  cases  of  extensive  destruction  of  the  glands  without  Addison's  disease  are 
explained  by  a  persistence  of  the  chromaffin  structures  elsewhere,  while  exten- 
sive involvement  of  the  extra-capsular  chromaffin  system  may  itself  be  suffi- 
cient to  cause  the  symptoms,  the  adrenals  themselves  being  intact. 

Few  changes  of  importance  are  found  in  other  organs.  The  spleen  is  oc- 
casionally enlarged;  the  thymus  may  be  persistent.  The  other  organs  show 
only  the  alterations  associated  with  a  protracted  illness. 

Symptoms. — In  the  words  of  Addison,  the  characteristic  symptoms  are 
"anemia,  general  languor  or  debility,  remarkable  feebleness  of  the  heart's 


865 

action,  irritability  of  the  stomach,  and  a  peculiar  change  of  color  in  the 
skin." 

The  onset  is,  as  a  rule,  insidious.  The  feelings  of  weakness,  as  a  rule, 
precede  the  pigmentation.  In  other  instances  the  gastro-intestinal  symptoms, 
the  weakness,  and  the  pigmentation  come  on  together.  There  are  a  few  cases 
in  the  literature  in  which  the  whole  process  has  been  acute,  following  a  shock 
or  some  special  depression.  There  are  three  important  symptoms : 

(a)  PIGMENTATION  OP  THE  SKIN.— This,  as  a  rule,  first  attracts  the  atten- 
tion of  the  patient's  friends.  The  grade  of  coloration  ranges  from  a  light 
yellow  to  a  deep  brown,  or  even  black.  In  typical  cases  it  is  diffuse,  but  always 
deeper  on  the  exposed  parts  and  in  the  regions  where  the  normal  pigmentation 
is  more  intense,  as  the  areolse  of  the  nipples  and  about  the  genitals ;  also  wher- 
ever the  skin  is  compressed  or  irritated,  as  by  the  waistband.  At  first  it  may 
be  confined  to  the  face  and  hands.  Occasionally  it  is  absent.  Patches  show- 
ing atrophy  of  pigment,  leucoderma,  may  occur.  The  pigmentation  is  found 
on  the  mucous  membranes  of  the  mouth,  conjunctivas,  and  vagina.  Pig- 
mentation of  the  mucous  membrane  is  not  distinctive.  It  has  been  found 
in  chronic  stomach  troubles,  etc.  (Fr.  Schultze),  and  is  common  in  the  negro. 
A  patchy  pigmentation  of  the  serous  membranes  has  often  been  found.  Over 
the  diffusely  pigmented  skin  there  may  be  little  mole  like  spots  of  deeper  pig- 
mentation, and  upon  the  trunk,  particularly  on  the  lower  abdomen,  it  may 
be  "ribbed"  like  the  sand  on  the  seashore. 

(&)  GASTRO-INTESTINAL  SYMPTOMS. — The  disease  may  set  in  with  attacks 
of  nausea  and  vomiting,  spontaneous  in  character.  Toward  the  close  there 
may  be  pain  with  retraction  of  the  abdomen,  and  even  features  suggestive  of 
peritonitis.  A  marked  anorexia  may  be  present.  The  gastric  symptoms  are 
variable  throughout  the  course ;  occasionally  they  are  absent.  Attacks  of  diar- 
rhea are  frequent  and  come  on  without  obvious  cause. 

(c)  ASTHENIA,  the  most  characteristic  feature  of  the  disease,  may  be 
manifested  early  as  a  feeling  of  inability  to  carry  on  the  ordinary  occupation, 
or  the  patient  may  complain  constantly  of  feeling  tired.  The  weakness  is 
specially  marked  in  the  muscular  and  cardio-vascular  systems.  There  may  be 
an  extreme  degree  of  muscular  prostration  in  an  individual  apparently  well 
nourished,  whose  muscles  feel  firm  and  hard.  The  cardio-vascular  asthenia 
is  manifest  in  a  feeble,  irregular  action  of  the  heart,  which  may  come  on  in 
paroxysms,  in  attacks  of  vertigo,  or  of  syncope,  in  one  of  which  the  disease 
may  prove  fatal.  The  blood  pressure  is  low,  falling  to  70  or  80  mm.  of  Hg. 
Headache  is  a  frequent  symptom ;  convulsions  occasionally  occur.  Pain  in  the 
back  may  be  an  early  and  important  symptom. 

Ansemia,  a  symptom  specially  referred  to  by  Addison,  is  not  common.  In 
a  majority  of  the  patients  the  blood  count  is  normal.  McMunn  has  described 
an  increase  in  the  urinary  pigments,  and  a  pigment  has  been  isolated  of  very 
much  the  same  character  as  the  melanin  of  the  skin. 

The  mode  of  termination  is  either  by  syncope,  which  may  occur  even  early 
in  the  disease,  by  gradual  progressive  asthenia,  or  by  the  development  of  tuber- 
culous lesions.  In  two  cases  I  have  known  a  noisy  delirium  with  urgent 
dyspnoea  to  precede  the  fatal  event. 

Diagnosis.— Pigmentation  of  the  skin  is  not  confined  to  Addison's  disease. 
The  following  conditions  may  give  rise  to  an  increase  in  the  pigment;  some 


866  DISEASES   OP   THE   DUCTLESS   GLANDS 

of  which,  e.  g.,  a  and  &,  are  due,  as  in  Addison's  disease,  to  disturbance  in  the 
chromaffin  system. 

(a)  Abdominal  growths — tubercle,  cancer,  or  lymphoma.  In  tuberculosis 
of  the  peritoneum  pigmentation  is  not  uncommon. 

(&)  Pregnancy,  in  which  the  discoloration  is  usually  limited  to  the  face, 
the  so-called  masque  des  femmes  enceintes.  Uterine  disease  is  a  common  cause 
of  a  patchy  melasma. 

(c)  Hcemochromatosis,  associated  with  hypertrophic  cirrhosis,  pigmenta- 
tion of  the  skin,  and  diabetes. 

(d)  In  overworked  persons  of  constipated  habit  and  with  sluggish  livers 
there  may  be  a  patchy  staining  of  the  face  and  forehead. 

(e)  The  vagabond's  discoloration,  caused  by  the  irritation  of  lice  and  dirt, 
which  may  reach  a  very  high  grade,  and  has  sometimes  been  mistaken  for 
Addison's  disease. 

(/)  In  rare  instances  there  is  deep  discoloration  of  the  skin  in  melanotic 
cancer,  so  deep  and  general  that  it  has  been  confounded  with  melasma  supra- 
renale. 

(g)   In  certain  cases  of  exophthalmic  goitre  abnormal  pigmentation  occurs. 

(h)  In  a  few  rare  instances  the  pigmentation  in  scleroderma  may  be 
general  and  deep. 

(t)  In  the  face  there  may  be  an  extraordinary  degree  of  pigmentation  due 
to  innumerable  small  black  comedones.  If  not  seen  in  a  very  good  light,  the 
face  may  suggest  argyria.  Pigmentation  of  an  advanced  grade  may  occur 
in  chronic  ulcer  of  the  stomach  and  in  dilatation  of  the  organ. 

(/)  Argyria  could  scarcely  be  mistaken,  and  yet  I  was  consulted  in  a  case 
in  which  the  diagnosis  of  Addison's  disease  had  been  made  by  several  good 
observers. 

(Jc)  Arsenic  when  taken  for  many  months  may  cause  a  most  intense  pig- 
mentation of  the  skin. 

(1)  With  arterio-sclerosis  and  chronic  heart-disease  there  may  be  marked 
melanoderma. 

(ra)  In  pernicious  anaemia  the  pigmentation  may  be  extreme,  most  com- 
monly due  to  the  prolonged  administration  of  arsenic. 

(n)  There  is  a  form  of  deep  pigmentation,  usually  in  women,  which  per- 
sists for  years  without  change  and  without  any  special  impairment  of  health. 
I  have  met  with  two  cases ;  in  one  the  pigmentation  was  a  little  more  leaden 
than  is  usual  in  Addison's  disease ;  in  both  the  condition  had  lasted  some 
years. 

(o)  In  ochronosis  there  may  be  a  deep  melanotic  pigmentation  of  the  face 
and  hands. 

In  any  case  of  unusual  pigmentation  these  various  conditions  must  be 
sought  for;  the  diagnosis  of  Addison's  disease  is  scarcely  justifiable  without 
the  asthenia.  In  many  instances  it  is  difficult  early  in  the  disease  to  arrive 
at  a  definite  conclusion.  The  occurrence  of  fainting  fits,  of  nausea,  and  gas- 
tric irritability  are  important  indications.  As  the  lesion  of  the  capsules  is 
almost  always  tuberculous,  in  doubtful  cases  the  tuberculin  test  may  be  used. 
In  two  of  my  cases,  robust,  healthy  men  with  pigmentation  and  gastric  symp- 
toms, the  reaction  was  obtained. 

Prognosis.  — The  disease  is  usually  fatal.    The  cases  in  which  the  bronzing 


DISEASES    OF    THE    SUPEAEENAL   BODIES  867 

is  slight  or  does  not  occur  run  a  more  rapid  course.  There  are  occasionally 
acute  cases  which,  with  great  weakness,  vomiting,  and  diarrhoea,  prove  fatal 
in  a  few  weeks.  In  a  few  cases  the  disease  is  much  prolonged,  even  to  six  or 
ten  years.  In  rare  instances  recovery  has  taken  place,  and  periods  of  improve- 
ment, lasting  many  months,  may  occur. 

Treatment. — When  asthenia  appears  the  patient  should  he  confined  to  bed 
and  sudden  efforts  and  muscular  exercise  should  not  be  allowed.  Fatal  syn- 
cope may  at  any  time  occur.  In  three  of  my  cases  death  was  sudden.  For  the 
debility  arsenic  and  strychnia  are  useful ;  for  the  diarrhoea  large  doses  of  bis- 
muth, and  for  the  irritability  of  the  stomach  creosote,  hydrocyanic  acid,  ice, 
and  champagne.  The  diet  should  be  light  and  nutritious.  As  the  disease  is 
nearly  always  tuberculous  an  open  air  treatment  may  be  c'arried  out.  Tuber- 
culin may  be  tried,  particularly  if  the  case  is  seen  early. 

Operation  has  been  suggested.  The  lesion  is  usually  localized,  and  nowa- 
days it  should  not  be  a  difficult  matter  to  remove  the  diseased  glands ;  but,  so  far 
as  we  know,  in  animals  this  is  always  a  fatal  procedure,  and  in  any  case,  unless 
there  were  supernumerary  adrenals  and  a  considerable  portion  of  the  extra- 
capsular  chromaffin  intact,  the  operation  would  be  useless. 

ADRENAL  THERAPY. — Evidently  the  relation  of  Addison's  disease  to  the 
adrenals  is  not  quite  the  same  as  that  of  myxosdema  to  the  thyroid  gland,  in 
which  the  insufficiency  is  promptly  and  permanently  relieved  by  the  adminis- 
tration of  preparations  of  the  thyroid.  The  tuberculous  nature  of  the  lesions 
in  most  of  the  cases  of  Addison's  disease  is  in  itself  an  obstacle,  and  there  is 
usually  widespread  cicatricial  involvement  of  the  sympathetic  system.  There 
is  now  a  large  series  of  cases  treated  with  various  preparations,  but  only  a 
very  few  with  satisfactory  results.  In  only  two  of  my  patients  was  there 
marked  improvement.  In  one,  which  I  have  reported,  all  the  severer  symp- 
toms disappeared,  the  pigmentation  cleared  up,  and  the  patient  died  subse- 
quently of  an  acute  infection,  which  apparently  had  nothing  to  do  with  the 
disease.  The  adrenals  were  found  sclerotic  but  not  tuberculous.  The  dried 
gland  may  be  given  in  doses  of  from  5  to  20  grains  (0.3  to  1.3  gm.)  three 
times  a  day.  There  are  also  liquid  extracts.  Epinephrin  may  also  be  used 
and  when  the  blood  pressure  is  low  it  can  be  given  systematically,  carefully 
testing  its  effects. 

2.  OTHEE  AFFECTIONS  OF  THE  SUPEAEENAL  GLANDS 

Hyperplasia  of  the  cortex  has  been  met  with  in  defective  development  of 
the  genitals.  Enlargement  is  not  uncommon  in  chronic  nephritis  and  in  ar- 
terio-sclerosis.  The  latter  has  been  attributed  to  the  overactivity  of  the  gland. 
Hypertrophy  with  tumor  has  also  been  associated  with  a  remarkable  precocious 
development  of  the  sexual  organs.  When  one  gland  is  diseased  the  other  may 
be  enlarged.  In  cases  of  disease  of  both  glands  the  chromaffin  tissues  along 
the  aorta  and  in  the  sympathetic  system  have  been  found  hypertrophied. 

Hypoplasia. — There  is  an  interesting  association  of  absence  of  the  adrenals 
or  absence  of  the  medulla  with  anomalies  of  the  brain,  particularly  anen- 
cephaly.  It  has  been  suggested  that  chronic  hypoplasia  associated  with  insuf- 
ficiency of  the  internal  secretion  is  responsible  for  the  low  blood  pressure  in 
the  specific  fevers  and  in  conditions  of  debility.  Some  have  attributed  the 


868  DISEASES    OF    THE    DUCTLESS    GLANDS 

"white  line,"  the  anaemic  vaso-motor  skin  reflex,  to  adrenal  insufficiency,  but, 
in  any  case,  it  is  too  common  to  be  of  much  import. 

Haemorrhage. — Acute  hsemorrhagic  adrenalitis  presents  a  picture  some- 
what resembling  acute  pancreatitis — a  sudden  onset  with  pain,  vomiting,  pro- 
found prostration  and  death  within  a  few  days.  In  other  cases  convulsions 
occur  or  the  patient  falls  into  a  typhoid  state  with  profound  asthenia.  In 
children  the  disease  may  be  associated  with  purpura,  both  cutaneous  and 
visceral. 

Tumors. — Both  carcinoma  and  sarcoma  have  been  described.  They  are 
very  apt  to  undergo  fatty  degeneration  and  hemorrhage,  so  that  they  may 
form  very  large  cysts.  In  children  excessive  development  of  the  genitals  with 
hair  and  fat  has  been  found,  as  noted  by  Bullock  and  Sequeira,  who  have  col- 
lected a  number  of  cases.  On  this  account  a  suggestion  has  been  made  that 
the  adrenal  cortex  has  an  hormonic  internal  secretion  which  influences  sexual 
development.  Robert  Hutchison  has  described  a  remarkable  syndrome  in 
children  of  adrenal  tumor,  exophthalmos,  and  cranial  tumors;  and  William 
Pepper  (tertius)  has  described  a  form  characterized  by  rapid  growth,  diffuse 
involvement  of  the  liver,  and  great  distention  of  the  abdomen  without  ascites 
or  jaundice. 

n.    DISEASES   OF  THE  THYMUS   GLAND 

While  probably  an  organ  of  internal  secretion  the  thymus  in  structure  has 
little  resemblance  to  the  other  ductless  glands,  with  the  exception  of  the 
epiphysis  cerebri,  and  must  be  classed  as  an  epithelial  rather  than  as  a  lym- 
phoid  organ  (Pappenheimer). 

At  birth  the  thymus  gland  weighs  about  12  grams;  from  the  first  to  the 
fifth  year  about  23  grams;  from  the  sixth  to  the  tenth  year  about  26  grams; 
from  the  eleventh  to  the  fifteenth  year  about  37^  grams,  and  from  the  six- 
teenth to  the  twentieth  year  about  25^  grams,  after  which  it  undergoes  a 
gradual  atrophy  (Hammar).  Involution  not  taking  place,  a  "persistent 
thymus"  remains. 

The  function  of  the  gland  is  not  known.  Friedleben,  whose  remarkable 
monograph  (1858)  is  a  storehouse  of  all  knowledge  on  the  subject,  found  no 
ill  effects  from  extirpation,  but  this  has  not  been  confirmed.  There  is  an  ob- 
scure relationship  between  the  thymus  and  the  sexual  glands.  After  castration 
N.  Patton  found  persistency  and  hypertrophy  of  the  gland.  A  disturbance  of 
the  normal  development  of  the  bones,  particularly  in  ossification,  also  occurs 
(Basch)  and  there  is  an  increase  in  the  excitability  of  the  nerves.  The  nature 
of  the  internal  secretion  is  unknown.  Many  experiments  have  been  made 
with  extract  from  the  gland,  but  without  definite  results. 

1.     HYPEETEOPHY   OF   THE   THYMUS 

The  size  of  the  gland  varies  so  greatly  that  it  is  not  easy  to  define  the  limits 
between  persistency  and  enlargement.  Between  the  manubrium  sterni  and  the 
vertebral  column  in  an  infant  of  eight  months  the  distance  is  only  2.2  cm. 
(Jacobi),  so  that  it  is  easy  to  understand  how  an  enlarged  gland  may  induce 
what  Warthin  calls  "thymic  tracheostenosis."  There  would  appear  to' be,  as 
this  author  suggests,  three  groups  of  cases: 


DISEASES    OF   THE   THYMUS   GLAND  869 

(a)  Thymic  stridor,  either  congenital  or  developing  soon  after  birth,  vary- 
ing in  intensity  and  aggravated  by  crying  and  coughing. 

(&)  Thymic  asthma,  sometimes  known  as  Copp's  or  Miller's  asthma,  which 
is  an  exaggerated  and  more  persistent  form  of  the  .stridor.  While  much  dis- 
pute exists  as  to  this  form,  there  can  be  no  doubt  as  to  its  occurrence,  as  there 
are  cases,  those  reported  by  Siegel  and  Konig,  for  example,  in  which  complete 
relief  has  followed  removal  of  the  gland.  Olivier  has  collected  39  cases  of 
thymectomy  with  24  recoveries. 

(c)  Lastly,  in  a  few  cases  sudden  death  has  been  met  with,  usually  in 
connection  with  the  condition  of  lymphatism  about  to  be  described. 

Persistence  of  the  gland  has  been  met  with  in  many  affections,  such  as 
Graves'  disease,  Addison's  disease,  acromegaly,  myasthenia  gravis,  rickets, 
etc.  Many  observers  have  regarded  the  association  of  an  enlargement  with 
Graves'  disease  as  more  than  accidental  and  as  a  sort  of  compensatory  process. 

2.     ATKOPHY  OP  THE  THYMUS 

This  is  met  with  accidentally  in  children  who  show  no  special  pathological 
changes,  especially  as  Ruhrah  has  shown,  in  marasmus  and  the  chronic  wasting 
disorders  of  children. 

Of  other  morbid  conditions  met  with,  haemorrhages  are  not  uncommon. 
Many  mediastinal  tumors  originate  in  the  remnants  of  the  thymus;  dermoid 
tumors  and  cysts  have  also  been  met  with;  tuberculosis  and  syphilis  of  the 
gland  are  occasionally  seen. 

The  condition  described  by  Dubois,  met  with  sometimes  in  the  subjects  of 
congenital  syphilis,  in  which  there  are  fissure  like  cavities  in  the  gland  filled 
with  a  purulent  fluid,  is  stated  by  Chiari  and  by  Dudgeon  to  be  a  post  mortem 
softening. 

3.     STATUS  THYMICO-LYMPHATICUS 
(Lymphatism) 

Definition. — A  condition  in  children  of  hyperplasia  of  the  lymphatic  tissues 
and  of  the  thymus,  in  association  with  a  flabby,  fat  overgrowth  of  the  body 
and  hypoplasia  of  the  heart  and  blood  vessels. 

The  subjects  of  lymphatism,  as  this  condition  has  been  called,  have  a 
lowered  resistance,  and  are  liable  to  sudden  death  from  trifling  and  apparently 
inadequate  causes.  The  so-called  "thymic  death"  has  been  much  discussed. 
In  young  infants  who  have  been  found  dead  in  bed,  or  who  have  been  suddenly 
attacked  with  dyspnoea  and  cyanosis  and  died  in  a  few  minutes,  the  thymus 
gland  has  been  found  enlarged.  Paltauf  increased  our  knowledge  of  this  con- 
dition when  he  described  (in  1889)  a  lymphatic  constitution,  in  which  there 
was  hyperplasia  of  the  general  lymphatic  apparatus,  enlargement  of  the  thymus 
and  of  the  spleen,  with  a  fat,  flabby  state  of  the  body. 

Pathology. — The  children  have  a  well-developed  panniculus  adiposus,  are 
often  large  for  their  age,  and  with  relatively  large  heads.  There  are  hyperpla- 
sia of  the  lymphatic  apparatus  and  structures  of  the  tonsillar  ring,  moderate 
enlargement  of  the  external  and  internal  lymph  glands,  and  hyperplasia  of  the 
solitary  and  agminated  follicles  of  the  small  and  large  intestines.  In  the  mod- 


8?0  DISEASES   OF   THE   DUCTLESS   GLANDS 

erately  enlarged  spleen  the  Malphigian  bodies  may  stand  out  very  prominently, 
and  if  anaemic  look  like  large  tubercles.  The  thymus  may  measure  as  much  as 
10  cm.  in  length,  is  swollen  and  soft,  and  on  section  exudes  a  milky  white  fluid. 
The  bone  marrow  has  been  found  hyperplastic,  and  in  young  adults  the  yellow 
is  replaced  by  the  red  marrow.  A  small  heart,  small  aorta  and  peripheral  ves- 
sels have  been  found,  and  sometimes  an  associated  condition  of  rickets. 

Symptoms. — The  subjects  of  lymphatism  are  usually  fat,  often  anaemic  and 
flabby,  but  are  regarded  as  in  good  health.  It  is  usually  met  with  in  children, 
but  the  condition  may  persist  beyond  puberty,  and  is  seen  in  the  flabby  young 
adults  with  pasty  complexions,  large  heads,  and  slender  skeletons. 

What  has  called  special  attention  to  the  condition  is  the  tragedy  of  sudden 
death  following  trifling  causes — as  the  prick  of  a  hypodermic  needle,  a  sud- 
den plunge  into  cold  water,  but  much  more  often  in  anaesthesia,  either  by  ether 
or  chloroform,  when  an  amount  has  been  given,  not  itself  lethal.  Possibly, 
too,  some  of  the  sudden  deaths  of  convalescents  from  infectious  fevers  are  from 
this  cause,  and  the  remarkable  cases  of  sudden  death  during  bathing,  or  of 
persons  who  have  fallen  into  the  water,  and  though  immediately  rescued  were 
dead.  Two  explanations  have  been  offered  of  this  sudden  death:  first,  that  it 
is  due  to  mechanical  pressure  of  the  enlarged  thymus  on  the  trachea.  This  is 
not  likely,  as  the  majority  of  these  cases  have  shown  no  previous  signs  of 
thymic  asthma,  and  in  only  one  of  Blumer's  9  cases  was  there  any  evidence 
of  this.  The  other  view  is  that  it  is  a  toxaemia  from  an  overproduction  of  the 
internal  secretion  of  the  thymus  and  of  the  lymph  glands. 

Diagnosis. — Suspected  cases  should  be  carefully  examined  before  trifling 
operations.  The  enlargement  of  the  superficial  glands  of  the  tonsillar  tissues 
and  of  the  spleen  is  easily  determined.  A  persistence  of  the  thymus  is  indi- 
cated by  an  area  of  dulness  at  the  upper  part,  and  particularly  to  the  left  of 
the  sternum  merging  with  the  cardiac  flatness  and  which  shifts  upward  with 
extreme  retraction  of  the  head  and  neck  (Boggs).  A  distinct  bulging  may 
be  seen,  or  the  top  of  the  gland  may  be  felt  in  the  episternal  notch.  The 
X-ray  picture  may  show  a  definite  shadow.  With  th'e  laryngoscope  a  narrow- 
ing of  the  windpipe  may  be  seen.  A  careful  blood  count  should  always  be 
made,  as  there  may  be  a  marked  lymphocytosis.  It  is  not  easy  to  determine 
the  existence  of  vascular  hypoplasia. 

Treatment.— Lymphatism  is  a  condition  out  of  which  the  child  gradually 
grows.  A  general  tonic  treatment  with  iron  and  arsenic  should  be  given. 
A  large  thymus  causing  compression  should  be  removed.  Treatment  by  the 
X-ray  is  often  successful. 


m.    DISEASES   OF  THE   THYROID   GLAND 

1.     CONGESTION 

At  puberty,  in  girls,  often  at  the  onset  of  menstruation,  the  gland  enlarges ; 
in  certain  women  the  neck  becomes  fuller  at  each  menstruation,  and  it  was 
an  old  idea  that  the  gland  enlarged  at  or  after  defloration.  The  slight  enlarge- 
ment at  puberty  may  persist  for  months  and  cause  uneasiness,  but,  as  a  rule,  it 
disappears  completely.  I  do  not  remember  a  single  instance  in  which  the 


DISEASES    OF    THE    THYROID    GLAND  871 

goitre  has  remained,  though,  of  course,  such  a  possibility  has  to  be  considered. 
From  mechanical  causes,  as  tight  collars,  repeated  crying,  or  prolonged  use  of 
the  voice,  the  gland  may  swell  for  a  short  time. 

2.     THYEOIDITIS 

Etiology. — Inflammation  of  the  gland,  which  is  nearly  always  secondary  to 
some  infection,  may  be  simple  or  purulent.  It  hao  been  met  with  most  fre- 
quently in  typhoid  fever,  small-pox,  measles,  pneumonia,  rheumatic  fever,  and 
mumps.  Epidemics  of  thyroiditis  have  been  reported.  It  is  a  rare  disease 
in  ordinary  hospital  practice.,  and  did  not  occur  in  one  of  our  series  of  1,500 
cases  of  typhoid  fever. 

Symptoms. — The  whole  gland  may  be  involved,  or  only  one  lobe.  There  are 
swelling,  pain  on  pressure,  redness  over  the  affected  part,  and,  when  suppura- 
tion occurs,  softening  or  fluctuation.  Often  the  acute  inflammation  subsides 
spontaneously.  Myxcedema  has  followed  destruction  of  the  entire  gland  by 
acute  suppuration. 

A  remarkable  sclerotic  thyroiditis  has  been  described  by  Riedel  and  is 
sometimes  called  after  his  name.  It  is  important,  as,  in  the  rapidity  of  its 
evolution  and  in  the  production  of  a  diffuse  tumor  involving  the  whole  gland, 
the  clinical  picture  may  resemble  cancer.  The  gland  becomes  firmly  fixed 
to  the  surrounding  parts  and  serious  effects  may  be  produced  by  compression 
of  the  trachea  and  of  the  recurrent  laryngeal  nerves.  The  cut  section  of  the 
gland  is  white  and  smooth,  and  microscopically  consists  of  a  dense  fibrous 
tissue. 

3.     TUMOES    OF  THE   THYEOID 

Of  these  the  most  important  are: 

(a)  Infective  granulomata — tuberculosis,  actinomycosis,  and  syphilis. 
Cases  are  very  rarely  met  with.  Swelling  of  the  gland  has  been  seen  in  the 
recent  syphilitic  infection,  and  gummata  may  occur  in  the  congenital  form. 

(&)  Adenomata,  simple  or  malignant.  The  latter  may  cause  extensive 
metastases,  as  in  the  case  reported  by  Hayward,  in  which  tumors  resembling 
thyroid  tissue  occurred  in  the  lungs  and  various  bones. 

(c)  Cancer  and  sarcoma,  which  are  rare,  have  a  surgical  interest. 

4.     ABERRANT  AND  ACCESSORY  THYROIDS 

In  various  places,  from  the  root  of  the  tongue  to  the  arch  of  the  aorta, 
fragments  of  thyroidal  tissue  have  been  found.  These  aberrant  portions  of 
the  gland  are  very  apt  to  enlarge  and  undergo  cystic  degeneration.  In  the 
mediastinum  they  may  form  large  tumors,  and  in  the  pleura  I  have  seen  an 
accessory  cystic  thyroid  occupy  the  upper  portion,  and  a  case  was  reported 
by  F.  A.  Packard,  in  which  the  cystic  gland  filled  nearly  the  entire  side.  The 
so-called  lingual  thyroid  is  not  uncommon,  varying  in  size  from  a  hemp  seed 
to  a  pea,  usually  free  in  the  deep  muscles  of  the  tongue,  or  attached  to  the 
hyoid  bone.  When  enlarged  the  lingual  goitre  may  form  a  tumor  of  con- 
siderable size.  The  true  thyroid  gland  has  been  absent,  and  removal  of  the 
lingual  jroitre  has  been  followed  by  myxoadema. 


872  DISEASES    OF    THE    DUCTLESS    GLANDS 

5.     GOITRE 
(Struma,  Bronchocele) 

Definition. — A  chronic  enlargement  of  the  thyroid  gland,  of  unknown 
origin,  occurring  sporadically  or  endemically. 

Distribution. — Goitre,  on  the  whole,  is  rare  in  the  United  States;  it  is 
perhaps  most  common  in  the  region  of  the  Great  Lakes.  In  an  investigation 
in  Michigan,  Dock  found  a  large  number  of  cases  and  the  disease  is  not  very 
uncommon  in  Lower  Canada.  In  England  it  is  common  in  certain  regions; 
the  Thames  valley,  the  Dales,  Derbyshire,  Sussex,  and  Hampshire.  It  is  very 
prevalent  about  Oxford  and  the  upper  Thames  valley.  In  Switzerland,  in  the 
mountains  of  Germany  and  Austria,  the  mountainous  districts  of  France, 
and  in  the  Pyrenees  the  disease  is  very  prevalent.  In  regions  of  Central 
Asia,  in  the  Abyssinian  mountains,  and  in  the  Himalayas  there  are  many  foci 
of  the  disease. 

Etiology. — The  disease  is  rarely  congenital  except  in  very  goitrous  dis- 
tricts. Cases  are  most  common  at  or  about  puberty,  and  the  tendency  dimin- 
ishes after  the  twentieth  year.  Women  are  much  more  frequently  attacked 
than  men,  in  a  proportion  of  6  or  8  to  1. 

In  its  endemic  form  the  disease  occurs  at  every  latitude  and  in  every  alti- 
tude, in  valleys  and  in  plains,  and  in  various  climates.  It  seems  to  be  much 
less  prevalent  by  the  seashore. 

The  cause  is  obscure.  The  water  in  goitrous  districts  is  hard,  rich  in  lime 
and  magnesia,  poor  in  iodine,  and  (so  Eedin  affirms  of  the  Swiss  waters)  with 
a  high  degree  of  radio-activity.  Others  speak  of  a  "miasma"  of  the  soil  which 
gets  into  the  drinking  water.  McCarrison  in  Kashmir  found  that  the  specific 
agent  could  be  killed  by  boiling  the  water  and  that  it  did  not  pass  a  Berkefeld 
filter.  He  produced  goitre  in  himself  and  in  others  by  the  daily  consumption 
of  the  residue  of  the  filter,  but  the  residue  when  boiled  was  harmless.  The 
disease  was  transmitted  to  goats  who  drank  water  contaminated  by  goitre  pa- 
tients. There  are  "goitre  springs"  and  "goitre  wells."  These  and  other  facts 
strongly  suggest  a  specific  organism ;  and  this  view  is  supported  by  the  remark- 
able outbreaks  of  acute  goitre  in  schools,  lasting  for  a  few  months  and  disap- 
pearing. In  one  such  outbreak  161  boys  among  350  and  245  girls  among  381 
were  attacked  (Guillaume). 

Morbid  Anatomy. — Usually  the  whole  gland  is  involved,  but  one  lobe  only 
may  be  attacked.  When  the  enlargement  is  uniform,  and  the  appearance  of 
the  gland  natural,  it  is  spoken  of  as  parenchymatous  goitre;  when  the  blood 
vessels  are  very  large,  vascular  goitre.  In  both  forms  there  is  an  increase  in 
the  colloid  material  of  the  follicles.  Degenerations  of  various  kinds  are  com- 
mon, particularly  cystic,  in  which  there  are  many  large  and  small  cavities 
with  colloid  contents.  In  some  of  these  cystic  forms  there  are  papillary  in- 
growths into  the  alveoli.  Sometimes  the  cysts  contain  blood  and  extensive 
hemorrhages  occur  in  the  gland. 

Symptoms. — When  small  a  goitre  is  not  inconvenient,  but  when  large 
pressure  symptoms  may  cause  the  patient  to  seek  relief.  The  windpipe  may 
be  flattened  from  pressure,  usually  of  an  enlarged  isthmus,  or  it  is  narrowed 
by  circular  compression.  The  symptoms  are  more  or  less  marked  stridor  and 


DISEASES    OF   THE    THYEOID    GLAND  873 

cough,  which  may  persist  for  years  without  special  aggravation.  They  may 
be  present  with  very  large  glands,  or  with  the  small  encircling  goitre,  or  with 
the  goitre  which  passes  deeply  beneath  the  sternum.  Pressure  on  the  recur- 
rent nerves  may  cause  attacks  of  dyspncea,  particularly  at  night,  and  the  voice 
may  be  altered.  Pressure  on  the  vagus  is  not  common.  Sometimes  there  is 
difficulty  in  swallowing,  and  the  veins  of  the  neck  may  be  compressed.  The 
heart  is  often  involved,  either  from  pressure  on  the  vagi,  or  there  is  dilatation 
of  the  organ  associated  with  dyspncea.  This  is  sometimes  spoken  of  as  the 
"goitre  heart"  in  centra-distinction  to  the  cardiac  condition  in  Graves'  dis- 
ease. 

Prognosis. — Many  cases  in  the  young  get  well;  too  often  in  goitrous  dis- 
tricts the  tumor  persists.  It  may  disappear  on  leaving  the  district.  Many 
cases  get  well  without  medical  treatment,  but  when  pressure  symptoms  occur 
surgery  gives  relief. 

Treatment. — In  goitrous  districts  the  drinking  water  should  be  boiled. 
Iodine  in  some  form-  is  used  extensively,  and  often  is  curative.  Its  effect 
is  to  stimulate  the  gland  to  healthy  action.  In  young  people  2  to  5  grains 
(0.13  to  0.3  gm.)  of  potassium  or  sodium  iodide  may  be  given  daily.  Iodine 
injections  into  the  gland  have  been  used  but  are  not  advisable.  Iodine  may  be 
applied  externally  as  an  ointment  (5  per  cent.).  The  X-rays  have  been  tried 
with  success.  When  the  gland  is  large,  surgical  measures  must  be  re- 
sorted to. 

6.     HYPOTHYEOIDISM 
(Cretinism  and  Myxcedema) 

Definition. — A  constitutional  affection  due  to  the  loss  of  function  of  the 
thyroid  gland,  characterized  clinically  by  a  myxcedematous  condition  of  the 
subcutaneous  tissues  and  mental  failure,  and  anatomically  by  atrophy  of  the 
thyroid  gland. 

History. — As  early  as  1859  Schiff  had  noted  that  in  the  dog  removal  of 
the  gland  was  followed  by  certain  symptoms.  Gull  described  "A  cretinoid 
change  in  women,"  and  in  the  eighties  the  observations  of  Ord  and  other 
English  physicians  separated  a  well  defined  clinical  entity  called  "myxcedema." 

Kocher  (in  1883)  reported  that  30  of  his  first  100  thyroidectomies  had 
been  followed  by  a  very  characteristic  picture,  to  which  he  gave  the  name 
"caehexia  strumipriva,"  an  observation  which  had  already  been  made  in  the 
previous  year  by  the  Reverdins,  who  also  had  recognized  the  relation  of  this 
change  to  the  disease  known  as  "myxcedema."  The  researches  of  Horsley, 
and  the  elaborate  investigation  of  the  Committee  of  the  Clinical  Society  of 
London,  made  it  clear  that  the  changes  following  complete  removal  of  the 
gland,  the  so-called  cachexia  strumipriva,  myxoedema,  and  the  sporadic  cretin- 
ism, were  one  and  the  same  disease,  due  to  the  loss  of  the  function  of  the 
thyroid  gland.  Schiff  and  Horsley  demonstrated  that  animals  could  be  saved 
by  the  transplantation  of  the  glands.  Lastly  came  the  discovery  of  George 
Murray  and  Howitz  that  feeding  with  the  thyroid  extract  replaced  the  gland 
function,  and  cured  the  disease.  The  activity  of  the  gland  is  in  some  way 
connected  with  the  metabolism  of  iodine.  Baumann  determined  the  presence 
of  this  body  in  the  secretion  of  the  thyroid  as  an  organic  combination  which 
57 


874  DISEASES    OF    THE    DUCTLESS    GLANDS 

he  called  iodothyrin,  not  to  be  confounded  with  the  simple  extract  of  the 
gland,  which  is  usually  called  thyrcoidin. 

The  outcome  of  a  host  of  researches  has  heen  the  recognition  of  the  enor- 
mous importance  of  the  internal  secretion  of  the  gland,  which  is  essential 
for  the  normal  growth  of  the  body  in  childhood,  and  for  the  maintenance  of 
the  proper  metabolism  of  the  epidermic  tissues  and  of  the  brain. 

Clinical  Forms. — There  are  three  groups  of  cases — cretinism,  myxoedema 
proper,  and  operative  myxcedema.  To  Felix  Simon  is  due  the  credit  of  recog- 
nizing that  these  were  one  and  the  same  condition  and  all  due  to  loss  of  func- 
tion of  the  thyroid  gland. 

CRETINISM. — Two  forms  are  recognized — the  sporadic  and  the  endemic. 
In  the  sporadic  form  the  gland  may  be  congenitally  absent,  or  is  atrophied 
after  one  of  the  specific  fevers,  or  the  condition  develops  with  goitre.  The 
disease  is  not  very  uncommon.  I  was  able  to  collect  the  histories  of  58  cases 
in  a  few  years  in  the  United  States  and  Canada.  It  is  more  common  in  females 
than  in  males — 35  in  my  series. 

Morbid  Anatomy. — Absence  of  the  gland,  or  complete  fibrous  atrophy, 
is  the  common  condition.  Goitre  with  any  trace  of  gland  tissue  is  rare.  In 
the  sporadic  form  sometimes  the  hypophysis  and  thymus  have  been  found  en- 
larged. Arrest  of  development,  a  brachycephalic  skull  in  the  endemic,  and  a 
doliocephalic  in  the  sporadic  form,  are  the  chief  skeletal  changes. 

Symptoms. — In  the  congenital  cases  the  condition  is  rarely  recognized 
before  the  infant  is  six  or  seven  months  old.  Then  it  is  noticed  that  the  child 
does  not  grow  so  rapidly  and  is  not  bright  mentally.  The  tongue  looks  large 
and  hangs  out  of  the  mouth.  The  hair  may  be  thin  and  the  skin  very  dry. 
Usually  by  the  end  of  the  first  year  and  during  the  second  year  the  signs  be- 
come very  marked.  The  face  is  large,  looks  bloated,  the  eyelids  are  puffy 
and  swollen ;  the  ala?  nasi  are  thick,  the  nose  looks  depressed  and  flat.  Denti- 
tion is  delayed,  and  the  teeth  which  appear  decay  early.  The  abdomen  is 
swollen,  the  legs  are  thick  and  short,  and  the  hands  and  feet  are  undeveloped 
and  pudgy.  The  face  is  pale  and  sometimes  has  a'  waxy,  sallow  tint.  The 
fontanelles  remain  open ;  there  is  much  muscular  weakness,  and  the  child  can 
not  support  itself.  In  the  supraclavicular  regions  there  are  large  pads  of 
fat.  The  child  does  not  develop  mentally  and  may  lapse  into  a  state  of  im- 
becility. 

In  cases  in  which  the  atrophy  of  the  gland  follows  a.  fever  the  condition 
may  not  come  on  until  the  fourth  or  fifth  year,  or  later.  This  is  really,  as 
Parker  determined,  a  juvenile  myxcedema.  In  a  few  of  the  sporadic  forms 
cretinism  develops  with  an  existing  goitre.  It  may  retard  development,  bodily 
and  mental,  without  ever  progressing  to  complete  imbecility. 

ENDEMIC  CRETINISM. — This  occurs  wherever  goitre  is  very  prevalent,  as  in 
parts  of  Switzerland,  Savoy,  Tyrol,  and  the  Pyrenees.  It  .formerly  prevailed 
in  parts  of  England.  I  know  of  no  centres  in  the  United  States  or  Canada. 
The  clinical  features  of  the  disease  are  the  same  as  in  the  sporadic  form, 
stunted  growth  and  feeble  mind,  plus  goitre.  To  some  poison  in  the  water — 
mineral  or  organic — the  thyroid  changes  have  been  attributed,  but  whatever 
the  toxic  agent  may  be,  it  is  the  interference  with  the  function  of  the  gland 
that  leads  to  the  cretinous  change  in  the  body. 

The  diagnosis  is  very  easy  after  one  has  seen  a  case,  or  good  illustrations. 


DISEASES    OF    THE    THYROID    GLAND  875 

Infants  a  year  or  so  old  sometimes  become  flabby,  lose  their  vivacity,  or  show 
a  protuberant  abdomen,  and  lax  skin  with  slight  cretinoid  appearance.  These 
milder  forms,  as  they  have  been  termed,  are  probably  due  to  transient  func- 
tional disturbance  in  the  gland. 

MYXCEDEMA  OF  ADULTS  (Gull's  Disease). — Women  are  much  more  fre- 
quently affected  than  men — in  a  ratio  of  6  to  1.  The  disease  may  affect  several 
members  of  a  family,  and  it  may  be  transmitted  through  the  mother.  In  some 
instances  there  has  been  first  the  appearance  of  exophthalmic  goitre.  Though 
occurring  most  commonly  in  women,  it  seems  to  have  no  special  relation  to 
the  catamenia  or  to  pregnancy;  the  symptoms  of  myxcedema  may  disappear 
during  pregnancy  or  may  develop  post  partum.  Myxcedema  and  exophthalmic 
goitre  may  occur  in  sisters.  It  is  not  so  common  in  America  as  in  England. 
In  sixteen  years  I  saw  only  10  cases  in  Baltimore,  7  of  which  were  in  the 
hospital.  C.  P.  Howard  has  collected  100  American  cases,  of  which  86  were 
in  women.  The  symptoms  of  this  form,  as  given  by  Ord,  are  marked  increase 
in  the  general  bulk  of  the  body,  a  firm,  inelastic  swelling  of  the  skin,  which 
does  not  pit  on  pressure ;  dryness  and  roughness,  which  tend  with  the  swelling 
to  obliterate  in  the  face  the  lines  of  expression;  imperfect  nutrition  of  the 
hair;  local  tumefaction  of  the  skin  and  subcutaneous  tissues,  particularly  in 
the  supraclavicular  region.  The  physiognomy  is  altered  in  a  remarkable  way : 
the  features  are  coarse  and  broad,  the  lips  thick,  the  nostrils  broad  and  thick, 
and  the  mouth  is  enlarged.  Over  the  cheeks,  sometimes  the  nose,  there  is  a 
reddish  patch.  There  is  a  striking  slowness  of  thought  and  of  movement.  The 
memory  becomes  defective,  the  patients  grow  irritable  and  suspicious,  and 
there  may  be  headache.  In  some  instances  there  are  delusions  and  hallucina- 
tions, leading  to  a  final  condition  of  dementia.  The  gait  is  heavy  and  slow. 
The  temperature  may  be  below  normal.  The  functions  of  the  heart,  lungs,  and 
abdominal  organs  are  normal.  Hemorrhage  sometimes  occurs.  Albuminuria 
is  sometimes  present,  more  rarely  glycosuria.  Death  is  usually  due  to  some 
intercurrent  disease,  most  frequently  tuberculosis  (Greenfield).  The  thyroid 
gland  is  diminished  in  size  and  may  become  completely  atrophied  and  con- 
verted into  a  fibrous  mass.  The  subcutaneous  fat  is  abundant,  and  in  one 
or  two  instances  a  great  increase  in  the  mucin  has  been  found.  The  larynx 
is  also  involved. 

The  course  of  the  disease  is  slow  but  progressive,  and  extends  over  ten  or 
fifteen  years.  A  condition  of  acute  and  temporary  myxcedema  may  develop  in 
connection  with  enlargement  of  the  thyroid  in  young  persons.  Myxcedema 
may  follow  exophthalmic  goitre.  In  other  instances  the  symptoms  of  the  two 
diseases  have  been  combined.  I  have  reported  a  case  in  which  a  young  man 
became  bloated  and  increased  in  weight  enormously  during  three  months,  then 
had  tachycardia  with  tremor  and  active  delirium,  and  died  within  six  months 
of  the  onset  of  the  symptoms. 

OPERATIVE  MYXCEDEMA;  CACHEXIA  STRUMIPRIVA. — Horsley  showed  that 
complete  removal  of  the  thyroid  in  monkeys  was  followed  by  the  production 
of  a  condition  similar  to  that  of  myxcedema  and  sometimes  associated  with 
spasms  or  tetanoid  contractures,  and  followed  by  apathy  and  coma.  An  identi- 
cal condition  sometimes  follows  extirpation  of  the  thyroid  in  man.  The  dis- 
ease follows  only  a  certain  number  of  total  and  a  much  smaller  proportion  of 
partial  removals  of  the  thyroid  gland.  Of  408  cases,  in  69  the  operative 


876  DISEASES    OF    THE    DUCTLESS    GLANDS 

myx oedema  occurred  (Kocher).  If  a  small  fragment  of  the  thyroid  remains, 
or  if  there  are  accessory  glands,  which  in  animals  are  very  common,  the  symp- 
toms do  not  develop.  Operative  myxcedema  is  very  rare  in  America.  A  few 
years  ago  I  was  able  to  find  only  two  cases,  one  of  which,  McGraw's,  referred 
to  in  previous  editions  of  this  work,  has  since  been  cured. 

The  diagnosis  of  myxcedema  is  easy,  as  a  rule.  The  general  aspect  of  the 
patient — the  subcutaneous  swelling  and  the  pallor — suggests  Bright's  disease, 
which  may  be  strengthened  by  the  discovery  of  tube  casts  and  of  albumin  in 
the  urine;  but  the  solid  character  of  the  swelling,  the  exceeding  dryness  of 
the  skin,  the  yellowish  white  color,  the  low  temperature,  the  loss  of  hair,  and 
the  dull,  listless  mental  state  should  suffice  to  differentiate  the  two  conditions. 
In  dubious  cases  not  too  much  stress  should  be  laid  upon  the  supraclavicular 
swellings.  There  may  be  marked  fibro-fatty  enlargements  in  this  situation  in 
healthy  persons,  the  supraclavicular  pseudo-lipomata  of  Verneuil. 

Treatment. — The  patients  suffer  in  cold  and  improve  greatly  in  warm 
weather.  They  should  therefore  be  kept  at  an  even  temperature,  and  should, 
if  possible,  move  to  a  warm  climate  during  the  winter  months.  Repeated  warm 
baths  with  shampooing  are  useful.  Our  art  has  made  no  more  brilliant 
advance  than  in  the  cure  of  these  disorders  due  to  disturbed  function  of  the 
thyroid  gland.  That  we  can  to-day  rescue  children  otherwise  doomed  to  help- 
less idiocy — that  we  can  restore  to  life  the  hopeless  victims  of  myxcedema — 
is  a  triumph  of  experimental  medicine  for  which  we  are  indebted  very  largely 
to  Victor  Horsley  and  to  his  pupil  Murray.  Transplantation  of  the  gland  was 
first  tried;  then  Murray  used  an  extract  subcutaneously.  Hector  Mackenzie  in 
London  and  Howitz  in  Copenhagen  introduced  the  method  of  feeding.  We 
now  know  that  the  gland,  taken  either  fresh,  or  as  the  watery  or  glycerin  ex- 
tract, or  dried  and  powdered,  is  equally  efficacious  in  a  majority  of  all  the  cases 
of  myxcedema  in  infants  or  adults.  Many  preparations  are  now  on  the  mar- 
ket, but  it  makes  little  difference  how  the  gland  is  administered.  The  dried 
powdered  gland  and  the  glycerin  extract  are  most  convenient.  It  is  well  to 
begin  with  the  powdered  gland,  1  grain  (0.065  gm.)  three  times  a  day,  of  the 
Parke  Davis  preparation,  or  one  of  the  Burroughs  and  Welcome  tablets.  The 
dose  may  be  increased  gradually  until  the  patient  takes  10  or  15  grains 
(0.6  gm.  to  1  gm.)  in  the  day.  In  many  cases  there  are  no  unpleasant  symp- 
toms; in  others  there  are  irritation  of  the  skin,  restlessness,  rapid  pulse,  and 
delirium;  in  rare  instances  tonic  spasms,  the  condition  to  which  the  term 
thyroidism  is  applied.  The  results,  as  a  rule,  are  most  astounding — unparal- 
leled by  anything  in  the  whole  range  of  curative  measures.  Within  six  weeks 
a  poor,  feeble-minded,  toad-like  caricature  of  humanity  may  be  restored  to 
mental  and  bodily  health.  Loss  of  weight  is  one  of  the  first  and  most  striking 
effects;  one  of  my  patients  lost  over  30  pounds  within  six  weeks.  The  skin 
becomes  moist,  the  urine  is  increased,  the  perspiration  returns,  the  temperature 
rises,  the  pulse  rate  quickens,  and  the  mental  torpor  lessens.  Ill  effects  are 
rare.  Two  or  three  cases  with  old  heart  lesions  have  died  during  or  after  the 
treatment;  in  one  instance  a  temporary  condition  of  Graves'  disease  was. 
induced. 

The  treatment,  as  Murray  suggests,  must  be  carried  out  in  two  stages — 
one,  early,  in  which  full  doses  are  given  until  the  cure  is  effected;  the  other, 
the  permanent  use  of  small  doses  sufficient  to  preserve  the  normal  metabolism. 


DISEASES    OF    THE    THYEOID    GLAND  877 

In  the  cases  of  cretinism  it  seems  to  be  necessary  to  keep  up  the  treatment 
indefinitely.  I  have  seen  several  instances  of  remarkable  relapse  follow  the 
cessation  of  the  use  of  the  extract. 

7.     HYPERTHYROIDISM;  EXOPHTHALMIC  GOITRE 
(Graves',  Basedow's,  or  Parry's  Disease) 

Definition.— A  disease  characterized  by  goitre,  exophthalmos,  tachycardia, 
and  tremor,  associated  with  a  perverted  or  hyperactive  state  of  the  thyroid 
gland. 

Historical  Note.— In  the  posthumous  writings  of  Caleb  Hillier  Parry 
(1825)  is  a  description  of  8  cases  of  Enlargement  of  the  Thyroid  Gland  in 
Connection  with  Enlargement  or  Palpitation  of  the  Heart.  In  the  first  case, 
seen  in  1786,  he  also  described  the  exophthalmos :  "The  eyes  were  protruded 
from  their  sockets,  and  the  countenance  exhibited  an  appearance  of  agitation 
and  distress,  especially  in  any  muscular  movement."  The  Italians  claim  that 
Flajani  described  the  disease  in  1800.  I  have  not  been  able  to  see  his  original 
account,  but  Moebius  states  that  it  is  meagre  and  inaccurate,  and  bears  no 
comparison  with  that  of  Parry.  If  the  name  of  any  physician  is  to  be  asso- 
ciated with  the  disease,  undoubtedly  it  should  be  that  of  the  distinguished  old 
Bath  physician.  Graves  described  the  disease  in  1835  and  Basedow  in  1840. 

Etiology.—  Age — In  Sattler's  collection  of  3,477  cases  only  184  were  under 
the  age  of  sixteen. 

Sex — In  England  and  America  the  proportion  of  females  is  greatly  in 
excess,  as  much  probably  as  20  to  1,  but  in  Sattler's  collected  cases  from  the 
literature  the  ratio  was  5.4  to  1,  which  would  indicate  marked  differences  in 
different  countries. 

A  strong  family  predisposition  may  exist  and  five  or  six  members  may  be 
affected.  Fright  is  a  rare  cause.  Various  depressive  influences,  such  as  worry, 
nervous  strain,  disappointment  in  love,  illnesses,  and  mental  shocks,  as  well 
as  dread  of  the  disease  itself,  may  have  an  important  influence. 

Pathology. —The  disease  is  regarded  by  some  as  a  pure  neurosis,  in  favor  of 
which  are  urged  the  onset  after  a  profound  emotion,  the  absence  of  lesions,  and 
the  cure  which  has  followed  in  a  few  cases  after  operations  upon  the  nose. 
Of  late  the  views  of  Moebius  and  Greenfield  have  prevailed,  that  exophthalmic 
goitre  is  primarily  a  disease  of  the  thyroid  gland  (hyperthyroidism) ,  in  antith- 
esis to  myxffidema  (athyroidism) .  The  clinical  contrast  between  these  two 
diseases  is  most  suggestive — the  increased  excitability  of  the  nervous  system, 
the  flushed,  moist  skin,  the  vascular  erythism  in  the  one;  the  dull  apathy, 
the  low  temperature,  slow  pulse,  and  dry  skin  of  the  other.  The  changes  in 
the  gland  in  exophthalmic  goitre  are,  as  shown  by  Greenfield,  those  of  an  organ 
in  active  evolution — viz.,  increased  proliferation,  with  the  production  of  newly 
formed  tubular  spaces  and  absorption  of  the  colloid  material  which  is  replaced 
by  a  more  mucinous  fluid.  The  thyroid  extract  given  in  excess  produces  symp- 
toms not  unlike  those  of  Parry's  disease — tachycardia,  tremor,  headache,  sweat- 
ing, and  prostration.  Beclere  has  reported  a  case  in  which  exophthalmos 
developed  after  an  overdose.  Use  of  the  thyroid  extract  usually  aggravates 
the  symptoms  of  exophthalmic  goitre.  The  most  successful  line  of  treatment 


878  DISEASES    OF    THE    DUCTLESS    GLANDS 

has  been  that  directed  to  diminish  the  bulk  of  the  goitre.  These  are  some  of 
the  considerations  which  favor  the  view  that  the  symptoms  are  due  to  disturbed 
function  of  the  thyroid  gland,  probably  to  hypersecretion  of  materials  which 
induce  a  sort  of  chronic  intoxication.  Myxoedema  may  develop  in  the  late 
stages,  and  there  are  transient  oedema  and  in  a  few  cases  scleroderma,  which 
indicate  that  the  nutrition  of  the  skin  is  involved. 

Anatomical  Changes. — In  rare  instances  the  thyroid  gland  has  been  stated 
to  be  normal.  In  the  majority  of  cases  there  is  active  hyperplasia  of  the  gland, 
with  enlarged  and  newly  formed  follicles,  and  an  increase  in  the  lymphoid 
tissue  of  the  gland  stroma.  Involuntary  and  regressive  changes  are  common; 
the  hyperplasia  may  cease  and  the  gland  returns  to  the  colloid  state.  Finally, 
in  certain  cases,  atrophy  of  the  cell  elements  takes  place. 

The  iodine  content  of  the  gland  bears  a  direct  relationship  to  the  amount 
of  colloid ;  the  gland  in  hyperplasia  has  the  lowest  percentage,  the  pure  colloid 
glands  the  highest. 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  In  the  acute 
form  the  disease  may  arise  with  great  rapidity.  In  a  patient  of  J.  H.  Lloyd's, 
of  Philadelphia,  a  woman,  aged  thirty-nine,  who  had  been  considered  perfectly 
healthy,  but  whose  friends  had  noticed  that  for  some  time  her  eyes  looked 
rather  large,  was  suddenly  seized  with  intense  vomiting  and  diarrhoea,  rapid 
action  of  the  heart,  and  great  throbbing  of  the  arteries.  The  eyes  were  promi- 
nent and  staring  and  the  thyroid  gland  was  found  much  enlarged  and  soft. 
The  gastro-intestinal  symptoms  continued,  the  pulse  became  more  rapid,  the 
vomiting  was  incessant,  and  the  patient  died  on  the  third  day  of  the  illness. 
Only  the  abdominal  and  thoracic  organs  could  be  examined  and  no  changes 
were  found.  I  saw  two  rapidly  fatal  cases  at  the  Philadelphia  Hospital,  one  of 
which,  under  F.  P.  Henry's  care,  had  marked  cerebral  symptoms.  The  acute 
cases  are  not  always  associated  with  delirium. 

More  frequently  the  onset  is  gradual  and  the  disease  is  chronic.  There 
are  four  characteristic  symptoms  of  the  disease — tachycardia,  exophthalmos., 
enlargement  of  the  thyroid,  and  tremor. 

TACHYCARDIA. — Rapid  heart  action  is  only  one  of  a  series  of  remarkable 
vascular  phenomena  in  the  disease.  The  pulse  rate  at  first  may  be  not  more 
than  95  or  100,  but  when  the  disease  is  established  it  may  be  from  140  to 
160,  or  even  higher.  Irregularity  is  not  common,  except  toward  the  close.  In 
a  well  developed  case  the  visible  area  of  cardiac  pulsation  is  much  increased, 
the  action  is  heaving  and  forcible,  and  the  shock  of  the  heart  sounds  is  well 
felt.  The  large  arteries  at  the  root  of  the  neck  throb  forcibly.  There  is 
visible  pulsation  in  the  peripheral  arteries.  The  capillary  pulse  is  readily 
seen,  and  there  are  few  diseases  in  which  one  may  see  at  times  with  greater 
distinctness  the  venous  pulse  in  the  veins  of  the  hand.  The  throbbing  pulsa- 
tion of  the  arteries  may  be  felt  even  in  the  finger  tips.  Vascular  erythema  is 
common — the  face  and  neck  are  flushed  and  there  may  be  a  widespread  ery- 
thema of  the  body  and  limbs.  On  auscultation  murmurs  are  usually  heard 
over  the  heart,  a  loud  apex  systolic  and  loud  bruits  at  the  base  and  over  the 
manubrium.  The  sounds  of  the  heart  may  be  very  intense.  In  rare  instances 
they  may  be  heard  at  some  distance  from  the  patient;  according  to  Graves, 
as  far  as  four  feet.  Attacks  of  acute  dilatation  of  the  heart  may  occur  with 
dyspnoea,  cough,  and  a  frothy  bloody  expectoration. 


DISEASES    OF   THE    THYROID    GLAND  879 

EXOPHTHALMOS.— A  characteristic  facial  aspect  is  given  to  Graves'  disease 
by  the  staring  expression,  caused  in  part  by  protrusion  of  the  eyeballs,  but 
mere  particularly  by  retraction  of  the  lids  exposing  the  sclerge  above  and  below 
the  cornea?.  The  exophthalmos,  which  may  be  unilateral,  usually  follows  the 
vascular  disturbance.  The  protrusion  may  become  very  great  and  the  eye  may 
even  be  dislocated  from  the  socket,  or  both  eyes  may  be  destroyed  by  panoph- 
thalmitis,  a  condition  present  in  one  of  Basedow's  cases.  The  vision  is  normal. 
Graefe  noted  that  when  the  eyeball  is  moved  downward  the  upper  lid  does  not 
follow  it  as  in  health.  This  is  known  as  Graefe's  sign.  The  palpebral  aper- 
ture is  wider  than  in  health,  owing  to  spasm  or  retraction  of  the  upper  lid 
(Stellwag's  sign).  The  patient  winks  less  frequently  than  in  health.  There 
is  marked  tremor  of  the  lids  and  they  contract  spasmodically  in  advance  of 
the  elevating  eyeball.  Moebius  has  called  attention  to  the  lack  of  convergence 
of  the  two  eyes.  Changes  in  the  pupils  and  in  the  optic  nerves  are  rare.  Pul- 
sation of  the  retinal  arteries  is  common. 

ENLARGEMENT  OF  THE  THYROID  is  the  rule.  It  may  be  general  or  in  only 
one  lobe,  and  is  rarely  so  large  as  in  ordinary  goitre.  It  may  be  absent.  The 
swelling  is  firm,  but  elastic.  There  are  rarely  pressure  signs.  The  vessels 
are  usually  much  dilated,  and  the  whole  gland  may  be  seen  to  pulsate.  A 
thrill  may  be  felt  on  palpation  and  on  auscultation  a  loud  systolic  murmur,  or 
more  commonly  a  bruit  de  diable.  A  double  murmur  is  common  and  is  path- 
ognomonic  (Guttmann). 

TREMOR  is  the  fourth  cardinal  symptom,  and  was  really  first  described  by 
Basedow.  It  is  involuntary,  fine,  about  eight  to  the  second.  It  is  of  great 
importance  in  the  diagnosis  of  the  early  cases. 

Other  symptoms  are  anaemia,  emaciation,  and  slight  fever.  Attacks  of 
vomiting  and  diarrhoea  may  occur.  The'  latter  may  be  very  severe  and  distress- 
ing, recurring  at  intervals.  The  greatest  complaint  is  of  the  forcible  throbbing 
in  the  arteries,  often  accompanied  .with  unpleasant  flushes  of  heat  and  pro- 
fuse perspirations.  An  erythematous  flushing  is  common.  Pruritus  may  be  a 
severe  and  persistent  symptom.  Multiple  telangiectases  have  been  described. 
Solid,  infiltrated  oedema  is  not  uncommon.  It  may  be  transitory.  A  remark- 
able myxcedematous  state  may  supervene.  Pigmentary  changes  are  very  com- 
mon. They  may  be  patchy  or  generalized.  The  coexistence  of  scleroderma 
and  Graves'  disease  has  been  frequently  noticed.  Irritability  of  temper, 
change  in  disposition,  and  great  mental  depression  have  been  described.  An 
important  complication  is  acute  mania,  in  which  the  patient  may  die  in  a 
few  days.  Weakness  of  the  muscles  is  not  uncommon,  particularly  a 
feeling  of  "giving  way"  of  the  legs.  If  the  patient  holds  the  head  down 
and  is  asked  to  look  up  without  raising  the  head,  the  forehead  remains 
smooth  and  is  not  wrinkled,  as  in  a  normal  individual  (Joffroy).  A 
feature  of  interest  noted  by  Charcot  is  the  great  diminution  in  the  electrical 
resistance,  which  may  be  due  to  the  saturation  of  the  skin  with  moisture 
owing  to  the  vaso-motor  dilatation  (Hirt).  Bryson  has  noted  the  fact  that  the 
chest  expansion  may  be  greatly  diminished.  The  emaciation  may  be  extreme. 
Glycosuria  and  albuminuria  are  not  infrequent  complications.  True  diabetes 
may  occur. 

The  course  of  the  disease  is  usually  chronic,  lasting  several  years.  After 
persisting  for  six  months  or  a  year  the  symptoms  may  disappear.  There  are 


880  DISEASES    OF    THE    DUCTLESS    GLAXDS 

remarkable  instances  in  which  the  symptoms  have  come  on  with  great  inten- 
sity, following  fright,  and  have  disappeared  again  in  a  few  days. 

Prognosis. — Statistics  are  misleading  as  only  the  severe  cases  come  under 
hospital  treatment.  Sattler  estimates  the  mortality  at  11  per  cent.  In  Hale 
White's  series  it  was  84  in  214  cases.  In  the  hands  of  Kocher  and  the  Mayos 
the  mortality  from  operation  is  below  4  per  cent,  and  some  70  per  cent,  of 
cases  are  claimed  to  have  been  cured. 

Diagnosis. — Few  diseases  are  so  easily  recognized.  The  difficulty  is  with 
the  partially  developed  forms,  formes  frustes,  which  are  not  uncommon.  The 
nervous  state,  the  tremor,  and  tachycardia  may  be  the  only  features,  or  there 
may  be  slight  swelling  of  the  thyroid  with  tremor  alone.  The  greatest  diffi- 
culty arises  in  the  cases  of  hysterical  tremor  with  rapid  heart  action.  Doubt- 
ful cases  may  be  tested  by  the  careful  administration  of  iodine  internally,  as 
patients  with  hyperthyroidism  show  a  marked  intolerance,  even  to  small  doses. 
A  differential  count  of  the  leucocytes  shows  an  increase  in  the  mononuclears. 

Treatment. —  (a)  The  disease  is  serious  enough  to  warrant  strong  measures 
systematically  carried  out;  much  valuable  time  is  lost  in  trying  various  rem- 
edies. The  patient  should  be  in  bed,  at  absolute  rest,  and  see  very  few  per- 
sons. To  quiet  the  heart's  action  the  icebag  may  be  continuously  applied 
through  the  day,  and  veratrum  viride,  aconite,  or  strophanthus  given  in  full 
doses.  Ergot,  belladonna,  phosphate  of  soda,  small  doses  of  opium,  and  many 
other  remedies  are  recommended,  and  in  some  instances  I  have  seen  benefit 
from  the  belladonna  and  the  phosphate  of  soda.  Electricity  may  be  helpful. 

(6)  Serum  Therapy. — Two  methods  are  employed:  feeding  with  the  milk 
of  dethyroidized  goats,  introduced  by  Lanz,  which  is  obtainable  as  a  substance 
called  rodagen.  Good  results  have  been  reported  by  Mackenzie  and  others. 
Beebe,  on  the  other  hand,  uses  the  serum  of  animals  into  which  human  thyroid 
extract  has  been  injected.  Excellent  results  have  been  obtained,  but  the 
method  has  the  danger  associated  with  the  use  of  foreign  sera. 

(c)  Surgical  Treatment. — Removal  of  part  of  the  thyroid  gland  offers  the 
best  hope  of  permanent  cure.  It  is  remarkable  with  what  rapidity  all  the 
symptoms  may  disappear  after  partial  thyroidectomy.  A  second  operation 
may  be  necessary  in  severe  cases.  The  results  obtained  by  the  brothers  Mayo 
and  by  Kocher  give  a  remarkable  percentage  of  recoveries.  The  operation 
under  cocaine  may  be  done  with  safety  when  the  condition  of  the  heart  and 
the  extreme  tachycardia  do  not  contraindicate  it.  Tying  of  the  arteries  and 
exothyropexia  are  also  recommended.  Excision  of  the  superior  cervical  ganglia 
of  the  sympathetic  has  one  beneficial  result,  viz.,  the  production  of  slight 
ptosis,  which  obviates  the  staring  character  of  the  exophthalmos. 

Marked  benefit  has  followed  the  use  of  the  X-rays  in  a  few  cases. 

IV.    DISEASES    OF   THE    PARATHYROID    GLANDS 

The  parathyroid  bodies  occur,  as  a  rule,  in  two  pairs  on  either  side  of  the 
lateral  lobes  of  the  thyroid  gland;  small  ovoid  structures  from  6  to  8  mm. 
in  length.  Some  observers  regard  them  as  simply  supplementary  to  the  thy- 
roid, without  a  special  function ;  others  believe  that  they  have  an  important  in- 
ternal secretion  supplementing  that  of  the  thyroid  gland  and  controlling  cal- 
cium metabolism. 


DISEASES    OF    THE    PARATHYROID    GLANDS  881 

The  studies  of  Gley,  Halsted,  and  others  leave  no  question  as  to  the 
importance  of  these  glands.  Following  their  removal  in  animals  there  are 
twitching,  spasms  of  the  voluntary  muscles,  gradual  paralysis  with  dyspnoea, 
and  death  from  exhaustion.  These  sometimes  disappear  when  a  saline  extract 
of  the  parathyroid  is  injected  into  a  vein,  or  if  the  parathyroid  glands  are  fed 
or  transplanted.  The  association  of  tetany  with  the  disturbance  of  the  func- 
tion of  the  thyroid  seems  to  be  definitely  established.  MacCallum  has  shown 
the  importance  of  the  function  of  these  glands  in  controlling  calcium  metabol- 
ism, and  it  is  possible  that  in  impoverishment  of  the  tissues  in  this  ingredient 
is  to  be  sought  the  cause  of  the  great  excitability  of  the  nervous  system  and  of 
tetany. 

These  studies  have  thrown  great  light  upon  various  spasmodic  disorders 
of  children,  and  some  have  gone  so  far  as  to  embrace  such  conditions  as 
laryngismus,  infantile  convulsions,  and  tetany  under  the  term  "spasmophilia" 
(Heubner). 

These  glands  have  also  hormonic  relations,  as  yet  not  thoroughly  under- 
stood, with  the  other  ductless  glands,  and  have  some  influence  on  carbohydrate 
metabolism. 

The  definite  association  of  the  glands  with  tetany  is  sufficient  warrant  for 
treating  this  disease  here. 

TETANY 

Definition. — An  affection  characterized  by  bilateral,  chronic,  or  intermit- 
tent spasms  of  the  extremities,  with  gradually  increasing  irritability  of  the 
nerves. 

Etiology.— The  following  groups  are  made  by  Frankl-Hochwart : 
(a)  TETANY  OF  ADULTS. — (1)  Epidemic  tetany,  also  known  as  rheumatic 
tetany,  idiopathic  workman's  tetany,  or  shoemaker's  cramp.  In  certain  parts 
of  the  Continent  of  Europe  the  disease  has  prevailed  widely,  particularly  in 
the  winter  season.  Von  Jacksch,  who  has  described  an  epidemic  form  occur- 
ring in  young  men  of  the  working  classes,  sometimes  with  slight  fever,  regards 
the  disease  as  infectious.  This  form  is  acute,  lasting  only  two  or  three  weeks, 
and  rarely  proving  fatal. 

(2)  Tetany  of  gastric  and  intestinal  disorders,  as  dyspepsia,  gastrectasis, 
diarrhoea,  and  helminthiasis.    The  form  associated  with  dilatation  of  the  stom- 
ach is  rare,  not  more  than  30  cases  having  been  reported. 

(3)  Tetany  of  the  acute  infectious  diseases   (typhoid,  cholera,  influenza, 
measles,  scarlatina,  etc.).     In  some  typhoid  epidemics  many  cases  have  oc- 
curred. 

(4)  Tetany  following  poisoning  from  chloroform,  morphia,  ergot,  lead, 
alcohol,  and  uraemia.    Isolated  examples  of  each  have  been  reported. 

(5)  Tetany  may  also  develop  during  pregnancy  or  recur  in  successive  preg- 
nancies.   From  its  occurrence  in  nursing  women,  Trousseau  called  it  "nurse's 
contracture." 

(6)  Tetany  following  removal  of  the  thyroid  gland  is  probably  due  to  a 
removal  of  the  parathyroid  bodies  at  the  same  time. 

(7)  Tetany  may  complicate  other  nervous  disorders,  as  Basedow's  disease, 
cerebral  tumor,  cysts  of  the  cerebellum,  and  syringomyelia. 


882  DISiJJABEa    OF    THE    DUCTLESS    ULAJNUb 


(&)  TETANY  IN  CHILDREN.  —  Tetany  bears  a  definite  relation  to  gastro- 
intestinal disorders,  acute  infections,  and  rickets  in  childhood. 

Mild  cases  of  tetany  are  not  uncommon  in  children,  particularly  in  con- 
nection with  rickets  and  gastro-intestinal  disorders.  The  other  forms  are  not 
common,  either  in  the  United  States  or  in  England.  Campbell  Howard  re- 
ported from,  my  clinic  8  cases  of  tetany,  4  accompanying  dilatation  of  the 
stomach,  2  with  hyperacidity  without  dilatation,  1  with  chronic  diarrhoea, 
and  1  occurring  in  connection  with  repeated  pregnancies  and  lactation. 

Morbid  Anatomy.  —  It  is  now  well  established  that  the  tetany  following 
extirpation  of  the  thyroid  gland  is  due  to  coincident  removal  of  the  parathy- 
roids; and  the  observations  of  MacCallum  suggest  that,  occurring  spontan- 
eously, it  is  associated  with  insufficiency  of  the  parathyroids,  which  appear  to 
control  calcium  metabolism.  Absence  or  perversion  of  the  parathyroid  secre- 
tion leads  to  impoverishment  of  the  tissues  in  calcium,  and  to  hyperexcit- 
ability  of  the  nerves. 

Symptoms.  —  In  cases  associated  with  general  debility  or  in  children  with 
rickets  the  spasm  is  limited  to  the  hands  and  feet.  The  fingers  are  bent  at  the 
metacarpo-phalangeal  joint,  extended  at  the  terminal  joints,  pressed  close  to- 
gether, and  the  thumb  is  contracted  in  the  palm  of  the  hand.  The  wrist  is 
flexed,  the  elbows  are  bent,  and  the  arms  are  folded  over  the  chest.  In  the 
lower  limbs  the  feet  are  extended  and  the  toes  adducted.  The  muscles  of  the 
face  and  neck  are  less  commonly  involved,  but  in  severe  cases  there  may  be 
trismus,  and  the  angles  of  the  mouth  are  drawn  out.  The  skin  of  the  hands 
and  feet  is  sometimes  tense  and  cedematous.  The  spasms  are  usually  parox- 
ysmal and  last  for  a  variable  time.  In  children  the  attack  may  pass  off  in  a 
few  hours.  In  some  of  the  more  severe  chronic  cases  in  adults  the  stiffness  and 
contracture  may  continue  or  even  increase  for  many  days,  and  the  attack  may 
last  as  long  as  two  weeks.  In  the  acute  cases  the  temperature  may  be  elevated 
and  the  pulse  quickened.  In  the  severe  paroxysms  there  may  be  involvement 
of  the  muscles  of  the  back  and  of  the  thorax,  inducing  dyspnoea  and  cyanosis. 
Certain  additional  features,  valuable  in  diagnosis,  are  present. 

Trousseau's  symptom  :  "So  long  as  the  attack  is  not  over,  the  paroxysms 
may  be  reproduced  at  will.  This  is  effected  by  simply  compressing  the  affected 
parts,  either  in  the  direction  of  their  principal  nerve  trunks  or  over  their 
blood  vessels,  so  as  to  impede  the  venous  or  arterial  circulation." 

Chvostek's  symptom  is  shown  in  the  remarkable  increase  in  the  mechanical 
excitability  of  the  motor  nerves.  A  slight  tap,  for  example,  in  the  course  of 
the  facial  nerve  will  throw  the  muscles  to  which  it  is  distributed  into  active 
contraction.  Erb  has  shown  that  the  electrical  irritability  of  the  motor  nerves, 
especially  to  the  galvanic  current,  is  also  greatly  increased,  and  Hofmann 
has  demonstrated  the  heightened  excitability  of  the  sensory  nerves,  the 
slightest  pressure  on  which  may  cause  paraesthesia  in  the  region  of  distribu- 
tion. 

Diagnosis.  —  The  disease  is  readily  recognized.  It  is  a  mistake  to  call 
instances  of  carpo-pedal  spasm  of  children  true  tetany.  It  is  common  to  find 
in  rickety  children  or  in  cases  of  severe  gastro-intestinal  catarrh  a  transient 
spasm  of  the  fingers  or  even  of  the  arms.  By  many  authors  these  are  consid- 
ered cases  of  mild  tetany,  and  there  are  all  grades  in  rickety  children  between 
the  simple  carpo-pedal  spasm  and  the  condition  in  which  the  four  extremities 


DISEASES    OF   THE    SPLEEN  883 

are  involved;  but  it  is  well,  I  think,  to  limit  the  term  tetany  to  the  more  severe 
affection. 

With  true  tetanus  the  disease  is  scarcely  ever  confounded,  as  the  commence- 
ment of  the  spasm  in  the  extremities,  the  attitude  of  the  hands,  and  the  etio- 
logical  factors  are  very  different.  Hysterical  contractures  are  usually  uni- 
lateral. 

Treatment.— In  the  case  of  children  the  condition  with  which  the  tetany 
is  associated  should  be  treated.  Baths  and  cold  sponging  are  recommended 
and  often  relieve  the  spasm  as  promptly  as  in  child-crowing.  Bromide  of 
potassium  may  be  tried.  In  severe  cases  chloroform  inhalations  may  be  given. 
Massage,  electricity,  and  the  spinal  icebag  have  also  been  used  with  success. 
Cases,  however,  may  resist  all  treatment,  and  the  spasms  recur  for  many  years. 
The  thyroid  extract  should  be  tried.  Gottstein  reports  relief  in  a  case  of  long 
standing,  and  Bramwell  reports  one  case  of  operative  tetany  and  one  of  the 
idiopathic  form  successfully  treated  in  this  way. 

In  gastric  tetany,  especially  when  due  to  dilatation  of  the  stomach,  the 
mortality  is  high,  and  recovery  without  operative  interference  is  rare:  of  27 
cases  collected  by  Eiegel,  16  terminated  fatally.  Cunningham  collected  8  cas.es 
treated  surgically,  with  a  mortality  of  37.5  per  cent.,  as  compared  with  70  per 
cent,  treated  by  medical  means.  Eegular,  systematic  lavage  with  large  quan- 
tities of  saline  or  mildly  antiseptic  solutions  is  sometimes  beneficial. 

The  administration  of  calcium  is  frequently  effective.  It  may  be  given 
as  calcium  lactate  in  doses  of  15  grains  (1  gm.)  every  three  or  four  hours. 
In  severe  cases  much  larger  amounts  may  be  given. 


V.    DISEASES    OF    THE    SPLEEN 

1.     GENERAL    EEMARKS. 

Though  a  ductless  gland,  the  spleen  is  not  known  to  have  an  internal  secre- 
tion, and  its  functions  are  as  yet  ill  understood.  It  is  not  an  organ  essential 
to  life.  In  the  fetus  it  takes  part  in  the  formation  of  the  red  blood  corpuscles, 
and  as  it  contains  haematoblasts,  it  is  possible  that  in  the  adult  this  function 
may  be  exercised  to  some  extent,  particularly  in  cases  of  severe  anemia. 

Haemolysis  is  generally  believed  to  be'  its  special  function,  a  view — not 
held  by  all  physiologists — based  upon  the  presence  of  a  large  percentage  of 
organic  compounds  of  iron,  the  deposit  in  the  organ  of  blood  pigments  in  vari- 
ous diseases,  the  presence  of  many  macrophages  containing  red  blood  cor- 
puscles, and  upon  the  evidence,  after  removal  of  the  spleen,  of  compensatory 
haemolysis  in  many  newly  formed  haemo-lymph  glands  (Warthin). 

Removal  of  the  spleen,  an  operation  practised  by  the  ancients  in  the  belief 
that  it  improved  the  wind  of  runners,  is  not,  as  a  rule,  followed  by  serious 
effects.  There  may  be  slight  eosinophilia  and  temporary  anaemia,  and  later 
there  is  usually  slight  leucocytosis,  with  relative  increase  of  the  lymphocytes. 

In  infections  the  organ  enlarges  and  micro-organisms  are  present  in  large 
numbers.  It  has  been  supposed  to  play  some  part  in  the  processes  of  immunity 
and  phagocytosis  goes  on  actively  in  the  organ.  In  experimental  anaemia 
caused  by  various  haamolytic  agents  the  spleen  enlarges,  and  in  these  condi- 
tions Bunting  and  Norris  found  evidence  of  vicarious  blood  formation.  Chronic 


884  DISEASES    OF    THE    DUCTLESS    GLANDS 

enlargement  of  the  spleen  may  be  present  with  very  little  disturbance  of 
health.  Attacks  of  anemia  sooner  or  later  occur,  and  consecutive  fibrosis  may 
occur  in  the  liver  with  jaundice  and  ascites  (Banti's  disease). 

2.     MOVABLE  SPLEEN 

Movable  or  wandering  spleen  is  seen  most  frequently  in  women  the  sub- 
jects of  enteroptosis.  It  may  be  present  without  signs  of  displacement  of 
other  organs.  It  may  be  found  accidentally  in  individuals  who  present  no 
symptoms  whatever.  In  other  cases  there  are  dragging,  uneasy  feelings  in  the 
back  and  side.  All  grades  are  met  with,  from  a  spleen  that  can  be  felt  com- 
pletely below  the  margin  of  the  ribs  to  a  condition  in  which  the  tumor-mass 
impinges  upon  the  pelvis;  indeed,  the  organ  has  been  found  in  an  inguinal 
hernia !  In  the  large  majority  of  all  cases  the  spleen  is  enlarged.  Sometimes 
it  appears  that  the  enlargement  has  caused  relaxation  of  the  ligaments;  in 
other  instances  the  relaxation  seems  congenital,  as  movable  spleens  have  been 
found  in  different  members  of  the  same  family.  Possibly  traumatism  may 
account  for  some  of  the  cases.  Apart  from  the  dragging,  uneasy  sensations. 
and  the  worry  in  nervous  patients,  wandering  spleen  causes  very  few  serious 
symptoms.  Torsion  of  the  pedicle  may  produce  a  very  alarming  and  serious 
condition,  leading  to  great  swelling  of  the  organ,  high  fever,  or  even  to 
necrosis.  A  young  woman  was  admitted  to  my  colleague  Kelly's  ward  with 
a  tumor  supposed  to  be  ovarian,  but  which  proved  to  be  a  wandering,  moder- 
ately enlarged  spleen.  She  was  transferred  to  the  medical  ward,  where  she 
had  suddenly  very  great  pain  in  the  abdomen,  a  large  swelling  in  the  left  flank, 
and  much  tenderness.  Halsted  operated  and  found  an  enormously  enlarged 
spleen  in  a  condition  of  necrosis,  adherent  to  the  adjacent  parts  and  to  the 
abdominal  wall.  He  laid  it  open  freely,  and  large  necrotic  masses  of  spleen 
tissue  discharged  for  some  time.  She  made  a  good  recovery. 

The  diagnosis  of  a  wandering  spleen  is  usually  easy  unless  the  organ  be- 
comes fixed  and  is  deformed  by  adhesions  and  perisplenitis.  The  shape  of  the 
organ  and  the  sharp  margin  with  the  notches  are  the  points  to  be  specially 
noted. 

The  treatment  of  the  condition  is  important.  Occasionally  the  organ  may 
be  kept  in  position  by  a  properly  adapted  belt  and  a  pad  under  the  left  costal 
margin.  Removal  of  the  displaced  organ  has  been  advised  and  carried  out  in 
many  cases,  and  nowadays  it  is  not  a  very  serious  operation.  It  is,  however, 
as  a  rule  unnecessary.  In  two  cases  of  enlarged  spleen  under  my  care,  with 
great  mobility,  causing  much  discomfort  and  uneasiness,  Halsted  completely 
relieved  the  condition  by  replacing  the  spleen,  packing  it  in  position  with 
gauze,  and  allowing  firm  adhesions  to  take  place.  Both  these  patients  were 
seen  more  than  eighteen  months  after  the  operation  and  the  organ  had 
remained  in  position. 

3.     EUPTUEE  OF  THE  SPLEEN 

This  is  of  interest  in  connection  with  the  spontaneous  rupture  in  cases  of 
acute  enlargement  during  typhoid  fever  or  malaria,  which  is  very  rare.  Rup- 
ture of  a  malarial  spleen  may  follow  a  blow,  or  a  fall,  or  an  exploratory  punc- 
ture. In  India  and  in  Mauritius  rupture  of  the  spleen  is  stated  to  be  very 


DISEASES    OF    THE    SPLEEN"  885 

common.  Fatal  haemorrhage  may  follow  puncture  of  a  swollen  spleen  with  a 
hypodermic  needle.  Occasionally  the  rupture  results  from  the  breaking  of  an 
infarct  or  of  an  abscess.  The  symptoms  are  those  of  haemorrhage  into  the, 
peritoneum,  and  the  condition  demands  immediate  laparotomy. 

4.     INFAECT,    ABSCESS    AND    CYSTS    OF    THE    SPLEEN 

Emboli  in  the  splenic  arteries  causing  infarcts  may  be  either  infective  or 
simple.  They  are  seen  most  frequently  in  ulcerative  endocarditis  and  in  septic 
conditions.  Infarcts  may  also  follow  the  formation  of  thrombi  in  the  branches 
of  the  splenic  artery  in  cases  of  fever.  They  are  not  very  infrequent  in 
typhoid.  In  a  few  instances  the  infarcts  have  followed  thrombosis  in  the 
splenic  veins.  They  are  chiefly  of  pathological  interest.  The  infarct  of  the 
spleen  may  be  suspected  in  cases  of  septicaemia  or  pyaemia  when  there  are  pain 
in  the  splenic  region,  tenderness  on  pressure,  and  slight  swelling  of  the  organ ; 
on  several  occasions  I  have  heard  a  well-marked  peritoneal  friction  rub.  Occa- 
sionally in  the  infective  infarcts  large  abscesses  are  formed,  and  in  rare 
instances  the  whole  organ  may  be  converted  into  a  sac  of  pus. 

Tumors  of  the  spleen,  hydatid  and  other  cysts  of  the  organ,  and  gummata 
are  rare  conditions  of  anatomical  interest.  In  Hodgkin's  disease  the  organ 
may  be  enlarged  and  smooth,  or  irregular  from  the  presence  of  nodular  tumors. 

Cysts  are  rare;  I  have  seen  but  two,  one  an  echinococcus,  and  the  other  a 
double  cyst  of  the  hilus.  The  latter  apparently  are  very  common,  and  prob- 
ably arise  from  a  haematoma  subcapsular  or  in  the  hilus.  They  have  been  suc- 
cessfully removed.  Very  small  cysts  are  not  infrequent  in  connection  with 
polycystic  disease  of  the  liver  and  the  kidneys.  A  dermoid  cyst  has  been  de- 
scribed. The  diagnosis  of  cysts  is  not  often  made ;  the  mass  is  usually  irreg- 
ular in  the  region  of  the  spleen,  but  the  splenic  outlines  are  marked.  In  the 
case  I  saw  with  two  cysts  at  the  hilus,  the  tumor  was  very  movable,  very 
irregular,  and  I  urged  operation  on  the  grounds  of  mechanical  discomfort,  and 
increase  in  size.  In  a  recent  paper  Musser  stated  that  there  have  been  21 
operations,  all  successful,  in  cysts  of  this  sort. 

5.     PEIMAEY  SPLENOMEGALY  WITH  ANAEMIA 
(Splenic  Ancemia,  Banti's  Disease) 

Definition. — A  primary  disease  of  the  spleen  of  unknown  origin,  character- 
ized by  progressive  enlargement,  attacks  of  anaemia,  a  tendency  to  haemorrhage, 
and  in  some  cases  a  secondary  cirrhosis  of  the  liver,  with  jaundice  and  ascites. 
That  the  spleen  itself  is  the  seat  of  the  disease  is  shown  by  the  fact  that  com- 
plete recovery  follows  its  removal. 

History. — The  name  "splenic  anaemia"  was  applied  to  a  group  of  cases  by 
Griesinger  in  1866.  H.  C.  Wood,  in  1871,  described  cases  as  the  splenic  form 
of  pseudo-leukemia.  The  real  study  of  the  disease  was  initiated  by  Banti  in 
1883.  In  France  the  condition  was  called  "primitive  splenomegaly,"  and  many 
different  types  of  the  disease  have  been  described.  Here  we  shall  deal  only 
with  the  form  referred  to  in  the  definition  as  splenic  anaemia  and  Banti's 

disease. 

Etiology. — In  the  majority  of  cases  the  enlargement  of  the  spleen  comes 


886  DISEASES    OF    THE    DUCTLESS    GLANDS 

on  without  any  recognizable  cause.  In  a  few  of  my  cases  malaria  has  been 
present,  but  in  the  greater  number  the  first  thing  noticed  has  been  the  me- 
chanical inconvenience  of  the  big  spleen.  Males  are  more  frequently  attacked 
than  females.  It  is  a  disease  of  young  and  middle  life,  the  majority  of  cases 
occurring  before  the  fortieth  year.  It  is  also  met  with  in  young  children. 
Many  of  the  cases  of  infantile  splenic  anaemia  of  von  Jaksch  and  of  the  Italian 
writers  belong  to  this  disease. 

Morbid  Anatomy. — The  spleen  is  greatly  enlarged,  coming  perhaps  next 
to  the  size  of  the  leukaemic  organ.  It  is  very  firm,  the  capsule  is  thickened, 
the  texture  of  the  gland  very  tough  and  firm,  and  .the  whole  in  a  state  of 
advanced  fibrosis.  Banti  has  described  a  proliferation  of  the  endothelial  cells 
of  the  venous  sinuses  of  the  pulp,  and  he  believes  there  are  very  characteristic 
histological  changes. 

The  blood  vessels  in  the  neighborhood  of  the  spleen  may  be  very  large, 
particularly  the  vasa  brevia,  and  ths  splenic  vein  itself  and  the  portal  vein 
may  be  enormously  dilated,  and  show  atheroma  and  calcification.  The  lym- 
phatic glands  are  not  involved.  Hyperplasia  of  the  bone  marrow  has  been 
found,  but  no  other  changes  of  special  importance. 

The  cases  of  the  Gaucher  type,  primitive  endothelioma  of  the  spleen,  do 
not  belong  in  this  group. 

Symptoms. — The  disease  is  extraordinarily  chronic;  seven  of  my  cases  had 
a  longer  duration  than  ten  years.  Usually  the  first  feature  to  attract  atten- 
tion is: 

Splenomegaly. — The  enlargement  is  uniform,  smooth,  painless,  usually 
reaches  to  the  navel,  very  often  to  the  anterior  superior  spine,  and  the  organ 
may  occupy  the  whole  of  the  left  half  of  the  abdomen.  It  may  exist  for  years 
without  any  symptoms  other  than  the  inconvenience  caused  by  the  distention 
of  the  abdomen.  Following  an  infarct  pain  may  be  present. 

Ancemia. — Sooner  or  later  the  patients  become  anaemic.  The  attack  may 
develop  with  rapidity,  and  in  children  a  severe  and  even  fatal  form  may 
follow  in  a  few  weeks.  More  commonly  the  pallor  is  gradual  and  the  patient 
may  come  under  observation  for  the  first  time  with  swelling  of  the  feet,  short- 
ness of  breath,  and  all  the  signs  of  advanced  anaemia.  The  blood  picture  is, 
as  a  rule,  that  of  a  secondary  anaemia  with  a  very  low  color  index  and  a 
marked  leucopenia.  The  red  blood  corpuscles  may  fall  as  low  as  two  million 
and  in  an  average  of  a  series  of  uncomplicated  cases  the  leucocyte  count  was 
under  3,500  per  c.  mm.  There  are  no  special  changes  in  the  differential  count. 
Following  a  severe  haemorrhage  there  may  be  a  rise  in  the  leucocytes.  Some 
patients  have  permanent  slight  anaemia  of  the  secondary  type ;  others  remain 
very  well  except  for  recurring  attacks  of  anaemia,  of  great  severity,  which  may 
be  independent  of  haemorrhage. 

The  question  whether  the  anaemia  splenica  infantum  of  von  Jaksch  and 
the  Italian  writers  is  the  same  malady  has  been  much  discussed.  There  are 
cases  in  which  enlargement  of  the  spleen  without  obvious  cause  has  been  fol- 
lowed by  a  rapidly  progressing  anaemia  with  marked  leucopenia.  A  very  sug- 
gestive thing  is  that  in  a  case  in  a  child,  with  a  blood  count  below  one  mil- 
lion' reds,  removal  of  the  spleen  was  followed  by  complete  recovery. 

Hemorrhages. — Bleeding,  usually  haematemesis,  may  be  a  special  feature  of 
the  disease  ana  may  occur  for  many  years.  One  of  my  patients  had  recurring 


DISEASES    OF   THE    SPLEEN  887 

attacks  for  twelve  years,  and  one  at  the  London  Hospital,  noted  by  E.  Hutch- 
ison, for  fifteen  years.  In  such  cases  the  diagnosis  of  ulcer  of  the  stomach 
may  be  made.  The  bleeding  may  be  of  great  severity.  On  several  occasions 
one  of  my  patients  was  brought  into  the  hospital  completely  exsanguine;  in 
two  the  hemorrhage  proved  directly  fatal ;  in  a  third  the  haemorrhage  proved 
fatal  ten  days  after  a  successful  removal  of  the  spleen.  The  bleeding  comes, 
as  a  rule,  from  cesophageal  varices.  Melaena  may  be  present.  Haematuria  oc- 
curred in  one  of  my  cases;  purpura  is  not  uncommon. 

Ascites. — Usually  a  terminal  event,  it  may  be  due  to  the  enlarged  spleen 
itself  or  to  secondary  cirrhosis  of  the  liver.  When  due  to  the  liver,  it  is  asso- 
ciated with  slight  jaundice. 

Jaundice. — Icterus  has  been  a  rare  symptom  in  my  cases.  Enlargement 
of  the  spleen  may  persist  for  many  years  without  any  consecutive  change  in 
the  liver.  One  patient  has  splenomegaly  with  repeated  haemorrhages  and 
has  now  (1912)  had  more  than  twelve  years  of  good  health  after  splenectomy. 
Slight  jaundice  may  persist  for  years,  sometimes  with  enlargement  of  the 
liver,  in  others  with  distinct  reduction  in  its  volume,  and  in  either  case  with 
a  progressive  cirrhosis — the  features  to  which  Banti  called  special  attention. 

Course  of  the  Disease. — It  is  extraordinarily  chronic.  A  patient  may  for 
ten  or  twelve  years  have  a  large  spleen  causing  no  inconvenience,  then  an 
attack  of  anaemia  may  occur,  from  which  recovery  gradually  takes  place; 
or  the  first  symptom  may  be  ascites  or  a  severe  haemorrhage  from  the  stomach. 
As  a  rule,  the  anaemia  becomes  more  or  less  chronic,  with  marked  exacerba- 
tions, and  in  the  later  stages  jaundice  with  ascites  develops. 

Diagnosis. — Here  may  be  mentioned  a  series  of  forms  of  splenomegaly 
which  differ  essentially  from  the  splenic  anaemia,  and  in  which,  so  far  as  we 
know,  the  condition  of  the  spleen  is  not  primary. 

SPLENOMEGALY  WITH  ACHOLUKIC  JAUNDICE. — This  type,  first  described 
by  Minkowski  and  sometimes  called  after  his  name,  is  usually  a  familial  form, 
often  hereditary.  It  is  consistent  with  good  health  throughout  life,  and  there 
may  be  no  symptoms.  Characteristic  features  are:  (a)  its  familial  form;  (&). 
chronic  enlargement  of  the  spleen;  (c)  good  health;  (d)  chronic  slight  jaun- 
dice; (e)  presence  of  urobilin  in  the  urine,  but  absence  of  bile  pigment.  In 
a  few  instances  gall  stone  colic  has  been  present,  due  to  the  presence  of  small 
calculi.  Chauffard  showed  that  the  red  blood  corpuscles  in  these  cases  have 
an  increased  fragility,  the  cause  of  which  is  unknown,  but  this  is  an  essential 
feature  in  the  haemolytic  jaundice.  In  the  familial  form  good  health  is  the 
rule,  but  in  the  acquired  form  the  patient  often  becomes  anaemic  and  is  very 
ill.  Cures  have  been  reported  after  splenectomy. 

SPLENOMEGALY  OF  THE  GAUCHER  TYPE  (Primary  Endothelioma  of  the 
Spleen). — In  a  dozen  or  more  cases  the  enlarged  spleen  has  retained 
its  form  and  presents  on  section  a  grayish  red  appearance,  with  whitish  spots 
or  streaks ;  but  histologically  shows  large  cells  from  20  to  40  /*  in  size,  filling 
the  alveolar  spaces.  The  nature  of  this  affection,  first  described  by  Gaucher 
in  1882,  has  been  much  discussed.  The  general  opinion  now  is  that  of  Stengel, 
that  it  is  a  type  of  new  growth,  an  endothelioma ;  in  any  case,  it  differs  entirely 
from  the  splenic  anaemia. 

SPLENOMEGALY  ASSOCIATED  WITH  PRIMARY  PYLETHROMBOSIS. — Cases 
have  been  reported  of  enlarged  spleen  in  connection  with  phlebitis  of  the 


888  DISEASES    OF    THE    DUCTLESS    GLANDS 

splenic  and  portal  veins,  and  clinically  such  cases  closely  resemble  Banti's 
disease.  The  spleen  is  very  large  and  there  are  jaundice  and  ascites  with 
moderate  anaemia.  The  recognition  of  the  pylethrombosis  is  only  made  post 
mortem. 

HEPATIC  SPLENOMEGALY. — Three  varieties  of  cirrhosis  of  the  liver  may 
lead  to  great  enlargement  of  the  spleen  with  anaemia  and  a  symptom-complex 
resembling  that  of  splenic  anaemia. 

(a)  Alcoholic  Cirrhosis. — With  recurring  haemorrhages,  a  consecutive  an- 
aemia, ascites,  and  an  unusually  large  spleen,  the  condition  may  simulate 
closely  the  last  stage  of  splenic  anaemia.     The  history,  particularly  the  late 
appearance  of  the  hepatic  changes,  may  be  the  most  important  point.    In  the 
cases  in  which  I  have  been  in  doubt  the  difficulty  has  arisen  from  an  im- 
perfect history  and  from  the  presence  of  recurring  haemorrhages. 

(b)  Syphilitic  Cirrhosis. — Great  enlargement  of  the  spleen  may  follow 
gummous  hepatitis,   either  congenital   or   acquired.      Toward  the   close   the 
picture  is  very  similar  to  Banti's  disease — slight  jaundice,  ascites,  big  spleen, 
recurring  haemorrhages,  and  marked  anaemia.    Signs  of  other  syphilitic  lesions 
and  the  irregular  nodular  liver  may  suggest  the  diagnosis. 

(c)  In  a  few  cases  of  hypertrophic  cirrhosis,  as  in  Hanot's  form  and  in 
haemochromatosis,  the  spleen  may  be  greatly  enlarged,  and  in  the  late  stages, 
when  ascites  and  haemorrhages  occur,  the  clinical  picture  may  be  like  that  of 
splenic  anaemia. 

SPLENOMEGALY  IN  PERNICIOUS  ANEMIA. — Sometimes  the  spleen  is  greatly 
enlarged  in  this  disease,  reaching  to  the  navel,  but,  as  a  rule,  the  lower  blood 
count,  the  high  color  index,  the  large  number  of  nucleated  red  blood  cor- 
puscles, and  the  clinical  course  enable  one  to  make  the  diagnosis. 

TROPICAL  SPLENOMEGALY. — Kala-azar  has  been  considered  elsewhere  and 
can  be  distinguished  by  the  presence  of  the  Lei shman- Donovan  bodies  in  the 
splenic  blood.  There  are  big  spleens  with  anaemia  in  the  Tropics  which  are 
not  Kala-azar,  and  the  experience  of  some  of  the  physicians  in  Cairo  indicates 
that  some  of  these,  at  any  rate,  are  of  the  ordinary  splenic  anaemia  type,  in 
which  removal  of  the  organ  cures  the  disease. 

Treatment. — In  the  first  stage  with  simple  splenomegaly  nothing  is  indi- 
cated; the  patients,  as  a  rule,  look  very  well.  For  the  anaemia  the  usual 
measures  may  be  adopted,  and  the  patient  gets  gradually  better.  The  ultimate 
outlook  is  bad,  and  there  is  only  one  radical  cure — removal  of  the  spleen. 
This  has  now  been  done  in  a  sufficiently  large  number  of  cases  to  determine 
its  value.  Of  6  of  my  cases  3  have  recovered;  one  is  alive  more  than  12 
years  after  the  operation,  another  between  6  and  7.  One  died  on  the  table 
from  haemorrhage,  a  second  from  shock,  and  a  third  died  ten  days  after  from 
a  rupture  of  the  oesophageal  varix.  Armstrong  of  Montreal  has  collected  32 
cases  operated  upon  with  9  deaths.  The  fact  that  removal  of  the  spleen  is 
followed  by  complete  recovery,  even  after  the  appearance  of  the  jaundice  and 
of  chronic  anaemia,  is  the  best  proof  that  the  source  of  the  trouble  is  in  this 
organ  itself,  and  is  one  of  the  best  warrants  for  the  recognition  of  the  disease 
as  a  separate  clinical  entity. 


DISEASES    OF   THE    PITUITARY   BODY  889 


VI.    DISEASES    OF    THE    PITUITARY    BODY 

The  hypophysis  cerebri  consists  of  two  lobes,  (a)  an  anterior  lobe,  originat- 
ing from  the  roof  of  the  pharynx  and  composed  of  large  granular  epithelial 
cells  arranged  in  columns  surrounded  by  large  venous  spaces  into  which  their 
secretion  discharges;  and  (&)  a  smaller  posterior  lobe  which  arises  from  the 
floor  of  the  third  ventricle  and  is  composed  ( 1 )  of  a  central  neuroglial  portion 
(pars  nervosa)  and  (2)  an  investment  of  epithelial  cells  (pars  intermedia). 
The  secretion  of  the  posterior  lobe  is  supposed  by  some  to  find  its  way  into 
the  cerebro-spinal  fluid. 

Complete  experimental  removal  of  the  gland  is  fatal  (Paulesco).  Partial 
removal  leads,  in  young  animals,  to  a  stunting  of  growth,  to  adiposity  and 
failure  of  sexual  development,  in  adult  animals  to  adiposity  and  genital  dys- 
trophy (Gushing). 

Modern  knowledge  of  the  functions  of  the  gland  began  with  the  studies 
of  Marie  on  the  relation  of  the  pituitary  gland  to  acromegaly  and  gigantism. 
Then  Schafer  and  Oliver  discovered  that  injection  of  an  extract  of  the  gland 
caused  a  rise  in  the  blood  pressure.  Since  these  two  cardinal  observations  an 
enormous  amount  of  work  has  been  done,  and  we  are  beginning  to  appreciate 
the  remarkable  influence  of  this  small  structure  upon  the  processes  of  develop- 
ment and  metabolism.  Briefly,  the  anterior  lobe  influences  growth  and  de- 
velopment, and  is  necessary  to  life ;  the  posterior  lobe  influences  the  metabolism 
of  the  carbohydrates  and  fats. 

Disturbances  in  the  function  of  the  pituitary  gland  are  not  clearly  grouped, 
as  in  the  thyroid,  into%the  effects  of  deficiency  and  excess,  though  one  can 
usually  differentiate  states  of  hyper-  and  hypopituitarishi.  The  hypophysis 
appears  to  be  closely  related  to  other  glands  of  internal  secretion  and,  as  is 
well  known,  involvement  of  any  member  of  the  series  causes  a  physiological 
readjustment  in  the  activity  of  the  others.  Owing  to  the  situation  of  the  gland 
it  is  very  liable  to  feel  the  effect  of  pressure  in  neighboring  or  even  in  distant 
lesions,  so  that  disturbance  of  function  may  be  due  not  only  to  a  primary 
involvement,  but  to  secondary  compression.  As  a  result  of  his  experimental 
work  and  studies  of  clinical  cases  Gushing  prefers  to  group  the  conditions 
associated  with  disturbance  of  the  function  of  the  gland  under  the  term 
"dyspituitarism"  and  recognizes  a  number  of  groups: 

(a)  Cases  of  tumor  growth  showing  signs  of  distortion  of  neighboring 
structures,  and  also  the  constitutional  effects  of  altered  glandular  activity. 
The  X-rays  show  changes  in  the  configuration  of  the  pituitary  fossa;  there 
are  pressure  signs  on  the  adjacent  cranial  nerves,  bi-temporal  hemianopia, 
optic  atrophy,  and  occulomotor  palsies.  Uneinate  fits  are  not  unusual.  Epi- 
staxis  is  common  and  cerebro-spinal  rhinorrhoea  may  occur  in  rare  cases. 
The  constitutional  effects  vary  from  primary  over-activity  to  glandular  under- 
activity. 

(&)  Cases  in  which  the  neighborhood  manifestations  are  pronounced  but 
the  constitutional  features  are  slight.  The  characteristic  regional  signs  of 
tumor  are  marked,  but  there  may  be  slight  or  very  transient  evidence  of  dis- 
turbed glandular  activity,  perhaps  only  disturbed  carbohydrate  metabolism 
with  adiposity. 
58 


890  DISEASES    OF    THE    DUCTLESS    GLANDS 

(c)  Cases  in  which  the  neighborhood  manifestations  are  absent  or  slight, 
though   the  glandular   symptoms   are   unmistakable.      The   gland  is  not  so 
large  as  to  cause  regional  symptoms.     There  are  skeletal  changes  on  the  side 
of  overgrowth  or  undergrowth.     Disturbance  of  carbohydrate  metabolism  is 
a  matter  of  modified  posterior  lobe  activity,  whether  occurring  as  a  lowering 
of  the  assimilation  limit,  which  is  so  often  associated  with  the  early  stages 
of  acromegaly,  or  a  great  increase  in  tolerance,  such  as  characterizes  all  grades 
of  hypopituitarism.    In  posterior  lobe  insufficiency  there  are  a  tendency  to  the 
deposition  of  fat,  a  subnormal  temperature,  drowsiness,  slow  pulse,  dry  skin, 
loss  of  hair,  and  an  extraordinary  high  tolerance  for  sugars.     Most  of  the 
cases  of  acromegaly  fall  in  this  group  and  show  at  first  evidences  of  hyper- 
pituitarism,  and  later  of  insufficiency.     In  the  adult,  adiposity,  high  sugar 
tolerance,  subnormal  temperature,  psychic  manifestations,  and  sexual  infantil- 
ism of  the  reversive  type  indicate  hypopituitarism  and  may  exist  without  the 
regional  symptoms  of  tumor  (Gushing). 

(d)  Hypophysial  symptoms  may  be  shown  by  patients  with  internal  hydro- 
cephalus  from  any  cause,  probably  by  interference  with  the  passage  of  the 
posterior  lobe  secretion  into  the  cerebro-spinal  fluid,   and  this   obstructive 
dyspituitarism  may  result  from  any  lesion,  inflammatory  or  neoplastic,  in  the 
neighborhood  of  the  third  ventricle. 

These  are  the  most  important  of  the  groups  to  which  Gushing  refers,  but 
there  are  also  cases  with  manifestations  indicating  involvement  of  other 
internal  secretions  together  with  that  of  the  hypophysis,  and  a  large  group  in 
which  transient  hypophysial  symptoms  occur,  as,  in  pregnancy,  cranial  injuries 
and  infectious  diseases. 

It  is  quite  clear  that  disturbances  in  the  function  of  the  pituitary  gland 
may  lead  to  remarkable  changes  in  growth ;  liyperpituitarism  may  lead  to 
gigantism,  when  the  process  antedates  ossification  of  the  epiphyses — the  Lau- 
nois  type ;  to  acromegaly  when  it  is  of  later  date ;  hypopituitarism  to  adiposity, 
with  skeletal  and  sexual  infantilism  when  the  process  originates  in  child- 
hood— the  Frolich  type;  to  adiposity  and  sexual  infantilism  of  the  reversive 
type  when  originating  in  the  adult. 

Much  has  been  done  to  clear  the  subject,  but  much  remains,  particularly 
to  clear  up  the  relations  of  the  various  types  of  infantilism  which  have  been 
described — the  Lorain,  the  Brissaud,  the  pancreatic,  the  intestinal — to  the 
different  internal  secretions.  One  condition  is  important  enough  to  merit 
separate  consideration,  the  one  differentiated  clearly  by  Marie  and  known 
as  acromegaly.  (The  student  is  referred  to  Hastings  Gilford's  "Disorders  of 
Post-natal  Growth,"  to  Vincent's  "Innere  Secretion,"  Ergeb.  d.  PJiys.,  IX  and 
X,  and  to  Cushing's  work,  "The  Pituitary  Gland  and  Its  Disorders,"  J.  B. 
Lippincott  Co.,  1912.) 

ACROMEGALY 

Definition. — A  dystrophy  characterized  by  increase  in  size  of  the  face  and 
extremities  associated  with  perverted  function  of  the  pituitary  gland. 

The  essence  of  the  disease  is  a  hyperpituitarism  which,  if  it  antedates 
ossification  of  the  epiphyses,  leads  to  gigantism,  and  in  the  adult  leads  to  over- 
growth of  the  skeleton  and  other  changes  which  we  know  as  acromegaly. 

Etiology. — It  is  a  rare  disease,  and  rather  more  frequent  in  women.     It 


DISEASES    OF   THE    PITUITARY    BODY  891 

affects  particularly  persons  of  large  size.  Twenty  per  cent,  of  acromegalics 
are  above  six  feet  in  height  when  the  symptoms  begin,  and  fully  40  per  cent, 
of  giants  are  acromegalics  (Sternberg).  Trauma,  the  infections,  and  emo- 
tional shock  have  preceded  the  onset  of  the  disease. 

Pathology. — Practically  all  of  the  cases  show  changes  in  the  pituitary- 
gland,  hyperplasia,  adenoma,  fibroma,  or  sarcoma,  causing  distention  of  the 
sella  turcica  and,  in  the  late  stages,  pressure  on  surrounding  structures;  the 
symptoms  of  the  disease  are  in  part  due  to  disturbance  of  the  function  of 
the  gland,  and  in  part  to  the  pressure  on  the  adjacent  parts. 

The  bones  show  the  most  striking  changes ;  there  is  a  general  enlargement 
of  the  extremities,  but  the  skeleton  on  the  whole  is  more  or  less  affected. 
The  enlargement,  due  to  a  periosteal  growth,  is  most  evident  in  the  hands  and 
feet.  The  bones  of  the  face  are  always  involved.  The  orbital  arches,  frontal 
prominences,  zygoma,  malar,  and  nasal  bones  are  all  increased  in  size,  the 
lower  jaw  is  elongated,  thickened,  and  the  teeth  separated.  The  X-ray  picture 
shows  very  characteristic  changes  in  the  sella  turcica.  The  skin  and  sub- 
cutaneous tissues  are  thickened,  so  that  the  enlargement  of  the  extremities  is 
not  altogether  bony,  and  the  hypertrophy  is  seen  in  the  soft  parts  of  the  face 
as  well. 

The  brain  has  been  found  large,  but  the  most  important  changes  are  those 
due  to  pressure  at  the  base.  The  internal  organs  have  been  found  enlarged, 
and  in  Osborne's  case  the  heart  weighed  2  Ibs.  9  oz. 

Symptoms. — As  already  mentioned,  when  the  pituitary  gland  is  involved 
in  tumor  growth,  which  is  the  common  condition  in  acromegaly,  the  symptoms 
may  be  grouped  into  those  due  to  the  mechanical  effects  and  those  associated 
with  perversion  of  the  secretion  of  the  gland. 

(a)  REGIONAL  SYMPTOMS. — Headache  is  common,  usually  frontal.  Som- 
nolence has  been  noted  in  many  cases,  and  in  one  of  my  patients  was  the  first 
symptom.  Ocular  features  occur  in  a  large  proportion  of  the  cases,  bitemporal 
hemianopia,  optic  atrophy,  and,  in  the  late  stages,  pressure  on  the  third  nerve 
and  the  abducens.  One  eye  only  may  be  affected.  Exophthalmos  may  occur. 
Deafness  is  not  infrequent.  Irritability  of  temper,  marked  change  in  the 
disposition,  great  depression,  and  progressive  dementia  have  been  noted.  Epi- 
staxis  and  rhinorrhrea  may  be  present. 

(6)  SYMPTOMS  DUE  TO  THE  PERVERSION  OF  THE  INTERNAL  SECRETION 
itself  form  the  striking  features  of  the  disease.  The  patient's  friends  first 
notice  a  gradual  increase  in  the  features,  which  become  heavy  and  thick;  or 
the  patient  himself  may  notice  that  he  takes  a  larger  size  of  hat,  or  with  ths 
progressive  enlargement  of  the  hands  a  larger  size  of  gloves.  The  enlarge- 
ment of  the  extremities  does  not  interfere  with  their  free  use. 

The  hypertrophy  is  general,  involving  all  the  tissues,  and  gives  a  curious 
spadelike  character  to  the  hands.  The  lines  on  the  palms  are  much  deepened. 
The  wrists  may  be  enlarged,  but  the  arms  are  rarely  affected.  The  feet 
are  involved  like  the  hands  and  are  uniformly  enlarged.  The  big  toe,  however, 
may  be  much  larger  in  proportion.  The  nails  are  usually  broad  and  large,  but 
there  is  no  curving,  and  the  terminal  phalanges  are  not  bulbous.  The  head 
increases  in  volume,  but  not  as  much  in  proportion  as  the  face,  which  becomes 
much  elongated  and  enlarged  in  consequence  of  the  increase  in  the  size  of 
the  superior  and  inferior  maxillary  bones.  The  latter  in  particular  increases 


392  DISEASES    OF    THE    DUCTLESS    GLANDS 

greatly  in  size,  and  often  projects  below  the  upper  jaw.  The  alveolar  processes 
are  widened  and  the  teeth  are  often  separated.  The  soft  parts  also  increase 
in  size,  and  the  nostrils  are  large  and  broad.  The  eyelids  are  sometimes  greatly 
thickened,  and  the  ears  enormously  hypertrophied.  The  tongue  in  some 
instances  becomes  greatly  enlarged.  Late  in  the  disease  the  spine  may  be 
affected  and  the  back  bowed — kyphosis.  The  bones  of  the  thorax  may  slowly 
and  progressively  enlarge.  With  this  gradual  increase  in  size  the  skin  of  the 
hands  and  face  may  appear  normal.  Sometimes  it  is  slightly  altered  in  color, 
coarse,  or  flabby,  but  it  has  not  the  dry,  harsh  appearance  of  the  skin  in 
myxoedema.  The  muscles  are  sometimes  wasted. 

Also  associated  with  disturbance  of  the  function  of  the  gland  is  the  diabetes 
noticed  in  many  cases,  which  is  common  in  the  early  stages;  in  the  advanced 
stages  there  is  an  extraordinary  high  tolerance  for  sugar.  Symptoms  on  the 
part  of  other  ductless  glands  are  common.  Goitre  is  of  frequent  occurrence. 
Amenorrhcea  is  the  earliest  symptom  in  women.  Impotence  is  common  in 
advanced  cases  in  men. 

The  various  symptoms  of  the  disease  are  now  readily  explained  with  the 
knowledge  we  possess  of  the  functions  of  the  gland,  which  have  already  been 
discussed. 

Treatment.— The  use  of  extracts  of  the  gland  has  been  extensively  tried. 
Possibly  now  with  our  better  knowledge  of  the  functions  of  the  different  parts 
we  shall  arrive  at  a  more  intelligent  organo-therapy.  Unquestionably  glandu- 
lar therapy  should  only  be  used  when  the  condition  has  passed  into  its  ultimate 
stage  of  glandular  insufficiency — a  stage  which  is  indicated  usually  by  an  in- 
creased sugar  tolerance. 

Surgical  treatment  has  been  carried  out  in  a  number  of  cases  following 
Schloffer's  suggestion.  Doubtless  the  chief  surgical  indication  is  to  give  relief 
to  the  local  pressure  symptoms  when  there  is  marked  glandular  enlargement. 
The  tumor  or  glandular  struma  may  be  reached  by  a  transphenoidal  or  a  sub- 
temporal  route.  Partial  removal  of  the  growth  or  ,the  evacuation  of  a  cyst 
under  favorable  circumstances  may  save  the  optic  nerves  from  complete  pres- 
sure atrophy. 


VII.    INFANTILISM 

Definition. — The  failure  of  the  appearance  of  the  primary  and  secondary 
sexual  characteristics,  together  with  the  retention  of  mental  and  bodily  con- 
ditions of  childhood. 

Etiology. — It  is  not  possible  at  present  to  make  a  satisfactory  classification 
either  of  the  causes  or  of  the  cases  of  infantilism — in  some  no  cause  is  evident, 
in  others  the  failure  in  development  has  followed  obvious  disease,  and  there 
are  cases  directly  dependent  upon  loss  of  some  internal  secretion. 

I.  Cachectic  infantilism  is  by  no  means  uncommon,  as  any  serious 
chronic  malady  may  delay  sexual  development.  For  example,  the  children 
affected  with  hookworm  disease  may  reach  the  age  of  20  or  older  before  the 
change  from  the  infantile  to  the  adult  state.  Syphilis  is  a  very  common  cause. 
In  regipns  in  which  malaria  is  very  prevalent  delayed  sexual  development  is 
not  uncommon  in  children,  and  we  see  it  not  infrequently  in  cases  of  con- 


INFANTILISM  893 

genital  heart  disease.     There  is  also  a  toxic  infantilism  due  to  the  slow  and 
prolonged  action  of  alcohol  and  tobacco. 

II.  Idiopathic  Infantilism   (So-called  Lorain  Type). — "In  this  variety 
the  figure  is  so  small  that,  at  first  sight,  it  looks  like  that  of  a  child.    When 
the  patient  is  stripped,  however,  his  outlines  are  seen  to  be  those  of  an  adult, 
and  not  those  of  childhood.    The  head  is  proportionately  small,  and  the  trunk 
well  formed;  for  the  shoulders  are  broad  compared  to  the  hips,  and  the  bony 
prominences  and  the  muscles  stand  out  distinctly.     We  have  before  us  a 
miniature  man  (or  woman,  as  the  case  may  be),  and  not  one  who  has  retained 
the  characteristics  of  childhood  beyond  the  proper  time.    There  is,  indeed,  no 
growth  of  facial,  pubic  or  axillary  hair,  yet  the  genital  organs,  though  small, 
are  well  shaped  and  quite  large  enough  for  the  size  of  the  body.    The  intelli- 
gence in  both  sexes  is  generally  normal"  (John  Thomson). 

The  cause  of  this  form  is  yet  unknown,  but  it  is  probably  associated  with 
perversion  of  the  pituitary  secretions.  It  has  also  been  called  an  "angioplastic 
infantilism,"  in  the  belief  that  it  was  due  to  a  defect  of  development  of  the 
vascular  system. 

III.  The  Hormonic  Type. — Here  we  are  on  safer  ground,  as  we  know  def- 
initely of  several  varieties  directly  dependent  upon  changes  in  the  ductless 
glands.     The  most  important  of  these  are: 

(a)  THYROID AL  OR  CRETINOID  INFANTILISM. — This  form  has  already  been 
described. 

(&)  The  FROLICH  TYPE,  dystrophia  adiposo-genitalis,  associated  with  a 
tumor  of  the  pituitary  region,  is  characterized  by  great  obesity  and  genital 
hypoplasia.  The  symptoms  are  due  to  a  secretory  deficit,  for  they  are  capable 
of  experimental  reproduction  by  partial  glandular  extirpation  in  animals  (Gush- 
ing). There  are  adult  and  infantile  types,  just  as  there  are  in  myxcedema;  in 
the  former  the  individual  becomes  fat  and  the  sexual  organs  revert  to  the  pre- 
adolescent  state.  The  Brissaud  type  is  in  all  probability  due  to  hypopituitar- 
ism.  A  round,  chubby  face,  under-developed  skeleton,  prominent  abdomen, 
large  layer  of  fat  over  the  whole  body,  rudimentary  sexual  organs,  no  growth 
of  hair  except  on  the  head,  and  absence  of  the  second  dentition,  are  some  of 
the  prominent  features  of  this  form,  which  Brissaud  attributed  to  hypothyroid- 
ism,  but  which  appears  more  likely  to  be  due  to  dyspituitarism. 

(c)  PANCREATICO-INTESTINAL  TYPE. — Bramwell,  Herter,  Freedman,  and 
others  have  reported  cases  of  infantilism  associated  with  intestinal  changes. 
Bramwell  thought  the  pancreas  was  at  fault,  and  his  cases  improved  remark- 
ably under  treatment  with  pancreatic  .extract.  In  Herter's  case  there  were 
looseness  of  the  bowels,  often  fatty  stools,  and  a  change  in  the  flora  of  the 
intestine  with  a  rise  in  the  ethoieal  sulphates  in  the  urine. 

IV.  Progeria. — Under  this  term  Hastings  Gilford  has  described  a  condi- 
tion in  children  of  incomplete  development   (infantilism)    with  premature 
decay.     The  facial  appearance,  the  attitude,  the  loss  of  hair,  wasting  of  the 
skin,  are  those  of  old  age,  and  post  mortem  the  most  extensive  fibroid  changes 
in  the  organs,  particularly  in  the  arteries  and  kidneys.     The  condition  is 
probably  associated  with  unknown  changes  in  the  internal  secretions. 


SECTION   XI 

DISEASES   OF   THE    NERVOUS    SYSTEM 
A.    GENERAL   INTRODUCTION 

The  Neurone. — ITS  STRUCTURE. — The  nervous  system  is  a  combination  of 
an  immense  number  of  units  called  neurones  and  all  having  an  essentially 
similar  structure.  Each  is  composed  of  a  receptive  cell  body  and  of  conduct- 
ing elements — namely,  protoplasmic  processes  or  dendrites,  and  the  axis- 
cylinder  process  or  axone.  The  dendrites  conduct  impulses  toward  the  cell 
body  (cellulipetal  conduction)  and  the  axones  conduct  them  away  from  the 
cell  (cellulifugal  conduction).  Depending  upon  whether  the  axones  conduct 
impulses  in  a  direction  away  from  or  toward  the  cerebrum  they  are  called 
efferent  or  afferent.  The  axis-cylinder  process  gives  off  at  varying  intervals 
lateral  branches  called  collaterals,  running  at  right  angles  to  the  process,  and 
these,  and  finally  the  axis-cylinder  process  itself,  split  up  at  their  terminations 
into  many  fine  fibres,  forming  the  end  brushes.  These,  known  as  arborizations, 
surround  the  body  of  one  or  more  of  the  many  other  cells,  or  interlace  with 
their  protoplasmic  processes.  Thus,  the  terminals  of  the  axone  of  one  neu- 
rone are  related  to  the  dendrites  and  cell  bodies  of  other  neurones  by  contact 
or 'by  concrescence. 

FUNCTION  OF  THE  NEURONE. — As  already  stated,  the  function  of  the  neu- 
rone is  to  conduct  nervous  impulses.  Reduced  to  its  'simplest  form,  the  mode 
of  action  may  be  represented  by  two  cells,  one  of  wjiich,  reacting  to  the  en- 
vironment, conducts  impulses  inward,  whereas  the  other,  awakened  by  this 
afferent  impulse,  conducts  an  impulse  outward.  This  reflex  response  Marshall 
Hall  showed  to  be  the  fundamental  principle  of  action  of  the  nervous  system. 
The  environment  acts  on  the  afferent  neurones  through  special  sense  organs, 
so  that  a  variety  of  afferent  impulses,  olfactory,  visual,  auditory,  gustatory, 
tactile,  painful,  thermic,  muscular,  visceral,  and  vascular,  may  be  originated. 
The  efferent  neurones  convey  impulses  outward  to  non-nervous  tissues,  to  the 
skeletal,  visceral,  and  vascular  muscles  and  to  the  secretory  glands,  whose 
activities  may  thus  be  augmented  or  inhibited.  The  more  important  reflex 
centres  lie  in  the  bulbo-spinal  axis.  The  situation  of  the  vascular  and  respira- 
tory centres  in  the  bulb  makes  it  the  vital  centre  of  the  body.  In  the  spinal 
cord  the  location  of  many  reflex  centres,  particularly  those  for  the  muscle 
tendons  and  for  some  of  the  viscera,  is  represented  in  the  table  on  page  898. 
The  visceral  mechanism  is  almost  wholly  regulated  by  the  bulbo-spinal  axis, 
and  its  reactions  are  usually  unperceived.  Only  in  conditions  of  disease 
do  the  visceral  reflexes  "rise  into  consciousness,"  and  it  is  at  such  times  that 
the  referred  pains  and  areas  of  tenderness  are  produced  in  the  skin-fields  of 

894 


GENERAL    INTRODUCTION  895 

the  spinal  segments  corresponding  to  the  centre  for  registration  of  the  visceral 
reflex. 

DEGENERATION  AND  REGENERATION  OF  THE  NEURONE. — The  nutrition  of 
the  neurone  depends  in  large  part  upon  the  condition  of  the  cell  body,  and 
this  in  turn  upon  the  activity  of  the  nucleus.  If  the  cell  is  injured  in  any 
manner  the  processes  degenerate,  or  the  processes  separated  from  the  cell 
degenerate.  Though  the  nerve  cells  cease  to  multiply  soon  after  birth,  they 
nevertheless  retain  remarkable  powers  of  growth  and  repair.  Injury  to  the 
cell  body  may  not  be  recovered  from,  but  if  the  axone  be  severed  and  degenera- 
tion take  place  in  consequence,  it  may  under  favorable  circumstances  be 
replaced  by  sprouts  from  the  central  stump,  and  its  function  be  regained. 
Bethe  and  others  believe  that  the  peripheral  section,  independently  of  the  cell 
body,  has  the  power  of  regeneration.  It  is  probable,  however,  that  both  factors 
play  a  part  in  the  regeneration — namely,  the  down  growth  of  the  axone  from 
the  central  end  of  the  divided  nerve  as  well  as  the  changes  in  the  periphery, 
which  are  most  marked  in  the  cells  of  the  sheath  of  Schwann. 

Cell  Systems. — The  cell  bodies  of  the  neurones  are  collected  more  or  less 
closely  together  in  the  gray  matter  of  the  brain  and  spinal  cord  and  in  the 
ganglia  of  the  peripheral  nerves.  Their  processes,  especially  the  axis-cylinder 
processes,  run  for  the  most  part  in  the  white  tracts  of  the  brain  and  spinal 
cord  and  in  the  peripheral  nerves.  In  this  way  the  different  parts  of  the 
central  nervous  system  are  brought  into  relation  with  each  other  and  with  the 
rest  of  the  body.  Furthermore,  the  axis-cylinder  processes  arising  from  cells 
subserving  similar  functions  are  collected  together  into  bundles  or  tracts, 
and  though  in  many  cases  the  course  of  these  tracts  and  the  functions  which 
they  possess  are  extremely  complicated  and  as  yet  have  not  been  completely 
unravelled,  nevertheless  some  of  them  are  simple  and  fairly  well  understood. 
Bv  the  study  of  the  degenerations  that  have  resulted  from  injury  or  from 
the  toxins  of  certain  diseases  which  possess  an  affinity  for  one  or  another  of 
these  individual  tracts  or  systems,  it  has  been  possible  to  trace  the  course  of 
certain  of  them  through  the  nervous  system.  Fortunately  for  the  clinician, 
the  best  understood  and  the  simplest  system  in  its  arrangement  is  that  which 
conveys  motor  impulses  from  the  cortex  to  the  periphery — the  so-called  pyram- 
idal tract. 

The  Motor  System. — Motor  impulses  starting  in  the  left  side  of  the  brain 
cause  contractions  of  muscles  on  the  right  side  of  the  body,  and  those  from 
the  right  side  of  the  brain  in  muscles  of  the  left  side  of  the  body.  Leaving, 
out  of  consideration  some  few  exceptions,  it  may  be  stated  as  a  general  rule 
that  the  motor  path  is  crossed,  and  that  the  crossing  takes  place  in  the  upper 
segment  (Figs.  10  and  11).  Every  muscular  movement,  even  the  simplest, 
requires  the  activity  of  many  neurones.  In  the  production  of  each  movement 
special  neurones  are  brought  into  play  in  a  definite  combination,  and  acting 
in  this  combination  specific  movement  is  the  result.  In  other  words,  all  the 
movements  of  the  body  are  represented  in  the  central  nervous  system  by  com- 
binations of  neurones — that  is,  they  are  localized.  Muscular  movements  are 
localized  in  every  part  of  the  motor  path,  so  that  in  cases  of  disease  of  the 
nervous  system  a  study  of  the  motor  defect  often  enables  one  to  fix  upon  the 
site  of  the  process,  and  it  would  be  hard  to  over-estimate  the  importance  of  a 
thorough  knowledge  of  such,  localization.  A  voluntary  motor  impulse  starting 


896 


DISEASES    OF   THE    NERVOUS    SYSTEM 


FIG.  10. — DIAGRAM  OF  MOTOR  PATH  FROM  LEFT  BRAIN.  The  upper  segment  is  black,  the 
,  lower  red.  The  nuclei  of  the  motor  cerebral  nerves  are  shown  in  red  on  the  right 
side;  on  the  left  side  the  cerebral  nerves  of  that  side  are  indicated.  A  lesion  at  1 
would  cause  upper  segment  paralysis  in  the  arm  of  the  opposite  side — cerebral 
monoplegia;  at  2,  upper  segment  paralysis  of  the  whole  opposite  side  of  the  body — 
hemiplegia;  at  3,  upper  segment  paralysis  of  the  opposite  face,  arm,  and  leg,  and 
lower  segment  paralysis  of  the  eye  muscles  on  the  same  side — crossed  paralysis; 
at  4,  upper  segment  paralysis  of  opposite  arm  and  leg,  and  lower  segment  paralysis 
of  the  face  and  the  external  rectus  on  the  same  side — crossed  paralysis;  at  5,  upper 
segment  paralysis  of  all  muscles  below  lesion,  and  lower  segment  paralysis  of 
muscles  represented  at  level  of  lesion — spinal  paraplegia;  at  6,  lower  segment 
paralysis  of  muscles  localized  at  seat  of  lesion — anterior  poliomyelitis.  (Van 
Gehuchten,  modified.) 


GENERAL   INTRODUCTION 


897 


from  the  brain  cortex  must  pass  through  at  least  two  neurones  before  it  can 
reach  the  muscles,  and  we  therefore  speak  of  the  motor  tract  as  being  com- 
posed of  two  segments — an  upper  and  a  lower. 

THE  LOWER  MOTOR  SEGMENT. — The  neu- 
rones of  the  lower  segment  have  the  cell  bodies 
and  their  protoplasmic  processes  in  the  different 
levels  of  the  ventral  horns  of  the  spinal  cord  and 
in  the  motor  nuclei  of  the  cerebral  nerves.  The 
axis-cylinder  processes  of  the  lower  motor  neu- 
rones leave  the  spinal  cord  in  the  ventral  roots 
and  run  in  the  peripheral  nerves,  to  be  dis- 
tributed to  all  the  muscles  of  the  body,  where 
they  end  in  arborizations  in  the  motor  end 
plates.  These  neurones  are  direct — that  is,  their 
cell  bodies,  their  processes,  and  the  muscles  in 
which  they  end  are  all  on  the  same  side  of  the 
body. 

The  ventral  roots  of  the  spinal  cord  are  col- 
lected, from  above  down,  into  small  groups, 
which,  after  joining  with  the  dorsal  roots  of  the 
same  level  of  the  cord,  leave  the  spinal  canal 
between  the  vertebrae  as  the  spinal  nerves.  That 
part  of  the  cord  from  which  the  roots  forming 
a  single  spinal  nerve  arise  is  called  a  segment,  FIG.  H.-^DIAGRAM  OF^MOTOR 
and  corresponds  to  the  nerve  which  arises  from  PATH  FROM  EACH  HEMI- 
it  and  not  to  the  vertebra  to  which  it  may  be 
opposite.  With  the  exception  of  the  cervical 
region,  in  which  all  the  nerve  roots  but  the 
eighth  emerge  from  above  the  vertebras,  the  roots 
of  each  segment  for  the  remainder  of  the  cord 
leave  the  spinal  canal  below  the  vertebra  of 
corresponding  number,  and  consequently,  owing 
to  the  fact  that  during  growth  the  bony  canal  lengthens  much  more  than 
the  cord  itself,  the  more  tailward  one  goes  the  greater  is  the  discrepancy 
in  position  between  each  spinal  segment  and  its  particular  vertebra.  This 
must  be  borne  in  mind  when  determining  upon  the  site  of  a  lesion  known  to 
occupy  a  given  segment,  for  it  may  lie  far  above  the  vertebra  of  like  number 
and  name.  A  chart  has  been  prepared  from  numerous  measurements  by  Reid 
showing  the  level  of  the  various  segments  of  the  cord  in  relation  to  the  spines 
of  the  vertebrae.  The  axis-cylinder  processes  which  go  to  make  up  any  one 
peripheral  nerve  do  not  necessarily  arise  from  the  same  segment  of  the  spinal 
cord;  in  fact,  most  peripheral  nerves  contain  processes  from  several  often 
quite  widely  separated  segments.  Most  of  the  long  striped  muscles,  further- 
more, having  originated  in  the  embryo  from  more  than  one  myatome,  are 
innervated  from  more  than  one  segment. 

Our  knowledge  of  the  localization  of  the  muscular  movements  in  the  gray 
matter  of  the  lower  motor  segment  is  far  from  complete,  but  enough  is  known 
to  aid  materially  in  determining  the  site  of  a  spinal  lesion.  The  following 
table,  in  which  is  included  for  each  of  the  spinal  segments  the  centres  of  repre- 


SPHERE,  SHOWING  THE 
CROSSING  OF  THE  PATH, 
WHICH  TAKES  PLACE  IN 
THE  UPPER  SEGMENT  BOTH 
FOR  THE  CRANIAL  AND 
SPINAL  NERVES.  (Van  Ge- 
huchten,  colored.) 


898 


DISEASES    OF   THE    NERVOUS    SYSTEM 


sentatiou  for  the  more  important  skeletal  muscles,  the  main  reflex  centres, 
and  the  main  location  of  the  segmental  skin-field,  has  been  prepared  from  the 
studies  of  Starr,  Edinger,  Wichmann,  Sherrington,  Bolk,  and  others: 
LOCALIZATION  OF  THE  FUNCTIONS  IN  THE  SEGMENTS  OF  THE  SPINAL  CORD 


SEGMENT. 

STRIPED  MUSCLES. 

REFLEX. 

SKIN-FIELDS  (CF.  Fios. 

16  AND  17). 

I.  II  and 
III  C. 

Splenius  capitis. 
Hyoid  muscles. 
Sterno-mastoid. 
Trapezius. 
Diaphragm  (C  III-V). 
Levator  scapulae  (C  III-V). 

Hypochondrium  (?). 
Sudden  inspiration  pro- 
duced by  sudden  press- 
ure beneath  the  lower 
border    of    ribs    (dia- 
phragmatic). 

Back  of  head  to  ver- 
tex. 
Neck  (upper  part). 

IV  C. 

Trapezius. 
Diaphragm. 
Levator  scapulae. 
Scaleni  (C  IV-T  I). 
Teres  minor. 
Supraspinatus. 
Rhomboid. 

Dilatation  of  the  pupil 
produced  by  irritation 
of  neck.  Reflex 
through  the  sympathe- 
tic (C  IV-T  I). 

Neck  (lower  part  to 
second  rib). 
Upper  shoulder. 

VC. 
VIC. 

Diaphragm. 
Teres  minor. 
Supra  and  infra  spinatus  (C 
V-VI). 
Rhomboid. 
Subscapularis. 
Deltoid. 
Biceps. 
Brachialis  anticus. 
Supinator  longus  (C  V-VII). 
Supinator  brevis  (C  V-VII). 
Pectoralis  (clavicular  part)  . 
Serratus  magnus. 

Scapular  (C  V-T  I). 
Irritation  of  skin  over  the 
scapula  produces  con- 
traction of  the  scapular 
muscles. 
Supinator    longus    and 
biceps. 
Tapping    their    tendons 
produces  fl  e  x  i  o  n  of 
forearm. 

Outer  side  of  shoul- 
der and  upper  arm 
over     deltoid     re- 
gion. 

Teres  m;nor  and  major 
Infraspinatus. 
Deltoid. 
Biceps. 
Brachialis  anticus. 
Supinator  longus. 
Supinator  brevis. 
Pectoralis  (clavicular  part). 
Serratus  magnus  (C  V-VIII). 
Coraco-brachialis. 
Pronator  teres. 
Triceps  (outer  and  long  heads). 
Extensors  of  wrist  (C  VI-VIII)  . 

Triceps.    Tapping  elbow 
tendon  produce!  exten- 
sion of  forearm. 
Posterior    wrist.      Tap- 
ping tendons  causes  ex- 
tension of  hand  (C  VI- 
VII). 

Outer   side   of   fore- 
arm,    front     and 
back. 
Outer    half    of 
hand  (?). 

VII  C. 

Teres  major. 
Subscapularis. 
Deltoid  (posterior  part). 
Pectoralis  major  (costal  part). 
Pectoralis  minor. 
Serratus  magnus. 
Pronators  of  wrist. 
Triceps. 
Extensors  of  wrist  and  fingers. 
Flexors  of  wrist. 
Latissimus  dorsi  (C  VI-VIII). 

Scapulo-humeral.     Tap- 
ping the  inner  lower 
edge  of  scapula  causes 
adduction  of  the  arm. 
Anterior     wrist.       Tap- 
ping anterior  tendons 
causes  flexion  of  wrist 
(C  VII-VIII). 

Inner  side  and  back 
of  arm   and   fore- 
arm. 
Radial    half   of    the 
hand. 

INTRODUCTION 

LOCALIZATION  OF  THE  FUNCTIONS  IN  THE  SEGMENTS  OF  THE  SPINAL  CORD  (Continued) 


SEGMENT. 

STRIPED  MUSCLES. 

REFLEX. 

SKIN-FIELDS  (CF.  FIGS. 

16  AND  17). 

VIII  C. 

Pectoralis  major  (costal  part). 
Pronator  quadratus. 
Flexors  of  wrist  and  fingers. 
Latissimus. 
Radial  lumbricales  and  inter- 
.  ossei. 

Palmar.  Stroking  palm 
causes  closure  of  fin- 
gers. 

Forearm  and  hand, 
inner  half. 

IT. 

Lumbricales  and  interossei. 
Thenar  and  hypothenar  emi- 
nences (C  VII-T  I). 

Upper  arm,  inner 
half. 

II  to 
XII  T. 

Muscles  of  back  and  abdomen. 
Erectores  spinse  (T  I-LV). 
Intercostals  (T  I-T  XII). 
Rectus  abdominis  (T  V-T  XII). 
External  oblique  (T  V-XII). 
Internal  oblique  (T  VII-L  I). 
Transversalis  (T  VII-L  I). 

Epigastric.   Tickling 
mammary     region 
causes    retraction     of 
epigastrium     (T    IV- 
VII). 
Abdominal.    Stroking 
side  of  abdomen  causes 
retraction  of  belly   (T 
IX-XII). 

Skin  of  chest  and 
abdomen  in  ob- 
lique dorso-ventral 
zones.  The  nipple 
lies  between  the 
zone  of  T  IV  and 
T  V.  The  umbil- 
licus  lies  in  the 
field  of  T  X. 

IL. 

Lower  part  of  external  and  in- 
ternal oblique  and  transver- 
salis. 
Quadratus  lumborum  (L  I-II). 
Cremaster. 
Psoas  major  and  minor  (?). 

Cremasteric.  Stroking 
inner  thigh  causes  re- 
traction of  scrotum 
(L  I-II). 

Skin  over  lowest  ab- 
dominal zone  and 
groin. 

II  L. 

Psoas  major  and  minor. 
Iliacus. 
Pectineus. 
Sartorius  (lower  part). 
Flexors  of  knee  (Remak). 
Adductor  longus  and  brevis. 

Front  of  thigh. 

IIIL. 

Sartorius  (lower  part). 
Adductors  of  thigh. 
Quadriceps  femoris  (L  II-L  IV). 
Inner  rotators  of  thigh. 
Abductors  of  thigh. 

Patellar  tendon.  Tap- 
ping tendon  causes  ex- 
tension of  leg.  "Knee- 
jerk." 

Front  and  inner  side 
of  thigh. 

IV  L. 

Flexors  of  knee  (Ferrier). 
Quadriceps  femoris. 
Adductors  of  thigh. 
Abductors  of  thigh. 
Extensors    of    ankle     (tibalis 
anticusj. 
Glutei  (medius  and  minor). 

Gluteal.  Stroking  but- 
tock causes  dimpling 
in  fold  of  buttock 
(L  IV-V). 

Mainly  inner  side  of 
thigh  and  leg  to 
ankle. 

VL. 

Flexors   of   knee    (ham-string 
muscles)  (L  IV-S  II). 
Outward  rotators  of  thigh. 
Glutei. 
Flexors  of  ankle  (gastrocnemius 
and  soleus)  (L  IV-S  II). 
Extensors  of  toes  (L  IV-S  I). 
Peronaei. 

Back  of  leg,  and  part 
of  foot. 

900  DISEASES    OF   THE    NERVOUS    SYSTEM 

LOCALIZATION  OF  THE  FUNCTIONS  IN  THE  SEGMENTS  OF  THE  SPINAL  CORD  (Continued) 


SEGMENT. 

STRIPED  MUSCLES. 

REFLEX. 

SKIN-FIELDS  (CF.  FIGS. 

1C  AND   17). 

I  to 
IIS. 

Flexors  of  ankle  (L  V-S  II). 
Long  flexor  of  toes  (L  V-S  II). 
Peronsei. 
Intrinsic  muscles  of  foot. 

Foot  reflex.       Extension 
of  Achilles  tendon 
causes  flexion  of  ankle 
(SI-II).  Ankle-clonus. 
Plantar.       Tickling  sole 
of  foot  causes  flexion 
of  toes  or  extension  of 
great  toe  and  flexion 
of  others. 

Back   of   thigh,    leg, 
and     foot;     outef 
side. 

Illto 

VS. 

Perineal  muscles. 
Levator    and    sphincter    ani 
(S  I-III). 

Vesical  and  anal  reflexes. 

Skin     over     sacrum 
and  buttock. 
Anus. 
Perineum.    Genitals. 

FIG.  12. — DIAGRAMMATIC  EEPRESENTATION  OF  CORTICAL  LOCALIZATION  IN  THE  LEFT 
HEMISPHERE,  SHOWING  THE  SPEECH  CENTRES.  The  motor  areas  determined  by  uni- 
polar faradic  excitation  of  the  anthropoid  cortex  (Sherrington  and  Griinbaum)  are 
here  shown  stippled  in  red  and  lie  anterior  to  the  Rolandic  fissure.  The  sensory 
areas  presumably  lie  posterior  to  this  fissure  and  are  roughly  indicated  in  blue 
without  accurate  delineation.  Lying  as  it  does  on  the  upper  surface  of  the  hemi- 
sphere, the  leg  area  should  not  be  visible  on  a  lateral  view  such  as  is  given  here. 


GENERAL   INTRODUCTION 


901 


THE  UPPER  MOTOR  SEGMENT  AND  MOTOR  AREAS  OF  THE  CORTEX.— The 
cell  bodies  of  the  upper  motor  neurones  are  found  in  the  brain  cortex  lying 
for  the  most  part  in  a  strip  anterior  to  the  fissure  of  Rolando,  and  it  is  in 
this  region  that  we  find  the  movements  of  the  body  again  represented. 

The  clinical  studies  of  Hughlings  Jackson,  the  experiments  of  Hitzig  and 
Fritsch  and  of  Ferrier,  and  the  anatomical  studies  of  tract  myelinization  by 
Flechsig  laid  the  foundation  for  the  great' mass  of  most  excellent  work  which 
has  been  done  upon  this  subject.  We  owe  much  to  Victor  Horsley  and  his 
associates  for  their  careful  researches  in  this  direction.  True  motor  responses 
are  elicited  only  by  stimulation  anterior  to  the  Rolandic  fissure ;  practically  no 
point  over  the  ascending  frontal  convolution 
fails  to  respond  to  stimulation.  There  is  but 
slight  extension  of  the  motor  cortex  on  to 
the  paracentral  lobule  of  the  mesial  surface 
of  the  brain.  Movements  are  obtainable  not 
only  from  the  exposed  part  of  the  convolu- 
tion, but  also  from  its  hidden  surface  to  the 
very  depths  of  the  Rolandic  sulcus.  There 
is  an  area  of  representation  for  the  trunk 
between  the  centres  for  the  leg  and  arm,  and 
also  for  the  neck  between  those  of  the  arm 
and  face.  The  superior  and  inferior  genua 
are  the  landmarks  which  indicate  the  situa- 
tion of  these  small  areas  of  representation 
for  trunk  and  neck.  These  results  have  in 
large  measure  been  confirmed  by  Gushing  by 
unipolar  electrical  stimulation  of  the  human 
cortex  in  a  number  of  brain  cases.  From 
above  down  the  motor  areas  occur  in  the  fol- 
lowing order:  leg,  trunk,  arm,  neck,  head 
(Fig.  12).  Those  of  the  leg  and  arm  occupy 
the  upper  half  of  the  convolution,  and  that 
for  the  head,  including  movements  of  the 
face,  jaws,  tongue,  and  larynx,  the  lower 
half. 

The  speech  centres  are  indicated  in  the 
diagram  (Fig.  12)  in  accordance  with  the 
generally  accepted  views :  that  for  motor 

speech  occupies  the  posterior  part  of  the  left  third  frontal  or  Broca's  convolu- 
tion. It  is  a  disputed  point  whether  or  not  there  is  a  separate  centre  presiding 
over  the  movements  employed  in  writing.  Some  have  assumed  such  a  centre 
to  be  present  in  the  second  frontal  convolution  as  indicated  on  the  diagram. 
The  conjugate  movement  of  head  and  eyes  to  the  opposite  side  has  commonly 
been  found  in  apes  to  follow  stimulation  of  the  external  surface  of  the  frontal 
lobe.  Similarly  movements  of  the  eyes  may  be  elicited  from  the  occipital 
cortex,  but  probably  none  of  these  reactions  are  comparable  to  the  more  simple 
movements  through  the  pyramidal  tract  which  follow  stimulation  of  the 
ascending  frontal  convolution. 

The  axis-cylinder  processes  of  the  upper  motor  neurones  after  leaving  the 


FIG.  13. — DIAGRAM  OF  MOTOR  AND 
SENSORY  EEPRESENTATION  IN 
THE  INTERNAL  CAPSULE.  NL., 
Lenticular  nucleus.  NO.,  Cau- 
date nucleus.  THO.,  Optic 
.  thalamus.  The  motor  paths 
are  red  and  black,  the  sensory 
are  blue. 


902 


DISEASES    OF   THE   NERVOUS    SYSTEM 


gray  matter  of  the  motor  cortex  pass  into  the  white  matter  of  the  brain  and 
form  part  of  the  corona  radiata.  They  converge  and  pass  between  the  basal 
ganglia  in  the  internal  capsule.  Here  the  motor  axis-cylinders  are  collected 
into  a  compact  bundle — the  pyramidal  tract — occupying  the  knee  and  anterior 

two-thirds  of  the  posterior 
limb  of  the  internal  capsule. 
The  order  in  which  the 
movements  of  the  opposite 
side  of  the  body  are  repre- 
sented at  this  level,  as 
learned  from,  experimental 
observations  on  apes,  is 
given  in  Fig.  13. 

After  passing  through 
the  internal  capsule  the 
fibres  of  the  pyramidal  tract 
leave  the  hemisphere  by  the 


FIG.  14. — Diagram  of  Motor  and  Sensory  Paths  in  Crura. 


crus,  of  which  they  oc- 
cupy about  the  middle 
three-fifths  (Fig.  14).  The 

movements  of  the  tongue  and  lips  are  represented  nearest  the  middle  line. 
As  soon  as  the  tract  enters  the  crus,  some  of  its  axis-cylinder  processes 

leave  it  and  cross  the  middle  line  to  end  in  arborizations  about  the  ganglion 

cells  in  the  nucleus  of  the  third  nerve  on  the  opposite  side;  and  in  this  way, 

as  the  pyramidal  tract  passes 

down,  it  gives  off  at  different 

levels  fibres  which  end  in  the 

nuclei  of  all  the  motor  cere- 
bral nerves  on  the  opposite 

side  of  the  body.  Some  fibres, 

however,  go  to  the  nuclei  of 

the    same    side.     From    the 

crus  the  pyramidal  tract  runs 

through  the  pons  and  forms 

in  the  medulla  oblongatathe 

pyramid,     which     gives     its 

name  to  the  tract.     At  the 

lower  part   of  the  medulla, 

after  the  fibres  going  to  the     FlQ-  15- — DIAGRAM  OF  CROSS-SECTION  OP  THE  SPI- 

cerebral  nerves  have  crossed  NAL  CoKD>  SHOWING  MOTOR,  RED,  AND  SEN- 

SORY, BLUE,  PATHS.  1,  Lateral  pyramidal 
tract.  2,  Ventral  pyramidal  tract.  3,  Dorsal 
columns.  4,  Direct  cerebellar  tract.  5,  Ven- 
tro-lateral  ground  bundles.  6,  Ventro-lateral 


(Van  Gehuehten, 


the  middle  line,  a  large  pro- 
portion of  the  remaining 
fibres  cross,  decussating  with 
those  from  the  opposite  pyra- 
mid, and  pass  into  the  oppo- 
site side  of  the  spinal  cord, 
forming  the  crossed  pyramidal  tract  of  the  lateral  column  (fasciculus  cerebro- 
spinalis  lateralis)  (Fig.  15,  1).  The  smaller  number  of  fibres  which  do  not 
at  this  time  cross  descend  in  the  ventral  column  of  the  same  side,  forming  the 


ascending  tract  of  Gowers. 
colored.) 


GENERAL   INTRODUCTION  903 

direct  pyramidal  tract,  or  Tiirck's  column   (fasciculus  cerebro-spinalis  ven- 
tralis)   (Fig.  15,  2). 

At  every  level  of  the  spinal  cord  axis-cylinder  processes  leave  the  crossed 
pyramidal  tract  to  enter  the  ventral  horns  and  end  about  the  cell  bodies  of  the 
lower  motor  neurones.  The  tract  diminishes  in  size  from  above  downward. 
The  fibres  of  the  direct  pyramidal  tract  cross  at  different  levels  in  the  ventral 
white  commissure,  and  also,  it  is  believed,  end  about  cells  in  the  ventral  horns 
on  the  opposite  side  of  the  cord.  This  tract  usually  ends  about  the  middle  of 
the  thoracic  region  of  the  cord. 

The  Sensory  System. — The  path  for  sensory  conduction  is  more  compli- 
cated than  the  motor  path,  and  in  its  simplest  form  is  composed  of  at  least 
three  sets  of  neurones,  one  above  the  other.  The  cell  bodies  of  the  lowest  neu- 
rones are  in  the  ganglia,  on  the  dorsal  roots  of  the  spinal  nerves,  and  the  gan- 
glia of  the  sensory  cerebral  nerves.  These  ganglion  cells  have  a  special  form, 
having  apparently  but  a  single  process,  which,  soon  after  leaving  the  cell,' 
divides  in  a  T-shaped  manner,  one  portion  running  into  the  central  nervous  sys- 
tem and  the  other  to  the  periphery  of  the  body.  Embryological  and  com- 
parative anatomical  studies  have  made  it  seem  probable  that  the  peripheral 
sensory  fibre,  the  process  which  conducts  toward  the  cell,  represents  the  proto- 
plasmic processes,  while  that  which  conducts  away  from  the  cell  is  the  axis- 
cylinder  process.  In  the  peripheral  sensory  nerves  we  have,  then,  the  dendrites 
of  the  lower  sensory  neurones.  These  start  in  the  periphery  of  the  body  from 
their  various  specialized  end  organs.  The  axis-cylinder  processes  leave  the 
ganglia  and  enter  the  spinal  cord  by  the  dorsal  roots  of  the  spinal  nerves. 
After  entering  the  cord  each  axis-cylinder  process  divides  into  an  ascending 
and  a  descending  branch,  which  run  in  the  dorsal  fasciculi.  The  descending 
branch  runs  but  a  short  distance,  and  ends  in  the  gray  matter  of  the  same 
side  of  the  cord.  It  gives  off  a  number  of  collaterals,  which  also  end  in  the 
gray  matter.  The  ascending  branch  may  end  in  the  gray  matter  soon  after 
entering,  or  it  may  run  in  the  dorsal  fasciculi  as  far  as  the  medulla,  to  end 
about  the  nuclei  there.  In  any  case  it  does  not  cross  the  middle  line.  The 
lower  sensory  neurone  is  direct. 

The  cells  about  which  the  axis-cylinder  processes  and  their  collaterals  of 
the  lower  sensory  neurone  end  are  of  various  kinds.  They  are  known  as  sen- 
sory neurones  of  the  second  order.  In  the  first  place,  some  of  them  end  about 
the  cell  bodies  of  the  lower  motor  neurones,  forming  the  path  for  reflexes. 
They  also  end  about  cells  whose  axis-cylinder  processes  cross  the  middle  line 
and  run  to  the  opposite  side  of  the  brain.  In  the  spinal  cord  these  cells  are 
found  in  the  different  parts  of  the  gray  matter,  and  their  axis-cylinder  proc- 
esses run  in  the  opposite  ventro-lateral  ascending  tract  of  Gowers  (Fig.  15,  6) 
and  in  the  ground  bundles  (fasciculus  lateralis  proprius  and  fasciculus  ven- 
tralis  proprius). 

In  the  medulla  the  nuclei  of  the  dorsal  fasciculi  (nucleus  fasciculi  gracilis 
and  nucleus  fasciculi  cuneati)  contain  for  the  most  part  cells  of  this  character. 
Their  axis-cylinder  processes,  after  crossing,  run  toward  the  brain  in  the 
medial  lemniscus  or  bundle  of  the  fillet ;  certain  of  the  longitudinal  bundles  in 
the  formatio  reticularis  also  represent  sensory  paths  from  the  spinal  cord  and 
medulla  toward  higher  centres.  The  fibres  of  the  medial  lemniscus  or  fillet 
do  Dot,  however,  run  directly  to  the  cerebral  cortex.  They  end  about  cells  in 


904  DISEASES   OP   THE   NERVOUS   SYSTEM 

the  ventro-lateral  portion  of  the  optic  thalamus,  and  the  tract  is  continued  on 
by  way  of  another  set  of  neurones,  which  send  processes  to  end  in  the  cortex 
of  the  posterior  central  and  perietal  convolutions.  This  is  the  most  direct 
path  of  sensory  conduction,  but  by  no  means  the  only  one.  The  peripheral 
sensory  neurones  may  also  end  about  cells  in  the  cord  whose  axones  run  but 
a  short  distance  toward  the  brain  before  ending  again  in  the  gray  matter,  and 
the  path,  if  path  it  can  be  called,  is  made  up  of  a  series  of  these  superimposed 
neurones.  The  gray  matter  of  the  cord  itself  is  also  believed  to  offer  paths  of 
sensory  conduction.  All  these  paths  reach  the  tegmentum  and  optic  thalamus, 
and  thence  are  distributed  to  the  cortex  along  with  the  other  sensory  paths. 
There  may  also  be  paths  of  sensory  conduction  through  the  cerebellum  by  way 
of  the  direct  cerebellar  tract  and  Gowers'  bundle. 

From  this  short  summary  it  is  evident  that  the  possible  paths  for  the  con- 
duction of  afferent  impulses  are  many,  and  become  more  complex  as  the  various 
tracts  approach  the  brain  where  our  knowledge  of  them  is  somewhat  indefinite. 
The  anatomical  arrangement  of  the  two  lower  orders  of  sensory  neurones  is, 
however,  sufficiently  well  understood  to  be  of  great  clinical  value.  We  have 
seen  in  the  case  of  the  motor  neurones  that  the  distribution  of  the  peripheral 
nerves  to  the  muscles,  owing  largely  to  the  interlacing  into  plexuses  of  the 
neurones  from  the  various  spinal  units,  is  quite  different  from  that  of  the  ven- 
tral roots  themselves,  and  the  same  rule  holds  true  for  the  peripheral  nerve 
and  dorsal  root  distribution  for  the  cutaneous  areas.  The  cutaneous  fields 
corresponding  to  the  peripheral  nerves  are  well  known,  and  although  our 
knowledge  of  the  exact  site  and  outline  of  some  of  the  segmental  skin-fields, 
represented  by  the  dorsal  roots,  is  less  accurately  established,  nevertheless  they 
are  sufficiently  well  understood  to  be  of  aid  in  determining  the  segmental  level 
of  spinal  cord  and  of  dorsal  root  lesions.  Information  concerning  the  topogra- 
phy in  the  adult  of  these  skin  units  or  dermatomes  has  been  obtained  from 
various  sources;  from  morphological  studies;  from  anatomical  dissections; 
from  physiological  experimentation,  particularly  in  Sherrington's  hands ;  from 
the  study  of  anaesthesias  in  clinical  cases  after  traumatic  injuries  to  the  cord, 
and  from  Head's  studies  of  the  distribution  of  the  cutaneous  lesions  in  herpes 
zoster,  and  of  the  areas  of  referred  pain  and  tenderness  in  visceral  disease. 
The  diagrams  on  pages  906  and  907  embody  the  results  of  many  of  these  ob- 
servations. 

The  cutaneous  sensory  impressions  are  in  man  conducted  toward  the  brain, 
probably  on  the  opposite  side  of  the  cord — that  is,  the  path  crosses  to  the 
opposite  side  soon  after  entering  the  cord.  Muscular  sense,  on  the  other  hand, 
is  conducted  on  the  same  side  of  the  cord  in  the  fasciculus  of  Goll,  to  cross 
above  by  means  of  the  axones  of  sensory  neurones  of  the  second  order  in  the 
medulla. 

SENSORY  AREAS  OF  THE  BBAIN. — 'Head  and  Holmes  believe  that  there  are 
two  sensory  centres — one  in  the  optic  thalamus,  the  other  in  a  considerable 
area  of  the  cerebral  cortex.  The  thalamus  plays  a  three-fold  part  in  the  fate 
of  sensory  impulses.  Here  all  the  afferent  paths  terminate;  secondly,  it  con- 
tains a  mass  of  gray  matter  which  forms  the  centre  for  certain  fundamental 
elements  of  sensation,  particularly  those  capable  of  evoking  pleasure  and  dis- 
comfort and  consciousness  of  changes  of  state.  Thirdly,  in  the  lateral  part  of 
the  thalamus  is  the  centre  through  which  the  cortex  influences  the  essential 


GENERAL   INTRODUCTION  905 

thalamic  centre,  controlling  and  checking  its  activity.  On  their  way  from  the 
periphery  to  the  cortex  afferent  impulses  pay  toll  to  the  co-ordinate  mechan- 
isms of  the  spinal  cord  and  the  cerebellum.  At  the  thalamic  junction  they  are 
re-grouped  to  act  upon  the  two  terminal  centres.  One  of  these,  the  essential 
organ  of  the  optic  thalamus,  responds  to  all  those  elements  which  evoke  con- 
sciousness of  an  internal  change  in  state,  more  particularly  pleasure  and  dis- 
comfort. Sensory  impulses,  then,  pass  by  way  of  the  internal  capsule  to  the 
cortex,  and  these  authors  hold  that  in  the  main  five  groups  of  sensory  impulses 
are  distributed  in  this  way:  (1)  those  underlying  postural  recognition  and 
the  appreciation  of  passive  movement  and  weight;  (2)  the  impulses  underlying 
the  recognition  of  tactile  differences;  (3)  those  upon  which  depends  the  recog- 
nition of  size  and  space;  (4)  those  which  enable  us  to  localize  the  spot  stimu- 
lated; and  (5)  thermal  impulses. 

These  afferent  materials  are  combined  in  the  cortex  with  each  other  and 
with  other  sense  impressions  in  intellectual  processes.  The  cortical  area  con- 
cerned is  that  situated  between  the  pre-central  fissure  and  the  occipital  lobe. 

The  paths  for  the  conduction  of  the  stimuli  which  underlie  the  special 
senses  are  given  in  the  section  upon  the  cerebral  nerves,  and  it  is  only  neces- 
sary here  to  refer  to  what  is  known  of  the  cortical  representation  of  these  senses. 

Visual  impressions  are  localized  in  the  occipital  lobes.  The  primary  visual 
centre  is  on  the  mesial  surface  in  the  cuneus,  especially  about  the  calcarine 
fissure,  and  here  are  represented  the  opposite  visual  half-fields.  Some  authors 
believe  that  there  is  another  higher  centre  on  the  outer  surface  of  the  occipital 
lobe,  in  which  the  vision  of  the  opposite  eye  is  chiefly  represented.  However 
this  may  be,  most  authors  hold  that  the  angular  gyrus  of  the  left  hemisphere 
is  a  part  of  the  brain  in  which  are  stored  the  memories  of  the  meaning  of 
letters,  words,  figures,  and,  indeed,  of  all  seen  objects.  This  is  designated  as 
the  visual  speech  centre  on  the  diagram  (Fig.  12). 

Auditory  impressions  are  localized  for  the  most  part  in  the  first  temporal 
convolution  and  the  transverse  temporal  gyri,  and  it  is  in  this  region  in  the 
left  hemisphere  that  the  memories  of  the  meanings  of  heard  words  and  sounds 
are  stored.  Musical  memories  are  localized  somewhat  in  front  of  those  for 
words.  The  cortical  centres  for  smell  include  a  part  of  the  base  of  the  frontal 
lobe,  the  uncus,  and  perhaps  the  gyrus  hippocampi.  The  centres  for  taste 
are  supposed  to  be  situated  near  those  for  smell,  but  we  possess  as  yet  no 
definite  information  about  them. 

Topical  Diagnosis. — The  successful  diagnosis  of  the  position  of  a  lesion 
in  the  nervous  system  depends  upon  a  careful  and  exhaustive  examination  into 
all  the  symptoms  that  are  present,  and  then  endeavoring  with  the  help  of 
anatomy  and  physiology  to  determine  the  place,  a  disturbance  at  which  might 
produce  these  symptoms. 

The  abnormalities  of  motion  are  usually  the  most  important  localizing 
symptoms,  both  on  account  of  the  ease  with  which  they  can  be  demonstrated, 
and  also  because  of  the  comparative  accuracy  of  our  knowledge  of  the  motor 
path. 

Lesions  in  any  part  of  the  motor  path  cause  disturbances  of  motion.     If 

destructive,  the  function  of  the  part  is  abolished,  and  as  the  result  there  is 

paralysis.    If,  on  the  other  hand,  the  lesion  is  an  irritative  one,  the  structures 

are  thrown  into  abnormal  activity,  which  produces  abnormal  muscular  con~ 

59 


906 


DISEASES    OF    THE    NERVOUS    SYSTEM 


FIG.  16. — ANTERIOR  ASPECT  OP  THE  SEGMENTAL  SKIN-FIELDS  OF  THE  BODY,  COMBINED 
FROM  THE  STUDIES  OF  HEAD,  KOCHER,  STARR,  THORBURN,  EDINGER,  SHERRINGTON, 
WICHMANN,  SEIFFER,  BOLK,  CUSHING,  AND  OTHERS.  Heavy  lines  represent  levels 
of  fusior  of  dermatomes  and  the  preaxial  and  postaxial  lines  of  the  limbs. 


GENERAL   INTRODUCTION 


907 


FIG.  17. — POSTERIOR  ASPECT  OF  THE  SEGMENTAL,  SKIN-FIELDS  OF  THE  BODY, 


1)08  DISEASES    OF   THE    NERVOUS    SYSTEM 

traction.  The  character  of  the  paralysis  or  of  the  abnormal  muscular  contrac- 
tion varies  with  lesions  of  the  upper  and  lower  segment,  the  variations  depend- 
ing, first,  upon  the  anatomical  position  of  the  two  segments;  and,  secondly, 
upon  the  symptoms  which  are  the  result  of  secondary  degeneration  in  each  of 
the  segments. 

(a)  LESIONS  OF  THE  LOWER  OR  SPINO-MUSCULAR  SEGMENT. — Destructive 
Lesions. — It  has  been  stated  above  that  the  nutrition  of  all  parts  of  a  neurone 
depends  upon  their  connection  with  its  healthy  cell  body ;  and  if  the  cell  body 
be  injured,  its  processes  undergo  degeneration,  or  if  a  portion  of  a  process  be 
separated  from  the  cell  body,  that  part  degenerates  along  its  whole  length. 
This  so-called  secondary  degeneration  plays  a  very  important  role  in  the  symp- 
tomatology. 

In  the  lower  motor  segment  the  degeneration  not  only  affects  the  axis- 
cylinder  processes  which  run  in  the  peripheral  nerves,  but  also  the  muscle  fibres 
in  which  the  axis-cylinder  processes  end.  The  degeneration  of  the  nerves  and 
muscles  is  made  evident,  first  by  the  muscles  becoming  smaller  and  flabby, 
and,  secondly,  by  change  in  their  reaction  to  electrical  stimulation.  The  degen- 
erated nerve  gives  no  response  to  either  the  galvanic  or  the  faradic  current, 
and  the  muscle  does  not  respond  to  faradic  stimulation,  but  reacts  in  a  charac- 
teristic manner  to  the  galvanic  current.  The  contraction,  instead  of  being 
sharp,  quick,  lightning-like,  as  in  that  of  a  normal  muscle,  is  slow  and  lazy, 
and  is  often  produced  by  a  weaker  current,  and  the  anode-closing  contraction 
may  be  greater  than  the  cathode-closing  contraction.  This  is  the  reaction  of 
degeneration,  but  it  is  not  always  present  in  the  classical  form.  The  essential 
feature  is  the  slow,  lazy  contraction  of  the  muscle  to  the  galvanic  current,  and 
when  this  is  present  the  muscle  is  degenerated. 

The  myotatic  irritability,  or  muscle  reflex,  and  the  muscle  tonus  depend 
upon  the  integrity  of  the  reflex  arc,  of  which  the  lower  motor  segment  is  the 
efferent  limb,  and  in  a  paralysis  due  to  lesion  of  this  segment  the  muscle 
reflexes  (tendon  reflexes)  are  abolished  and  there  is  a  diminished  muscular 
tension. 

Lower  segment  paralyses  have  for  their  characteristics  degenerative  atrophy 
with  the  reaction  of  degeneration  in  the  affected  muscles,  loss  of  their  reflex 
excitability,  and  a  diminished  muscular  tension.  These  are  the  general  char- 
acteristics, but  the  anatomical  relations  of  this  segment  also  give  certain 
peculiarities  in  the  distribution  of  the  paralyses  which  help  to  distinguish 
them  from  those  which  follow  lesions  of  the  upper  segment,  and  which  also 
aid  in  determining  the  site  of  the  lesion  in  the  lower  segment  itself.  The 
cell  bodies  of  this  segment  are  distributed  in  groups,  from  the  level  of  the 
peduncles  of  the  brain  throughout  the  whole  extent  of  the  spinal  cord  to  its 
termination  opposite  the  second  lumbar  vertebra,  and  their  axis-cylinder  proc- 
esses run  in  the  peripheral  nerves  to  every  muscle  in  the  body;  so  that  the 
component  parts  are  more  or  less  widely  separated  from  each  other,  and  a 
local  lesion  causes  paralysis  of  only  a  few  muscles  or  groups  of  muscles,  and 
not  of  a  whole  section  of  the  body,  as  is  the  case  where  lesions  affect  the  upper 
segment.  The  muscles  which  are  paralyzed  indicate  whether  the  disease  is  in 
the  peripheral  nerves  or  spinal  cord;  for,  as  we  have  seen  above,  the  muscles 
are  represented  differently  in  the  .peripheral  nerves  and  in  the  spinal  cord. 
Sensory  symptoms,  which  may  accompany  the  paralysis,  are  often  of  great 


GEXEBAL   INTRODUCTION  909 

assistance  in  making  a  local  diagnosis.  Thus,  in  a  paralysis  with  the  charac- 
teristics of  a  lesion  of  the  lower  motor  segment,  if  the  paralyzed  muscles  are 
all  supplied  by  one  nerve,  and  the  anesthetic  area  of  the  skin  is  supplied  by 
that  nerve,  it  is  evident  that  the  lesion  must  be  in  the  nerve  itself.  On  the 
other  hand,  if  the  muscles  paralyzed  are  not  supplied  by  a  single  nerve,  but 
are  represented  close  together  in  the  spinal  cord,  and  the  anesthetic  area 
corresponds  to  that  section  of  the  cord  (see  table),  it  is  equally  clear  that  the 
lesion  must  be  in  the  cord  itself  or  in  its  nerve  roots. 

Irritative  Lesions  of  the  Lower  Motor  Segment. — Lesions  of  this  segment 
cause  comparatively  few  symptoms  of  irritation.  The  fibrillary  contractions 
which  are  so  common  in  muscles  undergoing  degeneration  are  probably  due  to 
stimulation  of  the  cell  bodies  in  their  slow  degeneration,  as  in  progressive  mus- 
cular atrophy,  or  to  irritation  of  the  axis-cylinder  processes  in  the  peripheral 
nerves,  as  in  neuritis.  Lesions  which  affect  the  motor  roots  as  they  leave  the 
central  nervous  system  may  cause  spasmodic  contractions  in  the  muscles  sup- 
plied by  them.  Certain  convulsive  paroxysms,  of.  which  laryngismus  stridu- 
lus  is  a  type,  and  to  which  the  spasms  of  tetany  also  belong,  are  believed  to 
be  due  to  abnormal  activity  in  the  lower  motor  centres.  These  are  the  "lowest 
level  fits"  of  Hughlings  Jackson.  Certain  poisons,  as  strychnia  and  that  of 
tetanus,  act  particularly  upon  these  centres. 

The  lower  motor  segment  may  be  involved  in  all  diseases  involving  the 
peripheral  nerves  in  cerebral  and  spinal  meningitis,  in  injuries,  in  haemor- 
rhages and  tumors  of  the  medulla  and  cord  or  their  membranes,  in  lesions 
of  the  gray  matter  of  the  segment,  in  anterior  poliomyelitis,  progressive  mus- 
cular atrophy,  bulbar  paralysis,  ophthalmoplegia,  syringomyelia,  etc. 

(&)  LESIONS  OF  THE  UPPER  MOTOR  SEGMENT. — Destructive  lesions  cause 
paralysis,  as  in  the  lower  motor  segment,  and  here  again  the  secondary  degen- 
eration which  follows  the  lesion  gives  to  the  paralysis  its  distinctive  character- 
istics. In  this  case  the  paralysis  is  accompanied  by  a  spastic  condition,  shown 
in  an  exaggeration  of  muscle  reflex  and  an  increase  in  the  tension  of  the 
muscle.  It  is  not  accurately  known  how  the  degeneration  of  the  pyramidal 
fibres  causes  this  excess  of  the  muscle  reflex.  The  usual  explanation  is  that 
under  normal  circumstances  the  upper  motor  centres  are  constantly  exerting 
a  restraining  influence  upon  the  activity  of  the  lower  centres,  and  that  when 
the  influence  ceases  to  act,  on  account  of  disease  of  the  pyramidal  fibres,  the 
lower  centres  take  on  increased  activity,  which  is  made  manifest  by  an  exag- 
geration of  the  muscle  reflex. 

We  have  seen  that  the  neurones  composing  each  segment  of  the  motor  path 
are  to  be  considered  as  nutritional  units,  and  therefore  the  secondary  degen- 
eration in  the  upper  segment  stops  at  the  beginning  of  the  lower.  For  this 
reason  the  muscles  paralyzed  from  lesions  in  the  upper  segment  do  not  undergo 
degenerative  atrophy,  nor  do  they  show  any  marked  change  in  their  electrical 
reactions. 

The  separate  parts  of  the  upper  motor  segment  lie  much  more  closely 
together  than  do  those  of  the  lower  segment,  and  therefore  a  small  lesion 
may  cause  paralysis  in  many  muscles.  This  is  more  particularly  true  in  the 
internal  capsule,  where  all  the  axis-cylinder  processes  of  this  segment  are  col- 
lected into  a  compact  bundle — the  pyramidal  tract.  A  lesion  in  this  region 
usually  causes  paralysis  of  most  of  the  muscles  on  the  opposite  side  of  the 


910  DISEASES    OP   THE    NERVOUS    SYSTEM 

body — that  is,  hemiplegia.  The  pyramidal  tract  continues  in  a  compact  bun- 
dle, giving  off  fibres  to  the  motor  nuclei  at  different  levels ;  a  lesion  anywhere 
in  its  course  is  followed  by  paralysis  of  all  the  muscles  whose  spinal  centres 
are  situated  below  the  lesion.  When  the  disease  is  above  the  decussation,  the 
paralysis  is  on  the  opposite  side  of  the  body ;  when  below,  the  paralyzed  muscles 
are  on  the  same  side  as  the  lesion.  Above  the  internal  capsule  the  path  is 
somewhat  more  separated,  and  in  the  cortex  the  centres  for  the  movements  of 
the  different  sections  of  the  body  are  comparatively  far  apart,  and  a  sharply 
localized  lesion  in  this  region  may  cause  a  more  limited  paralysis,  affecting 
a  limb  or  a  segment  of  a  limb — the  cerebral  monoplegias;  but  even  here  the 
paralysis  is  not  confined  to  an  individual  muscle  or  group  of  muscles,  as  is 
commonly  the  case  in  lower  segment  paralysis  (see  Fig.  10  and  explanation). 

To  sum  up,  the  paralyses  due  to  lesions  of  the  upper  motor  segment  are 
widespread,  often  hemiplegic;  the  paralyzed  muscles  are  spastic  (the  tendon 
reflexes  exaggerated),  they  do  not  undergo  degenerative  atrophy,  and  they  do 
not  present  the  degenerative  reaction  to  electrical  stimulation. 

There  is  an  exception  to  the  above  statement — that  is,  in  the  paralyses 
which  follow  a  complete  transverse  lesion  of  the  spinal  cord.  Here  the  limbs 
are  of  course  completely  paralyzed,  but  instead  of  being  spastic  they  are  flaccid 
and  the  deep  reflexes  are  absent.  The  muscles  react  normally  'to  electricity. 
There  is  no  satisfactory  explanation  of  the  loss  of  the  reflexes  under  these 
conditions. 

Irritative  Lesions  of  the  Upper  Motor  Segment. — Our  knowledge  of  such 
lesions  is  confined  for  the  most  part  to  those  acting  on  the  motor  cortex.  The 
abnormal  muscular  contractions  resulting  from  lesions  so  situated  have  as 
their  type  the  localized  convulsive  seizures  classed  under  Jacksonian  or  cortical 
epilepsy,  which  are  characterized  by  the  convulsion  beginning  in  a  single  mus- 
cle or  group  of  muscles  and  involving  other  muscles  in  a  definite  order,  de- 
pending upon  the  position  of  their  representation  in  the  cortex.  For  instance, 
such  a  convulsion,  beginning  in  the  muscles  of  the  face,  next  involves  those  of 
the  arm  and  hand,  and  then  the  leg.  The  convulsion  is  usually  accompanied 
by  sensory  phenomena  and  followed  by  a  weakness  of  the  muscles  involved. 

A  majority  of  lesions  of  the  motor  cortex  are  both  destructive  and  irrita- 
tive— i.  e.,  they  destroy  the  nerve  cells  of  a  certain  centre,  and  either  in  their 
growth  or  by  their  presence  throw  into  abnormal  activity  those  of  the  sur- 
rounding centres. 

The  upper  motor  segment  is  involved  in  nearly  all  the  diseases  of  the 
brain  and  spinal  cord,  especially  in  injuries,  tumors,  abscesses,  and  haemor- 
rhages; transverse  lesions  of  the  cord;  syringomyelia,  progressive  muscular 
atrophy,  bulbar  paralysis,  etc.  One  lesion  often  involves  both  the  upper  and 
the  lower  motor  segments,  and  there  is  paralysis  in  the  different  parts  of  the 
body,  with  the  characteristics  of  each.  Such  a  combination  enables  us  in 
many  cases  to  make  an  accurate  local  diagnosis. 

Lesions  in  the  optic  path  and  in  the  different  speech  centres  also  give 
localizing  symptoms,  which  should  always  be  looked  for. 

(c)  LESION.S  OF  THE  SENSORY  PATH. — Here  again  the  lesion  may  be 
either  irritative  or  destructive.  Irritative  lesions  cause  abnormal  subjective 
sensory  impressions — paraesthesia,  formication,  a  sense  of  cold  or  constriction, 
and  pain  of  every  grade  of  intensity.  The -character  of  the  sensory  symptoms 


GENERAL    INTRODUCTION  911 

gives  very  little  indication  as  to  the  position  of  the  irritating  process.  In- 
tense pain  is,  as  a  rule,  a  symptom  of  a  lesion  in  the  peripheral  sensory  neu- 
rones, but  it  may  be  caused  by  a  disease  of  the  sensory  path  within  the  central 
nervous  system. 

The  exact  distribution  of  symptoms  gives  more  accurate  data,  for  if  they 
are  confined  to  the  distribution  of  a  peripheral  nerve  or  of  a  spinal  seg- 
ment the  indication  is  plain.  If  one  side  of  the  body  is  more  or  less  com- 
pletely affected,  the  lesion  is  somewhere  within  the  brain,  etc. 

Destructive  Lesions. — A  complete  destruction  of  the  sensory  paths  from 
any  part  of  the  body  would  of  course  deprive  that  part  of  sensation  in  all  its 
qualities.  This  occurs  most  frequently  from  injury  to  the  peripheral  sensory 
neurones  within  the  peripheral  nerves,  and  the  area  of  anaesthesia  depends 
upon  the  nerve  injured.  Complete  transverse  lesion  of  the  cord  causes  com- 
plete anesthesia  below  the  injury. 

Unilateral  lesions  of  the  cord,  medulla,  dorsal  part  of  the  pons,  tegmentum, 
thalamus,  internal  capsule,  and  cortex  cause  disturbances  of  sensation  on  the 
opposite  side  of  the  body;  here  again  the  extent  of  the  defect  more  than  its 
character  helps  us  to  determine  the  position  of  the  lesion.  Hemianaisthesia 
involving  the  face  as  well  as  the  rest  of  the  body  can  only  occur  above  the 
place  where  the  sensory  paths  from  the  fifth  nerve  have  crossed  the  middle 
line  on  their  way  to  the  cortex.  This  is  in  the  upper  part  of  the  pons.  From 
this  point  to  where  they  leave  the  internal  capsule  the  sensory  paths  are  in 
fairly  close  relation,  and  are  at  times  involved  in  a  very  small  lesion.  Above 
the  internal  capsule  the  paths  diverge  quickly,  and  for  this  reason  only  an 
extensive  lesion  can  involve  them  all,  and  in  lesions  of  this  part  we  are  more 
apt  to  have  the  sensory  disturbances  confined  to  one  or  another  region  of  the 
body.  Unilateral  lesions  of  the  thalamus,  pons,  medulla,  and  cord  usually 
cause  sensory  disturbances  on  the  same  side  of  the  body,  as  well  as  those  on 
the  opposite  side.  These  are  due  to  the  involvement  of  the  sensory  paths  as 
they  enter  the  central  nervous  system  at  or  a  little  below  the  site  of  the 
lesion  and  before  the  axones  of  the  sensory  neurones  of  the  second  order  have 
crossed  the  middle  line.  The  area  of  disturbed  sensation  on  the  same  side  is 
limited  to  the  distribution  of  one  or  more  spinal  segments  and  often  indicates 
tccurately  the  position  and  extent  of  the  diseased  process.  As  a  rule,  destruc- 
tive lesions  of  the  central  nervous  system  do  not  involve  all  the  paths  of 
sensory  conduction,  and  the  loss  of  sensation  is  not  complete.  It  is  often 
astonishing  how  very  slight  the  sensory  disturbances  are  which  result  from 
an  extensive  lesion.  Sensation  may  be  diminished  in  all  of  its  qualities,  or, 
what  is  more  common,  certain  qualities  may  be  affected  while  others  are 
normal.  These  cases  of  dissociation  of  sensation,  or  so-called  elective  sensory 
paralysis,  have  been  much  studied  of  late.  Thus,  the  sense  of  pain  and  tem- 
perature may  be  lost  while  that  of  touch  remains  normal,  as  is  often  the  case 
in  diseases  of  the  spinal  cord,  or  there  may  be  simply  a  loss  of  the  muscular 
sense  and  of  the  stereognostic  sense  (the  complex  sensory  impression  which 
enables  one  to  recognize -an  object  placed  in  the  hand),  as  occurs  frequently 
from  lesions  of  the  cortex.  Occasionally  pain  sensation  persists  with  loss  of 
tactile  and  thermic  sensations.  Almost  every  other  combination  has  been  de- 
scribed. It  is  the  distribution  more  than  the  character  of  the  sensory  defect 
that  is  of  importance,  and  often  the  distribution  gives  but  uncertain  indica- 


912  DISEASES    OF    THE    NERVOUS    SYSTEM 

tion  of  the  position  of  the  lesion.    The  combination  of  the  sensory  defect  with 
different  forms  of  paralysis  gives  the  most  certain  diagnostic  signs- 


B.    SYSTEM  DISEASES 
I.     INTRODUCTION 

There  are  certain  diseases  of  the  nervous  system  which  are  confined,  if 
not  absolutely,  still  in  great  part,  to  definite  tracts  (combinations  of  neurones) 
which  subserve  like  functions.  These  tracts  are  called  systems,  and  a  disease 
which  is  confined  to  one  of  them  is  a  system  disease.  If  more  than  one  system 
is  involved,  the  process  is  called  a  combined  system  disease.  Just  what  dis- 
eases should  be  classed  under  these  names  has  given  rise  to  much  discussion 
but  to  very  little  agreement.  We  can  not  speak  positively;  our  knowledge  is 
as  yet  not  sufficiently  accurate,  either  in  regard  to  the  exact  limits  of  the  sys- 
tems themselves,  or  to  the  nature  and  extent  of  the  morbid  process  in  the 
several  diseases. 

It  may  be  said  that  the  nervous  system  is  composed  of  two  great  systems 
of  neurones,  the  afferent  or  sensory  system  and  the  efferent  or  motor  system, 
and  the  connections  between  them.  (See  General  Introduction.) 

Locomotor  ataxia  is  a  disease  confined  at  its  onset  to  the  afferent  system, 
and  progressive  muscular  atrophy  is  one  of  the  efferent  system.  Representing 
typical  system  diseases  as  we  now  understand  them,  they  have  been  taken  as 
the  basis  of  the  classification.  Several  theories  have  been  advanced  to  explain 
why  a  disease  should  be  limited  to  a  definite  system  of  neurones.  One  view  is 
based  upon  the  idea  that  in  certain  individuals  one  or  the  other  of  these  sys- 
tems has  an  innate  tendency  to  undergo  degeneration;  another  assumes  that 
neurones  with  a  similar  function  have  a  similar  chemical  construction  (which 
differs  from  that  of  neurones  with  a  different  function),  and  this  is  taken  to 
explain  why  a  poison  circulating  in  the  blood  should  show  a  selective  action 
for  a  single  functional  system  of  neurones. 

In  the  afferent  tract  locomotor  ataxia  stands  alone  as  a  system  disease, 
and  we  now  believe  that  herpes  zoster  is  an  inflammation  of  the  dorsal  root 
ganglia  and  stands  in  the  same  relation  to  tabes  that  acute  anterior  polio- 
myelitis does  to  chronic  progressive  muscular  atrophy.  In  the  efferent  tract 
progressive  (central)  muscular  atrophy  is  the  chief  representative,  as  in  it 
the  whole  motor  path  is  more  or  less  involved.  Theoretically,  primary  lateral 
sclerosis  is  a  disease  confined  to  the  upper  segment  of  the  efferent  tract,  while 
chronic  anterior  poliomyelitis  involves  the  lower  segment  of  the  tract. 

In  connection  with  locomotor  ataxia,  general  paralysis  is  considered  on 
account  of  their  frequent  association  and  as  they  are  but  different  expressions 
of  one  and  the  same  morbid  process;  and  with  progressive  (central)  muscular 
atrophy,  the  other  forms  of  muscular  atrophy  are  considered  as  a  matter  of 
convenience.  In  other  instances,  too,  diseases  are  arranged  in  positions  to 
which  they  might  not  be  entitled,  had  a  rigid  classification  of  system  diseases 
been  maintained. 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM     913 

II.     DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM 

1.     LOCOMOTOR   ATAXIA 
(Tabes  Dorsalis;  Posterior  Spinal  Sclerosis) 

Definition. — An  affection  characterized  clinically  by  sensory  disturbances, 
incoordination,  trophic  changes,  and  involvement  of  the  special  senses,  par- 
ticularly the  eyes.  Anatomically  there  are  found  degenerations  of  the  root 
fibres  of  the  dorsal  columns  of  the  cord,  of  the  dorsal  roots,  and  at  times  of 
the  spinal  ganglia  and  peripheral  nerves.  Degenerations  have  been  described 
in  the  brain,  particularly  the  cortex  cerebri,  in  the  ganglion  cells  of  the  cord, 
and  in  the  endogenous  fibres  of  the  dorsal  columns. 

Etiology. — It  is  a  widespread  disease,  more  frequent  in  cities  than  in  the 
country.  The  relative  proportion  may  be  judged  from  the  fact  that  of  16,562 
cases  in  the  neurological  dispensary  of  the  Johns  Hopkins  Hospital  there 
were  201  cases  of  locomotor  ataxia.  Males  are  attacked  more  frequently  than 
females,  the  proportion  being  nearly  10  to  1.  The  disease,  although  uncom- 
mon in  the  negro,  is  seen  in  them  more  frequently  than  some  authors  state. 
It  is  a  disease  of  adult  life,  the  great  majority  of  cases  occurring  between  the 
thirtieth  and  fiftieth  years.  Occasionally  cases  are  seen  in  young  men,  and 
it  may  occur  in  children  with  hereditary  syphilis.  Syphilis  is  the  important 
cause.  In  the  Johns  Hopkins  Hospital  the  percentage,  as  found  by  Thomas, 
was  63.1.  Erb's  figures  are  most  striking — of  300  cases  of  tabes  in  private 
practice,  89  per  cent,  had  had  syphilis.  Moebius  goes  so  far  as  to  say,  "The 
longer  I  reflect  upon  it,  the  more  firmly  I  believe  that  tabes  never  originates 
without  syphilis,"  and  recent  results  of  cases  tested  with  the  Wassermann  reac- 
tion bear  out  this  statement. 

Contributing  causes  are  excessive  fatigue,  overexertion,  injury,  exposure  to 
cold  and  wet,  and  sexual  excesses.  There  are  instances  in  which  the  disease 
has  closely  followed  severe  exposure.  Trauma  has  been  noted  in  a  few  cases. 
Alcoholic  excess  does  not  seem  to  predispose  to  the  disease.  There  are  now 
a  good- many  cases  on  record  of  the  existence  of  the  disease  in  both  husband 
and  wife,  and  a  few  in  which  the  children  were  also  affected. 

Morbid  Anatomy  and  Pathology. — Posterior  spinal  sclerosis,  although  the 
most  obvious  gross  change,  is  now  no  longer,  as  in  Romberg's  time,  an  ade- 
quate description  of  the  condition.  The  dorsal  fibres  are  of  two  kinds,  those 
with  their  cell  bodies  outside  the  cord  in  the  spinal  ganglia,  the  so-called 
exogenous,  or  root  fibres,  and  those  which  arise  from  cells  within  the  cord, 
the  endogenous  fibres.  These  two  sets  occupy  fairly  well-determined  regions, 
and  a  study  of  early  cases  of  tabes  has  shown  that  it  is  the  exogenous  or  root 
fibres  that  are  first  affected.  The  fibres  of  the  dorsal  roots  enter  the  cord  in 
two  divisions,  an  external  and  an  internal;  the  former  is  composed  of  fibres 
of  small  calibre,  which,  in  the  cord,  make  up  Lissauer's  tract,  and  occupy  the 
space  between  the  apex  of  the  dorsal  cornua  and  the  periphery  of  the  cord, 
and  really  do  not  form  part  of  the  dorsal  columns.  They  are  short,  soon  enter- 
ing the  gray  matter,  and  do  not  seem  to  be  affected,  or  only  slightly  so,  in 
early  cases. 

The  larger  fibres  enter  the  cord  by  the  internal  division,  just  medial  to  the 


914  DISEASES    OF    THE    NERVOUS    SYSTEM 

cornua,  in  what  is  known  as  the  root  entry  zone.  Some  enter  the  gray  matter 
of  the  spinal  cord  almost  directly  and  others  after  a  longer  course,  while  still 
others  run  in  the  cord  to  the  medulla,  to  end  in  the  nuclei  of  the  dorsal  col- 
umns. As  the  fibres  of  every  spinal  nerve  enter  the  cord  between  the  dorsal 
cornua  and  the  nerve  fibres  which  have  entered  lower  down,  the  fibres  from 
each  root  are  successively  pushed  more  and  more  toward  the  median  line,  and 
so  in  the  cervical  cord  the  fasciculi  of  Goll  are  largely  composed  of  long  fibres 
derived  from  the  sacral  and  lumbar  Toots. 

That  it  is  the  coarse  dorsal  root  fibres  which  are  first  affected  in  tabes  is 
generally  admitted,  but  there  is  much  divergence  of  opinion  as  to  the  char- 
acter and  location  of  the  initial  process. 

Nageotte  calls  attention  to  the  frequency  of  a  transverse,  interstitial  neu- 
ritis of  the  dorsal  roots  just  after  they  have  left  the  ganglia  and  are  still  sur- 
rounded by  the  dura,  and  he  believes  that  it  is  this  neuritis  which  is  the 
primary  lesion  in  tabes.  Obersteiner  and  Eedlich  have  laid  great  stress  on 
the  presence  of  an  inflammation  of  the  pia  mater  over  the  dorsal  aspect  of  the 
cord,  which  involves  the  root  fibres  as  they  pass  through.  They  point  out 
that  it  is  just  here  that  the  dorsal  roots  are  most  vulnerable,  for  at  this  point 
— that  is,  while  surrounded  by  the  pia — they  are  almost  completely  devoid  of 
their  myelin  sheaths.  Changes  in  the  blood-vessels  of  the  cord,  of  the  pia,  and 
of  the  nerve  roots  have  been  described  in  early  tabes,  and  Marie  and  Guillain 
have  advanced  the  belief  that  the  changes  in  the  cord  are  due  to  an  affection 
(syphilis)  of  the  posterior  lymphatic  system  which  is  confined  to  the  dorsal 
columns  of  the  cord,  the  pia  mater  over  them,  and  the  dorsal  roots.  For  them 
the  changes  in  the  nervous  system  are  only  apparently  radicular  or  systemic. 

With  the  Marchi  stain,  degeneration  of  the  root  fibres  in  the  root-entry 
zone  is  a  constant  finding.  This  change  is  radicular  in  the  sense  that  it  varies 
in  intensity  with  the  different  roots  and  is  most  marked  in  the  sacral  and 
lumbar  regions.  The  degeneration  is  not  found  in  the  dorsal  roots,  but  begins 
within  the  cord  just  beyond  where  the  root  fibres  lose  their  neurolemma  and 
their  myelin  sheaths.  Degenerated  fibres  may  be  traced  into  the  dorsal  gray 
matter  and  among  the  ganglion  cells  of  the  columns  of  Clarke.  The  long  col- 
umns which  ascend  the  cord  also  degenerate. 

In  more  advanced  cases,  in  addition  to  the  lesion  described  above,  there  are 
degeneration  of  the  dorsal  roots  and  some  alteration  of  the  cells  in  the  spinal 
ganglia.  The  fibres  distal  to  the  ganglia  are  practically  normal,  although  at 
times  the  sensory  fibres,  at  the  periphery  of  a  limb,  show  degeneration.  Within 
the  cord,  the  exogenous  fibres  are  diseased  as  already  described;  there  is  also 
degeneration  in  the  endogenous  system  of  fibres.  Optic  atrophy  is  frequently 
found.  The  other  cranial  nerves,  especially  the  fifth  with  its  ganglion,  have 
been  found  degenerated. 

The  disease  occasionally  spreads  beyond  the  sensory  system  in  the  cord, 
and  in  advanced  cases  the  cells  in  the  ventral  horns  may  be  degenerated  in 
association  with  muscular  atrophy.  Mott  very  generally  found  more  or  less 
marked  changes  in  the  pyramidal  fibres;  these  he  believed  to  be  evidence  of 
changes  in  the  cerebral  cortex.  Degeneration  of  the  cortex  may  exist,  but 
even  in  cases  where  the  mental  symptoms  are  absent,  or  very  mild,  similar 
though  slight  changes  have  been  described,  just  as  in  general  paralysis,  without 
marked  tabetic  symptoms,  there  may  be  degeneration  of  the  dorsal  columns- 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM     915 

The  close  association,  or  even  identity,  of  tabes  and  general  paralysis  will  be 
considered  later. 

Symptoms. — These  are  best  considered  under  three  stages — the  incipient 
stage,  the  ataxic  stage,  and  the  paralytic  stage. 

INCIPIENT  STAGE. — This  is  sometimes  called  the  pre-ataxic  stage.  The 
manner  in  which  tabes  makes  its  onset  differs  very  widely  in  the  different 
cases,  and  mistakes  in  diagnosis  are  often  made  early  in  the  disease.  The  fol- 
lowing are  the  most  characteristic  initial  symptoms : 

Pains,  usually  of  a  sharp  stabbing  character;  hence,  the  term  lightning 
pains.  They  last  for  only  a  second  or  two  and  are  most  common  in  the  legs 
or  about  the  trunk,  and  tend  to  follow  dorsal  root  areas.  They  dart  from 
place  to  place.  At  times  they  are  associated  with  a  hot  burning  feeling  and 
often  leave  the  affected  area  painful  to  pressure,  and  occasionally  herpes  may 
follow.  The  intensity  of  the  pain  varies  from  a  sore,  burning  feeling  of  the 
skin  to  a  pain  so  intense  that,  were  it  not  for  momentary  duration,  it  would 
exceed  human  endurance.  They  occur  at  irregular  intervals,  and  are  prone 
to  follow  excesses  or  to  come  on  when  health  is  impaired.  When  typical,  these 
pains  are  practically  pathognomonic  of  the  condition.  The  gastric  crises  and 
other  crises  may  occur.  Parasthesia  may  also  be  among  the  first  symptoms — 
numbness  of  the  feet,  tingling,  etc. — and  at  times  a  sense  of  constriction  about 
the  body. 

Ocular  Symptoms. —  (a)  Optic  atrophy.  This  occurs  in  about  10  per  cent, 
of  the  cases,  and  is  often  an  early  and  even  the  first  symptom.  There  is  a 
gradual  loss  of  vision,  which  in  a  large  majority  of  cases  leads  to  total  blind- 
ness. (&)  Ptosis,  which  may  be  double  or  single,  (c)  Paralysis  of  the  exter- 
nal muscles  of  the  eye.  This  may  be  of  a  single  muscle  or  occasionally  of  all 
the  muscles  of  the  eye.  The  paralysis  is  often  transient,  the  patient  merely 
complaining  that  he  saw  double  for  a  certain  period,  (d)  Argyll-Robertson 
pupil,  in  which  there  is  loss  of  the  iris  reflex  to  light  but  contraction  during 
accommodation.  The  pupils  are  often  very  small — spinal  myosis. 

Bladder  Symptoms. — The  first  warning  of  the  disease  which  the  patient 
has  may  be  a  certain  difficulty  in  emptying  the  bladder.  Incontinence  of 
urine  occurs  only  at  a  later  stage  of  the  disease.  Decrease  in  sexual  desire 
and  power  may  also  be  an  early  symptom. 

Trophic  Disturbances. — These  usually  occur  later  in  the  disease,  but  at 
times  they  are  very  early  symptoms,  and  it  is  not  very  infrequent  to  have  one's 
attention  called  to  the  trouble  by  the  presence  of  a  perforating  ulcer  or  of  a 
characteristic  Charcot's  joint. 

Loss  of  the  Deep  Reflexes. — This  early  and  most  important  symptom  may 
occur  years  before  the  development  of  ataxia.  Even  alone  it  is  of  great  mo- 
ment, since  it  is  very  rare  to  meet  with  individuals  in  whom  the  knee  and 
ankle  jerks  are  normally  absent.  The  combination  of  loss  of  either  of  these 
with  one  or  more  of  the  symptoms  mentioned  above,  especially  with  the  light- 
ning pains  and  ptosis  or  Argyll-Robertson  pupil,  is  practically  diagnostic. 
These  reflexes  gradually  decrease,  and  one  may  be  lost  before  the  other,  or 
disappear  first  in  one  leg. 

These  are  the  most  common  symptoms  of  the  initial  stage  of  tabes  and 
may  persist  for  years  without  the  development  of  incoordination.  The  patient 
may  look  well  and  feel  well,  and  be  troubled  only  by  occasional  attacks  of 


916  DISEASES    OF    THE    NERVOUS    SYSTEM 

lightning  pains  or  of  one  of  the  other  subjective  symptoms.  Moebius  goes 
so  far  as  to  state  that  the  typical  Argyll-Robertson  pupil  means  either  tabes 
or  general  paralysis,  and  that  paralysis  of  the  external  muscles  of  the  eye 
developing  in  adults  is  of  almost  equal  importance,  especially  if  it  develops 
painlessly. 

The  time  between  the  syphilitic  infection  and  the  occurrence  of  the  first 
symptoms  of  locomotor  ataxia  varies  within  wide  limits.  About  one-half  the 
cases  occur  between  the  sixth  and  fifteenth  year,  but  many  begin  even  later 
than  this. 

The  disease  may  never  progress  beyond  this  stage,  and  when  optic  atrophy 
develops  early  and  leads  to  blindness,  ataxia  rarely,  if  ever,  supervenes,  but  the 
mental  symptoms  of  paresis  not  infrequently  follow,  a  sequence  which  must 
be  kept  in  mind.  There  is  a  sort  of  antagonism  between  the  ocular  symptoms 
and  the  progress  of  the  ataxia.  Charcbt  laid  considerable  stress  upon  this,  and 
both  Dejerine  and  Spiller  have  since  emphasized  the  point. 

ATAXIC  STAGE. — Motor  Symptoms. — The  ataxia  is  believed  to  be  due  to 
a  disturbance  or  loss  of  the  afferent  impulses  from  the  muscles,  joints,  and 
deep  tissues,  and  a  disturbance  of  the  muscle  sense  itself  can  usually  be  dem- 
onstrated. It  develops  gradually.  One  of  the  first  indications  to  the  patient  is 
inability  to  get  about  readily  in  the  dark  or  to  maintain  his  equilibrium  when 
washing  his  face  with  the  eyes  shut.  When  the  patient  stands  with  the  feet 
together  and  the  eyes  closed,  he  sways  and  has  difficulty  in  maintaining  his 
position  (Romberg's  symptom),  and  he  may  be  quite  unable  to  stand  on  one 
leg.  He  does  not  start  off  promptly  at  the  word  of  command.  On  turning 
quickly  he  is  apt  to  fall.  He  descends  stairs  with  more  difficulty  than  he 
ascends  them.  Gradually  the  characteristic  ataxic  gait  develops.  The  patient, 
as  a  rule,  walks  with  a  stick,  the  eyes  are  directed  to  the  ground,  the  body 
is  thrown  forward,  and  the  legs  are  wide  apart.  In  walking,  the  leg  is  thrown 
out  violently,  the  foot  is  raised  too  high  and  is  brought  down  in  a  stamping 
manner  with  the  heel  first,  or  the  whole  sole  comes  in  contact  with  the  ground. 
Ultimately  the  patient  may  be  unable  to  walk  without  the  assistance  of  two 
canes.  This  gait  is  very  characteristic,  and  unlike  that  seen  in  any  other  dis- 
ease. The  incoordination  is  not  only  in  walking,  but  in  the  performance  of 
other  movements.  If  the  patient  is  asked,  when  in  the  recumbent  posture,  to 
touch  one  knee  with  the  other  foot,  the  irregularity  of  the  movement  is  very 
evident.  Incoordination  of  the  arms  is  less  common,  but  usually  develops  in 
some  grade.  It  may  in  rare  instances  exist  before  the  incoordination  of  the 
legs.  It  may  be  tested  by  asking  the  patient  to  close  his  eyes  and  to  touch 
the  tip  of  the  nose  or  the  tip  of  the  ear  with  the  finger,  or  with  the  arms 
thrust  out  to  bring  the  tips  of  the  fingers  together.  The  incoordination 
may  early  be  noticed  by  a  difficulty  which  the  patient  experiences  in  but- 
toning his  collar  or  in  performing  one  of  the  ordinary  routine  acts  of  dress- 
ing. 

One  of  the  most  striking  features  of  the  disease  is  that  with  marked  inco- 
ordination there  is  but  little  loss  of  muscular  power.  The  grip  of  the  hands 
may  be  strong  and  firm,  the  power  of  the  legs,  tested  by  trying  to  flex*  them, 
may  be  unimpaired,  and  their  nutrition,  except  toward  the  close,  may  be 
unaffected. 

There  is  a  remarkable  muscular  relaxation  (hypotonia)  which  enables  the 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM     91? 

joints  to  be  placed  in  positions  of  hyperextension  and  hyperflexion.  It  gives 
sometimes  a  marked  backward  curve  to  the  legs. 

Sensory  Symptoms. — The  lightning  pains  may  persist.  They  vary  greatly 
in  different  cases.  Some  patients  are  rendered  miserable  by  the  frequent  occur- 
rence of  the  attacks;  others  escape  altogether.  In  addition,  common  symp- 
toms are  tingling,  pins  and  needles,  particularly  in  the  feet,  and  areas  of 
hyperassthesia  'or  of  anesthesia.  The  patient  may  complain  of  a  change  in 
the  sensation  in  the  soles  of 'the  feet,  as  if  cotton  was  interposed  between  the 
floor  and  the  skin.  Sensory  disturbances  occur  less  frequently  in  the  hands. 
Objective  sensory  disturbances  can  usually  be  demonstrated,  and,  indeed, 
almost  every  variety  of  sensory  disturbance  has  been  described.  Bands  of  a 
moderate  grade  of  anaesthesia  about  the  chest  are  not  uncommon ;  they  are  apt 
to  follow  the  distribution  of  spinal  segments.  The  most  marked  disturbances 
are  usually  found  on  the  legs.  Retardation  of  the  sense  of  pain  is  common, 
and  a  pin  prick  on  the  foot  is  first  felt  as  a  simple  tactile  impression,  and  the 
sense  of  pain  is  not  perceived  for  a  second  or  two  or  may  be  delayed  for  as  much 
as  ten  seconds.  The  pain  felt  may  persist.  A  curious  phenomenon  is  the 
loss  of  the  power  of  localizing  the  pain.  For  instance,  if  the  patient  is  pricked 
on  one  limb  he  may  say  that  he  feels  it  on  the  other  (allocheiria),  or  a  pin 
prick  on  the  foot  may  be  felt  on  both  feet.  The  muscular  sense  which  is  usu- 
ally affected  early,  becomes  much  impaired  and  the  patient  no  longer  recog- 
nizes the  position  in  which  his  limbs  are  placed.  This  may  be  present  in  the 
pre-ataxic  stage. 

Reflexes. — As  mentioned,  the  loss  of  the  knee  and  ankle  jerks  is  one  of  the 
earliest  symptoms  of  the  disease.  Occasionally  a  case  is  found  in  which  they 
are  retained,  and  anatomically  it  has  been  shown  that  in  these  cases  the  lumbar 
segments  were  little  if  at  all  involved.  The  skin  reflexes  may  at  first  be 
increased,  but  later  are  usually  involved  with  the  deep  reflexes. 

Special  Senses. — The  eye  symptoms  noted  above  may  be  present,  but,  as 
mentioned,  ataxia  is  rare  with  atrophy  of  the  optic  nerve. 

Deafness  may  occur,  due  to  lesion  of  the  auditory  nerve.  There  may  also 
be  attacks  of  vertigo.  Olfactory  symptoms  are  rare. 

Visceral  Symptoms. — Among  the  most  remarkable  sensory  disturbances 
are  the  tabetic  crises,  severe  paroxysms  of  pain  referred  to  various  viscera; 
thus,  laryngeal,  gastric,  nephric,  rectal,  urethral,  and  clitoral  crises  have  been 
described.  The  most  common  are  the  gastric  and  laryngeal.  Gastric  crises 
may  occur  early  and  persist  as  the  most  prominent  feature.  Starr  found  them 
as  the  first  symptom  18  times  in  450  cases.  The  onset  is  usually  sudden,  with 
pain  of  a  severe  burning,  twisting  type  in  the  epigastrium,  radiating  to  the 
back  and  behind  the  sternum.  Vomiting  follows  the  pain,  and  may  be  quite 
independent  of  food.  Pallor,  sweating,  cold  extremities,  and  a  small  pulse 
are  associated,  and  in  rare  instances  death  occurs  in  collapse.  The  attacks  are 
not  unlike  and  are  probably  of  the  same  nature  as  the  so-called  abdominal 
angina  pectoris.  The  blood  pressure  may  be  very  high,  as  reported  by  Barker, 
and  it  seems  not  improbable  that  the  condition  is  associated  with  angiospasm 
in  the  territory  of  the  gastric  and  mesenteric  vessels.  No  special  change  may 
be  found  at  autopsy.  In  the  laryngeal  crises  there  may  be  true  spasm  with 
dyspnoea  and  noisy  inspiration.  A  patient  may  die  in  the  attack.  There  are 
also  nasal  crises,  associated  with  sneezing  fits. 


918  DISEASES    OF    THE    NERVOUS    SYSTEM 

The  sphincters  are  frequently  involved.  Early  in  the  disease  there  may 
be  a  retardation  or  hesitancy  in  making  water.  Later  there  is  retention,  and 
cystitis  may  occur.  Unless  great  care  is  taken  the  inflammation  may  extend 
to  the  kidneys.  Constipation  is  extremely  common.  Later  in  the  disease  the 
sphincter  ani  is  weakened.  The  sexual  power  is  usually  lost  in  the  ataxic 
stage. 

Trophic  Changes. — Skin  rashes,  such  as  herpes,  oedema,  or  local  sweating, 
may  develop  in  the  course  of  the  lightning  pains.  •  Alteration  in  the  nails  may 
occur.  A  perforating  ulcer  may  develop  on  the  foot,  usually  beneath  the  great 
toe.  A  perforating  buccal  ulcer  has  also  been  described.  Onychia  may  prove 
very  troublesome. 

Arthropathies  (Charcot's  Joints). — Anatomically  there  are:  (1)  enlarge- 
ment of  the  capsule  with  thickening  of  the  synovial  membranes  and  increase 
in  the  fluids;  (2)  slight  enlargement  of  the  ends  of  the  bones,  with  slight 
exostoses;  (3)  a  dull  velvety  appearance  of  the  cartilages,  with  atrophy  in 
places  (V.  E.  Henderson).  The  knees  are  most  frequently  involved.  The 
spine  is  affected  in  rare  instances.  Eecurring  trauma  is  an  important  element 
in  the  causation,  but  trophic  disturbances  have  a  strong  influence  in  the  eti- 
.  ology.  A  striking  feature  is  the  absence  of  pain.  Suppuration  may  occur, 
also  spontaneous  fractures.  Among  other  trophic  disturbances  may  be  men- 
tioned atrophy  of  the  muscles,  which  is  usually  a  late  manifestation,  but  may 
be  localized  and  associated  with  neuritis.  In  any  very  large  collection  of  cases 
many  instances  of  atrophy  are  found,  due  either  to  involvement  of  the  ventral 
horns  or  to  peripheral  neuritis. 

Aneurism  is  found  in  many  cases,  in  as  high  as  20  per  cent,  of  some  series. 

Cerebral  Symptoms. — Hemiplegia  may  develop  at  any  stage  of  the  disease, 
more  commonly  when  it  is  well  advanced.  It  may  be  due  to  haemorrhagic 
softening  in  consequence  of  disease  of  the  vessels  or  to  progressive  cortical 
changes.  Hemianassthesia  is  sometimes  present.  Very  rarely  the  hemiplegia 
is  due  to  coarse  syphilitic  disease. 

Dementia  paralytica  frequently  exists  with  tabes;  indeed,  we  have  come 
to  regard  these  two  diseases  as  simply  different  localizations  of  the  same 
morbid  process.  In  other  instances  melancholia,  dementia,  or  paranoia  oc- 
cur. 

PARALYTIC  STAGE. — After  persisting  for  an  indefinite  number  of  years 
the  patient  gradually  loses  the  power  of  walking  and  becomes  bedridden  or 
paralyzed.  In  this  condition  he  is  very  likely  to  be  carried  off  by  some  inter- 
current  affection,  such  as  pyelo-nephritis,  pneumonia,  or  tuberculosis. 

THE  COURSE  OF  THE  DISEASE. — A  patient  may  remain  in  the  pre-ataxic 
stage  for  an  indefinite  period ;  and  the  loss  of  knee-jerk  and  the  gray  atrophy 
of  the  optic  nerves  may  be  the  sole  indication  of  the  true  nature  of  the  disease. 
In  such  cases  incoordination  rarely  develops.  In  a  majority  of  cases  the 
progress  is  slow,  and  after  six  or  eight  years,  sometimes  less,  the  ataxia  is  well 
developed.  The  symptoms  may  vary  a  good  deal;  thus,  the  pains,  which  may 
have  been  excessive  at  first,  often  lessen.  The  disease  may  remain  stationary 
for  years ;  then  exacerbations  occur  and  it  makes  rapid  progress.  Occasionally 
the  process  seems  to  be  arrested.  There  are  instances  of  what  may  be  called 
acute  ataxia,  in  which,  within  a  year  or  even  less,  the  incoordination  is  marked, 
and  the  paralytic  stage  may  develop  within  a  few  months.  The  disease  itself 


DISEASES  OP  THE  AFFERENT  OR  SENSORY  SYSTEM     919 

rarely  causes  death,  and  after  becoming  bedridden  the  patient  may  live  for 
fifteen  or  twenty  years. 

Diagnosis.— In  the  initial  stage  the  lightning  pains  are  almost  distinctive, 
and  when  combined  with  any  of  the  other  signs  are  quite  so.  The  association 
of  progressive  atrophy  of  the  optic  nerves  with  loss  of  knee-jerk  is  also  char^ 
acteristic.  The  early  ocular  palsies  are  of  the  greatest  importance.  A  squint, 
ptosis,  or  the  Argyll-Robertson  pupil  may  be  the  first  symptom,  and  may  exist 
with  the  loss  only  of  the  knee-jerk.  Loss  of  the  knee-jerk  alone,  however,  does 
occasionally  occur  in  healthy  individuals.  A  history  of  preceding  syphilis 
lends  added  weight  to  the  symptoms,  and  its  presence  or  absence  may  be  of 
the  utmost  importance  in  determining-  the  diagnosis.  The  Wassermann  reac- 
tion is  present  in  a  large  proportion  of  all  cases,  and  a  study  of  the  spinal  fluid 
may  be  a  help  in  doubtful  cases  (see  General  Paresis).  • 

The  diseases  most  likely  to  be  confounded  with  locomotor  ataxia  are:  (a) 
PERIPHERAL  NEURITIS. — The  steppage  gait  of  arsenical,  alcoholic,  or  diabetic 
paralysis  is  quite  unlike  that  of  locomotor  ataxia.  In  these  forms  there  is  a 
paralysis  of  the  feet,  and  the  leg  is  lifted  high  in  order  that  the  toes  may  clear 
the  floor.  The  use  of  the  word  ataxia  in  this  connection  should  no  longer  be 
continued.  In  the  rare  cases  in  which  the  muscle  sense  nerves  are  particularly 
affected  and  in  which  there  is  true  ataxia,  the  absence  of  the  lightning  pains 
and  eye  symptoms  and  the  history  will  suffice  in  a  majority  of  cases  to  make 
the  diagnosis  clear.  In  diphtheritic  paralysis  the  early  loss  of  the  knee-jerk 
and  the  associated  eye  symptoms  may  suggest  tabes,  but  the  history,  the  exist- 
ence of  paralysis  of  the  throat,  and  the  absence  of  pains  render  a  diagnosis  easy. 

(6)  ATAXIC  PARAPLEGIA.— Marked  incoordination  with  spastic  paralysis 
is  characteristic  of  the  condition  which  Gowers  has  termed  ataxic  paraplegia. 
In  a  majority  of  the  cases  this  affection  is  distinguished  also  by  the  absence 
of  pains  and  of  eye  symptoms,  but  it  may  be  a  manifestation  of  the  cord  lesions 
in  tabo-paralysis. 

(c)  CEREBRAL  DISEASE. — In  diseases  of  the  brain  involving  the  afferent 
tracts  ataxia  is  at  times  a  prominent  symptom.     It  is  usually  unilateral  or 
limited  to  one  limb;  this,  with  the  history  and  the  associated  symptoms,  ex- 
cludes tabes. 

(d)  CEREBELLAR  DISEASE. — The   cerebellar   incoordination   has   only   a 
superficial  resemblance  to  that  of  locomotor  ataxia,  and  is  more  a  disturbance 
of  equilibrium  than  a  true  ataxia ;  the  knee-jerk  is  usually  present,  there  are 
no  lightning  pains,  no  sensory  disturbances:  while,  on  the  other  hand,  there 
are  headache,  optic  neuritis,  and  vomiting. 

(e)  ACUTE  SYPHILITIC  AFFECTIONS  involving  the  dorsal  columns  of  the 
cord  may  be  associated  with  incoordination  and  resemble  tabes  very  closely.    In 
a  case  under  my  care,  the  gait  was  characteristic  and  Romberg's  symptom  was 
present.    The  knee-jerk,  however,  was  retained  and  there  were  no  ocular  symp- 
toms.    The  condition  had  developed  within  three  months,  and  there  was  a 
well-marked  history  of  syphilis.    Tinder  large  doses  of  iodide  of  potassium  the 
ataxia  and  other  symptoms  completely  disappeared. 

(/)  GENERAL  PARESIS. — Even  though  these  two  diseases  are  so  nearly 
allied  and  often  associated,  it  is  of  very  great  practical  importance  to  deter- 
mine, when  possible,  whether  the  type  is  to  be  spinal  or  cerebral,  for,  in  the 
great  majority  of  cases,  when  this  is  established,  it  does  not  change.  The 


920  DISEASES    OF    THE    NERVOUS    SYSTEM 

difficulty  arises  in  the  premonitory  stage,  when  ocular  changes  and  abnormali- 
ties of  sensation  and  the  deep  reflexes  may  be  the  only  symptoms.  At  this 
stage  any  alteration  in  the  mental  characteristics  is  of  the  utmost  significance. 
(See  General  Paresis.)  Loss  of  the  deep  reflexes  and  lightning  pains  speak 
for  tabes;  active  reflexes,  with  ocular  changes,  especially  optic  atrophy,  are 
suggestive  of  paresis. 

(g)  VISCERAL  CRISES  and  NEURALGIC  SYMPTOMS  may  lead  to  error,  and  in 
middle-aged  men  with  severe,  recurring  attacks  of  gastralgia  it  is  always  well 
to  bear  in  mind  the  possibility  of  tabes,  and  to  make  a  careful  examination 
of  the  eyes  and  of  the  knee-jerk. 

Prognosis.  — Complete  recovery  can  not  be  expected,  but  arrest  of  the  process 
is  not  uncommon  and  a  marked  amelioration  of  the  symptoms  is  frequent. 
Optic-nerve  atrophy,  one  of  the  most  serious  events  in  the  disease,  has  this 
hopeful  aspect — that  incoordination  rarely  follows  and  the  progress  of  the 
spinal  symptoms  may  be  arrested.  On  the  other  hand,  mental  symptoms  are 
more  likely  to  follow.  The  optic  atrophy  itself  is  occasionally  checked.  On 
the  whole,  the  prognosis  in  tabes  is  bad.  The  experience  of  such  men  as  Weir 
Mitchell,  Charcot,  and  Gowers  is  distinctly  opposed  to  the  belief  that  locomotor 
ataxia  is  ever  completely  cured.  There  is  more  hope  now  that  in  very  early 
cases  coming  on  soon  after  infection  the  course  may  be  arrested  by  salvarsan. 
Death  is  usually  from  some  cardio-vascular  complication;  next  in  frequency 
from  tuberculosis  and  pneumonia  (Burr). 

Treatment. — To  arrest  the  progress  and  to  relieve,  if  possible,  the  symp- 
toms are  the  objects  which  the  practitioner  should  have  in  view.  A  quiet,  well- 
regulated  method  of  life  is  essential.  It  is  not  well,  as  a  rule,  for  a  patient  to 
give  up  his  occupation  so  long  as  he  is  able  to  keep  about  and  perform  ordinary 
work,  provided  there  is  no  evident  mental  change.  I  know  tabetics  who  have 
for  years  conducted  large  businesses,  and  there  have  been  several  notable  in- 
stances in  our  profession  of  men  who  have  risen  to  distinction  in  spite  of  the 
existence  of  this  disease.  Excesses  of  all  sorts,  more  particularly  in  baccho 
et  venere,  should  be  carefully  avoided.  A  man  in  the  pre-ataxic  stage  should 
not  marry. 

Care  should  be  taken  in  the  diet,  particularly  if  gastric  crises  have  oc- 
curred. To  secure  arrest  of  the  disease  many  remedies  have  been  employed. 
Salvarsan  in  small  repeated  doses  (0.2  gm.)  should  be  tried  in  early  cases, 
though  the  published  results  have  not,  on  the  whole,  been  satisfactory.  Neither 
mercury  nor  the  iodide  of  potassium  has  anything  like  the  same  influ- 
ence over  the  tabetic  lesions  that  they  have  over  the  ordinary  syphilitic  proc- 
esses. However,  when  the  syphilis  is  comparatively  recent,  when  symptoms 
develop  within  two  years  of  the  primary  infection,  the  disease  may  be  arrested 
by  mercury  and  iodide  of  potassium.  The  French  authors  have  recently  spoken 
much  more  hopefully  of  the  benefit  of  anti-syphilitic  treatment  in  early  cases 
of  tabes,  and  it  is  well  to  give  the  patient  the  benefit  of  salvarsan  and  a 
thorough  course  of  mercurial  inunctions  and  iodide  of  potassium.  Of  reme- 
dies which  may  be  tried  and  are  believed  by  some  writers  to  retard  the  progress, 
the  following  are  recommended:  Arsenic  in  full  doses,  nitrate  of  silver  in 
quarter-grain  doses,  Calabar  bean,  ergot,  and  the  preparations  of  gold. 

For  the  pains,  complete  rest  in  bed,  as  advised  by  Weir  Mitchell,  and 
counter-irritation  to  the  spine  (either  blisters  or  the  thermo-cautery)  may 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM     921 

be  employed.  The  severe  spells  which  come  on  particularly  after  excesses  of 
any  kind  are  often  promptly  relieved  by  a  hot  bath  or  by  a  Turkish  bath.  For 
the  severe  recurring  attacks  of  lightning  pains  spinal  cocainization  may  be 
tried.  A  prolonged  course  of  nitrate  of  silver  seems  in  some  cases  to  allay  the 
pains  and  lessen  the  liability  to  the  attacks.  Antipyrin  and  antifebrin  may  be 
employed,  and  occasionally  do  good,  but  their  analgesic  powers  in  this  disease 
have  been  greatly  overrated.  Cannabis  indica  is  sometimes  useful.  In  the 
severe  naroxysms  of  pain  hypodermics  of  morphia  or  of  cocaine  must  be  used. 
The  use  of  morphia  should  be  postponed  as  long  as  possible.  Electricity  is  of 
very  little  benefit.  For  the  severe  attacks  of  gastralgia  morphia  is  also  re- 
quired. Gastro-enterostomy  has  been  performed,  the  solar  plexus  has  been 
stretched,  and  the  dorsal  spinal  nerve  roots  of  the  seventh,  eighth,  ninth,  and 
tenth  have  been  divided  with  good  results.  The  laryngeal  crises  are  rarely 
dangerous.  An  application  of  cocaine  may  be  made  during  the  spasm,  or  a  few 
whiffs  of  chloroform  may  be  given,  or  nitrite  of  amyl.  In  all  cases  of  tabes 
with  increased  arterial  tension  the  prolonged  use  of  nitroglycerin,  given  in 
increasing  doses  until  the  physiological  effect  is  produced,  is  of  great  service  in 
allaying  the  neuralgic  pains  and  diminishing  the  frequency  of  the  crises.  Its 
use  must  be  guarded  when  there  is  aortic  insufficiency.  The  special  indication 
is  increased  tension.  The  bladder  symptoms  demand  constant  care.  When 
the  organ  can  not  be  perfectly  emptied  the  catheter  should  be  used,  and  the 
patient  may  be  taught  its  use  and  how  to  keep  it  thoroughly  sterilized. 

Frenkel's  method  of  re-education  often  helps  the  patient  to  regain  to  a 
considerable  extent  the  control  of  the  voluntary  movements  which  he  has  lost. 
By  this  method  the  patient  is  first  taught,  by  repeated  systematic  efforts,  to 
perform  simple  movements ;  from  this  he  goes  to  more  and  more  complex  move- 
ments. The  treatment  should  be  directed  and  supervised  by  a  trained  teacher, 
as  the  result  depends  upon  the  skill  of  the  teacher  quite  as  much  as  upon  the 
perseverance  of  the  patient. 

2.     GENEEAL  PAEALYSIS  OF  THE  INSANE  AND  TABO-PAEALYSIS 
(Dementia  Paratytica;  General  Paresis) 

As  has  been  said  in  the  last  section,  the  belief  in  the  essential  identity  of 
general  paralysis  and  tabes  has  gained  more  and  more  ground  and  has  much  in 
its  favor.  Mott  says :  "I  maintain  that  etiologically  and  pathogenetically  there 
is  one  tabes  which  may  begin  in  the  brain  (especially  in  certain  regions),  or  in 
the  spinal  cord  in  certain  regions,  or  in  the  peripheral  nervous  structures  con- 
nected with  vision,  or  in  nervous  structures  connected  with  the  viscera,  consti- 
tuting, therefore,  different  types,  any  of  which  may  be  present  or  be  associated 
with  one  or  all  of  the  others."  Fournier  has  taken  practically  the  same  view 
and  describes  them  together  under  the  heading  Les  Affections  Parasyphv- 
litiques. 

It  is  undoubted  that  most  cases  of  tabes  run  their  course  with  practically 
no  mental  symptoms,  and  that  case^  of  general  paralysis  may  never  present 
symptoms  that  suggest  tabes.  For  practical  purposes  we  are  forced  to  keep 
the  distinction  clearly  in  mind,  and  for  this  reason  it  seems  best,  at  le,ast  for 
the  present,  to  consider  them  separately. 
SO 


922  DISEASES   OF   THE   NERVOUS   SYSTEM 

There  is,  however,  a  group  of  cases  in  which  the  symptoms  of  the  two 
eases  are  associated  in  every  combination.    The  name  "tabo-paralysis"  has  been 
given  to  these  cases. 

General  Paralysis 

Definition. — A  chronic,  progressive  disease  of  the  brain  and  its  meninges, 
associated  with  psychical  and  motor  disturbances,  finally  leading  to  dementia 
and  paralysis. 

Etiology. — As  in  tabes,  the  important  factor  is  syphilis,  which  is  antece- 
dent in  both  conditions  in  practically  all  cases.  Males  are  affected  much  more 
frequently  than  females.  It  occurs  chiefly  between  the  ages  of  thirty  and  fifty- 
five,  although  it  may  begin  in  childhood  as  the  result  of  congenital  syphilis. 
An  overwhelming  majority  of  the  cases  are  in  married  people,  and  not  infre- 
quently both  husband  and  wife  are  affected,  or  one  has  paresis  and  the  other 
tabes.  Statistics  show  that  it  is  more  common  in  the  lower  classes  of  society, 
but  in  America  in  general  medical  practice  the  disease  is  certainly  more  com- 
mon in  the  well-to-do  classes.  Heredity  is  a  more  important  factor  here  thar 
in  tabes,  although  its  influence  is  not  great.  An  important  predisposing  cav.se 
is  "a  life  absorbed  in  ambitious  projects  with  all  its  strongest  mental  efforts,  its 
long-sustained  anxieties,  deferred  hopes,  and  straining  expectation"  (Mickle). 
The  habits  of  life  so  frequently  seen  in  active  business  men  in  our  large  cities, 
and  well  expressed  by  the  phrase  "burning  the  candle  at  both  ends,"  strongly 
predispose  to  the  disease. 

Morbid  Anatomy. — The  dura  is  often  thickened,  and  its  inner  surface  may 
show  the  various  forms  of  hypertrophic  pachymeningitis.  The  pia  is  cloudy, 
thickened,  and  adherent  to  the  cortex.  The  cerebro-spinal  fluid  is  increased  in 
the  meningeal  spaces,  especially  in  the  meshes  of  the  pia,  and  at  times  to  such 
an  extent  as  to  resemble  cysts.  The  brain  is  small,  and  weighs  less  than  nor- 
mal. The  convolutions  are  atrophied,  especially  in  the  anterior  and  middle 
lobes.  In  acute  cases  the  brain  may  be  swollen,  hyperaBmic,  and  cedematous. 
The  brain  cortex  is  usually  red,  and,  except  in  advanced  cases,  it  may  not  be 
atrophied,  the  atrophy  of  the  hemispheres  being  at  the  expense  of  the  whits 
matter.  The  lateral  ventricles  are  dilated  to  compensate  for  the  atrophy  of 
the  brain,  and  the  ependyma  may  be  granular.  The  fourth  ventricle  is  more 
constantly  dilated,  with  granulations  of  its  floor  covering  the  calamus  scripto- 
rius,  a  condition  seldom  seen  in  any  other  affection. 

The  disease  process  is  diffuse,  and  affects  practically  all  parts  of  the  brain, 
but  its  intensity  varies  greatly,  even  in  adjoining  areas.  As  a  rule,  the  cortex 
of  the  frontal  and  central  convolutions  and  the  gray  matter  about  the  ventricles 
are  most  affected. 

In  many  cases  changes  are  present  in  the  spinal  cord  and  peripheral  nerves. 
There  are  the  typical  tabetic  changes  described  in  the  preceding  section.  There 
may  be  degeneration  of  the  pyramidal  systems  of  fibres  secondary  to  the  cor- 
tical changes.  Most  commonly  there  is  a  combination  of  these  two  processes. 
Foci  of  haemorrhages,  and  softening  dependent  upon  coarse  vascular  changes, 
are  not  infrequently  found,  but  are  not  typical  of  the  disease. 

There  are  various  views  as  to  the  nature  of  the  changes.  The  vascular  the- 
ory is  that  from  an  inflammatory  process  starting  in  the  sheaths  of  the  arte- 
rioles  there  is  a  diffuse  parenchymatous  degeneration  with  atrophic  changes 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM    923 

in  the  nerve  cells  and  neuroglia.  The  syphilitic  toxin  causes  degeneration  in 
the  nervous  tissues  with  secondary  changes  in  the  neuroglia  ana  vascular  sys- 
tems. The  spirochaetes  are  found  in  the  nervous  tissues. 

Symptoms. — PRODROMAL  STAGE. — This  is  of  variable  duration,  and  is  char- 
acterized by  a  general  mental  state  which  finds  expression  in  symptoms  trivial 
in  themselves  but  important  in  connection  with  others.  Irritability,  inattention 
to  business  amounting  sometimes  to  indifference  or  apathy,  and  sometimes  a 
change  in  character,  marked  by  acts  which  may  astonish  the  friends  and  rela- 
tives, may  be  the  first  indications.  There  may  be  unaccountable  fatigue  after 
moderate  physical  or  mental  exertion.  Instead  of  apathy  or  indifference  there 
may  be  an  extraordinary  degree  of  physical  and  mental  restlessness.  The 
patient  is  continually  planning  and  scheming,  or  may  launch  into  extravagances 
and  speculation  of  the  wildest  character.  A  common  feature  at  this  period  is 
the  display  of  an  unbounded  egoism.  He  boasts  of  his  personal  attainments, 
his  property,  his  position  in  life,  or  of  his  wife  and  children.  Following  these 
features  are  important  indications  of  moral  perversion,  manifested  in  offences 
against  decency  or  the  law,  many  of  which  acts  have  about  them  a  suspicious 
effrontery.  Forgetf ulness  is  common,  and  may  be  shown  in  inattention  to  busi- 
ness details  and  in  the  minor  courtesies  of  life.  At  this  period  there  may  be 
no  motor  phenomena.  The  onset  of  the  disease  is  usually  insidious,  although 
cases  are  reported  in  which  epileptiform  or  apoplectiform  seizures  were  the 
first  symptoms.  Among  the  early  motor  features  are  tremor  of  the  tongue  and 
lips  in  speaking,  slowness  of  speech  and  hesitancy.  Inequality  of  the  pupils, 
the  Argyll-Robertson  pupil,  optic  atrophy,  and  changes  in  the  deep  reflexes 
may  precede  the  occurrence  of  mental  symptoms  for  years. 

SECOND  STAGE. — This  is  characterized  in  brief  by  mental  exaltation  or 
excitement  and  a  progress  in  the  motor  symptoms.  "The  intensity  of  the 
excitement  is  often  extreme,  acute  maniacal  states  are  frequent;  incessant 
restlessness,  obstinate  sleeplessness,  noisy,  boisterous  excitement,  and  blind,  un- 
calculating  violence  especially  characterize  such  states"  (Lewis).  It  is  at  this 
stage  that  the  delusion  of  grandeur  becomes  marked  and  the  patient  believes 
himself  to  be  possessed  of  countless  millions  or  to  have  reached  the  most  exalted 
sphere  possible  in  profession  or  occupation.  This  expansive  delirium,  as  it  is 
called,  is,  however,  not  characteristic,  as  was  formerly  supposed,  of  paralytic 
dementia.  Besides,  it  does  not  always  occur,  but  in  its  stead  there  may  be 
marked  melancholia  or  hypochondriasis,  or,  in  other  instances,  alternate  attacks 
of  delirium  and  depression. 

The  facies  has  a  peculiar  stolidity,  and  in  speaking  there  is  marked  tremu- 
lousness  of  the  lips  and  facial  muscles.  The  tongue  is  also  tremulous,  and  may 
be  protruded  with  difficulty.  The  speech  is  slow,  interrupted,  and  blurred. 
Writing  becomes  difficult  on  account  of  unsteadiness  of  the  hand.  Letters, 
syllables,  and  words  may  be  omitted.  The  subject  matter  of  the  patient's  let- 
ters gives  valuable  indications  of  the  mental  condition.  In  many  instances  the 
pupils  are  unequal,  irregular,  sluggish,  sometimes  large.  Important  symptoms 
in  this  stage  are  apoplectiform  seizures  and  paralysis.  There  may  be  slight 
syncopal  attacks  in  which  the  patient  turns  pale  and  may  fall.  Some  of  these 
are  petit  mal.  In  the  true  apoplectiform  seizure  the  patient  falls  suddenly, 
becomes  unconscious,  the  limbs  are  relaxed,  the  face  is  flushed,  the  breathing 
stertorous,  the  temperature  increased,  and  death  may  occur.  Epileptic  seizures 


924  DISEASES    OF    THE    NERVOUS    SYSTEM 

are  more  common  than  the  apoplectiform.  There  may  be  a  definite  aura.  The 
attack  usually  begins  on  one  side  and  may  not  spread.  There  may  be  twitchings 
either  in  the  facial  or  brachial  muscles.  Typical  Jacksonian  epilepsy  may 
occur.  Recurring  attacks  of  aphasia  are  not  uncommon,  and  paralysis,  either 
monoplegic  or  hemiplegic,  may  follow  these  epileptic  seizures,  or  may  come  on 
with  great  suddenness  and  be  transient.  In  this  stage  the  gait  becomes  im- 
paired, the  patient  trips  readily,  has  difficulty  in  going  up  or  down  stairs,  and 
the  walk  may  be  spastic  or  occasionally  tabetic.  This  paresis  may  be  pro- 
gressive. The  deep  reflexes  are  usually  increased,  but  may  be  lost.  Bladder  or 
rectal  symptoms  gradually  develop.  The  patient  becomes  helpless,  bedridden, 
and  completely  demented,  and  unless  care  is  taken  may  suffer  from  bedsores. 
Death  occurs  from  exhaustion  or  from  some  intercurrent  affection.  The  spinal 
cord  features  of  dementia  paralytica  may  come  on  with  or  precede  the  mental 
troubles.  There  are  cases  in  which  one  is  in  doubt  for  a  time  whether  the  symp- 
toms indicate  tabes  or  dementia  paralytica,  and  it  is  well  to  bear  in  mind  that 
every  feature  of  pre-ataxic  tabes  may  exist  in  the  early  stage  of  general  paresis. 

Tabo-paralysis 

Emphasis  has  been  laid  on  the  probable  identity  of  the  processes  underlying 
tabes  and  dementia  paralytica,  the  spinal  cord  in  the  first  case  receiving  the 
full  force  of  the  attack,  and  the  brain  in  the  second.  It  has  been  thought  that 
stress  is  the  factor  which  determines  the  location  of  the  process,  and  that  men 
whose  occupations  require  much  bodily  exercise  would  be  apt  to  have  tabes, 
while  those  whose  activities  are  largely  mental  would  suffer  from  paresis. 
Usually  when  the  cord  symptoms  are  pronounced  the  symptoms  from  the  brain 
remain  in  abeyance,  and  the  reverse  is  also  true.  There  are  exceptions  to  this, 
and  cases  of  well  marked  tabes  may  later  show  the  typical  symptoms  of  paresis, 
but  even  then  the  ataxia,  if  it  is  not  of  too  high  a  grade,  often  improves. 

Optic  atrophy,  when  it  occurs  in  the  pre-ataxic  stage  of  tabes,  usually  indi- 
cates that  the  ataxia  will  never  be  pronounced,  but  unfortunately  it  is  fre- 
quently followed  by  the  occurrence  of  mental  symptoms.  Mott  believes  that 
about  50  per  cent,  of  his  asylum  cases  of  tabo-paralysis  had  had  preceding  optic 
atrophy.  Its  occurrence  is  therefore  of  grave  significance.  The  mental  symp- 
toms may  be  delayed  for  many  years. 

The  symptom  complex  of  tabo-paralysis  is  made  up  of  a  combination  of 
the  symptoms  of  the  two  conditions,  and  varies  greatly.  It  may  begin  as  tabes 
with  lightning  pains,  bladder  symptoms,  Argyll-Robertson  pupil,  loss  of  the 
deep  reflexes,  etc.,  to  have  the  mental  symptoms  added  later;  or,  on  the  other 
hand,  cord  symptoms  may  come  on  after  the  patient  has  shown  marked  men- 
tal changes.  In  a  number  of  cases  the  symptoms  are  from  the  first  so  com- 
bined that  the  name  tabo-paralysis  is  at  once  applicable.  Absent  knee-jerks, 
ocular  palsies,  or  pupillary  symptoms  may  precede  the  breakdown  for  many 
years,  but  none  of  them  have  so  grave  a  significance  in  regard  to  the  mental 
state  as  has  optic  atrophy.  Other  types  of  alienation  may  interrupt  the 
course  of  tabes,  and  the  mistake  must  not  be  made  of  regarding  them  all  as 
general  paralysis.  In  such  instances  the  mind  may  become  clear- and  remain 
go  to  the  end. 

Diagnosis. — The  recognition  of  general  paralysis  in  the  earliest  stage  is 


DISEASES  OF  THE  AFFERENT  OR  SEXSORY  SYSTEM     925 

extremely  difficult,  as  it  is  often  impossible  to  decide  that  the  slight  alteration 
in  conduct  is  anything  more  than  one  of  the  moods  or  phases  to  which  most 
men  are  at  times  subject.  The  following  description  by  Folsom  is  an  admira- 
ble presentation  of  the  diagnostic  characters  of  the  early  stage  of  the  disease : 
"It  should  arouse  suspicion  if,  for  instance,  a  strong,  healthy  man,  in  or  near 
the  prime  of  life,  distinctly  not  of  the  'nervous/  neurotic,  or  neurasthenic 
type,  shows  some  loss  of  interest  in  his  affairs  or  impaired  faculty  of  attending 
to  them;  if  he  becomes  varyingly  absent-minded,  heedless,  indifferent,  negli- 
gent, apathetic,  inconsiderate,  and,  although  able  to  follow  his  routine  duties, 
his  ability  to  take  up  new  work  is,  no  matter  how  little,  diminished;  if  he  can 
less  well  command  mental  attention  and  concentration,  conception,  perception, 
reflection,  judgment ;  if  there  is  an  unwonted  lack  of  initiative,  and  if  exertion 
causes  unwonted  mental  and  physical  fatigue;  if  the  emotions  are  intensified 
and  easily  change,  or  are  excited  readily  from  trifling  causes;  if  the  sexual 
instinct  is  not  reasonably  controlled;  if  the  finer  feelings  are  even  slightly 
blunted;  if  the  person  in  question  regards  with  a  placid  apathy  his  own  acts 
of  indifference  and  irritability  and  their  consequences,  and  especially  if  at 
times  he  sees  himself  in  his  true  light  and  suddenly  fails  again  to  do  so;  if 
any  symptoms  of  cerebral  vaso-motor  disturbances  are  noticed,  however  vague 
or  variable." 

There  are  cases  of  cerebral  syphilis  which  closely  simulate  dementia  para- 
lytica.  The  mode  of  onset  is  important,  particularly  since  paralytic  symp- 
toms are  usually  early  in  syphilis.  The  affection  of  the  speech  and  tongue 
is  not  present.  Epileptic  seizures  are  more  common  and  more  liable  to  be 
cortical  or  Jacksonian  in  character.  The  expansive  delirium  is  rare.  While 
symptoms  of  general  paresis  are  not  common  in  connection  with  the  develop- 
ment of  gummata  or  definite  gummatous  meningitis,  there  are,  on  the  other 
hand,  instances  of  paresis  following  closely  upon  the  syphilitic  infection. 
Post  mortem  in  such  cases  there  may  be  nothing  more  than  a  general  arterio- 
sclerosis and  diffuse  meningo-encephalitis,  which  may  present  nothing  dis- 
tinctive, but  the  lesions,  nevertheless,  may  be  Caused  by  the  syphilitic  virus. 
Cases  also  occur  in  which  typical  syphilitic  lesions  are  combined  with  the  ordi- 
nary lesions  of  dementia  paralytica.  There  are  certain  forms  of  lead  enceph- 
alopathy  which  resemble  general  paresis,  and,  considering  the  association  of 
plumbism  with  arterio-sclerosis,  it  is  not  unlikely  that  the  anatomical  sub- 
stratum of  the  disease  may  result  from  this  poison.  Tumor  may  sometimes 
simulate  progressive  paresis,  but  in  the  former  the  signs  of  general  increase 
of  the  intracranial  pressure  are  usually  present.  The  Wassermann  reaction 
in  the  blood  or  spinal  fluid  is  nearly  constant. 

Cytodiagnosis. — The  study  of  the  cellular  elements  suspended  in  the  cere- 
bro-spinal  fluid  has  come  to  be  an  important  diagnostic  measure,  particularly 
in  tabes  and  paresis.  In  both  of  these  affections  spinal  lymphocytosis  is  the 
rule  and  is  usually  associated  with  a  marked  albumin  reaction — the  nor- 
mal fluid  containing  no  albumin,  or  at  most  minute  traces,  and  a  negligible 
number  of  formed  elements.  It  is  simply  the  expression  of  a  subacute  or 
chronic  inflammatory  process,  just  as  polymorphonuclear  leukocytosis  is  char- 
acteristic of  an  acute  process.  It  is,  however,  first  and  foremost  the  syphilitic 
triad — tabes,  paresis,  and  cerebro-spinal  lues — which  is  suggested  by  lympho- 
cytosis in  the  spinal  fluid.  Positive  reactions,  cytological  and  chemical,  are 


926  DISEASES   OF   THE   NERVOUS   SYSTEM 

among  the  earliest  somatic  symptoms,  and  may  therefore  clear  up  obscure 
cases  of  tabes  and  paresis,  just  at  the  time  when  diagnosis  is  most  difficult. 

Prognosis. — The  disease  rarely  ends  in  recovery.  As  a  rule  the  progress 
is  slowly  downward  and  the  case  terminates  in  a  fe^  years,  although  it  is 
occasionally  prolonged  ten  or  fifteen  years. 

Treatment. — Salvarsan  in  small  repeated  doses  may  be  tried  in  early  cases, 
after  which  large  doses  of  iodide  of  potassium  and  a  mercurial  course  should 
be  given.  Careful  nursing  and  the  orderly  life  of  an  asylum  are  the  only 
measures  necessary  in  a  great  majority  of  the  cases.  For  sleeplessness  and  the 
epileptic  seizures  bromides  may  be  used.  Prolonged  remissions,  which  are 
not  uncommon,  are  often  erroneously  attributed  to  the  action  of  remedies. 
Active  treatment  in  the  early  stage  by  wet-packs,  cold  to  the  head,  and  sys- 
tematic massage  has  been  followed  by  temporary  improvement. 

3.     ACUTE  POSTERIOR  GANGLIONITIS 
(Herpes  Zoster) 

Definition. — An  acute  disease  with  localization  in  the  cerebral  ganglia  and 
in  the  ganglia  of  the  posterior  nerve  roots,  associated  with  a  vesicular  inflam- 
mation of  the  skin  of  the  corresponding  cutaneous  areas. 

Distribution. — Herpes  most  frequently  occurs  in  the  region  of  the  dorsal 
roots  and  extends  in  the  form  of  a  half  girdle,  on  which  account  the  names 
"zona"  and  "zoster"  have  been  given.  The  trigeminal  region  is  very  often 
involved,  particularly  the  first  branch.  Common  forms  also  are  the  herpes 
sterno-nuchalis,  cervico-subclavicularis  and  dorso-ulnaris. 

Pathology. — Barensprung  first  showed  that  there  was  involvement  of  the 
spinal  ganglia.  The  exhaustive  studies  of  Head  and  Campbell  show  that  the 
primary  disease  is  an  acute  haemorrhagic  inflammation  of  the  ganglia  of  the 
posterior  nerve  roots  and  of  the  homologous  cranial  ganglia.  It  is  analogous 
to  acute  anterior  polio-myelitis.  There  are  inflammatory  foci,  hemorrhage  in 
and  destruction  of  certain  of  the  ganglion  cells  leading  to  degeneration  of  the 
axis-cylinders.  In  herpes  facialis  accompanying  pneumonia  W.  T.  Howard 
has  shown  that  similar  lesions  are  demonstrable  in  the  Gasserian  ganglion,  and 
Hunt  has  found  the  same  changes  in  the  otic  ganglion  in  herpes  auricularis. 
It  is  met  with  in  the  acute  infections,  particularly  pneumonia,  malaria,  and 
cerebro-spinal  fever.  Epidemics  have  been  described.  Micro-organisms  have 
been  found  in  the  cerebro-spinal  fluid. 

Symptoms. — In  ordinary  zona  there  is  often  a  slight  prodromal  period 
in  which  the  patient  feels  ill,  has  moderate  fever,  and  pain  in  the  side,  some- 
times of  such  severity  as  to  suggest  pleurisy.  On  the  third  or  fourth  day  the 
rash  appears.  The  characteristic  group  of  vesicles  has  a  segmental  distribu- 
tion limited  to  one  side  of  the  body.  One  or  more  of  the  adjoining  skin  fields 
is  usually  affected*.  With  involvement  of  the  cervical,  lumbar,  or  sacral  gang- 
lion the  zonal  or  girdle  form  of  the  vesicular  crop  is  naturally  lost  owing  to 
the  distortion  of  the  skin  fields  from  the  growth  of  the  limbs.  The  typical 
zonal  form  is  only  seen  in  involvement  of  the  thoracic  ganglia.  Groups  of 
vesicles  are  regularly  arranged  on  the  hyperaemic  skin,  at  first  filled  with  a 
clear  or  sometimes  bloody  serum,  which  later  becomes  purulent.  The  crop 
varies  greatly,  and  the  individual  vesicles  may  be  superficial,  in  which  case 


DISEASES    OF    THE    EFFERENT    OR    MOTOR    TRACT      927 

they  leave  no  scar,  or  they  may  be  deep  and  in  healing  leave  superficial  scars. 
By  far  the  most  serious  form  is  that  seen  in  the  upper  division  of  the  fifth. 
The  fever  may  be  high  and  the  eruption  very  profuse  with  great  swelling  and 
much  pain.  I  have  seen  several  cases  of  permanent  disfigurement  from  the 
scarring. 

It  seems  not  improbable,  as  Chauffard  suggests,  that  there  may  be  exten- 
sion of  the  disease  from  the  posterior  ganglia  to  the  neighboring  meninges  as 
there  may  be  pains  down  the  spine,  the  girdle  sensation,  exaggerated  knee- 
jerks,  the  Kernig  sign,  and  lymphocytosis  in  the  cerebro-spinal  fluid. 

Complications. — Perhaps  the  most  serious  of  these  is  that  occasionally  seen 
in  ophthalmic  zoster,  when  there  is  intense  inflammation  of  the  conjunctiva 
and  cornea  with  consecutive  pan-ophthalmitis  and  destruction  of  the  eye,  of 
which  I  have  seen  one  instance. 

In  a  few  cases  the  eruption  becomes  gangrenous.  Swelling  of  the  lymph 
glands  has  been  noted:  A  bilateral  distribution  has  occurred.  A  generalized 
herpes  zoster  is  occasionally  seen  with  a  widespread  vesicular  rash  on  the  face, 
neck,  trunk,  and  thighs.  A  facial  paralysis  may  develop  during  or  after  oph- 
thalmic or  cervical  herpes.  I  have  seen  swelling  of  the  parotid  gland  on  the 
same  side.  In  rare  cases  paralysis  of  the  extremities  has  occurred.  By  far 
the  most  distressing  complication  is  post-zonal  neuralgia.  After  recovery  from 
the  herpes,  hot  burning  sensations  are  not  uncommon  in  the  cutaneous  dis- 
tribution. In  other  instances,  particularly  in  old  people,  the  pain  persists 
and  for  years  may  be  a  terrible  affliction  resisting  all  measures  of  treatment. 
Gowers  speaks  of  suicide  in  despair,  one  instance  of  which  came  under  my 
notice. 

Treatment. — Care  should  be  taken  to  protect  the  vesicles;  a  one  per  cent, 
cocaine  ointment  with  lanolin  carefully  applied  on  lint  gives  relief  to  the  pain. 
In  very  severe  involvement  of  the  ophthalmic  division  of  the  fifth  nerve  the 
greatest  care  should  be  taken  to  keep  the  conjunctiva  clean.  For  the  severe 
post-zonal  neuralgia,  injections  into  the  spinal  cord  have  been  tried,  and  in 
cases  of  great  severity  the  posterior  nerve  roots  may  be  cut. 


in.     DISEASES  OF  THE  EFFERENT  OR  MOTOR  TRACT 

A.     OF    WHOLE    TRACT 
1.     PKOGEESSIVE    (CENTEAL)    MUSCULAR  ATROPHY 

(Poliomyelitis  Anterior  Chronica;  Amyotrophic  Lateral  Sclerosis;  Progressive 

Bulbar  Paralysis) 

Definition.  — A  disease  characterized  by  a  chronic  degeneration  of  the  motor 
tract,  usually  of  the  whole,  but  at  times  limited  to  the  lower  segment.  Asso- 
ciated with  it  is  a  progressive  atrophy  of  the  muscles,  with  more  or  less  spastic 
rigidity. 

Three  affections,  as  a  rule  described  apart,  belong  together  in  this  category : 
(a)  Progressive  muscular  atrophy  of  spinal  origin;  (6)  amyotrophic  lateral 
sclerosis;  and  (c)  progressive  bulbar  paralysis.  A  slow  atrophic  change  in  the 
motor  neurones  is  the  anatomical  basis,  and  the  disease  is  one  of  the  whole 


928  DISEASES    OF    THE    NERVOUS    SYSTEM 

motor  path,  involving,  in  many  cases,  the  cortical,  bulbar,  and  spinal  centres. 
There  may  be  simple  muscular  atrophy  with  little  or  no  spasm,  or  progressive 
wasting  with  marked  spasm  and  great  increase,  in  the  reflexes.  In  others, 
there  are  added  symptoms  of  involvement  of  the  motor  nuclei  in  the  medulla — 
a  glosso-labio-laryngeal  paralysis;  while  in  others,  again,  with  atrophy 
(especially  of  the  arms),  a  spastic  condition  of  the  legs  and  bulbar  phenomena, 
tremors  develop  and  signs  of  cortical  lesion.  These  various  stages  may  be 
traced  in  the  same  case. 

For  convenience,  bulbar  paralysis  will  be  considered  separately,  and  here 
are  taken  together  progressive  muscular  atrophy  and  amyotrophic  lateral  scle- 
rosis. 

The  disease  is  known  as  the  Aran-Duchenne  type  of  progressive  muscular 
atrophy  and  as  Cruveilhier's  palsy,  after  the  French  physician  who  early  de- 
scribed it.  Luys  and  Lockhart  Clarke  first  demonstrated  that  the  cells  of  the 
ventral  horns  of  the  spinal  cord  were  diseased.  Charcot  separated  two  types — 
one  with  simple  wasting  of  the  muscles,  due,  he  believed,  to  degeneration  con- 
fined to  the  ventral  horns  (and  to  this  he  restricted  the  name  progressive 
muscular  atrophy — type,  Aran-Duchenne)  ;  the  other,  in  which  there  was  spas- 
tic paralysis  of  the  muscles  followed  by  atrophy.  As  the  anatomical  basis  for 
this  he  assumed  a  primary  degeneration  of  the  pyramidal  tracts  and  a  second- 
ary atrophy  of  the  ventral  horns.  To  this  he  gave  the  name  of  amyotrophic 
lateral  sclerosis.  There  is  but  little  evidence,  however,  to  show  that  any  such 
sharp  distinction  can  be  made  between  the'se  two  diseases,  and  Leyden  and 
Gowers  regard  them  as  identical. 

Etiology. — The  cause  of  the  disease  is  unknown.  It  is  more  frequent  in 
males  than  in  females.  It  affects  adults,  usually  after  the  thirtieth  year, 
though  occasionally  younger  persons  are  attacked.  A  majority  of  all  cases  of 
progressive  muscular  atrophy  under  twenty  five  years  of  age  belong  to  the 
dystrophies.  Cold,  wet,  exposure,  fright,  and  mental  worries  are  mentioned 
as  possible  causes.  Certain  cases  follow  injury.  Hereditary  influences  are 
present  in  some  cases.  The  rare  form  which  occurs  in  infancy  usually  affects 
several  members  of  the  same  family.  Hereditary  and  family  influences,  how- 
ever, play  but  a  small  part  in  the  etiology,  and  in  this  it  is  in  contrast  to 
progressive  neural  muscular  atrophy  and  the  dystrophies.  Yet,  in  the  Farr 
family,  which  I  recorded  some  years  ago,  in  which  thirteen  members  were 
affected  in  two  generations,  with  the  exception  of  two,  the  cases  occurred  or 
proved  fatal  above  the  age  of  forty,  and  the  late  onset  speaks  rather  for  a  cen- 
tral affection.  The  spastic  form  may  develop  late  in  life — after  seventy — as 
a  senile  change. 

Morbid  Anatomy. — The  essential  anatomical  change  is  a  slow  degenera- 
tion of  the  motor  path,  involving  particularly  the  lower  motor  neurones.  The 
upper  neurones  are  also  involved,  either  first,  simultaneously,  or  at  a  later 
period.  Associated  with  the  degeneration  in  the  cells  of  the  ventral  horns  there 
is  a  degenerative  atrophy  of  the  muscles.  The  following  are  the  important 
anatomical  changes :  (a)  The  gray  matter  of  the  cord  shows  the  most  marked 
alteration.  The  large  ganglion  cells  of  the  ventral  horns  are  atrophied,  or, 
in  places,  have  entirely  disappeared,  the  neuroglia  is  increased,  and  the  medul- 
lated  fibres  are  much  decreased.  The  fibres  of  the  ventral  nerve-roots  passing 
through  the  white  matter  are  wasted,  (b)  The  ventral  roots  outside  of  the 


DISEASES    OF    THE    EFFERENT    OR   MOTOR    TRACT      929 

cord  are  also  atrophied,  (c)  The  muscles  affected  show  degenerative  atrophy, 
aud  the  inter-muscular •  branches  of  the  motor  nerves  are  degenerated,  (d) 
The  degeneration  of  the  gray  matter  is  rarely  confined  to  the  cord,  but  extends 
to  the  medulla,  where  the  nuclei  of  the  motor  cerebral  nerves  are  found  exten- 
sively wasted,  (e)  In  a  majority  of  all  the  cases  there  is  sclerosis  in  the  ventro- 
lateral  white  tracts,  the  lateral  pyramidal  tracts  particularly  are  diseased,  but 
the  degeneration  is  not  confined  to  them,  but  extends  into  the  ventro-lateral 
ground  bundles.  The  direct  cerebellar  and  the  ventro-lateral  ascending  tracts 
are  spared.  The  degeneration  in  the  pyramidal  tracts  extends  toward  the 
brain  to  different  levels,  and  in  several  cases  has  been  traced  to  the  motor  cor- 
tex, the  cells  of  which  have  been  found  degenerated.  In  the  medulla  the 
medial  longitudinal  fasciculus  has  been  found  diseased.  (/)  In  those  cases  in 
which  no  sclerosis  has  been  found  in  the  pyramidal  tracts  there  has  been  a 
sclerosis  of  the  ventro-lateral  ground  bundle  (short  tracts). 

Symptoms. — Irregular  pains  may  precede  the  onset-  of  the  wasting,  and 
cases  may  be  treated  for  chronic  rheumatism.  The  hands  are  usually  first 
affected,  and  there  is  difficulty  in  performing  delicate  manipulations.  The 
muscles  of  the  ball  of  the  thumb  waste  early,  then  the  interossei  and  lum- 
bricales,  leaving  marked  depressions  between  the  metacarpal  bones.  Ultimately 
the  contraction  of  the  flexor  and  extensor  muscles  and  the  extreme  atrophy 
of  the  thumb  muscles,  the  interossei,  and  lumbricales  produce  the  claw-hand 
— main  en  griff e  of  Duchenne.  The  flexors  of  the  forearm  are  usually  involved 
before  the  extensors.  In  the  shoulder-girdle  the  deltoid  is  first  affected;  it 
may  waste  even  before  the  other  muscles  of  the  upper  extremity.  The  trunk 
muscles  are  gradually  attacked;  the  upper  part  of  the  trapezius  long  remains 
unaffected.  Owing  to  the  feebleness  of  the  muscles  which  support  it,  the  head 
tends  to  fall  forward.  The  platysma  myoides  is  unaffected  and  often  hyper- 
trophies. The  arms  and  the  trunk  muscles  may  be  much  atrophied  before  the 
legs  are  attacked.  The  face  muscles  are  attacked  late.  Ultimately  the  inter- 
costal and  abdominal  muscles  may  be  involved,  the  wasting  proceeds  to  an 
extreme  grade,  and  the  patient  may  be  actually  "skin  and  bone,"  and,  as  "liv- 
ing skeletons,"  the  cases  are  not  uncommon  in  "museums"  and  "side-shows." 
Deformities  and  contractures  result,  and  lordosis  is  almost  always  present. 
A  curious  twitching  of  the  muscles  (fibrillation)  is  a  common  symptom,  and 
may  occur  in  muscles  which  are  not  yet  attacked.  It  is  a  most  important 
symptom,  but  is  not,  as  was  formerly  supposed,  a  characteristic  feature.  The 
irritability  of  the  muscles  is  increased.  Sensation  is  unimpaired,  but  the 
patient  may  complain  of  numbness  and  coldness  of  the  affected  limbs.  The 
galvanic  and  faradic  irritability  of  the  muscles  progressively  diminishes  and 
may  become  extinct,  the  galvanic  persisting  for  the  longer  time.  In  cases  of 
rapid  wasting  and  paralysis  the  reaction  of  degeneration  may  be  obtained. 
The  excitability  of  the  nerve  trunks  may  persist  after  the  muscles  have  ceased 
to  respond.  The  loss  of  power  is  usually  proportionate  to  the  wasting. 

The  foregoing  description  applies  to  the  group  of  cases  in  which  the  atro- 
phy and  paralysis  are  flaccid — atonic,  as  Gowers  calls  it.  In  other  cases, 
those  which  Charcot  describes  as  amyotrophic  lateral  sclerosis,  spastic  paraly- 
sis precedes  the  wasting.  This  ionic  atrophy  first  involves  the  arms  and  then 
the  legs.  The  reflexes  are  greatly  increased.  It  is  one  of  the  rare  conditions 
in  which  a  jaw  clonus  may  be  obtained.  The  most  typical  condition  of  spastic 


930  DISEASES    OF   THE    NERVOUS    SYSTEM 

paraplegia  may  be  produced.  On  starting  to  walk,  the  patient  seems  glued  to 
the  ground  and  makes  ineffectual  attempts  to  lift  the  toes;  then  four  or  five 
short,  quick  steps  are  taken  on  the  toes  with  the  body  thrown  forward;  and 
finally  he  starts  off,  sometimes  with  great  rapidity.  Some  of  the  patients  can 
walk  up  and  down  stairs  better  than  on  the  level.  The  wasting  is  never  so 
extreme  as  in  the  atonic  form,  and  the  loss  of  power  may  be  out  of  proportion 
to  it.  The  sphincters  are  unaffected.  Sexual  power  may  be  lost  early.  Cases 
are  met  with  which  correspond  accurately  to  the  clinical  picture  given  by 
Charcot  of  amyotrophic  lateral  sclerosis.  These  are  not  very  common,  and 
it  is  much  more  usual  to  have  a  combination  of  the  two  types.  A  flaccid 
atrophic  paralysis  with  increased  reflexes  is  often  met  with.  These  differences 
depend  upon  the  relative  extent  of  the  involvement  of  the  upper  and  lower 
motor  segments  and  the  time  of  the  involvement  of  each.  The  condition  may 
be  unilateral. 

As  the  degeneration  extends  upward  an  important  change  takes  place  from 
^he  occurrence  of  bulbar  symptoms,  which  may,  however,  precede  the  spinal 
.manifestations.  The  lips,  tongue,  face,  pharynx,  and  larynx  may  be  involved. 
The  lips  may  be  affected  and  articulation  impaired  for  years  before  serious 
symptoms  occur.  In  the  final  stage  there  may  be  tremor,  the  memory  fails, 
and  a  condition  of  dementia  supervenes. 

Gowers  gives  the  following  useful  classification  of  the  varieties  of  this 
affection:  (1)  Atonic  atrophy,  becoming  extreme;  (2)  muscular  weakness 
with  spasm,  but  without  wasting  or  with  only  slight  wasting;  and  (3)  atonic 
atrophy,  rarely  extreme  in  degree,  with  exaggeration  of  the  reflexes.  These 
conditions  may  "coexist  in  every  degree  and  combination — between  universal 
atonic  atrophy  on  the  one  hand  and  universal  spastic  paralysis  without  wast- 
ing on  the  other/' 

Diagnosis. — Progressive  (central)  muscular  atrophy  begins,  as  a  rule,  in 
adult  life,  without  hereditary  or  family  influences  (the  early  infantile  form 
being  an  exception),  and  usually  affects  first  the  muscles  of  the  thumb,  and 
gradually  involves  the  interossei  and  lumbricales.  Fibrillary  contractions  are 
common,  electrical  changes  occur,  and  the  deep  reflexes  are  usually  increased. 
These  characteristics  are  usually  sufficient  to  distinguish  it  from  the  other 
forms  of  muscular  wasting. 

In  syringo-myelia  the  symptoms  may  be  very  similar  to  those  in  the  spastic 
form  of  muscular  atrophy.  The  sensory  disturbances  in  the  former  disease, 
as  a  rule,  make  the  diagnosis  clear,  but  when  these  are  absent  or  but  little  de- 
veloped it  may  be  very  difficult  or  even  impossible  to  distinguish  the  diseases. 

Treatment. — The  disease  is  incurable.  The  downward  progress  is  slow  but 
certain,  though  in  a  few  cases  a  temporary  arrest  may  take  place.  With  a 
history  of  syphilis,  mercury  and  iodide  of  potassium  may  be  tried,  and  Gowers 
recommends  courses  of  arsenic  and  the  hypodermic  injection  of  strychnine. 
Probably  the  most  useful  means  is  systematic  massage,  particularly  in  the 
spastic  cases. 

Bulbar  Paralysis  (Glosso-labio-laryngeal  Paralysis} 

When  the  disease  affects  the  motor  nuclei  of  the  medulla  first  or  early,  it 
is  called  bulbar  paralysis,  but  it  has  practically  no  independent  existence,  as 
the  spinal  cord  is  sooner  or  later  involved. 


DISEASES    OF    THE    EFFERENT    OR   MOTOR   TRACT      931 

Symptoms.— The  disease  usually  begins  with  slight  defect  in  the  speech, 
and  the  patient  has  difficulty  in  pronouncing  the  dentals  and  linguals.  The 
paralysis  starts  in  the  tongue,  and  the  superior  lingual  muscle  gradually  be- 
comes atrophied,  and  finally  the  mucous  membrane  is  thrown  into  transverse 
folds.  In  the  process  of  wasting  the  fibrillary  tremors  are  seen.  Owing  to 
the  loss  of  power  in  the  tongue,  the  food  is  with  difficulty  pushed  back  into 
the  pharynx.  The  saliva  also  may  be  increased,  and  is  apt  to  accumulate  in 
the  mouth.  When  the  lips  become  involved  the  patient  can  neither  whistle  nor 
pronounce  the  labial  consonants.  The  mouth  looks  large,  the  lips  are  promi- 
nent, and  there  is  constant  drooling.  The  food  is  masticated  with  difficulty. 
Swallowing  becomes  difficult,  owing  partly  to  the  regurgitation  into  the 
nostrils,  partly  to  the  involvement  of  the  pharyngeal  muscles.  The  muscles 
of  the  vocal  cords  waste  and  the  voice  becomes  feeble,  but  the  laryngeal  paraly- 
sis is  rarely  so  extreme  as  that  of  the  lips  and  tongue. 

The  course  of  the  disease  is  slow  but  progressive.  Death  often  results 
from  an  aspiration  pneumonia,  sometimes  from  choking,  more  rarely  from 
involvement  of  the  respiratory  centres.  The  mind  usually  remains  clear.  The 
patient  may  become  emotional.  In  a  majority  of  the  cases  the  disease  is  only 
part  of  a  progressive  atrophy,  either  simple  or  associated  with  a  spastic  con- 
dition. In  the  later  stage  of  amyotrophic  lateral  sclerosis  the  bulbar  lesions 
may  paralyze  the  lips  long  before  the  pharynx  or  larynx  becomes  affected. 

The  diagnosis  of  the  disease  is  readily  made,  either  in  the  acute  or  chronic 
form.  The  involvement  of  the  lips  and  tongue  is  usually  well  marked,  while 
that  of  the  palate  may  be  long  deferred.  A  condition  has  been  described,  how- 
ever, which  may  closely  simulate  bulbar  paralysis.  This  is  the  so-called 
pseudo-bulbar  form  or  bulbar  palsy  of  cerebral  origin.  Bilateral  disease  of 
the  motor  cortex  in  the  lower  part  of  the  ascending  frontal  convolution,  or 
about  the  knee  of  the  internal  capsule,  may  cause  paralysis  of  the  lips  and 
tongue  and  pharynx,  which  closely  simulates  a  lesion  of  the  medulla.  Some- 
times the  symptoms  appear  on  one  side,  but  in  many  instances  they  develop 
suddenly  on  both  sides.  A  bilateral  lesion  has  usually  been  found,  but  in 
several  instances  the  disease  was  unilateral. 

The  so-called  acute  bulbar  paralysis  may  be  due  to  (a)  haemorrhagic  or 
embolic  softening  in  the  pons  and  medulla;  (&)  acute  inflammatory  softening, 
analogous  to  polio-myelitis,  occurring  occasionally  as  a  post-febrile  affection. 
It  has  occasionally  followed  diphtheria,  and  occurred  after  severe  electric 
shocks  of  high  voltage.  It  usually  comes  on  very  suddenly,  hence  the  term 
apoplectiform.  The  symptoms  in  this  form  may  correspond  closely  to  those 
of  an  advanced  case  of  chronic  bulbar  paralysis.  The  sudden  onset  and  the 
associated  symptoms  make  the  diagnosis  easy.  In  these  acute  cases  there 
may  be  loss  of  power  in  one  arm,  or  hemiplegia,  sometimes  alternate  hemi- 
plegia,  with  paralysis  on  one  side  of  the  face  and  loss  of  power  on  the  other 
side  of  the  body,  (c)  In  epidemics  of  polio-myelitis  cases  occur  with  acute 
bulbar  symptoms. 

2.  PROGRESSIVE  NEUKAL  MUSCULAR  ATROPHY 

This  form,  known  also  as  the  peroneal  type,  or  by  the  names  of  the  men 
who  have  described  it  most  accurately- — namely,  Charcot,  Marie,  and  Tooth— -- 


932  DISEASES    OF    THE    NERVOUS    SYSTEM 

occurs  either  as  a  hereditary  or  as  a  family  affection.  It  usually  begins 
in  early  childhood,  affecting  first  the  muscles  of  the  feet  and  the  peroneal 
group;  as  a  result  of  the  weakening  of  these  muscles,  club-foot,  either  pes 
equinus  or  pes  equino-varus,  occurs.  In  rare  instances  the  disease  may 
begin  in  the  hands,  but  the  upper  limbs,  as  a  rule,  are  not  affected  for 
some  years  after  the  legs  are  attacked,  and  the  trouble  then  begins  in  the 
small  muscles  of  the  hand.  Sensory  disturbances  are  frequently  present  and 
form  important  diagnostic  features.  Fibrillary  contractions  and  twitchings 
also  occur.  The  electrical  reactions  are  altered ;  there  is  either  a  'loss  or  a  very 
great  decrease  of  the  excitability,  which  can  be  demonstrated  not  only  in 
the  atrophic  muscles,  but  also  in  muscles  and  nerves  which  are  apparently 
normal. 

This  form  seems  to  stand  between  the  central  muscular  atrophy  and  the 
muscular  dystrophies.  Occurring  in  families  and  beginning  in  early  life,  it 
resembles  the  latter,  but  it  is  more  like  the  former  in  that  fibrillary  contrac- 
tions and  muscular  twitchings  are  common,  that  the  small  muscles  of  the 
hand  are  apt  to  be  involved,  and  that  electrical  changes  are  present.  In  the 
prominence  of  sensory  symptoms  it  differs  from  both.  In  cases  of  acquired 
double  club-foot  this  disease  should  be  suspected. 

3.     THE   MUSCULAE  DYSTROPHIES 
(Dystrophia  muscularis  progressiva,  Erb) 

Definition. — Muscular  wasting,  with  or  without  an  initial  hypertrophy, 
beginning  in  various  groups  of  muscles,  usually  progressive  in  character,  and 
dependent  on  primary  changes  in  the  muscles  themselves.  A  marked  heredi- 
tary disposition  is  met  with  in  the  disease. 

Etiology. — No  etiological  factors  of  any  moment  are  known  other  than 
heredity.  The  influence  may  show  itself  by  true  heredity — the  disease  occur- 
ring in  two  or  more  generations — or  several  members  of  the  same  generation 
may  be  affected,  showing  a  family  tendency.  Many  members  of  the  same 
family  may  be  attacked  through  several  generations.  Males,  as  a  rule,  are 
more  frequently  affected  than  females.  The  disease  is  usually  transmitted 
through  the  mother,  though  she  may  not  herself  be  affected.  As  many  as  20 
or  30  cases  have  been  described  in  five  generations.  In  Erb's  cases  44  per  cent, 
showed  no  heredity.  The  disease  usually  sets  in  before  puberty,  but  may  be 
as  late  as  the  twentieth  or  twenty-fifth  year,  or  in  some  instances  even  later. 

Symptoms. — The  first  symptom  noticed  is,  as  a  rule,  clumsiness  in  the 
movements  of  the  'child,  and  on  examination  certain  muscles  or  groups  of 
muscles  seem  to  be  enlarged,  particularly  those  of  the  calves.  The  extensors 
of  the  leg,  the  glutei,  the  lumbar  muscles,  the  deltoid,  triceps  and  infraspina- 
tus,  are  the  next  most  frequently  involved,  and  may  stand  out  with  great 
prominence.  The  muscles  of  the  neck,  face,  and  forearm  rarely  suffer.  Some- 
times only  a  portion  of  a  muscle  is  involved.  With  this  hypertrophy  of  some 
muscles  there  is  wasting  of  others,  particularly  the  lower  portion  of  the  pec- 
torals and  the  latissimus  dorsi.  The  attitude  when  standing  is  very  character- 
istic. The  legs  are  far  apart,  the  shoulders  thrown  back,  the  spine  is  greatly 
curved,  and  the  abdomen  protrudes.  The  gait  is  waddling  and.  awkward.  In 


DISEASES    OF   THE    EFFERENT    OR   MOTOR   TRACT      933 

getting  up  from  the  floor  the  position  assumed,  so  well-known  now  through 
Gowers'  figures,  is  pathognomonic.  The  patient  first  turns  over  in  the  all- 
fours  position  and  raises  the  trunk  with  his  arms;  the  hands  are  then  moved 
along  the  ground  until  the  knees  are  reached ;  then  with  one  hand  upon  a  knee 
he  lifts  himself  up,  grasps  the  other  knee,  and  gradually  pushes  himself  into 
the  erect  posture,  as  it  has  been  expressed,  by  climbing  up  his  legs.  The  strik- 
ing contrast  between  the  feebleness  of  the  child  and  the  powerful  looking 
pseudo-hypertrophic  muscles  is  very  characteristic.  The  enlarged  muscles  may, 
however^  be  relatively  very  strong. 

The  course  of  the  disease  is  slow,  but  progressive.  Wasting  proceeds  and 
finally  all  traces  of  the  enlarged  condition  of  the  muscles  disappear.  At  this 
late  period  distortions  and  contractions  are  common. 

The  muscles  of  the  shoulder-girdle  are  nearly  always  affected  early  in  the 
disease,  causing  a  symptom  upon  which  Erb  lays  great  stress.  With  the  hands 
under  the  arms,  when  one  endeavors  to  lift  the  patient,  the  shoulders  are 
raised  to  the  level  of  the  ears,  and  one  gets  the  impression  as  though  the  child 
were  slipping  through.  These  "loose  shoulders"  are  very  characteristic.  The 
abnormal  mobility  of  the  shoulder  blades  gives  them  a  winged  appearance,  and 
makes  the  arms  seem  much  longer  than  usual  when  they  are  stretched  out. 

There  are  no  sensory  symptoms.  The  atrophic  muscles  do  not  show  the 
reaction  of  degeneration  except  in  extremely  rare  instances. 

Clinical  Forms.  — A  number  of  different  types  have  been  described,  depend- 
ing upon  the  age  at  the  onset,  the  muscles  first  affected,  the  occurrence  of 
hypertrophy,  the  prominence  of  heredity,  etc.  But  Erb  has  shown  that  there 
is  no  sharp  division  between  these  different  forms,  and  classes  them  all  under 
the  name  of  dystropJiia  muscularis  progressiva.  For  convenience  of  descrip- 
tion he  subdivides  the  disease  into  two  large  groups : 

I.  Those  cases  which  occur  in  childhood. 

II.  The  cases  occurring  in  youth  and  adult  life. 

The  first  division  is  subdivided  into  (1)  the  hypertrophic  and  (2)  the 
atrophic  form. 

Under  the  hypertrophic  form,  which  is  the  pseudo-hypertrophic  muscular 
paralysis  of  authors,  he  thinks  it  is  useful  to  distinguish  between  the  cases  in 
which  (a)  the  enlarged  muscles  have  undergone  lipomatosis — i.  e.,  pseudo- 
hypertrophy — from  those  (&)  in  which  there  is  a  real  hypertrophy. 

The  atrophic  form  also  includes  two  subclasses:  (a)  Those  cases  in  which 
the  muscles  of  the  face  are  involved  early;  this  corresponds  to  the  infantile 
form  of  Duchenne — the  Landouzy-Dejerine  type.  (&)  Those  cases  in  which 
the  face  is  not  involved.  They  may  be  grouped  as  follows : 

I.  DystropJiia  muscularis  progressiva  infantum. 

1.  Hypertrophic  form. 

(a)   With  pseudo-hypertrophy. 
(&)   With  real  hypertrophy. 

2.  Atrophic  form. 

(a)  With  primary  involvement  of  the  face  (infantile  form  of 

Duchenne). 
(&)   Without  involvement  of  the  face. 

II.  DystropJiia  muscularis  progressiva  juvenum   vel   adultorum    (Erb's 
juvenile  form). 


934  DISEASES    OF   THE   NERVOUS    SYSTEM 

Morbid  Anatomy. — According  to  Erb,  the  disease  consists  in  a  change  in 
the  muscles  themselves.  At  first  the  muscle  fibres  hypertrophy,  and  become 
round;  the  nuclei  increase,  and  the  muscle  fibres  may  become  fissured.  At 
the  same  time  there  is  a  slight  increase  in  the  connective  tissue.  Sooner  or 
later  the  muscle  fibres  begin  to  atrophy,  and  the  nuclei  become  greatly  in- 
creased. Vacuoles  and  fissures  appear,  and  the  fibres  finally  become  com- 
pletely atrophic,  the  connective  tissue  becoming  markedly  increased.  Fat  may 
be  deposited  in  the  connective  tissue  to  such  an  extent  as  to  cause  hypertrophic 
lipomatosis — pseudo-hypertrophy.  The  different  stages  of  these  changes  may 
be  found  in  a  single  muscle  at  the  same  time. 

The  nervous  system  has  very  generally  been  found  to  be  without  demon- 
strable lesions,  but  in  certain  cases  changes  in  the  cells  of  the  ventral  horns 
have  been  described. 

Diagnosis. — The  muscular  dystrophies  can  usually  be  distinguished  readily 
from  the  other  forms  of  muscular  atrophy. 

(a)  In  the  cerebral  atrophy  loss  of  power  usually  precedes  the  atrophy, 
which  is  either  of  a  monoplegic  or  hemiplegic  type. 

(6)  From  progressive  (central)  muscular  atrophy  the  distinctions  are 
plainly  marked.  This  form  begins  in  the  small  muscles  of  the  hand,  a  situa- 
tion rarely,  if  ever,  affected  by  the  dystrophies,  which  involve  first  those  of 
the  calves,  the  trunk,  the  face,  or  the  shoulder-girdle.  In  the  central  atrophy 
the  reaction  of  degeneration  is  present  and  fibrillary  twitchings  occur  in  both 
the  atrophied  and  non-atrophied  muscles.  In  many  cases,  in  addition  to  the 
wasting  in  the  arms,  there  is  a  spastic  condition  in  the  legs  and  increase  in  the 
reflexes.  The  central  atrophies  come  on  late  in  life;  the  dystrophies  develop, 
as  a  rule,  early.  In  the  progressive  muscular  dystrophies  heredity  plays  an 
important  role,  which  in  the  central  form  is  quite  subsidiary.  In  the  rare 
cases  of  early  infantile  spinal  muscular  atrophy  occurring  in  families  the 
symptoms  are  so  characteristic  of  a  central  disease  that  the  diagnosis  presents 
no  difficulty. 

(c)  In  the  neuritic  muscular  atrophies,  whether  due  to  lead  or  to  trauma, 
the  general  characters  and  the  mode  of  onset  are  distinctive.    In  the  cases  of 
multiple  neuritis  seen  for  the  first  time  at  a  period  when  the  wasting  is  marked 
there  is  often  difficulty,  but  the  absence  of  family  history  and  the  distribution 
are  important  features.     Moreover,  the  paralysis  is  out  of  proportion  to  the 
atrophy.     Sensory  symptoms  may  be  present,  and  in  the  cases  in  which  the 
legs  are  chiefly  involved  there  is  usually  the  steppage  gait  so  characteristic  of 
peripheral  neuritis. 

(d)  Progressive  neural  muscular  atrophy.    Here  heredity  is  also  a  factor, 
and  the  disease  usually  begins  in  early  life,  but  the  distribution  of  atrophy 
and  paralysis,  which  in  this  affection  is  at  first  confined  to  the  periphery  of 
the  extremities,  helps  to  distinguish  it  from  the  dystrophies ;  while  the  occur- 
rence of  sensory  symptoms,  fibrillary  contractions,  and  the  marked  decrease  in 
the  electrical  excitability  usually  make  the  distinction  clear. 

The  outlook  in  the  primary  muscular  dystrophies  is  bad.  The  wasting 
progresses  uniformly,  uninfluenced  by  treatment.  Erb  holds  that  by  electricity 
and  massage  the  progress  is  occasionally  arrested.  The  general  health  should 
be  carefully  looked  after,  moderate  exercise  allowed,  frictions  with  oil  ap- 
plied to  the  muscles,  and  when  the  patient  becomes  bedfast,  as  is  inevitable 


DISEASES    OF    THE    EFFERENT    OR    MOTOR   TRACT      935 

sooner  or  later,   care  should  be  taken  to  prevent  contractures  in  awkward 
positions. 

The  forms  of  progressive  muscular  wasting — progressive  (central)  muscu- 
lar atrophy,  progressive  neural  muscular  atrophy,  and  the  muscular  dystro- 
phies— have  been  considered  as  distinct  diseases,  but  possibly  the  distinction 
may  not  be  so  sharp  as  we  believe.  Certain  cases  occur  which  seem  not  to 
belong  to  any  one  of  the  forms,  but  to  stand  between  them.  The  changes 
in  the  muscles  which  were  thought  to  be  characteristic  of  the  dystrophies  have 
been  found  in  the  other  forms.  The  central  form  occurs  as  a  family  disease 
in  infancy,  and  the  nervous  system  has  been  found  diseased  in  the  dystrophies. 


B.  SYSTEM  DISEASES  OF  THE  UPPER  MOTOR  SEGMENT 

The  question  of  an  uncomplicated  primary  degeneration  of  the  upper 
motor  neurones  has  not  been  decided.  Cases  with  a  clinical  picture  corre- 
sponding to  this  lesion  are  not  uncommon,  and  they  may  persist  for  a  long 
time  without  change.  Unfortunately  the  cases  which  have  come  to  autopsy 
have  shown  various  conditions.  In  only  two  or  three  has  the  disease  been 
so  nearly  confined  to  the  pyramidal  tract  that  they  can  be  used  as  an  argu- 
ment for  the  independence  of  this  condition.  The  cases  of  Minkowski,  Dresch- 
feld,  and  Striimpell  are  not  absolutely  conclusive,  as  they  are  not  quite  pure, 
although  they  go  far  to  prove  that  a  degeneration  in  the  pyramidal  tract  may 
be  uncomplicated,  at  least  for  a  long  time.  The  same  may  be  said  for  the 
group  of  cases  described  by  Bernhardt  and  Striimpell  under  the  name  heredi- 
tary spastic  spinal  paralysis,  in  which  the  extensive  systemic  degeneration  of 
the  pyramidal  tracts  is  combined  with  slight  degeneration  in  other  tracts  of 
the  cord. 

1.     SPASTIC  PARALYSIS  OF  ADULTS 
(Tabes  dorsalis  spasmodique;  Primary  Lateral  Sclerosis) 

Definition.  — A  gradual  loss  of  power  with  spasm  of  the  muscles  of  the 
body,  the  lower  extremities  being  first  and  most  affected,  unaccompanied  by 
muscular  atrophy,  sensory  disturbance,  or  other  symptoms.  The  pathological 
anatomy  is  undetermined,  but  a  systemic  degeneration  of  the  pyramidal  tracts 
is  assumed. 

Symptoms. — The  general  symptoms  of  spastic  paraplegia  in  adults  are 
very  distinctive.  The  patient  complains  of  feeling  tired,  of  stiffness  in  the 
legs,  and  perhaps  of  pains  of  a  dull  aching  character  in  the  back  or  in  the 
calves.  There  may  be  no  definite  loss  of  power,  even  when  the  spastic  condi- 
tion is  well  established.  In  other  instances  there  is  definite  weakness.  The 
stiffness  is  felt  most  in  the  morning.  In  a  well  developed  case  the  gait  is  most 
characteristic.  The  legs  are  moved  stiffly  and  with  hesitation,  the  toes  drag 
and  catch  against  the  ground,  and,  in  extreme  cases,  when  the  ball  of  the 
foot  rests  upon  the  ground  a  distinct  clonus  develops.  The  legs  are  kept 
close  together,  the  knees  touch,  and  in  certain  cases  the  adductor  spasm  may 
cause  cross-legged  progression.  On  examination,  the  legs  may  at  first  appear 


936  DISEASES    OF    THE    NERVOUS    SYSTEM 

tolerably  supple,  perhaps  flexed  and  extended  readily.  In  other  cases  the 
rigidity  is  marked,  particularly  when  the  limbs  are  extended.  The  spasm  of 
the  adductors  of  the  thigh  may  be  so  extreme  that  the  legs  are  separated  with 
the  greatest  difficulty.  In  cases  of  this  extreme  rigidity  the  patient  usually 
loses  the  power  of  walking.  The  nutrition  is  well  maintained,  the  muscles 
may  be  hypertrophied.  The  reflexes  are  greatly  increased.  The  slightest 
touch  upon  the  patellar  tendon  produces  an  active  knee-jerk.  The  rectus 
clonus  and  the  ankle  clonus  are  easily  obtained.  In  some  instances  the  slight- 
est touch  may  throw  the  legs  into  violent  clonic  spasm,  the  condition  to  which 
Brown-Sequard  gave  the  name  of  spinal  epilepsy.  The  superficial  reflexes 
are  also  increased.  The  arms  may  be  unaffected  for  years,  but  occasionally 
they  become  weak  and  stiff  at  the  same  time  as  the  legs. 

The  course  of  the  disease  is  progressively  downward.  Years  may  elapse 
before  the  patient  is  bedridden.  Involvement  of  the  sphincters,  as  a  rule, 
is  late;  occasionally,  however,  it  is  early.  The  sensory  symptoms  rarely  pro- 
gress, and  the  patients  may  retain  their  general  nutrition  and  enjoy  excellent 
health.  Ocular  symptoms  are  rare. 

Diagnosis. — The  diagnosis,  so  far  as  the  clinical  picture  is  concerned,  is 
readily  made,  but  it  is  often  very  difficult  to  determine  accurately  the  nature 
of  the  underlying  pathological  condition.  A  history  of  syphilis  is  present  in 
many  of  the  cases.  Cases  which  have  run  a  fairly  typical  clinical  course  upon 
coming  to  autopsy  have  been  found  to  have  been  due  to  very  different  condi- 
tions— transverse  myelitis,  multiple  sclerosis,  cerebral  tumor,  etc.  General 
paralysis  of  the  insane  may  begin  with  symptoms  of  spastic  paraplegia,  and 
Westphal  believed  that  it  was  only  in  relation  to  this  disease  that  a  primary 
sclerosis  of  the  pyramidal  tracts  ever  occurred.  In  any  case  the  diagnosis 
of  primary  systemic  degeneration  of  the  p3rramidal  tract  is,  to  say  the  least, 
doubtful. 

Treatment. — Not  much  can  be  done  to  check  the  progress  of  the  disease. 
Division  of  the  posterior  nerve  roots  is  permissible  when  the  motor  weakness 
is  due  chiefly  to  the  spasticity.  A  number  of  cases  have  been  operated  upon 
successfully.  The  same  practice  has  been  followed  in  the  spasticity  with 
bilateral  athetosis. 


2.  SPASTIC  PAEALYSIS  OF  INFANTS— SPASTIC  DIPLEGIA— BIRTH  PALSIES 
(Paraplegia,  cerebralis  spastica  (Heine};  Little's  Disease) 

In  this  condition  there  is  a  paralysis  with  spasm  of  all  extremities,  dating 
from  or  shortly  succeeding  birth,  more  rarely  following  the  fevers  or  an 
attack  of  convulsions.  The*  legs  are  usually  more  involved  than  the  arms ; 
there  "is  no  wasting,  no  disturbance  of  sensation.  The  reflexes  are  increased. 
The  mental  condition  is  usually  much  disturbed.  The  patients  are  often 
imbeciles  or  idiots,  helpless  in  mind  and  body.  Ataxic  and  athetoid  move- 
ments of  the  most  exaggerated  kind  may  occur. 

While  only  a  limited  number  of  cases  of  infantile  hemiplegia  are  con- 
genital, on  the  other  hand,  in  spastic  diplegia  and  paraplegia  a  large  pro- 
portion of  the  cases  results  from  injury  at  b.irth.  The  arms  may  be  so  slightly 
affected  as  to  make  it  difficult  to  determine  whether  it  is  a  case  of  diplegia  or 


DISEASES    OF    THE    EFFERENT    OR   MOTOR   TRACT      937 

paraplegia.  The  disease  usually  dates  from  birth,  and  a  majority  of  the  chil- 
dren are  born  in  first  labors  or  are  forceps  cases,  and  are  at  birth  asphyxiated 
blue  babies.  In  feet  presentations  there  may  be  laceration  or  tearing  of  the 
cerebro-spinal  membranes.  Premature  birth  is  also  given  as  a  cause. 

Morbid  Anatomy. — The  birth  palsies  which  ultimately  induce  the  spastic 
diplegias  or  paraplegias  are  most  frequently  the  result  of  meningeal  hemor- 
rhage. The  importance  of  this  condition  has  been  shown  by  the  studies  of 
Litzmann  and  Sarah  J.  McNutt.  The  bleeding  may  come  from  the  veins, 
or  from  the  longitudinal  sinus.  The  haemorrhage  has  in  many  cases  been 
greatest  over  the  motor  areas,  and  in  these  cases  the  intelligence  may  suffer 
but  little;  with  a  more  extensive  haemorrhage,  especially  when  it  implicates 
the  frontal  lobes,  any  grade  of  amentia  may  be  occasioned.  It  seems  probable 
that  the  sclerosis  found  in  these  cases  may  result  from  compression  by  the 
blood  clot.  In  other  instances  the  condition  may  be  due  to  a  fetal  meningo- 
encephalitis.  In  16  autopsies  collected  in  the  literature,  in  which  the  patients 
died  at  ages  varying  from  two  to  thirty,  the  anatomical  condition  was  either 
a  diffuse  atrophy,  which  was  most  common,  or  porencephalus.  From  the  fact 
that  certain  of  the  patients  are  born  prematurely,  before  the  pyramidal  tracts 
are  developed,  it  has  been  assumed  by  some  that  a  non-development  of  these 
tracts  is  the  cause  of  the  disease.  In  others  the  fibres  have  been  few  in  num- 
ber and  incompletely  myelinized.  This  hypothesis  has  been  urged  by  Marie, 
who  limits  the  name  spastic  paraplegia  to  that  group  of  the  infantile  cases 
in  which  there  is  no  evidence  of  involvement  of  the  brain — intellectual  dis- 
turbances, epilepsy,  etc.,  and  it  is  in  these  cases  that  he  believes  the  pyramidal 
tracts  have  remained  undeveloped. 

Symptoms. — At  first  nothing  abnormal  may  be  noticed  about  the  child.  In 
some  instances  there  have  been  early  and  frequent  convulsions;  then  at 
the  age  when  the  child  should  begin  to  walk  it  is  noticed  that  the  limbs  are 
not  used  readily,  and  on  examination  a  stiffness  of  the  legs  and  arms  is  found. 
Even  at  the  age  of  two  the  child  may  not  be  able  to  sit  up,  and  often  the 
head  is  not  well  supported  by  the  neck  muscles.  The  rigidity,  as  a  rule,  is 
more  marked  in  the  legs,  and  there  is  an  adductor  spasm.  When  supported 
on  the  feet,  the  child  either  rests  on  its  toes  and  the  inner  surface  of  the  feet, 
with  the  knees  close  together,  or  the  legs  may  be  crossed.  The  stiffness  of  the 
upper  limbs  varies.  It  may  be  scarcely  noticeable  or  the  rigidity  may  be  as 
marked  as  in  the  legs.  When  the  spastic  condition  affects  the  arms  as  well  as 
the  legs,  we  speak  of  the  condition  as  diplegia;  when  the  legs  alone  are  in- 
volved, as  paraplegia.  There  seems  to  be  no  sufficient  reason  for  considering 
them  separately.  The  spasticity  is  probably  due  to  interruption  of  the  cortico- 
spinal  fibres  which  exercise  an  inhibitory  influence  on  the  cells  of  the  anterior 
horns.  Constant  irregular  movements  of  the  arms  are  not  uncommon.  The 
child  has  great  difficulty  in  grasping  an  object  The  spasm  and  weakness 
may  be  more  evident  on  one  side  than  the  other.  The  mental  condition  is, 
as  a  rule,  defective  and  convulsive  seizures  are  common. 

Associated  with  the  spastic  paralysis  are  two  allied  conditions  of  consid- 
erable interest,  characterized  by  spasm  and  disordered  movements.  A  child 
with  spastic  diplegia  may  present,  in  an  unusual  degree,  irregular  movements 
of  the  muscles.  In  attempting  to  grasp  an  object  the  fingers  may  be  thrown 
out  in  a  stiff,  spasmodic,  irregular  manner,  or  there  may  be  constant  irregular 
61 


938  DISEASES    OF    THE    NERVOUS    SYSTEM 

movements  of  the  shoulders,  arms,  and  hands,  with  slight  incob'rdination  of 
the  head.  Cases  of  this  description  have  been  described  as  chorea  spastica, 
and  they  may  be  difficult  to  separate  from  multiple  sclerosis  and  from  Fried- 
reich's  ataxia. 

A  still  more  remarkable  condition  is  that  of  bilateral  atlieiosis,  in  which 
there  is  a  combination  of  spasm  more  or  less  marked  with  the  most  extra- 
ordinary bizarre  movements  of  the  muscles.  The  condition,  as  a  rule,  dates 
from  infancy.  The  patient  may  not  be  able  to  walk.  The  head  is  turned  from 
side  to  side;  there  are  continual  irregular  movements  of  the  face  muscles, 
and  the  mouth  is  drawn  and  greatly  distorted.  The  extremities  are  more  or 
less  rigid,  particularly  in  extension.  On  the  slightest  attempt  to  move,  often 
spontaneously,  there  are  extraordinary  movements  of  the  arms  and  legs,  par- 
ticularly of  the  arms,  somewhat  like  athetosis,  though  much  more  exagger- 
ated. The  patients  are  often  unable  to  help  themselves  on  account  of  these 
movements.  The  reflexes  are  increased.  The  mental  condition  is  variable.  The 
patient  may  be  idiotic,  but  in  3  of  the  6  cases  which  I  have  seen  the  patients 
were  intelligent.  Massalongo,  who  has  carefully  studied  this  condition,  de- 
scribes 3  cases  in  one  family.  I  have  collected  53  cases  from  the  literature, 
33  of  which  occurred  in  males  and  20  in  females. 

Treatment. — Little  can  be  done  for  these  children  when  the  symptoms  are 
extreme.  In  the  milder  cases  patient  training  may  do  much  to  better  the 
mental  state  when  feeble-mindedness  accompanies  the  motor  palsies.  Exer- 
cises and  massage  should  be  given  for  the  spastic  muscles,  and  in  many  in- 
stances tenotomies  and  tendon  transplantations  may  be  helpful  in  improving 
the  usefulness  particularly  of  the  lower  extremities.  Division  of  the  posterior 
nerve  roots  is  of  great  use  in  certain  cases.  On  the  view  that  most  of  these 
cases  date  back  to  an  intracranial  haemorrhage  during  parturition,  it  is 
reasonable  to  suppose  that  an  immediate  operation  with  the  removal  of  the 
cortical  clot — for  the  effusion  of  blood  is  usually  on  the  surface  of  the  hemi- 
sphere— might  ward  off  the  disastrous  consequences,  of  compression  on  the 
infant's  brain.  Cases,  with  asphyxia  and  convulsions  after  difficult  labors, 
have  been  operated  upon  soon  after  birth  by  Gushing  and  others,  and  cor- 
tical clots  have  been  removed.  In  some  cases  there  has  been  a  complete  restor- 
ation to  health  and  the  usual  spastic  sequels  have  not  occurred. 

3.  HEEEDITAEY  SPASTIC  PARAPLEGIA 

(Hereditary  Spastic  Spinal  Paralysis;  Family  form  of  Spastic  Spinal 

Paralysis) 

It  is  a  family  affection  and  only  occasionally  are  the  ascendants  affected. 
There  are  several  forms: 

1.  The  pure  spastic  paraplegia — Striimpell's  type — in  which  two  or  more 
members  of  a  family  are  attacked.    Trunk,  arms,  and  brain  are  not  affected. 

2.  Mixed  forms:   (a)  with  features  of  multiple  sclerosis  as  described  by 
Cestan  and  Guillain;  (&)  amyotrophic  lateral  sclerosis  type,  with  the  added 
feature  of  atrophy;  (c)  forms  resembling  Friedreich's  ataxia  and  the  hered- 
itary cerebellar  ataxia;  (d)  forms  resembling  cerebral  diplegia. 

In  a  majority  of  the  cases  the  disease  begins  in  children  between  the  sev- 


DISEASES    OF   THE    EFFERENT   OR   MOTOR   TRACT      939 

enth  and  the  fifteenth  years.  It  may  not  occur  until  the  twentieth  year.  Two, 
three,  or  four  members  of  a  family  are  affected.  Beginning  in  the  legs  with 
characteristic  spastic  gait  and  all  the  features  of  an  ordinary  spinal  paralysis, 
the  disease  may  extend  and  affect  the  arms,  or  there  are  added  the  symptoms 
of  multiple  sclerosis  or  of  one  of  the  other  above-named  affections.  Boys  are 
more  often  affected  than  girls,  88  to  51,  in  the  cases  collected  by  Delearde  and 
Minet, 

The  pathology  of  the  disease  is  still  under  discussion. 

Amaurotic  Family  Idiocy  (Sacks'  Disease). — A  remarkable  form  of  in- 
fantile paralysis  has  been  described  by  Sachs,  Peterson,  and  Hirsch.  The  dis- 
ease is  one  which  involves  the  entire  gray  matter  of  the  central  nervous  sys- 
tem. The  symptoms  as  summarized  by  Sachs  are:  (1)  Psychic  disturbances 
that  appear  in  early  life  (first  or  second  year)  and  progress  to  total  idiocy. 
(2)  Paresis,  and  ultimately  complete  paralysis  of  the  extremities,  which  may 
be  either  flaccid  or  spastic.  (3)  Increased,  decreased,  or  normal  tendon  re- 
flexes. (4)  Partial,  followed  by  total  blindness  (macular  changes,  with  sub- 
sequent atrophy  of  the  optic  nerve).  (5)  Marasmus  and  death,  usually  before 
the  second  year.  (6)  Distinct  familial  type.  Occasional  symptoms  are  nys- 
tagmus, strabismus,  hyperacusis,  or  impairment  of  hearing.  The  pathological 
changes  are  primitive  type  of  the  cerebral  convolutions,  macrogyria,  degen- 
erative changes  in  the  large  pyramidal  cells,  absence  of  the  tangential  fibres, 
and  decrease  of  the  fibres  of  the  white  matter.  The  blood-vessels  are  normal. 
There  is  also  degeneration  of  the  pyramidal  columns  of  the  cord.  Of  27  cases 
collected  by  Sachs,  17  occurred  in  six  families;  all  in  Hebrews. 

-  -^       t 

4.     EBB'S   SYPHILITIC  SPINAL  PAEALYSIS 

Erb  has  described  a  symptom  group  under  the  term  syphilitic  spinal 
paralysis,  to  which  much  attention  has  been  given.  The  points  upon  which 
he  lays  stress  are  a  very  gradual  onset  with  a  development  finally  of  the  fea- 
tures of  a  spastic  paresis;  the  tendon  reflexes  are  greatly  increased,  but  the 
muscular  rigidity  is  slight  in  comparison  with  the  exaggerated  deep  reflexes. 
There  is  rarely  much  pain,  and  the  sensory  disturbances  are  trivial,  but  there 
may  be  parsesthesia  and  the  girdle  sensation.  The  bladder  and  rectum  are 
usually  involved,  and  there  is  sexual  failure  or  impotence.  And,  lastly,  im- 
provement is  not  infrequent.  A  majority  of  instances  of  spastic  paralysis  of 
adults  not  the  result  of  slow  compression  of  the  cord  are  associated  with 
syphilis  and  belong  to  this  group. 

Erb  believes  the  lesion  to  be  a  special  form  of  transverse  myelitis,  but  per- 
haps it  should  be  classed,  with  the  system  diseases,  under  the  name  toxic  spas- 
tic spinal  paralysis. 

5.     SECONDARY  SPASTIC  PARALYSIS 

Following  any  lesion  of  the  pyramidal  tract  there  may  be  a  spastic  paraly- 
sis ;  thus,  in  a  transverse  lesion  of  the  cord,  whether  the  result  of  slow  com- 
pression (as  in  caries),  chronic  m}?elitis,  the  pressure  of  tumor,  chronic  men- 
ingo-myelitis,  or  multiple  sclerosis,  degeneration  takes  place  in  the  pyramidal 
tracts,  below  the  point  of  disease.  The  legs  soon  become  stiff  and  rigid,  and 
the  reflexes  increase.  Bastian  has  shown  that  in  compression  paraplegia  if  the 


940  DISEASES    OF    THE    NERVOUS    SYSTEM 

transverse  lesion  is  complete,  the  limbs  may  be  flaccid,  without  increase  in  the 
reflexes — paraplegic  flasque  of  the  French.  The  condition  of  the  patient 
in  these  secondary  forms  varies  very  much.  In  chronic  myelitis  or  in  mul- 
tiple sclerosis  he  may  be  able  to  walk  about,  but  with  a  characteristic  spastic 
gait.  In  the  compression  myelitis,  in  fracture,  or  in  caries,  there  may  be 
complete  loss  of  power  with  rigidity. 

It  may  be  difficult  or  even  impossible  to  distinguish  these  cases  from  those 
of  primary  spastic  paralysis.  Reliance  is  to  be  placed  upon  the  associated 
symptoms ;  when  these  are  absent  no  definite  diagnosis  as  to  the  cause  of  the 
spastic  paralysis  can  be  given. 

6.     HYSTERICAL  SPASTIC  PAEAPLEGIA 

There  is  no  spinal  cord  disease  which  may  be  so  accurately  mimicked  as 
spastic  paraplegia.  In  the  hysterical  form  there  is  wasting,  the  sensory  symp- 
toms are  not  marked,  the  loss  of  power  is  not  complete,  and  there  is  not  that 
extensor  spasm  so  characteristic  of  organic  disease.  The  reflexes  are,  as  a 
rule,  increased.  The  knee-jerk  is  present,  and  there  may  be  a  well  developed 
ankle  clonus.  Gowers  calls  attention  to  the  fact  that  it  is  usually  a  spurious 
clonus,  "due  to  a  half-voluntary  contraction  in  the  calf  muscles/'  A  true 
clonus  does  occur,  however,  and  there  may  be  the  greatest  difficulty  in  deter- 
mining whether  or  not  the  case  is  one  of  hysterical  paraplegia.  The  hysterical 
contracture  will  be  considered  later. 


C.     SYSTEM  DISEASES   OF  THE   LOWER   MOTOR   SEGMENT 

1.     CHRONIC   ANTERIOR  POLIO-MYELITIS 
(Progressive  Muscular  Atrophy — Aran-Duchenne) 

This  disease  has  been  considered  as  one  of  the  types  making  up  the  pro- 
gressive (central)  muscular  atrophies.  In  certain  rare  cases  the  process  is 
confined  to  the  lower  motor  segment.  They,  however,  differ  so  little  clinically 
from  many  of  the  cases  in  which  the  pyramidal  tracts  are  involved  that  it 
seems  better  to  make  no  sharp  distinction  between  them.  The  same  may  be 
said  of  chronic  bulbar  paralysis. 

2.     OPHTHALMOPLEGIA 

This  disease  is  at  times  due  to  a  chronic  degeneration  of  the  nuclei  of  the 
motor  nerves  of  the  eyeballs,  and  so  is  a  system  disease  of  the  lower  motor  seg- 
ment. It  is  treated  of  in  connection  with  the  other  ocular  palsies  for  the  sake 
of  simplicity  and  because  all  ophthalmoplegias  are  not  due  to  nuclear  disease. 

3.     ACUTE    POLIO-MYELITIS 

(Infantile  Spinal  Paralysis,  Heinc-Medin  Disease) 

The  epidemic  form  of  this  affection  has  been  considered  with  the  infectious 
diseases.  The  sporadic  cases  are  very  probably,  although  not  surely,  due  to 


DISEASES    OF    THE    EFFERENT    OR    MOTOR   TRACT      941 

the  same  infection.    They  present  the  same  clinical  picture  and  need  no  fur- 
ther consideration. 


4.     ACUTE    AND    SUBACUTE    POLIO-MYELITIS    IN    ADULTS 

An  acute  polio-myelitis  in  adults,  the  exact  counterpart  of  the  disease  in 
children,  is  recognized.  Many  of  the  cases  represent  the  sporadic  form  of 
polio-myelitis.  A  certain  number  of  the  cases  described  under  this  heading 
have  been  multiple  neuritis;  but  the  suddenness  of  onset,  the  rapid  wasting, 
and  the  marked  reaction  of  degeneration  are  thought  by  some  to  be  distin- 
guishing features.  Multiple  neuritis  may,  however,  set  in  with  rapidity; 
there  may  be  great  wasting  and  the  reaction  of  degeneration  is  sometimes 
present.  The  time  element  alone  may  determine  the  true  nature.  Recovery 
in  a  case  of  extensive  multiple  paralysis  from  polio-myelitis  will  certainly  be 
with  loss  of  power  in  certain  groups  of  muscles ;  whereas,  in  multiple  neuritis 
the  recovery,  while  slow,  may  be  perfect. 

The  subacute  form,  the  paralysie  generale  spinale  anterieure  subaigue  of 
Duchenne,  is  in  all  probability  a  peripheral  palsy.  The  paralysis  usually  be- 
gins in  the  legs  with  atrophy  of  the  muscles,  then  the  arms  are  involved,  but 
not  the  face.  Sensation,  as  a  rule,  is  not  involved. 

5.     ACUTE   ASCENDING    (LANDEY'S)    PAEALYSIS 

Definition.  — An  ascending  flaccid  paralysis,  beginning  in  the  legs,  rapidly 
extending  to  the  trunk  and  arms,  and  finally  involving  the  muscles  of  respira- 
tion. Sensation  and  electrical  reactions  are  normal,  and  there  is  retention  of 
sphincter  control. 

Etiology  and  Pathology. — The  disease  occurs  most  commonly  in  males 
between  the  twentieth  and  thirtieth  years.  It  has  sometimes  followed  the 
specific  fevers.  As  already  mentioned,  there  is  a  form  of  the  epidemic  polio- 
mvelitis  which  has  an  acute  course  and  a  clinical  picture  similar  to  Landry's 
paralysis ;  but  it  is  not  likely,  as  has  been  suggested,  that  this  disease  always 
represents  the  sporadic  variety.  Many  of  the  common  pathogenic  organisms 
may,  especially  in  patients  debilitated  by  disease,  give  rise  to  symptoms  of 
acute  ascending  paralysis.  Thus,  the  typhoid  bacillus  may  produce  clinically 
an  acute  ascending  paralysis.  The  most  careful  studies  have  not  solved  the 
problem  of  this  remarkable  disease.  There  are  two  views:  First,  that  it  is 
a  peripheral  neuritis.  Spiller  in  a  rapidly  fatal  case  found  destructive  changes 
in  the  peripheral  nerves  and  corresponding  alterations  in  the  cell  bodies  of 
the  ventral  horns.  He  suggests  that  the  toxic  agent  acts  on  the  lower  motor 
neurones  as  a  whole,  and  that  possibly  the  reason  why  no  lesions  were  found 
in  some  of  the  cases  is  that  the  more  delicate  histological  methods  were  not 
used.  Buzzard  has  isolated  a  micrococcus  (M.  thecalis)  in  pure  culture  in 
one  case,  and  found  the  organism  in  large  numbers  in  the  tissues  outside  the 
spinal  dura.  Secondly,  that  it  is  a  functional  disorder  without  a  recognizable 
anatomical  basis. 

Symptoms. —Weakness  of  the  legs,  gradually  progressing,  often  with  toler- 
able rapidity,  is  the  first  symptom.  In  some  cases  within  a  few  hours  the 
paralysis  of  the  legs  becomes  complete.  The  muscles  of  the  trunk  are  next 


942  DISEASES    OF    THE    NEKVOUS    SYSTEM 

affected,  and  within  a  few  days,  or  even  less  in  more  acute  cases,  the  arms 
are  also  involved.  The  neck  muscles  are  next  attacked,  and  finally  the  muscles 
of  respiration,  deglutition,  and  articulation.  The  reflexes  are  lost,  but  the 
muscles  neither  waste  nor  show  electrical  changes.  The  sensory  symptoms  are 
variable ;  in  some  cases  tingling,  numbness,  and  hyperassthesia  have  been  pres- 
ent. In  the  more  characteristic  cases  sensation  is  intact  and  the  sphincters 
are  uninvolved.  Enlargement  of  the  spleen,  which  occurred  in  the  only  two 
cases  in  my  wards,  has  been  noticed  in  several  other  cases.  The  course  of  the 
disease  is  variable.  It  may  prove  fatal  in  less  than  two  days.  Other  cases 
persist  for  a  week  or  for  two  weeks.  In  a  large  proportion  of  the  cases  the 
disease  is  fatal.  One  patient  was  kept  alive  for  41  days  by  artificial  respira- 
tion (C.  L.  Greene). 

Diagnosis.  — The  diagnosis  is  difficult,  particularly  from  certain  forms  of 
multiple  neuritis,  and  if  we  include  in  Landry's  paralysis  the  cases  in  which 
sensation  is  involved  distinction  between  the  two  affections  is  impossible.  We 
apparently  have  to  recognize  the  existence  of  a  rapidly  advancing  motor  par- 
alysis without  involvement  of  the  sphincters,  without  wasting  or  electrical 
changes  in  the  muscles,  without  trophic  lesions,  and  without  fever — features 
sufficient  to  distinguish  it  from  either  the  acute  central  myelitis  or  the  polio- 
myelitis anterior.  It  is  doubtful,  however,  whether  these  characters  always 
suffice  to  enable  us  to  differentiate  the  cases  of  multiple  neuritis.  The  cases 
of  acute  polio-myelitis  with  the  picture  of  an  acute  ascending  paralysis  should 
not  be  difficult  to  recognize  during  the  progress  of  an  epidemic. 

IV.     COMBINED    SYSTEM   DISEASES 

When  the  disease  is  not  confined  within  the  limits  of  either  the  afferent 
or  efferent  systems,  but  affects  both,  it  is  known  as  a  combined  system  disease. 
Some  authors  contend  that  the  diseases  usually  classed  under  this  head  are 
not  really  system  diseases,  but  are  diffuse  processes.'  This  is  the  view  taken 
by  Leyden  and  Goldscheider,  who  limit  the  term  system  disease  to  locomotor 
ataxia  and  progressive  muscular  atrophy. 

In  certain  cases  of  locomotor  ataxia  which  have  run  a  fairly  typical  course 
there  may  be  found  after  death,  besides  the  anatomical  picture  corresponding 
to  this  disease,  a  moderate  degeneration  of  the  pyramidal  tracts  and  of  the 
ventral  horns.  In  progressive  muscular  atrophy,  on  the  other  hand,  there  may 
be  degeneration  in  the  dorsal  columns.  During  life  these  secondary  involve- 
ments of  other  systems  may  or  may  not  be  accompanied  by  demonstrable 
symptoms,  and  when  such  do  occur  they  make  their  appearance  late  in  the 
disease. 

There  is  another  group  of  cases  in  which  from  the  very  first  the  symptoms 
point  to  an  involvement  of  both  the  afferent  and  efferent  systems,  and  it  is 
to  these  that  the  term  primary  combined  system  disease  is  usually  limited. 

1.     ATAXIC   PARAPLEGIA 

This  name  is  applied  by  Gowers  to  a  disease  characterized  clinically  by  a 
combination  of  ataxia  and  spastic  paraplegia,  and  anatomically  by  involvement 
of  the  dorsal  and  lateral  columns. 


COMBINED    SYSTEM   DISEASES  943 

The  disease  is  most  common  in  middle  aged  males.  Exposure  to  cold  and 
traumatism  have  been  occasional  antecedents.  In  striking  contrast  to  ordi- 
nary tabes  a  history  of  syphilis  is  rarely  to  be  obtained. 

The  anatomical  features  are  a  sclerosis  of  the  dorsal  columns,  which  is 
not  more  marked  in  the  lumbar  region  and  not  specially  localized  in  the  root 
zone  of  the  cuneate  fasciculi.  The  involvement  of  the  lateral  columns  is 
diffuse,  not  always  limited  to  the  pyramidal  tracts,  and  there  may  be  an 
annular  sclerosis.  Marie  believes  that  in  many  cases  the  distribution  of  the 
sclerosis  is  due  to  the  arterial  supply  and  not  to  a  true  systematic  degenera- 
tion, the  vessels  involved  being  branches  of  the  dorsal  spinal  artery. 

The  symptoms  are  well  denned.  The  patient  complains  of  a  tired  feeling 
in  the  legs,  not  often  of  actual  pain.  The  sensory  symptoms  of  true  tabes  are 
absent.  An  unsteadiness  in  the  gait  gradually  comes  on  with  progressive 
weakness.  The  reflexes  are  increased  from  the  outset,  and  there  may  be 
well  marked  ankle  clonus.  Bigidity  of  the  legs  comes  on  slowly,  but  it  is 
rarely  extreme  as  in  the  uncomplicated  cases  of  lateral  sclerosis.  From  the 
start  incoordination  is  a  well  characterized  feature,  and  the  difficulty  of  walk- 
ing in  the  dark,  or  swaying  when  the  eyes  are  closed,  may,  as  in  true  tabes,  be 
the  first  symptom  to  attract  attention.  In  walking  the  patient  uses  a  stick, 
keeps  the  eyes  fixed  on  the  ground,  the  legs  far  apart,  but  the  stamping  gait, 
with  elevation  and  sudden  descent  of  the  feet,  is  not  often  seen.  The  inco- 
ordination may  extend  to  the  arms.  Sensory  symptoms  are  rare,  but  Gowers 
calls  attention  to  a  dull,  aching  pain  in  the  sacral  region.  The  sphincters 
usually  become  involved.  Eye  symptoms  are  rare.  Late  in  the  disease  mental 
symptoms  may  occur,  similar  to  those  of  general  paresis. 

In  well  marked  cases  the  diagnosis  is  easy.  The  combination  of  marked 
incoordination  with  retention  of  the  reflexes  and  more  or  less  spasm  are  char- 
acteristic features.  The  absence  of  ocular  and  sensory  symptoms  is  an  impor- 
tant point. 

2.     PRIMAEY  COMBINED  SCLEEOSIS    (PUTNAM) 

The  studies  of  J.  J.  Putnam,  Dana,  Bastianelli,  Eisien  Eussell,  Collier, 
and  Batten  have  separated  from  among  the  lesions  of  the  cord  a  fairly  well 
defined  disease,  characterized  anatomically  by  a  diffuse  degeneration,  often  in 
discrete  patches.  The  dorsal  and  lateral  columns  are  constantly  involved, 
chiefly  in  the  thoracic  and  cervical  regions.  The  nerve  roots  and  the  gray 
matter  show  no  changes.  The  lesions  have  the  "appearance  of  a  non-sys- 
temic primary  neurone  degeneration,  not  dependent  upon  antecedent  inflam- 
mation" (E.  W.  Taylor). 

Of  Putnam's  50  cases,  31  were  women,  all  but  5  above  thirty  years  old. 
A  majority  of  the  patients  were  of  small  stature  and  slender  frame,  and  in 
many  there  had  been  a  general  lack  of  vigor  and  a  chronic  pallor  and  debility; 
7  presented  profound  anaemia.  There  was  no  luetic  history.  The  relation  of 
this  group  to  anaemia  is  interesting.  Eussell,  Batten,  and  Collier  make  three 
groups:  (1)  cases  of  profound  anaemia  (and  one  may  add  of  cachexia),  in 
which  during  life  no  symptoms  were  present,  but  in  which  there  were  found 
combined  scleroses  of  the  cord  post  mortem;  (2)  cases  of  progressive  per- 
nicious anaemia,  in  which  spinal  symptoms  have  occurred;  (3)  cases  of  chronic 


944  DISEASES   OF   THE   NERVOUS   SYSTEM 

sclerosis  of  the  cord,  in  which  there  occurs,  as  a  secondary  feature,  a  severe 
anaemia. 

The  symptoms  are  both  sensory  and  motor.  The  onset  is  usually  vvith 
numhness  in  the  extremities,  progressive  loss  of  strength,  and  emaciation. 
Paraplegia  gradually  develops,  before  which  there  have  been,  as  a  rule,  spastic 
symptoms  with  exaggerated  knee-jerk.  The  arms  are  affected  less  than  the 
legs.  Mental  symptoms  suggestive  of  dementia  paralytica  may  occur  toward 
the  close. 

3.     HEREDITARY  ATAXIA 
(Friedreich's  Ataxia) 

In  1861  Friedreich  reported  6  cases  of  a  form  of  hereditary  ataxia,  and 
the  affection  has  usually  gone  by  his  name.  Unfortunately,  paramyoclonus 
multiplex  is  also  called  Friedreich's  disease ;  so  it  is  best,  if  his  name  is  used 
in  connection  with  this  affection,  to  term  it  Friedreich's  ataxia.  It  is  a  very 
different  disease  in  many  respects  from  ordinary  tabes.  It  may  or  may  not 
be  hereditary.  It  is  really  a  family  disease,  several  brothers  and  sisters  being, 
as  a  rule,  affected.  The  143  cases  analyzed  by  Griffith  occurred  in  71  unrelated 
families.  In  his  series  inheritance  of  the  disease  itself  occurred  in  only  33 
cases.  Various  influences  in  the  parents  have  been  noted;  alcoholism  in  only 
7  cases.  Syphilis  has  rarely  been  present.  Of  the  143  cases,  86  were  males 
and  57  females.  The  disease  sets  in  early  in  life,  and  in  Griffith's  series  15 
occurred  before  the  age  of  two  years,  39  before  the  sixth  year,  45  between 
the  sixth  and  tenth,  20  between  the  eleventh  and  fifteenth,  18  between  the 
sixteenth  and  twentieth,  and  5  between  the  twentieth  and  twenty-fifth  years. 

The  morbid  anatomy  shows  an  extensive  sclerosis  of  the  dorsal  and  lateral 
columns  of  the  spinal  cord.  The  periphery  and  the  cerebellar  tracts  are  usu- 
ally involved.  The  observations  of  Dejerine  and  Letulle  are  of  special  interest, 
since  they  seem  to  indicate  that  the  change  in  this  disease  is  a  neurogliar 
(ectodermal)  sclerosis,  differing  entirely  from  the/  ordinary  spinal  sclerosis. 
According  to  this  view,  Friedreich's  disease  is  a  gliosis  of  the  dorsal  columns 
due  to  developmental  errors ;  but  the  question  is  still  unsettled. 

Symptoms. — The  ataxia  differs  somewhat  from  the  ordinary  form;  The 
incoordination  begins  in  the  legs,  but  the  gait  is  peculiar.  It  is  swaying, 
irregular,  and  more  like  that  of  a  drunken  man.  There  is  not  the  characteristic 
stamping  gait  of  the  true  tabes.  Eomberg's  symptom  may  or  may  not  be 
present.  The  ataxia  of  the  arms  occurs  early  and  is  very  marked ;  the  move- 
ments are  almost  choreiform,  irregular,  and  somewhat  swaying.  In  making 
any  voluntary  movement  the  action  is  overdone,  the  prehension  is  clawlike, 
and  the  fingers  may  be  spread  or  overextended  just  before  grasping  an  object. 
The  hand  frequently  moves  about  an  object  for  a  moment  and  then  suddenly 
pounces  upon  it.  There  are  irregular,  swaying  movements  of  the  head  and 
shoulders,  some  of  which  are  choreiform.  There  is  present  in  many  cases  what 
is  known  as  static  ataxia,  that  is  to  say,  ataxia  of  quiet  action.  It  occurs  when 
the  body  is  held  erect  or  when  a  limb  is  extended — irregular,  oscillating  move- 
ments of  the  head  and  body  or  of  the  extended  limb. 

Sensory  symptoms  are  not  usually  present.  The  deep  reflexes  are  lost  early 
in  the  disease,  and,  next  to  the  ataxia,  this,  is  the  most  constant  and  important 


COMBINED'  SYSTEM    DISEASES  945 

symptom.  The  skin  reflexes '«*re  usually  normal,  and  the  pupillary  reflex  to 
light  is  practically  never  affected. 

Nystagmus  is  a  characteristic  symptom.  Atrophy  of  the  optic  nerve  rarely 
occurs.  A  striking  feature  is  early  deformity  of  the  feet.  There  is  talipes 
equinus,  and  the  patient  walks  on  the  outer  edge  of  the  feet.  The  big  toe  is 
flexed  dorsally  on  the  first  phalanx.  Scoliosis  is  very  common. 

Trophic  lesions  are  rare.  As  the  disease  advances  paralysis  comes  on  and 
may  ultimately  be  complete.  Some  of  the  patients  never  walk. 

Disturbance  of  speech  is  common.  It  is  usually  slow  and  scanning;  the 
expression  is  often  dull;  the  mental  power  is,  as  a  rule,  maintained,  but  late 
in  the  disease  becomes  impaired. 

Diagnosis. — The  diagnosis  of  the  disease  is  not  difficult  when  several  mem- 
bers of  a  family  are  affected.  The  onset  in  childhood,  the  curious  form  of 
incoordination,  the  loss  of  knee-jerks,  the  early  talipes  equinus,  the  posi- 
tion of  the  great  toe,  the  scoliosis,  the  nystagmus,  and  scanning  speech  make 
up  an  unmistakable  picture.  The  disease  is  often  confounded  with  chorea, 
with  the  ordinary  form  of  which  it  has  nothing  in  common.  With  hereditary 
chorea  it  has  certain  similarities,  but  usually  this  disease  does  not  set  in  until 
after  the  thirtieth  year. 

The  affection  lasts  for  many  years  and  is  incurable.  Care  should  be  taken 
to  prevent  contractures. 

Cerebellar  Type 

There  is  a  form  of  hereditary  ataxia,  described  by  Marie  as  cerebellar 
Jieredo-ataxia,  which  starts  later  in  life,  after  the  age  of  twenty,  with  disa- 
bility in  the  legs,  but  the  gait  is  less  ataxic  than  "groggy."  The  knee-jerks 
are  retained,  and  a  spastic  condition  of  the  legs  ultimately,  develops.  There 
is  no  scoliosis,  nor  does  club-foot  develop.  Sanger  Brown's  cases,  25  in  one 
family,  and  J.  H.  Neff's,  13,  appear  to  belong  to  this  type.  The  cerebellum 
has  been  found  atrophied  in  2  cases. 

4.     PEOGEESSIVE  INTEESTITIAL  HYPEETROPHIC  NEURITIS  OF  INFANTS 

Under  this  imposing  title  Dejerine  and  Sottas  described  a  rare  and  inter- 
esting affection.  It  is  a  family  disease,  and  begins  in  early  life.  The  symp- 
toms are  those  typical  of  locomotor  ataxia,  to  which^e  added  progressive  mus- 
cular atrophy,  with  involvement  of  the  face  and  a  hypertrophy  and  hardening 
of  the  peripheral  nerves.  As  the  name  indicates,  it  is  an  interstitial  hyper- 
trophic  neuritis  with  secondary  involvement  of  the  dorsal  columns  of  the  cord. 
This  disease  has  been  associated  with  progressive  neural  muscular  atrophy,  but 
Dejerine  has  shown  that  it  is  quite  distinct. 

5.     TOXIC  COMBINED  SCLEROSIS 

Certain  poisons  cause  changes  in  the  lateral  and  dorsal  columns  of  the 
cord  that  resemble  those  of  the  combined  system  diseases.  They  have  been 
demonstrated  in  pellagra  and  in  ergotism.  In  pernicious  anemia  and  many 
chronic  wasting  diseases  these  scleroses  occur,  and  are  believed  to  be  due  to  the 
action  of  poisons  produced  within  the  system. 


946  DISEASES    OF   THE    NERVOUS    SYSTEM 


;H'f 


C.    DIFFUSE  DISEASES  OF  THB^NERVOUS  SYSTEM 
I.    AFFECTIONS    OF    THE   MENINGES 

DISEASES    OF    THE    DURA    MATER 
(Pachymeningitis) 

Pachymeningitis  Externa. — CEREBRAL. — Haemorrhage  often  occurs  as  a 
result  of  fracture.  Inflammation  of  the  external  layer  of  the  dura  is  rare. 
Caries  of  the  bone,  either  extension  from  middle-ear  disease  or  due  to  syphilis, 
is  the  principal  cause.  In  the  syphilitic  cases  there  may  be  a  great  thickening 
of  the  inner  table  and  a  large  collection  of  pus  between  the  dura  and  the  bone. 

Occasionally  the  pus  is  infiltrated  between  the  two  layers  of  the  dura  mater 
or  may  extend  through  and  cause  a  dura-arachnitis. 

The  symptoms  of  external  pachymeningitis  are  indefinite.  In  the  syph- 
ilitic cases  there  may  be  a  small  sinus  communicating  with  the  exterior.  Com- 
pression symptoms  may  occur  with  or  without  paralysis. 

SPINAL. — An  acute  form  may  occur  in  syphilitic  affections  of  the  bones, 
in  tumors,  and  in  aneurism.  The  symptoms  are  those  of  a  compression  of 
the  cord.  A  chronic  form  is  much  more  common,  and  is  a  constant  accom- 
paniment of  tuberculous  caries  of  the  spine.  The  internal  surface  of  the  dura 
may  be  smooth,  while  the  external  is  rough  and  covered  with  caseous  masses. 
The  entire  dura  may  be  surrounded,  or  the  process  may  be  confined  to  the 
ventral  surface. 

Pachymeningitis  Interna  — This  occurs  in  three  forms:  (1)  Pseudo-mem- 
branous, (2)  purulent,  and  (3)  hsemorrhagic.  The  first  two  are  unimportant. 
Pseudo-membranous  inflammation  of  the  lining  membrane  of  the  dura  is  not 
usually  recognized,  but  a  most  characteristic  example  of  it  came  under  my 
observation  as  a  secondary  process  in  pneumonia.  Purulent  pachymeningitis 
may  follow  an  injury,  but  is  more  commonly  the  result  of  extension  from 
inflammation  of  the  pia.  It  is  remarkable  how  rarely  pus  is  found  between 
the  dura  and  arachnoid  membranes. 

/  v 

H^MORRHAGIC  PACHYMENINGITIS 

it 
(Hcematoma  of  the  Dura  Mater) 

Cerebral  Form. — This  remarkable  condition,  first  described  by  Virchow, 
is  very  rare  in  general  medical  pfltetice.  During  ten  years  no  instance  of  it 
came  under  my  observation  at  the  ^Montreal  General  Hospital.  On  the  other 
hand,  in  the  post-mortem  room  of  the  Philadelphia  Hospital,  which  received 
material  from  a  large  almshouse  and  asylum,  the  cases  were  not  uncommon, 
and  within  three  months  I  saw  four  characteristic  examples,  three  of  which 
came  from  the  medical  wards.  The  frequency  of  the  condition  in  asylum  work 
may  be  gathered  from  the  fact  that  in  1,185  post  mortems  at  the  Government 
Hospital  for  the  Insane,  Washington,  to  June  30,  1897,  there  were  197  cases 
with  "a  true  neo-membrane  of  internal  pachymeningitis"  (Blackburn).  Of 
these  cases,  45  were  chronic  dementia,  37  were  general  paresis,  30  senile  de- 


AFFECTIOXS    OF   THE   MENIXGES  947 

mentia,  28  chronic  mania,  28  chronic  melancholia,  22  chronic  epileptic  insan- 
ity, 6  acute  mania,  and  1  case  imbecility.  Forty-two  of  the  cases  were  in 
persons  over  seventy  years  of  age. 

It  has  also  been  found  in  profound  anaemia  and  other  diseases  of  the  blood 
and  of  the  blood  vessels,  and  is  said  to  have  followed  certain  of  the  acute 
fevers.  Herter  called  attention  to  the  not  infrequent  occurrence  of  the  lesion 
in  badly  nourished  cachectic  children. 

The  morbid  anatomy  is  interesting.  Virchow's  view  that  the  delicate  vas- 
cular membrane  precedes  the  haemorrhage  is  undoubtedly  correct.  Practically 
we  see  one  of  three  conditions  in  these  cases:  (a)  subdural  vascular  mem- 
branes, often  of  extreme  delicacy;  (&)  simple  subdural  haemorrhage;  (c)  a 
combination  of  the  two,  vascular  membrane  and  blood  clot.  Certainly  the 
vascular  membrane  niay  exist  without  a  trace  of  haemorrhage — simply  a 
fibrous  sheet  of  varying  thickness,  permeated  with  large  vessels,  which  may 
form  beautiful  arborescent  tufts.  On  the  other  hand,  there  are  instances  in 
which  the  subdural  haemorrhage  is  found  alone,  but  it  is  possible  that  in 
some  of  these  at  least  the  haemorrhage  may  have  destroyed  all  trace  of  the 
vascular  membrane.  In  some  cases  a  series  of  laminated  clots  are  found, 
forming  a  layer  from  3  to  5  mm.  in  thickness.  Cysts  may  occur  within  this 
membrane.  The  source  of  the  haemorrhage  is  probably  the  dural  vessels. 
Huguenin  and  others  hold  that  the  bleeding  comes  from  the  vessels  of  the 
pia  mater,  but  certainly  in  the  early  stage  of  the  condition  there  is  no  evidence 
of  this;  on  the  other  hand,  the  highly  vascular  subdural  membrane  may  be 
seen  covered  with  the  thinnest  possible  sheeting  of  clot,  which  has  evidently 
come  from  the  dura.  The  subdural  haemorrhage  is  usually  associated  with 
atrophy  of  the  convolutions,  and  it  is  held  that  this  is  one  reason  why  it  is  so 
common  in  the  insane,  especially  in  dementia  paralytica  and  dementia  senilis. 
We  meet  with  the  condition  also  in  phthisis  and  various  cachectic  conditions 
in  which  the  cerebral  wasting  is  as  common  and  almost  as  marked  as  in  cases 
of  insanity.  Konig  found  in  135  cases  of  haemorrhagic  pachymeningitis  from 
the  Berlin  Pathological  Institute  that  23  per  cent,  accompanied  phthisis. 
Atrophy,  however,  may  not  be  the  only  factor. 

The  symptoms  are  indefinite,  or  there  may  be  none  at  all,  especially  when 
the  haemorrhages  are  small  or  have  occurred  very  gradually,  and  the  diagnosis 
can  not  be  made  with  certainty.  Headache  has  been  a  prominent  symptom 
in  some  cases,  and  when  the  condition  exists  on  one  side  there  may  be  hemi- 
plegia.  The  most  helpful  symptoms  for  diagnosis,  indicating  that  the  haemor- 
rhage in  an  apoplectic  attack  is  meningeal,  are  (1)  those  referable  to  increased 
intracranial  pressure  (slowing  and  irregularity  of  the  pulse,  vomiting,  coma, 
contracted  pupils,  reacting  to  light  slowly  or  not  at  all)  and  (2)  paresis  and 
paralysis,  gradually  increasing  in  extent,  accompanied  by  symptoms  which 
point  to  a  cortical  origin.  Extensive  bilateral  disease  may,  however,  exist 
without  any  symptoms  whatever. 

Spinal  Form. — The  spinal  pachymeningitis  inierna,  described  by  Char- 
cot  and  Joffroy,  involves  chiefly  the  cervical  region  (P.  cervicalis  hyper- 
trophica).  The  space  between  the  cord  and  the  dura  is  occupied  by  a  firm, 
concentrically  arranged,  fibrinous  growth,  which  is  seen  to  have  developed 
within,  not  outside  of,  the  dura  mater.  It  is  a  condition  anatomically 
identical  with  the  haemorrhagic  pachymeningitis  interna  of  the  brain.  The 


948  DISEASES    OP   THE    NERVOUS    SYSTEM 

cord  is  usually  compressed;  the  central  canal  may  be  dilated — liydromyelus — 
and  there  are  secondary  degenerations.  The  nerve  roots  are  involved  in  the 
growth  and  are  damaged  and  compressed.  The  extent  is  variable.  It  may  be 
limited  to  one  segment,  but  more  commonly  involves  a  considerable  portion  of 
the  cervical  enlargement.  The  disease  is  chronic,  and  in  some  cases  presents 
a  characteristic  group  of  symptoms.  There  are  intense  neuralgic  pains  in  the 
course  of  the  nerves  whose  roots  are  involved.  They  are  chiefly  in  the  arms 
and  in  the  cervical  region,  and  vary  greatly  in  intensity.  There  may  be  hyper- 
aesthesia  with  numbness  and  tingling ;  atrophic  changes  may  develop,  and  there 
may  be  areas  of  anaesthesia.  Gradually  motor  disturbances  appear;  the  arms 
become  weak  and  the  muscles  atrophied,  particularly  in  certain  groups,  as  the 
flexors  of  the  hand.  The  extensors,  on  the  other  hand,  remain  intact,  so  that 
the  condition  of  claw-hand  is  gradually  produced.  The  grade  of  the  atrophy 
depends  much  upon  the  extent  of  involvement  of  the  cervical  nerve  roots,  and 
in  many  cases  the  atrophy  of  the  muscles  of  the  shoulders  and  arms  becomes 
extreme.  The  condition  is  one  of  cervical  paraplegia,  with  contractures, 
flexion  of  the  wrist,  and  typical  main  en  griffe.  Usually  before  the  arms  are 
greatly  atrophied  there  are  the  symptoms  of  what  the  French  writers  term 
the  second  stage — namely,  involvement  of  the  lower  extremities  and  the  grad- 
ual production  of  a  spastic  paraplegia,  which  may  develop  several  months  after 
the  onset  of  the  disease,  and  is  due  to  secondary  changes  in  the  cord. 

The  disease  runs  a  chronic  course,  lasting,  perhaps,  two  or  more  years. 
In  a  few  instances,  in  which  symptoms  pointed  definitely  to  this  condition, 
recovery  has  taken  place.  The  disease  is -to  be  distinguished  from  amyotrophic 
lateral  sclerosis,  syringomyelia,  and  tumors.  From  the  first  it  is  separated  by 
the  marked  severity  of  the  initial  pains  in  the  neck  and  arms ;  from  the  second 
by  the  absence  of  the  serisory  changes  characteristic  of  syringomyelia.  From 
certain  tumors  it  is  very  difficult  to  distinguish;  in  fact,  the  fibrinous  layers 
form  a  tumor  around  the  cord. 

The  condition  known  as  hcematoma  of  the  dura  mater  may  occur  at  any 
part  of  the  cord,  or,  in"  its  slow,  progressive  form — pachymeningitis  haem- 
orrhagica  interna — may  be  limited  to  the  cervical  region  and  produce  the 
symptoms  just  mentioned.  It  is  sometimes  extensive,  and  may  coexist  with 
a  similar  condition  of  the  cerebral  dura.  Cysts  may  occur  filled  with  haem- 
orrhagic  contents. 

DISEASES    OF  THE   PIA   MATER 
(Acute  Cerebro-spinal  Leptomeningitis) 

Etiology. — Under  cerebro-spinal  fever  and  tuberculosis  the  two  most  im- 
portant forms  of  meningitis  have  been  described.  Other  conditions  with  which 
meningitis  is  associated  are:  (1)  The  acute  fevers,  more  particularly  pneu- 
monia, erysipelas,  and  septicaemia;  less  frequently  small-pox,  typhoid  fever, 
scarlet  fever,  measles,  influenza,  etc.  (2)  Injury  or  disease  of  the  bones  of  the 
skull.  In  this  group  by  far  the  most  frequent  cause  is  necrosis  of  the  petrous 
portion  of  the  temporal  bone  in  chronic  otitis.  (3)  Extension  from  disease  of 
the  nose.  Meningitis  has  followed  perforation  of  the  skull  in  sounding  the 
frontal  sinuses,  suppurative  disease  of  these  sinuses,  and  necroses  of  the  cribri- 
form plate.  As  mentioned  under  cerebro-spinal  fever,  the  infection  is  thought 


AFFECTIONS    OF    THE    MEXINGES  949 

to  be  possible  through  the  nose.    (4)  As  a  terminal  infection  in  chronic  nephri- 
tis, arterio-sclerosis,  heart  disease,  gout,  and  the  wasting  diseases  of  children. 
The  following  etiological  table  of  the  chief  acute  forms  of  meningitis  may 
be  useful  to  the  student : 


"||   L  °ff  rrebr>Spina1}    SjtSSh   JDiplococcusintracellulari, 

23 

•§       2.  Pneumococcic.        >  ^eninges  involved  alone  or  in  a  general  1  pneumocOccus. 

3 

g 

r    1.  Tuberculous.  ...  Ranillns  tiihernnlnsis- 

S 

"* 

(a)  Secondary  to  pneumonia,  en- 

o. 

2.  Pneumo- 
coccic. 

docarditis,  etc. 
(6)  Secondary  to  disease  or  injury 

Pneumococcus. 

H 

^ 

of  cranium  or  its  fossae. 

I-) 

T3 

(a)  Following  local  disease  of  cra- 

e 

fl   •' 
O 

6 

0) 

3.  Pyogenic. 

nium  or  a  local  infection  elsewhere. 
(6)  Terminal  infection  in  various 

Various  forms  of  staphy- 
lococci  and  streptococci. 

CO 

chronic  maladies. 

<3 

4.  Miscella- 

In typhoid  fever,  influenza,  diph- 

Typhoid bacillus,  influ- 

neous acute 

theria,  gonorrhoea,  anthrax,  aetino- 

enza  bacillus,  diphtheria 

i 

infections.     [  mycosis,  and  other  acute  diseases. 

bacillus,  gonococcus,  etc. 

Morbid  Anatomy.  — The  basal  or  cortical  meninges  may  be  chiefly  attacked. 
The  degree  of  involvement  of  the  spinal  meninges  varieg.  In  the  form  asso- 
ciated with  pneumonia  and  ulcerative  endocarditis  the  disease  is  bilateral  and 
usually  limited  to  the  cortex.  In  extension  from  disease  of  the  ear  it  is  often 
unilateral  and  may  be  accompanied  with  abscess  or  with  thrombosis  of  the 
sinuses.  In  the  non-tuberculous  form  in  children,  in  the  meningitis  of  chronic 
Bright's  disease,  and  in  cachectic  conditions  the  base  is  usually  involved.  In 
the  cases  secondary  to  pneumonia  the  effusion  beneath  the  arachnoid  may  be 
very  thick  and  purulent,  completely  hiding  the  convolutions.  "The  ventricles 
also  may  be  involved,  though  in  these  simple  forms  they  rarely  present  the 
distention  and  softening  which  are  so  frequent  in  the  tuberculous  meningitis. 
For  a  more  detailed  description  the  student  is  referred  to  the  sections  on 
cerebro-spinal  fever  and  tuberculous  meningitis. 

Symptoms. — The  clinical  features  of  meningitis  have  already  been  de- 
scribed at  length  in  the  diseases  just  referred  to,  and  I  shall  here  give  a  gen- 
eral summary.  Cortical  meningitis  is  not  to  be  recognized  by  any  symptoms  or 
set  of  symptoms  from  a  condition  which  may  be  produced  by  the  poison  of 
many  of  the  specific  fevers.  In  the  cases  of  so-called  cerebral  pneumonia,  un- 
less the  base  is  involved  and  the  nerves  affected,  the  disease  is  unrecognizable, 
since  identical  symptoms  may  be  produced  by  intense  engorgement  of  the 
meninges.  In  typhoid  fever,  in  which  meningitis  is  very  rare,  the  twitchings, 
spasms,  and  retractions  of  the  neck  are  almost  invarkbly  associated  with 
cerebro-spinal  congestion,  not  with  meningitis.  Actual  meningitis  does,  how- 
ever, occur  in  typhoid  fever,  and  typhoid  bacilli  may  be  present  in  the  exudate. 

A  knowledge  of  the  etiology  gives  a  very  important  clew.  Thus,  in  middle- 
ear  disease  the  development  of  high  fever,  delirium,  vomiting,  convulsions,  and 
retraction  of  the  head  and  neck  would  be  extremely  suggestive  of  meningitis 
or  abscess.  Headache,  which  may  be  severe  and  continuous,  is  the  most  com- 
mon symptom.  While  the  patient  remains  conscious  this  is  usually  the  chief 
complaint,  and  even  when  semicomatose  he  may  continue  to  groan  an<i  to 


950 

place  his  hand  on  his  head.  In  the  fevers,  particularly  in  pneumonia,  there 
may  be  no  complaint  of  headache.  Delirium  is  frequently  early,  and  is  most 
marked  when  the  fever  is  high.  Convulsions  are  less  common  in  simple  than 
in  tuberculous  meningitis.  They  were  not  present  in  a  single  instance  in  the 
cases  which  I  have  seen  in  pneumonia,  ulcerative  endocarditis,  or  septicaemia. 
In  the  simple  meningitis  of  children  they  may  occur.  Epileptiform  attacks 
which  come  and  go  are  highly  characteristic  of  direct  irritation  of  the  cortex. 
Rigidity  and  spasm  or  twitchings  of  the  muscles  ar.e  more  common.  Stiffness 
and  retraction  of  the  muscles  of  the  neck  are  important  symptoms;  but  they 
are  by  no  means  constant,  and  are  most  frequent  when  the  inflammation  is 
extensive  on  the  meninges  of  the  cervical  cord.  There  may  be  trismus,  gritting 
of  the  teeth,  or  spastic  contraction  of  the  abdominal  muscles.  Vomiting  is 
a  common  symptom  in  the  early  stages,  particularly  in  basilar  meningitis. 
Constipation  is  usually  present.  In  the  late  stages  the  urine  and  faeces  may  be 
passed  involuntarily.  Optic  neuritis  is  rare  in  the  meningitis  of  the  cortex, 
but  is  not  uncommon  when  the  base  is  involved.  Leube  lays  stress  on  the 
hyperaesthesia  of  the  skin  »nd  muscles,  especially  of  the  muscles  of  the  neck 
and  calves. 

Important  symptoms  are  due  to  lesions  of  the  nerves  at  the  base.  Stra- 
bismus or  ptosis  may  occur.  The  facial  nerve  may  be  involved,  producing 
slight  paralysis,  or  -there  may  be  damage  to  the  fifth  nerve,  producing  an- 
esthesia and,  if  the  Gasserian  ganglion  is  affected,  trophic  changes  in  the 
cornea.  The  pupils  are  at  first  contracted,  subsequently  dilated,  and  perhaps 
unequal.  The  reflexes  in  the  extremities  are  often  accentuated  at  the  begin- 
ning of  the  disease ;  later  they  are  diminished  or  entirely  abolished.  Herpes 
is  common,  particularly  in  the  epidemic  form. 

Fever  is  present,  moderate  in  grade,  rarely  rising  above  103°.  In  the 
non-tuberculerus  leptomeningitis  of  debilitated  children  and  in  Bright's  dis- 
ease there  may.  be  little  or  no  fever.  The  pulse  may  be  increased  in  frequency 
at  first,  though  this  is  unusual.  One  of  the  striking  features  of  the  disease 
is  the  slowness  of  the  pulse  in  relation  to  the  temperature,  even  in  the  early 
stages.  Subsequently  it  may  be  irregular  and  still  slower.  The  very  rapid 
emaciation  which  often  occurs  is  doubtless  to  be  referred  to  a  disturbance  of 
the  cerebral  influence  upon  metabolism.  Kernig's  sign  has  been  described 
under  cerebro-spinal  fever.  There  may  be  a  concomitant  reflex  of  one  leg 
when  passive  flexion  is  made  of  the  other  (Brudzinksi's  sign)  ;  and  when  the 
neck  is  bent  forward  there  is  flexion  of  the  legs  both  at  the  knees  and  hips. 
Lumbar  puncture  is  exceedingly  valuable  for  diagnosis.  It  may  be  that  a 
turbid  fluid  indicates  an  acute  non-tuberculous  meningitis.  At  first  the  fluid 
may  be  only  opalescent.  -A  close  relationship  exists  between  the  severity  of 
the  symptoms,  the  height  of  the  pyrexia,  and  the  degree  of  turbidity  (Connal). 
As  a  rule  a  preponderance  of  polynuclear  leucocytes  is  present  with  the  men- 
ingococcus  or  the  pyogenic  organisms ;  a  mononuclear  exudate  is  characteristic 
of  tuberculosis.  It  is  to  be  remembered  that  in  tuberculous  meningitis  the 
fluid  is  usually  clear;  in  only  one  of  69  cases  was  it  opalescent  (Connal). 

Treatment. — There  are  no  remedies  which  in  any  way  control  the  course 
of  acute  meningitis.  An  ice-bag  should  be  applied  to  the  head  and,  if  the 
subject  is  young  and  full  blooded,  general  or  local  depletion  may  be  practised. 
Absolute  rest  and  quiet  should  be  enjoined.  When  disease  of  the  ear  is 


SCLEROSES    OF    THEjbRALNT  951 

present,  a  surgeon  should  be  early  called  in  consultation,  and  if  there  are 
symptoms  of  meningo-encephalitis  which  can  in  any  way  be  localized  trephin- 
ing should  be  practised.  An  occasional  saline  purge  will  do  more  to  relieve 
the  congestion  than  blisters  and  local  depletion.  The  warm  baths,  as  recom- 
mended by  Aufrecht  and  described  under  cerebro-spinal  fever,  should  be  given 
every  three  hours.  It  is  possible  that  recovery  may  follow  in  the  primary 
pneumococcus  form  (JSTetter)/  If  counter-irritation  is  deemed  essential,  the 
thermo-cautery  may  be  lightly  applied  to  the  back  of  the  neck.  Large  doses 
of  the  perchloride  of  iron,  iodide  of  potassium,  and  mercury  are  recommended 
by  some  authors.  Hexamethylenamine  in  doses  of  60  grains  (4  gm.)  daily 
may  be  tried,  as  Crowe  has  shown  that  it  is  excreted  in  the  cerebro-spinal  fluid 
and  controls  the  growth  of  organisms  in  the  meninges. 

The  application  of  an  ice-cap,  attention  to  the  bowels  and  stomach,  and 
keeping  the  fever  within  moderate  limits  by  sponging  are  the  necessary  meas- 
ures in  a  disease  recognized  as  almost  invariably  fatal,  in  which  also  the  cases 
of  recovery  are  extremely  doubtful.  Lumbar  puncture  may  be  used  as  a 
therapeutic  measure. 

The  posterior  basic  meningitis  of  Gee,  Lees,  and  Bartow  is  the  sporadic 
form  of  cerebro-spinal  fever  and  has  been  already  described. 

Meningism. — Sometimes  spoken  of  as  the  syndrome  of  Dupre,  this  is  a 
condition  in  which  there  are  symptoms  of  meningitis,  but  post  mortem  the 
characteristic  pathological  changes  are  not  present.  It  is  practically  the  con- 
dition described  formerly  as  meningeal  irritation,  and  is  seen  most  frequently 
in  the  acute  fevers  of  children,  particularly  in  pneumonia  and  typhoid  fever, 
sometimes  in  alcoholism  and  in  middle-ear  disease. 

Chronic  Leptomeningitis. — This  is  rarely  seen  apart  from  syphilis  or  tuber- 
culosis, in  which  the  meningitis  is  associated  with  the  growth  of  the  granu- 
lomata  in  the  meninges  and  about  the  vessels.  The  symptoms  in  such  cases 
are  extremely  variable,  depending  entirely  upon  the  situation  of  the  growth. 
The  epidemic  meningitis  may  run  a  very  chronic  course,  but  of  all  forms  the 
posterior  basic  may  be  the  most  protracted,  as  cases  have  been  described  with 
a  duration  of  a  year  or  more.  Quincke's  meningitis  serosa  is  considered  with 
hydrocephalus. 

II.     SCLEROSES    OF   THE   BRAIN 

General  Remarks. — The  supporting  tissue  of  the  central  nervous  system 
is  the  neuroglia,  derived  from  the  ectoderm,  with  distinct  morphological  and 
chemical  characters.  The  meninges  are  composed  of  true  connective  tissue 
derived  from  the  mesoderm,  a  little  of  which  enters  the  brain  and  cord  with 
the  blood-vessels.  The  neuroglia  plays  the  chief  part  in  pathological  processes 
within  the  central  nervous  system,  but  changes  in  the  connective  tissue  ele- 
ments may  also  be  important.  A  convenient  division  of  the  cerebro-spinal 
scleroses  is  into  degenerative,  inflammatory,  and  developmental  forms. 

The  degenerative  scleroses  comprise  the  largest  and  most  important  sub- 
division, in  which  provisionally  the  following  groups  may  be  made:  (a)  The 
common  secondary  degeneration  which  follows  when  nerve  fibres  are  cut  off 
from  their  trophic  centres;  (&)  toxic  forms,  among  which  may  be  placed  the 
scleroses  from  lead  and  ergot,  and,  most  important  of  all,  the  scleroses  of  the 


952  DISEASES   $F    THE    NEKVOUS    SYSTEM 

dorsal  columns,  due  in  such  a  large  proportion  of  cases  to  the  virus  of  syphilis; 
(c)  the  sclerosis  associated  with  change  in  the  smaller  arteries  and  capillaries, 
which  is  met  with  as  a  senile  process  in  the  convolutions. 

The  inflammatory  scleroses  embrace  a  less  important  and  less  extensive 
group,  comprising  secondary  forms  which  follow  irritative  inflammation 
about  tumors,  foreign  bodies,  hemorrhages,  and  abscess.  Possibly  a  similar 
change  may  follow  the  primary,  acute  encephalitis,  which  Striimpell  holds  is 
the  initial  lesion  in  the  cortical  sclerosis  which  is  so  commonly  found  post 
mortem  in  infantile  hemiplegia. 

The  developmental  scleroses  are  believed  to  be  of  a  purely  neurogliar  char- 
acter, and  embrace  the  new  growth  about  the  central  canal  in  syringomyelia 
and,  according  to  recent  French  writers,  the  sclerosis  of  the  dorsal  columns 
in  Friedreich's  ataxia. 

Anatomically  we  meet  with  the  following  varieties : 

Miliary  sclerosis  is  a  term  which  has  been  applied  to  several  different 
conditions.  Gowers  mentions  a  case  in  which  there  were  grayish  red  spots  at 
the  junction  of  the  white  and  gray  matters,  and  in  which  the  neuroglia  was 
increased.  There  is  also  a  condition  in  which,  on  the  surface  of  the  convolu- 
tions, there  are  small  nodular  projections,  varying  from  a  half  to  five  or  more 
millimetres  in  diameter. 

Diffuse  sclerosis,  which  may  involve  an  entire  hemisphere,  or  a  single 
lobe,  in  which  case  the  term  sclerose  lobaire  has  been  applied  to  it  by  the 
French.  It  is  not  an  important  condition  in  gsneral  medical  practice,  but 
occurs  most  frequently  in  idiots  and  imbeciles.  In  extensive  cortical  sclerosis 
of  one  hemisphere  the  ventricle  is  usually  dilated.  The  symptoms  of  this 
condition  depend  upon  the  region  affected.  There  may  be  a  considerable 
extent  of  sclerosis  without  symptoms  or  without  much  mental  impairment. 
In  a  majority  of  cases  there  is  hemiplegia  or  diplegia  with  imbecility  or 
idiocy. 

Tuberous  Sclerosis.  — In  this  remarkable  form,  which  is  also  known  as 
hypertrophic  sclerosis,  there  are  on  the  convolutions  areas,  projecting  beyond 
the  surface,  of  an  opaque  white  color  and  exceedingly  firm.  The  sclerosis 
may  not  disturb  the  symmetry  of  the  convolution,  but  simply  cause  a  great 
enlargement,  increase  in  the  density,  and  a  change  in  the  color. 

These  three  forms  are  not  of  much  practical  interest  except  in  asylum  and 
institution  work.  The  fourth  variety  forms  a  well  characterized  disease  of  con- 
siderable importance,  namely,  multiple  sclerosis. 

Multiple  (Insular:  Disseminated)  Sclerosis  (Sclerose  en  plaques.}  — 
DEFINITION. — A  chronic  affection  of  the  brain  and  cord,  characterized  by 
localized  areas  in  which  the  nerve  elements  are  more,  or  less  replaced  by 
neuroglia.  This  may  occur  in  the  brain  or  cord  alone,  more  commonly  in  both. 

ETIOLOGY. — The  cause  is  unknown.  Kahler,  Marie,  and  others  assign  great 
importance  to  the  infectious  diseases,  particularly  scarlet  fever.  Injury  has 
occasionally  preceded  the  onset.  It  is  most  common  in  young  persons  and  in 
females.  Several  members  in  a  family  may  be  attacked. 

MORBID  ANATOMY. — The  sclerotic  areas  are  widely  distributed  through 
tfie  brain  and  cord,  and  cases  limited  to  either  part  alone  are  almost  un- 
Known.  The  grayish  red  areas  are  scattered  indifferently  through  the  white 
and  gray  matter  (E.  W.  Taylor).  The  patches  are  most  abundant  in  the 


SCLEROSES    OF    THE    BRAIN  953 

neighborhood  of  the  ventricles,  and  in  the  pons,  cerebellum,  basal  ganglia, 
and  the  medulla.  The  cord  may  be  only  slightly  involved  or  there  may  be 
very  many  areas  throughout  its  length.  The  cervical  region  is  apt  to  be 
most  affected.  The  nerve  roots  and  the  branches  of  the  cauda  equina  are 
often  attacked.  Histologically  in  the  sclerosed  patches  there  is  a  degeneration 
of  the  medullary  sheaths,  with  the  persistence  for  some  time  of  the  axis- 
cylinders.  These  naked  axis-cylinders  are  thought  by  some  to  be  new  formed 
nerve  fibres.  Accompanying  this  there  is  marked  proliferation  of  the  neu- 
roglia,  the  fibres  of  which  are  denser  and  firmer.  Secondary  degeneration., 
although  relatively  slight,  does  occur. 

SYMPTOMS. — The  onset  is  slow  and  the  disease  is  chronic.  Feebleness  of 
the  legs  with  irregular  pains  and  stiffness  are  among  the  early  symptoms. 
Indeed,  the  clinical  picture  may  be  that  of  spastic  paraplegia  with  great 
increase  in  the  reflexes.  The  following  are  the  most  important  features : 

(a)  Volitional  Tremor  or  So-called  Intention  Tremor. — There  is  no  paraly^ 
sis  of  the  arms,  but  on  attempting  to  pick  up  an  object  there  is  trembling 
or  rapid  oscillation.  A  patient  may  be  unable  to  lift  even  a  glass  of  water 
to  the  mouth.  The  tremor  may  be  marked  in  the  legs,  and  in  the  head, 
which  shakes  as  he  walks.  When  the  patient  is  recumbent  the  muscles 
may  be  perfectly  quiet.  On  attempting  to  raise  the  head  from  the  pillow, 
trembling  at  once  comes  on.  (b)  Scanning  Speech. — .The  words  are  pro- 
nounced slowly  and  separately,  or  the  individual  syllables  may  be  accentu- 
ated. This  staccato  or  syllabic  utterance  is  a  common  feature,  (c)  Nys- 
tagmus, a  rapid  oscillatory  movement  of  both  eyes,  is  more  common  in  nultiple 
sclerosis  than  any  other  affection  of  the  nervous  system. 

Sensation  is  unaffected  in  a  majority  of  the  cases.  Optic  atrophy  may 
occi  r  early,  but  is  usually  partial,  rarely  leading  to  complete  blindness.  The 
sphincters,  as  a  rule,  are  unaffected  until  the  last  stages.  Mental  debility  is 
not  uncommon.  Remarkable  remissions  occur  in  the  course  of  the  disease,  in 
which  for  a  time  all  the  symptoms  may  improve.  Vertigo  is  common,  and 
there  may  be  sudden  apoplectiform  attacks,  such  as  occur  in  general  paresis. 
The  presence  of  the  extensor  plantar  reflex  (Babinski  sign)  and  the  absence  of 
the  abdominal  reflexes  are  common. 

The  symptoms,  on  the  whole,  are  extraordinarily  variable,  corresponding 
to  the  very  irregular  distribution  of  the  nodules. 

DIAGNOSIS. — The  diagnosis  in  well  marked  cases  is  easy.  Volitional  tremor, 
scanning  speech,  and  nystagmus  form  a  characteristic  symptom-group.  With 
this  there  is  usually  more  or  less  spastic  weakness  of  the  legs.  Paralysis  agitans, 
certain  cases  of  general  paresis,  and  occasionally  hysteria  may  simulate  the 
disease  very  closely.  If  the  case  is  not  seen  until  near  the  end  the  diagnosis 
may  be  impossible.  Buzzard  holds  that  of  all  organic  diseases  of  the  nervous 
system  disseminated  sclerosis  in  its  early  stages  is  that  which  is  most  com- 
monly taken  for  hysteria.  The  points  to  be  relied  upon  in  the  differentiation 
are,  in  order  of  importance,  optic  atrophy,  the  nystagmus,  the  bladder  disturb- 
ances, when  present,  and  the  volitional  tremor.  The  tremor  in  hysteria  is  not 
volitional.  Unilateral  cases  are  recorded. 

Pseudo-sclerosis — the  Westphall-Striimpell  disease — is  a  rare  condition 
simulating  multiple  sclerosis  and  not  often  distinguished  from  it  during  life. 
Mental  changes  are  more  pronounced,  the  tremor  is  more  exaggerated,  the 
62 


954  DISEASES   OF   THE   NERVOUS    SYSTEM 

nystagmus  not  always  present,  and  the  gait  more  ataxic.  It  sets  in  earlitx, 
sometimes  in  the  first  decade,  and  in  a  majority  of  the  cases  no  lesions  have 
been  found  post  mortem. 

The  PROGNOSIS  is  unfavorable.  Ultimately,  the  patient,  if  not  carried  off 
by  some  intercurrent  affection,  becomes  bedridden. 

TREATMENT. — No  known  treatment  has  any  influence  on  the  progress  of 
sclerosis  of  the  brain.  Neither  the  iodides  nor  mercury  have  the  slightest 
effect,  but  a  prolonged  course  of  nitrate  of  silver  or  arsenic  may  be  tried.  The 
X-rays  have  been  used  with  success  (Raymond). 


D.    DIFFUSE  AND  FOCAL   DISEASES  OF  THE  SPINAL 

CORD 

I.    TOPICAL  DIAGNOSIS 

From  the  symptoms  presented  by  a  spinal  cord  lesion  it  is  possible  to 
determine  more  or  less  accurately  not  only  the  segmental  level  but  also  the 
transverse  extent  of  the  segmental  involvement.  The  effects  of  an  injury  or 
of  disease  may  be  circumscribed  and  involve  the  gray  matter  of  the  segment  or 
the  tracts  running  through  it;  it  may  be  more  extensive  and  involve  the  cord 
in  a  given  level  in  its  entire  transverse  extent ;  finally,  there  are  cases  in  which 
only  one  lateral  half  of  the  cord  is  implicated.  It  is  well  for  the  student  to 
have  a  definite  routine  to  follow  in  making  his  examinations,  for  each  factor 
may  be  helpful  in  determining  the  site  and  character  of  the  lesion.  Some  of 
the  more  important  points  to  observe  are  the  following:  (1)  subjective  sensa- 
tions, particularly  the  character  and  seat  of  pain,  if  any  be  present,  such  as  the 
radiating  pains  of  dorsal  root  compression;  (2)  the  patient's  attitude,  as  the 
position  of  the  arms  in  cervical  lesions,  the  character  of  the  respiration,  whether 
diaphragmatic,  etc.;  (3)  motor  symptoms,  the  groups  of  paralyzed  muscles 
and  their  electrical  reaction;  (4)  the  sensory  symptoms,  including  tests  for 
tactual,  thermic,  and  dolorous  impressions,  for  muscle  sense,  bone  sensation, 
etc.;  (5)  the  condition  of  the  reflexes,  both  the  tendon  and  the  skin  reflexes  as 
well  as  those  for  the  pupil,  the  bladder  and  rectum,  etc.;  (6)  the  surface  tem- 
perature and  condition  of  moisture  or  dryness  of  the  skin,  which  gives  an  indi- 
cation of  vaso-motor  paralysis.  The  table  on  pages  898-900  and  the  figures  on 
pages  906  and  907  will  be  useful  while  making  an  examination. 

Focal  Lesions. — We  have  seen  that  a  lesion  involving  a  definite  part  of  the 
gray  matter  of  the  spinal  cord,  owing  to  destruction  of  the  cell  bodies  of  the 
lower  motor  neurones  and  consequent  degeneration  of  their  axis-cylinder  proc- 
2sses,  is  accompanied  by  a  loss  of  power  to  perform  certain  definite  movements. 
Thus  a  disease,  such  as  anterior  poliomyelitis,  may  give  as  its  only  symptom  a 
characteristic  flaccid  paralysis,  and  the  seat  of  the  lesion  is  revealed  by  the 
muscles  involved.  If  from  injury  or  disease  a  lesion  involves  more  than  the 
gray  matter  and,  for  example,  if  the  neighboring  fibres  of  the  pyramidal  tract 
be  affected  there  may  be  in  addition  a  spastic  paralysis  of  the  muscles  whose 
centres  lie  in  the  lower  levels  of  the  cord.  The  degree  of  such  a  paralysis  de- 
pends upon  the  intensity  of  the  lesion  of  the  pyramidal  tract  and  may  vary 


TOPICAL  DIAGNOSIS  955 

from  a  slight  weakness  in  dorsal  flexion  of  the  ankle  to  an  absolute  paralysis  of 
all  the  muscles  below  the  lesion.  Again,  if  the  afferent  tracts  of  the  cord  are 
affected  sensory  symptoms  may  be  added  to  the  motor  palsy.  There  may  be 
disturbances  of  pain  and  temperature  sense  alone  or  touch  also  may  be  af- 
fected. This,  however,  is  more  rare  except  in  serious  lesions.  The  upper 
border  of  disturbed  sensation  often  indicates  most  clearly  the  level  of  the 
disease,  especially  when  this  is  in  the  thoracic  region  where  the  corresponding 
level  of  motor  paralysis  is  not  easily  demonstrated.  It  is  unusual  for  cutaneous 
anaesthesia  in  organic  lesions  of  the  cord  to  extend  above  the  level  of  the  second 
rib  and  the  tip  of  the  shoulder,  for  this  represents  the  lower  border  of  the  skin- 
field  of  the  fourth  cervical  (see  sensory  charts),  and  as  the  chief  centre  for  the 
diaphragm  lies  in  this  segment,  a  lesion  at  this  level  sufficiently  serious  to 
cause  sensory  disturbances  would  probably  occasion  motor  paralyses  as  well 
and  would  entirely  shut  off  the  movements  necessary  for  respiration.  It  is 
to  be  noted  ihv.t  the  demonstrable  upper  border  of  the  anaesthetic  field  may 
not  quite  reach  that  which  represents  the  level  of  the  lesion.  This  is  due  to 
the  functional  overlapping  of  the  segmental  skin-fields  (Sherrington)  and 
applies  more  to  touch  than  to  pain  and  temperature.  There  is  often  a  narrow 
zone  of  hyperaesthesia  above  the  anaesthetic  region. 

Complete  Transverse  Lesions.  — When  the  transverse  lesion  is  total  and  the 
lower  pert  of  the  cord  is  cut  off  entirely  from  above,  there  is  complete  sensory 
and  motor  paralysis  to  the  segmental  level  of  the  injury,  and  the  tendon  re- 
flexes, whose  centres  lie  below,  are  lost  instead  of  being  exaggerated,  as  they 
are  apt  to  be  in  case  the  lesion  is  a  focal  one.  The  symptomatology  of  total 
transverse  lesions  in  man  has  thus  been  given  by  Collier.  (1)  Total  flaccid 
paralysis  of  muscles  below  the  level  of  the  lesion.  ( Spastic  paralysis  indicates 
that  the  lesion  is  incomplete.)  (2)  Permanent  abolition  of  the  knee-jerk  and 
other  deep  reflexes  supplied  by  the  lower  segments  of  the  cord.  (3)  A  rapid 
Wasting  of  the  paralyzed  muscles  with  a  loss  of  the  faradic  excitability.  (4) 
The  sphincters  lose  their  tone  and  there  is  dribbling  of  urine.  (5)  There  is 
iotal  anaesthesia  to  the  level  of  the  lesion  (the  zone  of  hyperaesthesia  is  rarer) . 
(6)  The  only  sign  of  self-action  remaining  is  in  the  occasional  presence,  though 
in  reduced  degree,  of  certain  skin  reflexes  such  as  the  plantar  reflex  with  its 
dorsal  flexor  response  in  the  great  toe. 

Unilateral  Lesions. — The  motor  symptoms,  which  follow  lesions  limited 
to  one  lateral  half  of  the  cross  section  of  the  spinal  cord,  are  confined  to 
one  side  of  the  body;  they  are  on  the  same  side  as  the  lesion.  At  the  level 
of  the  lesion,  owing  to  destruction  of  cell  bodies  of  the  lower  system  of 
neurones,  there  will  be  found  flaccid  paralysis  and  atrophy  of  those  muscles 
whose  centres  of  innervation  happen  to  lie  at  this  level.  Owing  to  degeneration 
of  the  pyramidal  tract,  the  muscles  whose  centres  be  at  lower  levels  are  also 
paralyzed,  but  they  retain  their  normal  electrical  reactions,  become  spastic, 
and  do  not  atrophy  to  any  great  degree. 

The  sensory  symptoms  are  peculiar.  On  the  side  of  the  lesion  corresponding 
to  the  segment  or  segments  of  the  cord  involved  there  is  a  zone  of  anaesthesia 
to  all  forms  of  sensation.  Below  this  there  is  no  loss  in  the  perception  of  pain, 
temperature,  or  touch.  Indeed,  hyperaesthesia  has  been  described.  Muscle  sense 
is  disturbed,  and  the  ability  to  appreciate  the  size,  consistency,  weight,  and 
shape  of  an  object.  On  the  side  opposite  to  the  lesion  and  nearly  up  to  its 


956 


DISEASES    OF    THE    NERVOUS    SYSTEM 


level  there  is  complete  loss  of  perception  for  pain  and  temperature  and  there 
may  be  some  dulling  of  tactile  sense  as  well. 

The  following  table,  slightly  modified  from  Gowers,  illustrates  the  dis- 
tribution of  these  symptoms  in  a  complete  hemi-lesion  of  the  cord : 

Cord 


Zone  of  cutaneous  hyperaesthesia. 
Zone  of  cutaneous  anaesthesia. 
Lower  segment  type  of  paralysis 
with  atrophy. 

Lesion. 

Upper  segment  type  of  paralysis. 
Hypersesthesia  of  skin. 
Muscular  sense  and  allied  sensa- 
tions impaired. 
Reflex   action   first   lessened   and 
then  increased. 
Surface  temperature  raised. 

Muscular  power  normal. 
Loss  of  sensibility  of  skin  to  pain 
and  temperature. 
Muscular  sense  normal. 
Reflex  action  normal. 
Temperature  same  as  that  above 
lesion. 

This  combination  of  symptoms  was  first  recognized  by  Brown-Sequard, 
after  whom  it  has  been  named.  It  is  common  in  syphilitic  diseases  of  the 
cord,  tumors  and  stab-wounds,  and  is  not  infrequently  associated  with  syrin- 
gomyelia  and  haemorrhages  into  the  cord.  It  is  only  in  exceptional  cases, 
of  course,  that  the  lesion  is  absolutely  limited  to  the  hemi-section  of  the 
cord  and  the  symptoms  consequently  may  vary  somewhat  in  degree. 


H.    AFFECTIONS    OF   THE    BLOODVESSELS 


1.     CONGESTION 

Apart  from  actual  myelitis,  we  rarely  see  post  mortem  evidences  of  con- 
gestion of  the  spinal  cord,  and,  when  we  do,  it  is  usually  limited  either  to  the 
gray  matter  or  to  a  definite  portion  of  the  organ.  The  white  matter  is  rarely 
found  congested,  even  when  inflamed.  The  gray  matter  often  has  a  reddish 
pink  tint,  but  rarely  a  deep  reddish  hue,  except  when  myelitis  is  present.  If 
we  know  little  anatomically  of  conditions  of  congestion  of  the  cord,  we  know 
less  clinically,  for  there  are  no  features  in  any  way  characteristic  of  it. 

2.     ANEMIA 

So,  too,  with  this  state.  There  may  be  extreme  grades  of  anaemia  of 
the  cord  without  symptoms.  In  chlorosis,  for  example,  there  are  rarely 
symptoms  pointing  to  the  cord,  and  there  is  no  reason  to  suppose  that  such 
sensations  as  heaviness  in  the  limbs  and  tingling  are  especially  associated  with 
anosmia. 

Profound  anaemia  of  the  cord  follows  ligature  of  the  aorta.  In  experiments 
made  in  Welch's  laboratory  by  Herter  it  was  found  that  within  a  few 
moments  after  the  application  of  the  ligature  to  the  aorta  paraplegia  came 
on.  Paralysis  of  the  sphincters  occurred,  but  less  rapidly.  Observations 


AFFECTIONS    OF    THE    BLOOD    VESSELS  957 

made  by  Halsted  on  occlusion  of  the  abdominal  aorta  in  dogs  have  shown 
that  paraplegia  occurs  in  a  large  percentage  of  cases,  many  of  which,  how- 
ever, may  recover  as  the  collateral  circulation  is  established.  In  the  fatal  cases 
Gilman  found  extensive  alterations  in  the  cell  bodies  of  the  lower  part  of  the 
cord  with  degenerations.  This  condition  is  of  interest  in  connection  with  the 
occasional  rapid  development  of  a  paraplegia  after  profuse  hemorrhage,  usu- 
ally from  the  stomach  or  uterus.  It  may  come  on  at  once  or  at  the  end  of  a 
week  or  ten  days,  and  is  probably  due  to  an  anatomical  change  in  the  nerve 
elements  similar  to  that  produced  in  Herter's  experiments.  The  degeneration 
of  the  dorsal  columns  of  the  cord  in  pernicious  anaemia  has  already  been 
described. 

3.     EMBOLISM  AND   THEOMBOSIS 

Blocking  of  the  spinal  arteries  by  emboli  rarely  occurs.  It  may  be  pro- 
duced experimentally,  and  Money  found  that  it  was  associated  with  chorei- 
form  movements.  Thrombosis  of  the  smaller  vessels  in  connection  with  endar- 
teritis  plays  an  important  part  in  many  of  the  acute  and  chronic  changes 
in  the  cord. 

4.     ENDAETEEITIS 

It  is  remarkable  how  frequently  in  persons  over  fifty  the  arteries  of  the 
spinal  cord  are  found  sclerotic.  The  following  forms  may  be  met  with: 
(1)  A  nodular  peri-arteritis  or  endarteritis  associated  with  syphilis  and 
sometimes  with  gummata  of  the  meninges;  (2)  an  arteritis  obliterans,  with 
great  thickening  of  the  intima  and  narrowing  of  the  lumen  of  the  vessels, 
involving  chiefly  the  medium  and  larger-sized  arteries.  Miliary  aneurisms 
or  aneurisms  of  the  larger  vessels  are  rarely  found  in  the  spinal  cord. 

5.     H^IMOEEHAGE   INTO   THE   SPINAL   MEMBEANES;    H^MATOEEHACHIS 

In  meningeal  apoplexy,  as  it  is  called,  the  blood  may  lie  between  the 
dura  mater  and  the  spinal  canal — extra-meningeal  haemorrhage — or  within 
the  dura  mater — intra-meningeal  haemorrhage. 

Extra-meningeal  haemorrhage  occurs  usually  as  a  result  of  traumatism. 
The  exudation  may  be  extensive  without  compression  of  the  cord.  The  blood 
comes  from  the  large  plexuses  of  veins  which  may  surround  the  dura.  The 
rupture  of  an  aneurism  into  the  spinal  canal  may  produce  extensive  and  rap- 
idly fatal  haemorrhage. 

Intra-meningeal  haemorrhage  is  a  less  frequent  result  of  trauma,  but 
in  general  is  perhaps  rather  more  common.  It  is  rarely  extensive  from  causes 
acting  directly  on  the  spinal  meninges  themselves.  Scattered  haemorrhages 
are  not  infrequent  in  the  acute  infectious  fevers,  and  I  have  twice,  in 
malignant  small-pox,  seen  much  extravasation.  Bleeding  may  occur  also 
in  death  from  convulsive  disorders,  such  as  epilepsy,  tetanus,  and  strychnia 
poisoning,  and  has  been  recorded  in  association  with  difficult  parturition. 
The  most  extensive  haemorrhages  occur  in  cases  in  which  the  blood  comes 
from  rupture  of  an  aneurism  at  the  base  of  the  brain,  either  of  the  basilar 
or  vertebral  artery.  In  ventricular  apoplexy  the  blood  may  pass  from  the 
fourth  ventricle  into  the  spinal  meninges.  In  cranial  fractures,  particularly 


958  DISEASES    OF   THE    NERVOUS    SYSTEM 

those  of  the  base  of  the  skull,  the  resultant  haemorrhage  almost  always  finds  its 
way  into  the  subarachnoid  space  about  the  cord  and  may  be  demonstrated 
by  the  withdrawal  of  bloody  fluid  by  a  lumbar  puncture.  The  procedure  is  of 
considerable  diagnostic' value.  On  the  other  hand,  hemorrhage  into  the  spinal 
meninges  may  possibly  ascend  into  the  brain. 

Symptoms. — The  symptoms  in  moderate  grades  may  be  slight  and  in- 
definite. In  the  non-traumatic  cases  the  hemorrhage  may  either  come  on 
suddenly  or  after  a  day  or  two  of  uneasy  sensations  along  the  spine.  As 
a  rule,  the  onset  is  abrupt,  with  sharp  pain  in  the  back  and  symptoms  of 
irritation  in  the  course  of  the  nerves.  There  may  be  muscular  spasms,  or 
paralysis  may  come  on  suddenly,  either  in  the  legs  alone  or  both  in  the 
legs  and  arms.  In  some  instances  the  paralysis  develops  more  slowly  and 
is  not  complete.  There  is  no  loss  of  consciousness,  and  there  are  no  signs 
of  cerebral  disturbance.  The  clinical  picture  naturally  varies  with  the  site 
of  the  haemorrhage.  If  in  the  lumbar  region,  the  legs  alone  are  involved, 
the  reflexes  may  be  abolished,  and  the  action  of  the  bladder  and  rectum  is 
impaired.  If  in  the  thoracic  region,  there  is  more  or  less  complete  paraplegia, 
the  reflexes  are  usually  retained,  and  there  are  signs  of  disturbance  in  the 
thoracic  nerves,  such  as  girdle  sensations,  pains,  and  sometimes  eruption 
of  herpes.  In  the  cervical  region  the  arms  as  well  as  the  legs  may  be  involved ; 
there  may  be  difficulty  in  breathing,  stiffness  of  the  muscles  of  the  neck,  and 
occasionally  pupillary  symptoms. 

The  prognosis  depends  much  upon  the  cause  of  the  hemorrhage.  Ee- 
covery  may  take  place  in  the  traumatic  cases,  and  in  those  associated  with 
the  infectious  diseases. 

6.     HvEMOKKHAGE   INTO  THE   SPINAL   COED;    H^MATOMYELIA 

Most  frequently  a  result  of  traumatism,  intraspinal  hemorrhage  is  natu- 
rally more  common  in  males,  and  during  the  active  period  of  life.  Cases  have 
been  known  to  follow  cold  or  exposure;  it  occurs  also  in  tetanus  and  other 
convulsive  diseases,  and  hemorrhage  may  be  associated  with  tumors,  with 
syringomyelia  or  myelitis.  A  direct  injury  to  the  spine,  however,  from 
blows  or  from  falls,  is  by  far  the  most  common  cause.  Thorburn  was  among 
the  first  to  point  out  that  acute  flexure  of  the  neck,  often  without  attendant 
fracture  or  dislocation  of  the  vertebrae,  was  a  form  of  accident  that  most 
commonly  preceded  these  hemorrhages.  The  level  of  the  lesion,  for  this 
reason,  is  most  frequently  in  the  lower  cervical  region. 

Anatomical  Condition. — The  extent  of  the  hemorrhage  may  vary  from 
a  small  focal  extravasation  to  one  which  finds  its  way  in  columnar  fashion 
a  considerable  distance  up  and  down  the  cord.  The  bleeding  primarily 
takes  place  into  the  gray  matter,  and  this  as  a  rule  suffers  most,  but  the 
surrounding  medullated  tracts  may  be  thinned  out  and  lacerated.  In  a 
case  which  occurred  at  the  Montreal  General  Hospital  under  Wilkins  the 
hemorrhage  occupied  a  position  opposite  the  region  of  the  fifth  and  sixth 
cervical  nerves,  and  on  transverse  section  the  cord  was  occupied  by  a  dark  red 
clot  measuring  12  by  5  mm.,  around  which  the  white  substance  formed  a  thin, 
ragged  wall.  The  clot  could  be  traced  upward  as  far  as  the  second  cervical, 
and  downward  as  far  as  the  fourth  thoracic  segment. 


COMPRESSION  OF  THE  SPINAL  CORD  959 

Symptoms. — As  one  side  of  the  cord  is  usually  involved  more  than  the 
other,  a  type  of  the  Brown-Sequard  syndrome  is  common.  The  symptoms  are 
sudden  in  onset,  and  leave  the  patient  with  hyperaesthesia  and  a  paralysis  which 
becomes  spastic  and  is  most  marked  on  one  side,  while  anesthesia,  chiefly  to 
pain  and  temperature,  is  most  marked  on  the  opposite  side  of  the  body. 
Often  a  most  distressing  hyperesthesia,  usually  a  "pins  and  needles"  sensation, 
may  be  present  for  many  days,  but  there  is  rarely  any  acute  pain  of  the  radi- 
ating or  root  type.  As  hematomyelia  is  most  frequent  in  the  lower  cervical 
region,  in  addition  to  the  symptoms  just  mentioned  a  brachial  type  of  palsy  is 
commonly  seen,  with  flaccid  and  atrophic  paralysis  of  the  muscles  innervated 
from  the  lowest  cervical  and  first  thoracic  segments.  The  hemorrhage  may 
occur  in  segments  farther  down  the  cord,  the  lumber  enlargement  being  af- 
fected next  in  frequency  to  the  lower  cervical.  The  segmental  level  of  the 
paralysis  necessarily  would  vary  accordingly. 

The  condition  may  prove  rapidly  fatal,  particularly  if  the  extravasation 
is  bilateral  and  extends  high  enough  in  the  cord  to  involve  the  centres  for 
the  diaphragm.  More  frequently  there  is  a  more  or  less  complete  recovery 
with  a  residual  palsy  of  the  upper  extremity  and  a  partial  anesthesia,  corre- 
sponding to  the  level  of  the  lesion,  and  some  spasticity  of  the  leg. 

Diagnosis. — The  diagnosis  of  the  traumatic  cases  is  comparatively  easy, 
and  it  is  important  to  recognize  them,  as  they  are  often  needlessly  subjected 
to  operation  under  the  belief  that  they  are  instances  of  acute  compression. 
The  residual  symptoms  in  old  cases  may  closely  simulate  those  seen  in  syringo- 
myelia. 

Treatment. — Absolute  rest  is  important  and  the  patient  should  be  dis- 
turbed as  little  as  possible.  Special  care  must  be  given  the  skin  to  prevent 
bed-sores  and  to  the  bladder  to  prevent  cystitis.  Treatment  of  the  paralyzed 
parts  should  not  be  begun  for  six  weeks  after  the  hemorrhage,  when  electricity, 
gentle  massage,  and  passive  movements  are  indicated. 


HI.     COMPRESSION   OF   THE   SPINAL   CORD 

(Compression  Myelitis) 

Definition. — Interruption  of  the  functions  of  the  cord  by  slow  compression. 

Etiology. — Caries  of  the  spine,  new  growths,  aneurism,  and  parasites  are 
the  important  causes  of  slow  compression.  Caries,  or  Pott's  disease,  as  it  is 
usually  called,  after  the  surgeon  who  first  described  it,  is  in  the  great  majority 
of  instances  a  tuberculous  affection.  Pressure  paralysis  from  this  cause  is 
often  associated  with  angular  curvature,  but  in  a  large  proportion  of  all  the 
cases  the  involvement  of  the  cord  is  due  to  pachymeningitis  externa,  to  abscess, 
or  in  rare  cases  to  direct  spicules  of  bone.  There  may  be  a  tuberculous  pachy- 
meningitis without  caries.  The  paraplegia  in  Pott's  disease  may  occur  with- 
out any  spinal  deformity.  These  are  very  difficult  cases  to  recognize,  and  they 
are  usually  associated  with  pressure  of  tuberculous  material  inside  the  dura. 
In  a  few  rare  cases  the  paraplegia  may  be  due  to  a  secondary  myelitis.  In  a 
few  cases  it  is  due  to  syphilis  and  occasionally  to  extension  of  disease  from  the 
pharynx.  It  is  most  common  in  early  life,  but  may  occur  after  middle  ag<?. 


960  DISEASES    OF    THE    NERVOUS    SYSTEM 

It  may  follow  trauma.  Compression  occasionally  results  from  aneurism  of  the 
thoracic  aorta  or  the  abdominal  aorta,  in  the  neighborhood  of  the  cceliac  axis. 
Malignant  growths  frequently  cause  a  compression  paraplegia.  A  retroperito- 
neal  sarcoma  or  the  lymphadenomatous  growths  of  Hodgkin's  disease  may  in- 
vade the  vertebrae.  More  commonly,  however,  the  involvement  is  secondary 
to  scirrhus  of  the  breast.  Of  parasites,  the  echinococcus  and  the  cysticercus 
occasionally  occur  in  the  spinal  canal. 

Symptoms. — These  may  be  considered  as  they  affect  the  bones,  the  nerves, 
ind  the  cord. 

VERTEBRAL. — In  malignant  diseases  and  in  aneurism  erosion  of  the  bodies 
may  take  place  without  producing  any  deformity  of  the  spine.  Fatal  haemor- 
rhage may  follow  erosion  of  the  vertebral  artery.  In  caries,  on  the  other 
hand,  it  is  the  rule  to  find  more  or  less  deformity,  amounting  often  to  angular 
curvature.  The  compression  of  the  cord,  however,  is  rarely  if  ever  the  direct 
result  of  this  bony  kyphosis  but  is  due  to  the  thickening  of  the  dura  and  the 
presence  of  caseous  and  inflammatory  products  between  this  membrane  and 
the  bodies  of  the  diseased  vertebrae.  The  spinous  processes  of  the  affected 
vertebrae  are  tender  on  pressure,  and  pain  follows  jarring  movements  or  twist- 
ing of  the  spine.  There  may  be  extensive  tuberculous  disease  without  much 
deformity,  particularly  in  the  cervical  region.  In  the  case  of  aneurism  or 
tumor  pain  is  a  constant  and  agonizing  feature. 

NERVE-ROOT  SYMPTOMS. — These  result  from  compression  of  the  nerve 
roots  as  they  pass  out  between  the  vertebrae.  In  caries,  even  when  the  disease 
is  extensive  and  the  deformity  great,  radiating  pains  from  compression  involve- 
ment of  the  roots  are  rare.  Pains  are  more  common  in  cancer  of  the  spine 
secondary  to  that  of  the  breast,  and  in  such  cases  may  be  agonizing.  There 
may  be  acutely  painful  areas — the  anaesthesia  dolorosa — in  regions  of  the  skin 
which  are  anaesthetic  to  tactile  and  painful  impressions.  Trophic  disturb- 
ances may  occur,  particularly  herpes.  Pressure  on  the  ventral  roots  may  give 
rise  to  wasting  of  the  muscles  supplied  by  the  affected  nerves.  This  is  most 
noticeable  in  disease  of  the  cervical  or  lumbar  regi6ns. 

CORD  SYMPTOMS. —  (a)  Cervical  Region. — 'Not  infrequently  the  caries  is 
high  up  between  the  axis  and  the  atlas  or  between  the  latter  and  the  oc- 
cipital bone.  In  such  instances  a  retropharyngeal  abscess  may  be  present, 
giving  rise  to  difficulty  in  swallowing.  There  may  be  spasm  of  the  cervical 
muscles,  the  head  may  be  fixed,  and  movements  may  either  be  impossible  or 
cause  great  pain.  In  a  case  of  this  kind  in  the  Montreal  General  Hospital 
movement  was  liable  to  be  followed  by  transient,  instantaneous  paralysis  of  all 
four  extremities,  owing  to  compression  of  the  cord.  In  one  of  these  attacks 
the  patient  died. 

In  the  lower  cervical  region  there  may  be  signs  of  interference  with  the 
cilio-spinal  centre  and  dilatation  of  the  pupils.  Occasionally  there  is  flushing 
of  the  face  and  ear  of  one  side  or  unilateral  sweating.  Deformity  is  not 
so  common,  but  healing  may  take  place  with  the  production  of  a  callus  of 
enormous  breadth,  with  complete  rigidity  of  the  neck. 

(&)  Thoracic  Region. — The  deformity  is  here  more  marked  and  pressure 
symptoms  are  more  common.  The  time  of  onset  of  the  paralysis  varies 
very  much.  It  may  be  an  early  symptom,  even  before  the  curvature  is 
manifest,  and  it  is  noteworthy  that  Pott  first  described  the  disease  .'"hat 


COMPRESSION    OF   THE    SPINAL   CORD  961 

bears  his  name  as  "a  palsy  of  the  lower  limbs  which  is  frequently  found 
to  accompany  a  curvature  of  the  spine."  More  commonly  the  paralysis  is 
late,  occurring  many  months  after  the  curvature  has  developed.  The  para- 
plegia is  slow  in  its  development;  the  patient  at  first  feels  weak  in  the 
legs  or  has  disturbance  of  sensation,  numbness,  tingling,  pins  and  needles. 
The  girdle  sensation  may  be  marked,  or  severe  pains  in  the  course  of  the 
intercostal  nerves.  Motion  is,  as  a  rule,  more  quickly  lost  than  sensation. 
The  paraplegia  is  usually  of  the  spastic  type,  with  exaggeration  of  the  reflexes. 
Bastian's  symptom — abolition  of  the  reflexes — is  rarely  met  with  in  compres- 
sion from  caries  as  the  transverse  nature  of  the  lesion  is  rarely  complete.  The 
paraplegia  may  persist  for  months,  or  even  for  more  than  a  year,  and  recovery 
still  be  possible. 

(c)  Lumbar  Region. — In  the  lower  dorsal  and  lumbar  regions  the  symp- 
toms are  practically  the  same,  but  the  sphincter  centres  are  involved  and 
the  reflexes  are  not  exaggerated. 

Diagnosis.  — The  X-ray  picture  is  of  first  importance.  Caries  is  by  far  the 
most  frequent  cause  of  slow  compression  of  the  cord,  and  when  there  are  ex- 
ternal signs  the  recognition  is  easy.  There  are  cases  in  which  the  exudation 
in  the  spinal  canal  between  the  dura  and  the  bone  leads  to  compression  before 
there  are  any  signs  of  caries,  and  if  the  root  symptoms  are  absent  it  may  be 
extremely  difficult  to  arrive  at  a  diagnosis.  Janeway  has  called  attention  to 
persistent  lumbago  as  a  symptom  of  importance  in  masked  Pott's  disease,  par- 
ticularly after  injury.  Brown-Sequard's  paralysis  is  more  common  in  tumor 
and  in  injuries  than  in  caries.  Pressure  on  the  nerve  roots,  too,  is  less  fre- 
quent in  caries  than  in  malignant  disease.  The  cervical  form  of  pachymenin- 
gitis  also  produces  a  pressure  paralysis.  Pressure  from  secondary  carcinoma 
is  naturally  suggested  when  spinal  symptoms  follow  within  a  few  years  after 
an  operation  for  cancer  of  the  breast.  In  paraplegia  following  tumor  of  the 
vertebra  secondary  to  cancer  of  the  breast,  and  in  the  erosion  of  the  spine  by 
retroperitoneal  growths,  the  suffering  is  most  intense.  The  condition  has  been 
well  termed  paraplegia  dolorosa.  I  have  seen  two  cases  in  which  the  breast 
tumor  had  not  been  recognized. 

Treatment. — In  compression  by  aneurism  or  metastatic  tumors  the  con- 
dition is  hopeless.  In  the  former  the  pains  are  often  not  very  severe,  but 
in  the  latter  morphia  is  always  necessary.  On  the  other  hand,  compression 
by  caries  is  often  successfully  relieved  even  after  the  paralysis  has  persisted 
for  a  long  period.  When  caries  is  recognized  early,  rest  and  support  to 
the  spine  by  the  various  methods  now  used  by  surgeons  may  do  much  to 
prevent  the  onset  of  paraplegia.  When  paralysis  has  occurred,  rest  with 
extension  gives  the  best  hope  of  recovery.  It  is  to  be  remembered  that 
restoration  may  occur  after  compression  of  the  cord  has  lasted  for  many 
months,  or  even  more  than  a  year.  Cases  have  been  cured  by  recumbency 
alone,  enforced  for  weeks  or  months;  the  extradural  and  inflammatory 
products  are  absorbed  and  the  caries  heals.  In  earlier  days  brilliant  results 
were  obtained  in  these  cases  by  suspension,  a  method  introduced  by  J.  K. 
Mitchell  in  1826,  and  pursued  with  remarkable  success  by  his  son,  Weir 
Mitchell.  In  recent  years  the  suspension  methods  in  the  erect  posture  have 
been  largely  superseded  by  those  of  hyperextension  during  recumbency  with 
the  application  of  plaster  jackets  to  hold  the  body  and  spine  immovable  in  the 


962  DISEASES   OF   THE   NERVOUS   SYSTEM 

improved  position.  Forcible  correction  of  the  deformity  under  anesthesia  as 
sometimes  advocated  is  not  to  be  recommended;  but  the  gentler  partial  cor- 
rections, perhaps  repeated  several  times  with  a  few  weeks'  interval,  often  lead 
to  a  rapid  disappearance  of  paralyses  through  the  lessening  of  the  angular 
deformity  of  the  vertebra.  In  protracted  cases,  after  these  methods  have  been 
given  a  fair  trial,  laminectomy  may  become  advisable,  and  has  in  many  in- 
stances been  successful  in  relieving  paralyses  when  bloodless  methods  have 
failed. 

The  general  treatment  of  caries  is  that  of  tuberculosis — fresh  air,  good 
food,  cod-liver  oil,  and  arsenic. 


IV.    LESIONS   OF   THE    CAUDA   EQUINA   AND   CONUS 

MEDULLARIS 

The  spinal  cord  extends  only  to  the  second  lumbar  vertebra.  Injury, 
tumors,  and  caries  at  or  below  this  level  involve  not  the  cord  itself,  but  the 
bundle  of  nerves  known  as  the  cauda  equina  and  the  terminal  portion  of 
the  cord,  the  conus  medullaris.  Much  attention  has  been  given  to  lesions 
of  this  part.  Fractures  and  dislocations  are  common  in  the  lumbo-sacral 
region,  tumors  not  infrequently  involve  the  filaments  of  the  cauda  equina,  and 
some  of  the  nerves  are  often  entangled  in  the  cicatrix  of  a  spina  bifida. 

A  lesion  limited  to  the  conus  medullaris  is  rare.  A  myelitis  or  a  focal 
haematomyelia  may  be  limited  to  this  site  with  symptoms  referable  to  a 
lesion  of  the  lowest  sacral  segments — anaesthesia  over  the  buttocks,  perineum, 
and  genitalia,  paralysis  of  the  levator  ani  and  the  vesical  and  anal  sphincters, 
Such  a  focalized  lesion  has  been  known  to  follow  a  lumbar  puncture  made 
between  the  first  and  second  lumbar  vertebras. 

In  a  fracture  or  dislocation  of  the  first  lumbar  vertebra  the  conus  medul- 
laris may  be  compressed  together  with  the  lowest  sacral  nerves  given  off 
from  it.  It  is  rare,  however,  in  traumatic  cases  for  the  tip  of  the  cord  to 
suffer  injury  alone  without  simultaneous  involvement  of  the  nerve  roots  com- 
prising the  cauda  equina  from  the  second  lumbar  down.  In  fracture  or 
dislocation  of  the  fifth  lumbar  vertebra  the  sacral  roots  may  alone  be  involved. 
Thus  in  a  case  which  I  have  reported  the  patient  fell  from  a  bridge  and 
had  paralysis  of  the  legs  and  of  the  bladder  and  rectum.  When  seen  sixteen 
years  after  the  injury,  there  was  slight  weakness,  with  wasting  of  the  left 
leg;  there  was  complete  loss  of  the  function  in  the  ano-vesical  and  genital 
centres  with  anaesthesia  in  a  strip  at  the  back  part  of  the  thigh  (in  the  dis- 
tribution of  the  small  sciatic),  and  of  the  perineum,  scrotum,  and  penis.  The 
urethra  was  also  insensitive. 

It  is  sometimes  very  difficult  to  differentiate  between  a  lesion,  possibly 
at  the  first  lumbar  vertebra,  involving  the  lower  part  of  the  spinal  cord 
and  one  in  the  sacral  region  which  compromises  those  peripheral  nerves  of  the 
cauda  equina  that  are  given  off  from  the  same  segment.  This  is  particu- 
larly so  in  the  case  of  tumors,  for  in  fractures  or  caries  there  may  be  some 
palpable  indication  of  the  seat  of  trouble.  In  cauda  equina  lesions,  however, 
pressure  upon  the  nerve  roots  is  supposed  to  affect  motion  much  more  markedly 
than  sensation,  and  this  discrepancy  may  be  helpful  since  in  the  cord  lesions 


TUMORS    OF  SPINAL    COED   AND    ITS    MEMBRANES      963 

themselves  the  motor  and  sensory  disturbances  are  more  apt  to  have  a  corre- 
spondingly segmental  distribution. 

The  table  and  figures  given  in  the  general  introduction  will  be  found 
useful  in  determining  the  nerve  fibres  and  segments  involved  in  these  cases 
of  injury  of  the  cauda  equina. 


V.    TUMORS  OF  THE  SPINAL  CORD  AND  ITS  MEMBRANES 

Morbid  Anatomy. — New  growths  may  grow  in  the  cord  or  in  its  mem- 
branes, or  may  extend  into  them  from  the  spine.  These  invading  growths 
are  the  more  common  and  have  been  touched  upon  in  a  previous  section. 
Here  the  primary  spinal  growths  only  will  be  considered. 

Schlesinger's  tabulation  of  400  cases  shows  that  meningeal  tumors  are 
considerably  more  common  than  medullary  or  true  cord  tumors.  Solitary 
tubercles  are  by  far  the  most  frequent  medullary  growths.  The  meningeal 
tumors  may  be  either  intra-  or  extradural  and  the  intradural  sarcomata 
or  fibromata — it  is  often  difficult  to  tell  under  which  of  these  terms  they 
should  be  classified — are  by  far  the  most  common.  This  is  important  because 
these  particular  growths  remain  for  a  long  time  non-infiltrating  and  offer 
most  favorable  opportunities  for  surgical  treatment.  In  the  extradural  space 
echinococcus  cysts  are  in  some  countries  frequently  found.  They  are  usually 
multiple,  and,  indeed,  most  of  the  other  forms  of  tumor  may  be  multiple.  A 
lipcma,  psammoma,  myxoma,  neuroma,  and  other  varieties  of  growth  may 
be  met  with.  Gummata  and  gliosarcomata  are  not  infrequent  and  usually 
involve  both  the  cord  and  the  meninges. 

Tumors  are  more  commonly  situated  on  the  lateral  and  dorsal  surfaces 
of  the  cord,  but  there  is  no  level  of  the  spine  in  which  they  may  not  occur. 

The  effects  of  tumor  on  the  functions  of  the  cord  are  varied.  Slow  com- 
pression is  usually  produced  by  growths  external  to  the  cord,  and  it  is  remark- 
able what  a  high  grade  of  compression  the  cord  will  bear  without  serious  inter- 
ference with  its  functions.  In  cases  of  prolonged  interruption  of  function 
ascending  and  descending  degenerations  occur.  Tumors  developing  within  the 
cord  may  lead  to  syringomyelia. 

Symptoms. — These  will  naturally  vary  a  good  deal  with  the  segment  in- 
volved and  with  the  degree  of  pressure  and  the  extent  of  implication  of  the 
nerve  roots.  Neuralgic  pains  which  persist  over  a  particular  territory,  and  a 
slowly  progressive  paralysis  which  may  at  first  suggest  a  Brown-Sequard 
syndrome,  should  always  make  one  suspect  a  spinal  growth. 

The  symptoms  of  the  commoner  intradural  tumors  are  as  follows :  Radiat- 
ing (root)  pains  from  the  level  of  the  lesion;  segmental  atrophy  from  pressure 
on  the  ventral  horns ;  weakness  of  the  leg,  going  on  to  paralysis,  at  first  only 
on  the  side  occupied  by  the  growth,  and  due  to  pyramidal  tract  involvement; 
sensory  disturbances  on  the  opposite  side,  first  affecting  pain  and  temperature 
sense ;  with  increase  of  symptoms  the  crossed  type  of  paralysis  is  lost  and  motor 
palsy  occurs  on  both  sides  with  great  increase  of  reflexes;  even  in  advanced 
cases  the  sensory  paralysis  rarely  becomes  quite  complete,  since  some  tactual 
transmission  from  the  lower  sacral  segments  usually  persists ;  spasmodic,  pain- 
ful, jerking  movements  of  the  lower  extremities  are  very  characteristic  of  the 


964  DISEASES    OF    THE    NEEVOUS    SYSTEM 

advanced  cases.  These  symptoms  will  vary  naturally  with  the  character  of 
the  growth,  its  segmental  level,  place  of  origin,  and  other  factors,  but  in  no 
other  disease  is  there  the  same  coincidence  of  a  gradual  compression  paraplegia 
and  persistent  radiating  pain.  In  some  cases  pain  may  be  elicited  by  deep 
pressure  alongside  the  spinous  processes  at  the  level  of  the  growth,  and  the 
patient,  by  sudden  exertion,  or  by  straining,  coughing,  or  sneezing,  may  greatly 
increase  it. 

Diagnosis. — When  constant  and  severe  root  pains  are  associated  with  a 
progressive  paralysis,  the  diagnosis  may  be  easily  made.  Caries  may  cause 
identical  symptoms,  but  the  radiating  pains  are  rarely  so  severe.  Cervical 
meningitis  simulates  tumor  very  closely,  and  in  reality  produces  identical 
effects,  but  the  very  slow  progress  and  the  bilateral  character  from  the  outset 
may  be  sufficient  to  distinguish  it.  In  chronic  transverse  myelitis  the  symp- 
toms, according  to  Gowers,  may  resemble  tumor  very  closely  and  present  radi- 
ating pains,  a  sense  of  constriction,  and  progressive  paralysis.  Syringomyelia, 
too,  may  give  a  similar  picture.  A  radiogram  may  be  of  diagnostic  aid  in 
case  the  vertebra  -are  infiltrated  by  the  growth. 

The  nature  of  the  tumor  can  rarely  be  indicated  with  precision.  With  a 
marked  syphilitic  history  gumma  may  naturally  be  suspected,  or,  with  coex- 
isting tuberculous  disease,  a  solitary  tubercle. 

Treatment. — If  the  possibility  of  syphilitic  infection  is  present  the  iodide 
of  potassium  should  be  given  in  large  and  increasing  doses.  For  the  severe 
pains  counter-irritation  is  sometimes  beneficial,  particularly  the  thermo- 
cautery;  morphia  is,  however,  often  necessary.  A  successful  laminectomy 
offers  the  only  hope  of  relief  in  case  the  lesion  prove  to  be  non-syphilitic. 
Since  Horsley's  first  brilliant  operation  there  have  been  scores  of  cases  of 
successful  extirpation  of  spinal  cord  tumors.  The  intradural  fibrosarcomata 
are  the  most  favorable  cases  and  complete  restoration  of  function  in  the  cord 
may  follow  the  removal  of  the  tumor.  In  the  infiltrating  growths  the  nerve 
roots  may  be  divided,  or,  as  has  been  suggested,  even  the  cord  itself  sectioned 
for  the  relief  of  the  agonizing  pain,  but  ultimate  cure  is  hopeless  in  malignant 
growths  of  this  character. 


VI.  SYRINGOMYELIA 

Definition.  — A  gliomatous  new  growth  about  the  central  canal  of  the  spinal 
cord,  with  cavity  formation. 

Etiology  and  Morbid  Anatomy. — Syringomyelia  must  be  distinguished 
from  dilatation  of  the  central  canal — hydromyelus — slight  grades  of  which  are 
not  very  uncommon  either  as  a  congenital  condition  or  as  a  result  of  the 
pressure  of  tumors.  The  cavity  of  syringomyelia  has  a  variable  extent  in  the 
cord,  sometimes  running  the  entire  length,  but  in  many  cases  involving  only 
the  cervical  and  thoracic  regions  or  a  more  limited  area.  It  is  usually  in  the 
dorsal  portion  of  the  cord  and  may  extend  only  into  one  dorsal  cornu.  The 
transverse  section  may  be  oval  or  circular  or  narrow  and  fissure  like.  It  varies 
at  different  levels.  The  condition  is  now  regarded  as  a  gliosis,  a  development 
of  embryonal  neurogliar  tissue  in  which  haemorrhage  or  degeneration  takes 
place  with  the  formation  of  cavities. 


ACUTE    MYELITIS  965 

Of  190  cases,  133  were  in  men,  57  in  women  (Schlesinger).  A  large 
majority  of  the  cases  begin  before  the  thirtieth  year.  The  disease  has  been 
met  with  in  three  members  of  the  same  family. 

Symptoms. — The  clinical  features  are  extremely  complex.  In  the  classical 
form  there  are  irregular  pains,  chiefly  in  the  cervical  region ;  muscular  atrophy 
comes  on,  which  may  be  confined  to  the  arms,  or  sometimes  extends  to  the  legs. 
The  reflexes  are  increased  and  a  spastic  condition  develops  in  the  legs.  Ulti- 
mately the  clinical  picture  may  be  that  of  an  amyotrophic  lateral  sclerosis.  The 
tactile  sensation  is  usually  normal  and  the  muscular  sense  is  retained,  but  pain- 
ful and  thermic  sensations  are  not  recognized,  or  there  may  be  in  rare  instances 
complete  anaesthesia  of  the  skin  and  of  the  mucous  membranes.  This  com- 
bination of  loss  of  painful  and  thermic  sensations  with  paralysis  of  an 
amyotrophic  type  is  characteristic,  but  not  pathognomonic  of  the  disease. 
The  special  senses  are  usually  intact  and  the  sphincters  uninvolved.  Trophic 
troubles  are  not  uncommon.  Owing  to  the  loss  of  the  pain  and  heat  sensations, 
the  patients  are  apt  to  injure  themselves.  Scoliosis  also  may  be  present.  The 
loss  of  painful  and  thermic  impressions  is  due  to  the  fact  that  these  pass  to  the 
brain  in  the  peri-ependymal  gray  matter,  particularly  that  portion  in  the  dorsal 
roots,  which  is  almost  constantly  involved  in  syringomyelia.  The  tactile  sen- 
sation is  retained  because  the  postero-lateral  columns  are  uninvolved. 

Schlesinger,  in  his  monograph,  recognizes  the  following  types:  (1)  With 
the  classical  features  above  described,  which  may  begin  in  the  cervical  or  lum- 
bar regions;  (2)  a  motor  type,  with  the  picture  of  an  amyotrophic  or  a  spastic 
paralysis — the  sensation  may  be  undisturbed  for  years;  (3)  with  predominant 
sensory  features,  simulating  hysterical  hemiplegia,  or  with  general  pain  and 
temperature  anaesthesia;  (4)  with  pronounced  trophic  disturbances — to  this 
type  belong  the  cases  described  as  Morvan's  disease,  an  affection  characterized 
by  neuralgic  pains,  cutaneous  anaesthesia,  and  painless,  destructive  whitlows; 
and  (5)  the  tabetic  type,  either  a  combination  of  the  symptoms  of  tabes  in  the 
lower,  and  of  syringomyelia  in  the  upper  extremities,  or  a  pure  tabetic  symp- 
tom-complex, due  to  invasion  of  the  dorsal  columns  by  the  gliosis.  Arthropa- 
thies  occur  in  about  10  per  cent,  of  the  cases. 

Diagnosis. — In  typical  cases  the  diagnosis  is  easy.  The  combination  of  an 
amyotrophic  paralysis,  the  picture  of  progressive  muscular  atrophy  of  the 
Aran-Duchenne  type,  with  retention  of  tactile  and  loss  of  thermic  and  painful 
sensation,  is  probably  pathognomonic  of  the  disease.  Of  affections  with  which 
it  may  be  confounded,  anesthetic  leprosy  is  the  most  important,  since  the 
anaesthesia  and  the  wasting  may  closely  simulate  it;  but,  as  a  rule,  in  leprosy 
trophic  changes  are  more  or  less  marked.  There  is  often  loss  of  phalanges 
and  there  is  no  characteristic  dissociation  of  sensory  impressions. 

Treatment. — This  is  unsatisfactory,  but  in  a  few  cases  the  X-rays  have 
given  great  relief,  particularly  to  the  stiffness. 


VH.    ACUTE  MYELITIS 

Etiology. — Acute  myelitis  results  from  many  causes,  and  may  affect  the 
cord  in  a  limited  or  extended  portion — the  gray  matter  chiefly,  or  the  gray 
and  white  matter  together.  It  is  met  with:  (a)  As  an  independent  affection 


966  DISEASES   OF   THE   NERVOUS   SYSTEM 

following  exposure  to  cold,  or  exertion,  and  leading  to  rapid  loss  of  power 
with  the  symptoms  of  an  acute  ascending  paralysis.  (&)  As  a  sequel  of  the 
infectious  diseases,  such  as  small-pox,  typhus,  measles,  and  gonorrhoea,  (c) 
As  a  result  of  traumatism,  either  fracture  of  the  spine  or  very  severe  muscular 
effort.  Concussion  without  fracture  may  produce  it,  but  this  is  rare.  Acute 
myelitis,  for  instance,  scarcely  ever  follows  railway  accidents,  (d)  In  diseases 
of  the  bones  of  the  spine,  either  caries  or  cancer.  This  is  a  more  common 
cause  of  localized  acute  transverse  myelitis  than  of  the  diffuse  affection,  (e)  In 
disease  of  the  cord  itself,  such  as  tumors  and  syphilis ;  in  the  latter,  either  in 
association  with  gummata,  in  which  case  it  is  usually  a  late  manifestation ;  or 
it  may  follow  within  a  year  or  eighteen  months  of  the  primary  affection. 

Morbid  Anatomy. — In  localized  acute  myelitis  affecting  white  and  gray 
matter,  as  met  with  after  accident  or  an  acute  compression,  the  cord  is  swollen, 
the  pia  injected,  the  consistence  greatly  reduced,  and  on  incising  the  mem- 
brane an  almost  diffluent  material  may  escape.  In  less  intense  grades,  on  sec- 
tion at  the  affected  area,  the  distinction  between  the  gray  and  white  matter  is 
lost,  or  is  extremely  indistinct.  The  chief  features  have  already  been  described 
in  discussing  the  epidemic  form. 

Histologically  the  nerve  fibres  are  much  swollen  and  irregularly  distorted, 
the  axis-cylinders  are  beaded,  the  myelin  droplets  are  abundant,  and  the  lami- 
nated bodies  known  as  corpora  amylacea  may  be  seen.  Changes  in  the 
blood  vessels  are  striking;  the  smaller  veins  are  distended  and  may  show 
varicosities.  The  perivascular  lymph  spaces  contain  numerous  leucocytes,  and 
the  smaller  arteries  themselves  are  frequently  the  seat  of  hyaline  thrombi. 
The  ganglion  cells  are  swollen  and  irregular  in  outline,  the  protoplasm  is 
extremely  granular  and  vacuolated,  and  the  nuclei,  though  usually  invisible, 
may  show  signs  of  division,  and  the  processes  of  the  cells  are  not  seen.  The 
acute,  inflammatory,  hypereemic  or  red  softening  is  succeeded  by  stages  in 
which  the  affected  area  becomes  more  yellow  from  gradual  alteration  of  the 
blood  pigment,  and  finally  white  in  color  from  the  ^advancing  fatty  degenera- 
tion. In  cases  of  compression  myelitis,  a  sclerosis  may  gradually  be  produced 
with  the  anatomical  picture  of  a  chronic  diffuse  myelitis. 

Symptoms. — (a)  ACUTE  DIFFUSE  MYELITIS. — This  form  is  in  the  epidemic 
poliomyelitis,  or  occurs  in  connection  with  syphilis  or  one  of  the  infectious 
diseases,  or  is  seen  in  a  typical  manner  in  the  extension  from  injuries  or  from 
tumor.  The  onset,  though  scarcely  so  abrupt  as  in  hemorrhage,  may  be  sud- 
den; a  person  may  be  attacked  on  the  street  and  have  difficulty  in  getting 
home.  In  some  instances,  the  onset  is  preceded  by  pains  in  the  legs  or  back, 
or  a  girdle  sensation  is  present.  It  may  be  marked  by  chills,  occasionally  by 
convulsions;  fever  is  usually  present  from  the  beginning — at  first  sight,  but 
subsequently  it  may  become  high. 

The  motor  functions  are  rapidly  lost,  sometimes  as  quickly  as  in  Landry's 
ascending  paralysis.  The  paraplegia  may  be  complete,  and,  if  the  myelitis 
extends  to  the  cervical  region,  there  may  be  impairment  of  motion,  and  ulti- 
mately complete  loss  of  power  in  the  upper  extremities  as  well.  The  sensation 
is  lost,  but  there  may  at  first  be  hyperaesthesia.  The  reflexes  in  the  initial 
stage  are  increased,  but  in  acute  central  myelitis,  unless  limited  in  extent  to 
the  thoracic  and  cervical  regions,  the  reflexes  are  usually  abolished.  The  rec- 
tum and  bladder  are  paralyzed.  Trophic  disturbances  are  marked;  the  mus- 


ACUTE    MYELITIS  967 

cles  waste  rapidly;  the  skin  is  often  congested,  and  there  may  he  localized 
sweating.  The  temperature  of  the  affected  limbs  may  be  lowered.  Acute 
bed-sores  may  occur  over  the  sacrum  or  on  the  heels,  and  sometimes  a  multiple 
arthritis  is  present.  In  these  acute  cases  the  general  symptoms  become  greatly 
aggravated,  the  pulse  is  rapid,  the  tongue  becomes  dry;  there  is  delirium,  the 
fever  increases,  and  may  reach  107°  or  108°  F. 

The  course  of  the  disease  is  variable.  In  very  acute  cases  death  follows 
in  from  five  to  ten  days.  The  cases  following  the  infectious  diseases,  particu- 
larly the  fevers  and  sometimes  syphilis,  may  run  a  milder  course. 

The  diagnosis  of  this  variety  of  acute  myelitis  is  rarely  difficult.  In  com- 
mon with  the  acute  ascending  paralysis  of  Landry,  and  with  certain  cases  of 
multiple  neuritis,  it  presents  a  rapid  and  progressive  motor  paralysis.  From 
the  former  it  is  distinguished  by  the  more  marked  involvement  of  sensation, 
the  trophic  disturbances,  the  paralysis  of  bladder  and  rectum,  the  rapid  wast- 
ing, the  electrical  changes,  and  the  fever.  From  acute  cases  of  multiple 
neuritis  it  may  be  more  difficult  to  distinguish,  as  the  sensory  features  in  these 
cases  may  be  marked,  though  there  is  rarely,  if  ever,  in  multiple  neuritis  com- 
plete anaesthesia ;  the  wasting,  moreover,  is  more  rapid  in  myelitis.  The  blad- 
der and  rectum  are  rarely  involved — though  in  exceptional  cases  they  may  be 
• — and,  most  important  of  all,  the  trophic  changes,  the  development  of  bulls, 
bed-sores,  etc.,  are  not  seen  in  multiple  neuritis. 

(6)  ACUTE  TRANSVERSE  MYELITIS. — The  symptoms  naturally  differ  with 
the  situation  of  the  lesion. 

(1)  Acute  transverse  myelitis  in  the  thoracic  region,  the  most  common 
situation,  produces  a  very  characteristic  picture.  The  symptoms  of  onset 
are  variable.  There  may  be  initial  pains  or  numbness  and  tingling  in  the 
legs.  The  paralysis  may  set  in  quickly  and  become  complete  within  a  few 
days ;  but  more  commonly  it  is  preceded  for  a  day  or  two  by  sensations  of  pain, 
heaviness,  and  dragging  in  the  legs.  The  paralysis  of  the  lower  limbs  is  usu- 
ally complete,  and  if  at  the  level,  say,  of  the  sixth  thoracic  vertebra,  the  ab- 
dominal muscles  are  involved.  Sensation  may  be  partially  or  completely  lost. 
At  the  onset  there  may  be  numbness,  tingling,  or  even  hyperaesthesia  in  the 
legs.  At  the  level  of  the  lesion  there  is  often  a  zone  of  hypersesthesia,  which 
is  discovered  by  passing  a  test  tube  containing  hot  water  along  the  spine,  when 
the  sensation  of  warmth  changes  to  one  of  actual  pain.  A  girdle  sensation 
may  occur  early,  and  when  the  lesion  is  in  this  situation  it  is  usually  felt 
between  the  ensiform  and  umbilical  regions.  The  reflex  functions  are  variable. 
There  may  at  first  be  abolition  of  the  reflexes ;  subsequently,  those  which  pass 
through  the  segments  lower  than  the  one  affected  may  be  exaggerated  and 
the  legs  may  take  on  a  condition  of  spastic  rigidity.  It  does  not  always  hap- 
pen, however,  that  the  reflexes  are  increased  here,  for  in  a  total  transverse 
lesion  of  the  cord  they  are  usually  entirely  lost,  as  first  pointed  out  by  Bastian. 
That  this  is  not  due  to  the  preliminary  shock  is  shown  by  the  fact  that  the 
abolition  of  the  reflexes  may  be  permanent.  The  muscles  become  extremely 
flabby,  waste,  and  lose  their  faradic  excitability,  and  the  sphincters  lose  their 
tone.  The  temperature  of  the  paralyzed  limbs  is  variable.  It  may  at  first 
rise,  then  fall  and  become  subnormal.  Lesions  of  the  skin  are  not  uncommon, 
and  bed-sores  are  apt  to  form.  There  is  at  first  retention  of  urine  and  subse- 
quently spastic  incontinence.  If  the  lumbar  centres  are  involved,  there  are 


968  DISEASES    OF    THE    NERVOUS    SYSTEM 

from  the  outset  vesical  symptoms.  The  urine  is  alkaline  in  reaction  and  may 
rapidly  become  ammoniacal.  The  bowels  are  constipated  and  there  is  usually 
incontinence  of  the  fasces.  Some  writers  attribute  the  cystitis  associated  with 
transverse  myelitis  to  disturbed  trophic  influence. 

The  course  of  complete  transverse  myelitis  depends  a  good  deal  upon  its 
cause.  Death  may  result  from  extension.  Segments  of  the  cord  may  be  com- 
pletely and  permanently  destroyed,  in  which  case  there  is  persistent  paraplegia. 
The  pyramidal  fibres  below  the  lesion  undergo  the  secondary  degeneration,  and 
there  is  an  ascending  degeneration  of  the  dorsal  median  columns.  If  the 
lower  segments  of  the  cord  are  involved  the  legs  may  remain  flaccid.  In  some 
instances  a  transverse  myelitis  of  the  thoracic  region  involves  the  ventral  horns 
above  and  below  the  lesion,  producing  flaccidity  of  the  muscles,  with  wasting, 
fibrillar  contractions,  and  the  reaction  of  degeneration.  More  commonly,  how- 
ever, in  the  cases  which  last  many  months  there  is  more  or  less  rigidity  of 
the  muscles  with  spasm  or  persistent  contraction  of  the  flexors  of  the  knee. 

(2)  Transverse  Myelitis  of  the  Cervical  Region. — If  the  lesion  is  at  the 
level  of  the  sixth  or  seventh  cervical  nerves,  there  is  paralysis  of  the  upper 
extremities,  more  or  less  complete,  sometimes  sparing  the  muscles  of  the 
shoulder.  Gradually  there  is  loss  of  sensation.  The  paralysis  is  usually  com- 
plete below  the  point  of  lesion,  but  there  are  rare  instances  in  which,  the  arms 
only  are  affected,  the  so-called  cervical  paraplegia.  In  addition  to  the  symp- 
toms already  mentioned  there  are  several  which  are  more  characteristic  of 
transverse  myelitis  in  the  cervical  region,  such  as  the  occurrence  of  vomiting, 
hiccough,  and  slow  pulse,  which  may  sink  to  20  or  30,  pupillary  changes — 
myosis — sometimes  attacks  of  dysphagia,  dyspnoea,  or  syncope. 

Treatment  of  Acute  Myelitis. — In  the  rapidly  advancing  form  due  either 
to  a  diffuse  inflammation  in  the  gray  matter  or  to  transverse  myelitis,  the 
important  measures  are  scrupulous  cleanliness,  care  and  watchfulness  in  guard- 
ing against  bed-sores,  the  avoidance  of  cystitis,  either  by  systematic  catheteriza- 
tion  or,  if  there  is  incontinence,  by  a  carefully  adjusted  bed  urinal,  or  the  use 
of  antiseptic  cotton-wool  repeatedly  changed.  In  an  acute  onset  in  a  healthy 
subject  the  spine  may  be  cupped.  Counter-irritation  is  of  doubtful  advantage. 
Chapman's  ice-bag  is  sometimes  useful.  No  drugs  have  the  slightest  influence 
upon  an  acute  myelitis,  except  in  subjects  with  well-marked  syphilis,  in  which 
case  mercury  and  potassium  iodide  should  be  given  energetically.  Tonic  reme- 
dies, such  as  quinine,  arsenic,  and  strychnia,  may  be  used  in  the  later  stages. 
When  the  muscles  have  wasted,  massage  is  beneficial  in  maintaining  their 
nutrition.  The  patient  should  make  every  effort  to  perform  muscular  move- 
ments himself  and  thus  aid  improvement.  Electricity  should  not  be  used  in 
the  early  stages  of  myelitis.  It  is  of  no  value  in  the  transverse  myelitis  in 
the  thoracic  region  with  retention  of  the  nutrition  in  the  muscles  of  the  leg. 


E.    DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN 
I.    TOPICAL   DIAGNOSIS 

Only  certain  regions  of  the  brain  give  localizing  symptoms.    These  are  the 
cortical  motor  centres  and  the  associated .  sensory  centres,  the  speech  centres, 


TOPICAL   DIAGNOSIS  969 

the  centres  for  the  special  senses,  and  the  tracts  which  connect  these  cortical 
areas  with  each  other  and  with  other  parts  of  the  nervous  system. 

The  following  is  a  brief  summary  of  the  effects  of  lesions  from  the  cortex 
to  the  spinal  cord: 

The  Cerebral  Cortex. — (a)  Destructive  lesions  of  the  motor  cortex  cause 
paralysis  in  the  muscles  of  the  opposite  side  of  the  body.  The  paralysis  is  at 
first  flaccid,  but  the  spastic  condition  subsequently  develops.  The  extent  of 
the  paralysis  depends  upon  that  of  the  lesion.  It  is  apt  to  be  limited  to  the 
muscles  of  the  head  or  of  an  extremity,  giving  rise  to  the  cerebral  monoplegias. 
One  group  of  muscles  may  be  much  more  affected  than  others,  especially  in 
lesions  of  the  highly  differentiated  area  for  the  upper  extremity.  It  is  un- 
common to  find  all  the  muscle  groups  of  an  extremity  equally  involved  in 
cortical  monoplegia.  In  small  bilateral  symmetrical  lesions  monoplegia  of  the 
tongue  may  result  without  paralysis  of  the  face.  A  lesion  may  involve  centres 
lying  close  together  or  overlapping  one  another,  thus  producing  associated 
monoplegias — e.  g.,  paralysis  of  the  face  and  arm,  or  of  the  arm  and  leg,  but 
not  of  the  face  and  leg  without  involvement  of  the  arm.  Very  rarely  the  whole 
motor  cortex  is  involved,  causing  paralysis  of  the  opposite  side — cortical  hemi- 
plegia.  Usually  in  such  instances  there  is  marked  recovery,  so  that  only  a 
monoplegia  persists. 

Adjoining  and  posterior  to  the  motor  area  is  believed  to  be  the  region  of 
the  cortex  in  which  the  impulses  concerned  in  general  bodily  sensation  (cutane- 
ous sensibility,  muscle  sense,  visceral  sensations)  first  arrive  (the  somassthetic 
area).  Combined  with  the  muscular  weakness  there  is  usually  some  disturb- 
ance of  sensations,  particularly  of  those  of  the  muscular  sense.  In  lesions  of 
the  superior  parietal  lobe  the  stereognostic  sense  is  very  often  affected.  For 
example,  when  a  coin  or  a  knife  is  placed  in  the  hand  of  the  affected  limb,  the 
patient's  eyes  being  closed,  it  is  not  recognized,  owing  to  inappreciation  of 
the  form  and  consistence  of  the  object,  and  this  even  though  the  slightest  tac- 
tile stimulus  applied  to  the  fingers  or  surface  of  the  hand  is  felt  and  may  be 
correctly  localized.  The  sense  of  touch,  pain,  and  temperature  may  be  lowered, 
but  usually  not  markedly  unless  the  superior  and  inferior  parietal  lobules  are 
involved  in  subcortical  lesions.  Para?sthesias  and  vaso-motor  disturbances  are 
common  accompaniments  of  paralyses  of  cortical  origin. 

(&)  Irritative  lesions  cause  localized  spasms.  The  most  varied  muscle 
groups  corresponding  to  particular  movement  forms  may  be  picked  out.  If 
the  irritation  be  sudden  and  severe,  typical  attacks  of  Jacksonian  epilepsy  may 
occur.  These  convulsions  are  often  preceded  and  accompanied  by  subjective 
sensory  impressions.  Tingling  or  pain,  or  a  sense  of  motion  in  the  part,  is 
often  the  signal  symptom  (Seguin),  and  is  of  great  importance  in  determining 
the  seat  of  the  lesion. 

When  lesions  are  often  both  destructive  and  irritative,  there  are  combina- 
tions of  the  symptoms  produced  by  each.  For  instance,  certain  muscles  may 
be  paralyzed,  and  those  represented  near  them  in  the  cortex  may  be  the  seat 
of  localized  convulsions,  or  the  paralyzed  limb  itself  may  be  at  times  subject 
to  convulsive  spasms,  or  muscles  which  have  been  convulsed  may  become  par- 
alyzed. The  close  observation  of  the  sequence  of  the  symptoms  in  such  cases 
often  makes  it  possible  to  trace  the  progress  of  a  lesion  involving  the  motor 
cortex.  In  these  cases  the  most  frequent  cause  is  a  developing  tumor,  though 
63 


970  DISEASES    OF    THE    NERVOUS    SYSTEM 

sometimes  local  thickenings  of  the  membranes  of  the  brain,  small  abscesses, 
minute  haemorrhages,  or  fragments  of  a  fractured  skull  must  be  held  re- 
sponsible. 

In  another  section  lesions  involving  the  centres  for  the  special  senses  are 
considered,  and  we  shall  simply  refer  to  them  here.  The  symptoms  caused 
by  lesions  of  the  speech  centres  will  be  described  under  aphasia,  and  it  is 
only  necessary  to  note  here  the  near  situation  of  the  motor  speech  area  (Broca's 
centre)  in  the  left  inferior  frontal  convolution  to  the  centres  for  the  face  and 
tongue  on  that  side,  and  the  nearness  of  the  supposed  centre  for  writing  to 
that  of  the  hand  and  arm,  and  to  state  that  motor  aphasia  is  often  associated 
with  paralysis  of  the  right  side  of  the  face  and  the  right  arm.  Accompanying 
the  paralysis,  following  a  Jacksonian  fit,  of  the  right  face  or  arm  there  is  often 
a  transient  motor  aphasia. 

According  to  Flechsig,  the  sensori-motor  centres  are  limited  to  tolerably 
circumscribed  areas  in  the  cortex,  which  differ  from  other  portions  in  that  they 
are  provided  with  projection  fibres  which  connect  them  with  lower  centres. 
The  remaining  areas  of  the  cortex,  amounting,  he  believes,  to  about  two-thirds 
of  the  whole,  are  devoid  of  projection  fibres  and  are  concerned  entirely  in 
associative  activities.  These  latter  areas,  the  "association  centres"  of  Flech- 
sig, are  three  in  number:  (1)  The  anterior  association  centre,  including  the 
whole  of  the  frontal  lobe  in  front  of  the  somassthetic  area;  (2)  the  middle 
association  centre,  corresponding  to  the  cortex  of  the  island  of  Eeil;  and  (3) 
the  large,  posterior  association  centre,  including  the  prscuneus,  the  superior 
and  inferior  parietal  lobules,  the  supramarginal  and  angular  gyri,  and  the 
whole  of  the  temporal  and  occipital  lobes  except  the  auditory  and  visual  sen- 
sory areas. 

Flechsig  attributes  the  higher  psychic  functions,  especially  those  connected 
with  the  personality  of  the  individual,  to  the  anterior  association  centres,  while 
the  intellectual  activities  which  have  to  do  with  knowledge  of  the  external 
world  he  believes  correspond  to  the  functions  of  the  large  posterior  association 
centre.  Whether  these  views  be  true,  and,  if  so,  in  how  far  they  may  be  applied 
practically  in  the  localization  of  diseases,  especially  of  the  mind,  the  future  has 
to  decide. 

Centrum  Semiovale, — Lesions  in  this  part  may  involve  either  projection 
fibres  (motor  or  sensory)  or  association  fibres.  If  involvement  of  the  motor 
path  cause  paralysis,  this  has  the  distribution  of  a  cortical  palsy  when  the 
lesion  is  near  the  cortex,  and  of  a  paralysis  due  to  a  lesion  of  the  internal 
capsule  when  it  is  near  that  region.  These  lesions  of  the  motor  fibres  may 
be  associated  with  symptoms  due  to  interruption  in  the  other  systems  of  fibres 
running  in  the  centrum  semiovale;  there  may  be  sensory  disturbances — hemi- 
anaasthesia  and  hemianopia — and  if  the  lesion  is  in  the  left  hemisphere  one 
of  the  different  forms  of  aphasia  may  accompany  the  paralysis. 

Corpus  Callosum. — This  may  be  congenitally  absent  without  symptoms. 
An  acute  lesion  involving  a  large  portion  of  the  corpus  callosum  may,  how- 
ever, yield  symptoms  suggestive  of  its  localization  in  this  region.  In  the  case 
recorded  by  Reinhard,  in  which  the  situation  of  the  lesion  was  suspected  ante 
mortem,  there  was  a  disturbance  of  equilibration  (without  vertigo)  and  of 
the  synergetic  movements  of  both  halves  of  the  body.  The  autopsy  revealed 
a  gliosarcoma  which  had  destroyed  the  posterior  three-fourths  of  the  corpus 


TOPICAL    DIAGNOSIS  971 

callosum.  In  Bristowe's  4  cases  there  existed,  as  symptoms  common  to  all, 
pain  in  the  head  and  partial  or  complete  hemiplegia,  with  gradual  extension 
of  the  paralysis  to  the  opposite  side  of  the  body.  Toward  the  end  of  life  there 
were  disturbance  of  speech,  difficulty  in  deglutition,  incontinence  of  urine  and 
faeces,  and  dementia.  Here  the  symptoms  have  in  them  nothing  that  can  be 
looked  upon  as  pathognomonic ;  indeed,  many  of  the  phenomena  were  doubtless 
dependent  upon  involvement  of  the  projection  and  association  fibres  of  the 
centrum  semiovale. 

In  animals  in  which  the  corpus  callosum  has  been  cut  experimentally  pro- 
gressive emaciation  has  been  mentioned  as  a  characteristic  phenomenon. 

Internal  Capsule  (Fi.=<.  13). — Through  this  pass  within  a  rather  narrow 
area  all,  or  nearly  all,  of  the  projection  fibres  (both  motor  and  sensory)  which 
are  connected  with  the  cerebral  cortex.  It  is  divided  into  an  anterior  limb,  a 
knee,  and  a  posterior  limb,  the  latter  consisting  of  a  thalamo-lenticular  por- 
tion (its  anterior  two-thirds)  and  a  retro-lenticular  portion  (its  posterior 
third).  In  considering  the  effects  of  a  given  focal  lesion  involving  the  fibres 
of  the  internal  capsule,  it  is  not  to  be  forgotten  that  the  relations  of  the  two 
limbs  of  the  capsule  to  one  another  and  to  the  knee  vary  considerably  in  differ- 
ent horizontal  planes.  Much  of  the  confusion  in  the  bibliography  is  dependent 
upon  neglect  to  describe  the  horizontal  level  of  the  lesion,  as  well  as  its  situa- 
tion in  an  antero-posterior  direction.  The  principal  bundle  passing  through 
the  anterior  limb  of  the  capsule  is  that  which  connects  the  frontal  gyri  and 
the  medial  bundle  in  the  base  of  the  peduncle  (crus)  with  the  nuclei  of  the 
pons.  These  fibres  are  centrifugal,  and  innervate  chiefly  the  lower  motor 
nuclei  governing  bilaterally  innervated  muscles,  especially  those  of  the  eyes, 
head,  neck,  and  probably  those  of  the  mouth,  tongue,  and  larynx.  In  lower 
horizontal  planes  these  fibres  are  situated  near  the  knee  of  the  capsule.  It  is 
the  region  of  the  knee  of  the  capsule  which  transmits  especially  the  fibres  pass- 
ing from  the  cerebral  cortex  to  the  nuclei  of  the  facial,  hypoglossal,  and  third 
nerves.  The  path  which  supplies  the  nuclei  governing  the  muscles  used  in 
speech  passes  through  the  knee. 

The  pyramidal  tract  goes  through  the  thalamo-lenticular  portion  of  the 
capsule.  The  motor  fibres  are  arranged  according  to  definite  muscle  groups, 
or  rather  movement  forms,  those  for  the  movements  of  the  arm  being  anterior 
to  those  for  the  leg.  The  number  of  fibres  for  a  given  muscle  group  corre- 
sponds rather  to  the  degree  of  complexity  of  the  movements  than  to  the  size 
of  the  muscles  concerned.  Thus  the  areas  for  the  fingers  and  toes  are  relatively 
large. 

The  fibres  to  the  somasthetic  area  of  the  cortex — that  is,  those  from  the 
centre-lateral  group  of  nuclei  of  the  thalamus  and  the  tegmental  radiations — • 
carrying  impulses  concerned  in  general  bodily  sensation,  pass  upward  through 
the  posterior  part  of  the  thalamo-lenticular  portion  of  the  capsule.  Some  of 
these  fibres  pass  through  the  anterior  two-thirds  of  the  posterior  limb  along- 
side of  the  fibres  of  the  pyramidal  tract. 

Through  the  retro-lenticular  portion  of  the  posterior  limb,  opposite  the 
posterior  third  of  the  lateral  surface  of  the  thalamus,  pass  (1)  the  fibres  carry- 
ing impulses  concerned  in  the  sensations  of  the  opposite  visual  field  (optic 
radiation  from  the  lateral  geniculate  body  to  .the  visual  sense  area  in  the  occipi- 
tal cortex;  (2)  the  fibres  carrying  impulses  concerned  in  auditory  sensations 


972  DISEASES    OF   THE    NERVOUS    SYSTEM 

(radiation  from  the  medial  geniculate  body  to  the  auditory  sense  area  in  the 
cortex  of  the  temporal  lobe)  ;  (3)  the  fibres  (probably  centrifugal)  connecting 
the  cortex  of  the  temporal  lobe  with  the  nuclei  of  the  pons. 

With  this  preliminary  knowledge  concerning  the  internal  capsule,  it  is  not 
difficult  to  understand  the  symptoms  which  result  when  it  is  diseased. 

Since  here  all  the  fibres  of  the  upper  motor  segment  are  gathered  together 
in  a  compact  bundle,  a  lesion  in  this  region  is  apt  to  cause  complete  hemiplegia 
of  the  opposite  side,  followed  later  by  contractures ;  and  if  the  lesion  involves 
the  hinder  portion  of  the  posterior  limb  there  is  also  hemianassthesia,  incl"l/Ung 
even  the  special  senses  (Fig.  13).  As  a  rule,  however,  lesions  of  the  internal 
capsule  do  not  involve  the  whole  structure.  The  disease  usually  affects  mainly 
either  the  anterior  or  posterior  portions,  and  even  in  instances  in  which  at  first 
the  symptoms  point  to  total  involvement  there  is  a  disappearance  often  of  a 
large  part  of  the  phenomena  after  a  short  time.  Thus,  when  the  pyramidal 
tract  is  destroyed  (lesion  of  the  thalamo-lenticular  portion  of  the  capsule)  the 
arm  may  be  aifected  more  than  the  leg,  or  vice  versa.  The  facial  paralysis  is 
usually  slight,  though  if  the  lesion  be  well  forward  in  the  capsule  the  paralysis 
of  the  face  and  tongue  may  be  marked. 

Hemianaesthesia  alone  without  involvement  of  the  motor  fibres,  due  to  dis- 
ease of  the  capsule,  is  rare.  There  is  usually  also  at  least  partial  paralysis  of 
the  leg.  When  the  retro-lenticular  portion  of  the  capsule  is  destroyed  the 
hemianaesthesia  is  accompanied  by  hemianopsia,  disturbances  of  hearing,  and 
sometimes  of  smell  and  taste.  The  occurrence  of  hemianaesthesia  with  pain, 
hemichorea,  marked  tremor,  or  hemiathetosis — thalamic  syndrome — after  a 
capsular  hemiplegia  points  to  the  involvement  of  the  thalamus  or  of  the  hypo- 
thalamic  region. 

Charcot  and  others  have  described  cases  in  which  as  a  result  of  disease  of 
the  internal  capsule  there  has  been  paralysis  of  the  face  and  leg  without  in- 
volvement of  the  arm.  In  such  instances  the  lesion  is  linear,  extending  from 
the  posterior  part  of  the  anterior  limb  of  the  internal  capsule  backward  and 
lateralward  to  the  leg  region  in  the  posterior  limb  of  the  capsule,  the  region 
for  the  arm  escaping. 

Capsular  lesions  when  pure  are  not  usually  accompanied  by  aphasic  symp- 
toms, alexia,  or  agraphia.  A  "subcortical"  motor  aphasia  may  result  if 
the  lesion  is  bilateral,  as  in  pseudo-bulbar  paralysis,  or  if  on  the  left 
side  it  is  so  extensive  as  to  destroy  the  fibres  connecting  Broca's  convo- 
lution with  the  opposite  hemisphere,  as  well  as  the  pyramidal  fibres  on  the 
same  side. 

Crura  (Cerebral  Peduncles). — From  this  level  through  the  pons,  medulla, 
and  cord  the  upper  and  lower  motor  segments  are  represented,  the  first  by  the 
fibres  of  the  pyramidal  tracts  and  by  the  fibres  which  go  from  the  cerebral 
cortex  to  the  nuclei  of  the  cerebral  nerves,  the  latter  by  the  motor  nuclei  and 
the  nerve  fibres  arising  from  them.  Lesions  often  affect  both  motor  segments, 
and  produce  paralyses  having  the  characteristics  of  each.  Thus  a  single  lesion 
may  involve  the  pyramidal  tract  and  cause  a  spastic  paralysis  on  the  opposite 
side  of  the  body,  and  also  involve  the  nucleus  or  the  fibres  of  one  of  the  cerebral 
nerves,  and  so  produce  a  lower  segment  paralysis  on  the  same  side  as  the  lesion 
— crossed  paralysis.  In  the  crus  the  third  and  fourth  cerebral  nerves  run  near 
the  pyramidal  tract,  and  a  lesion  of  this  region  is  apt  to  involve  them  or  their 


TOPICAL   DIAGNOSIS  973 

nuclei,  causing  partial  paralysis  of  the  muscles  of  the  eye  on  the  same  side  as 
the  lesions,  combined  with  a  hemiplegia  of  the  opposite  side  (Fig.  10,  3). 

The  optic  tract  also  crosses  the  crus  and  may  be  involved,  giving  hemi- 
anopsia  in  the  opposite  halves  of  the  visual  fields. 

If  the  tegmentum  be  the  seat  of  a  lesion  which  does  not  involve  the 
base  of  the  peduncle  (or  pes)  there  may  be  disturbances  of  cutaneous 
and  muscular  sensibility,  ataxia,  disturbances  of  hearing,  or  oculo-motor 
paralysis.  An  oculo-motor  paralysis  of  one  side,  accompanied  by  a  hemi- 
ataxia  of  the  opposite  side,  appears  to  be  especially  characteristic  of  a  teg- 
mental  lesion. 

Corpora  Quadrigemina.  —Anatomical  studies  point  to  the  view  that  the 
superior  colliculus  (anterior  quadrigeminal  body)  represents  the  most  impor- 
tant subcortical  central  organ  for  the  control  of  the  eye-muscle  nuclei.  This 
is  supported  to  a  certain  extent  by  clinical  evidence,  though  as  yet  but  few  cases 
have  been  carefully  studied.  Sight  is  only  slightly,  if  at  all,  disturbed  when 
the  superior  colliculus  is  destroyed.  The  pupil  is  usually  widened,  and  the 
pupillary  reaction,  both  to  light  and  on  accommodation,  interfered  with. 
Apparently  actual  paralysis  of  the  eye  muscles  does  not  occur  unless  the  nucleus 
of  the  third  nerve  ventral  to  the  aqueduct  be  also  injured. 

The  inferior  colliculus  (posterior  quadrigeminal  body),  on  the  other  hand, 
has  been  shown  by  anatomical  study  to  be  an  important  way-station  in  the 
auditory  conduction-path.  A  large  part  of  the  lateral  lemniscus  ends  in  its 
nucleus,  and  from  it  emerge  medullated  fibres  which  pass  through  the  brach- 
ium  quadrigeminum  inferius  to  the  medial  geniculate  body.  Thence  a  large 
bundle  runs  through  the  retro-lenticular  portion  of  the  internal  capsule  to  the 
auditory  sense  area  in  the  cortex  of  the  temporal  lobe. 

Weinland  has  collected  19  cases  of  tumors  of  the  corpora  quadrigemina 
from  the  bibliography;  in  9  of  these  auditory  disturbances  were  especially 
noted.  Since  the  central  auditory  path  of  each  side  receive  impulses  from 
both  ears,  lesion  of  the  colliculus  on  one  side  may  dull  the  hearing  on  both 
sides,  though  the  opposite  ear  is  usually  the  more  defective.  Lesion  of  the 
inferior  colliculus  may  be  accompanied  by  disturbance  of  mastication,  owing 
to  paralysis  of  the  descending  (mesencephalic)  root  of  the  trigeminus.  The 
fourth  nerve  may  also  be  involved.  The  ataxia  which  sometimes  accompanies 
lesions  of  the  corpora  quadrigemina  is  probably  to  be  referred  to  disturbance 
in  conduction  in  the  medial  lemniscus. 

Pons  and  Medulla  Oblongata. — Lesions  involving  the  pyramidal  tract,  to- 
gether with  any  one  of  the  motor  cerebral  nerves  of  this  region,  cause  crossed 
paralysis.  A  lesion  in  the  lower  part  of  the  pons  is  apt  to  cause  a  lower-seg- 
ment paralysis  of  the  face  on  the  same  side  (destruction  of  the  nucleus  of  the 
facial  nerve  or  of  its  root  fibres)  and  a  spastic  paralysis  of  the  arm  and  leg  on 
the  opposite  side  (injury  to  pyramidal  tract)  (Fig.  10,  4).  The  abducens,  the 
motor  part  of  the  trigeminus,  and  the  hypoglossus  nerves  may  also  be  paralyzed 
in  the  same  manner.  When  the  central  fibres  to  the  nucleus  of  the  hypoglossus 
are  involved  a  peculiar  form  of  anarthria  results.  If  the  nucleus  itself  be 
diseased,  swallowing  is  interfered  with. 

When  the  sensory  fibres  of  the  fifth  nerve  are  interrupted,  together  with 
the  sensory  tract  (the  medial  lemniscus  or  fillet)  for  the  rest  of  the  body,  which 
has  already  crossed  the  middle  line,  there  is  a  crossed  sensory  paralysis — i.  e., 


974  DISEASES    OF    THE    NERVOUS    SYSTEM 

disturbed  sensation  in  the  distribution  of  the  fifth  on  the  side  of  the  lesion, 
and  of  all  the  rest  of  the  body  on  the  opposite  side. 

A  paralysis  of  the  external  rectus  muscle  of  one  eye  and  of  the  internal 
rectus  of  the  other  eye  (conjugate  paralysis  of  the  muscles  which  turn  the 
eyes  to  one  side),  in  the  absence  of  a  "forced  position"  of  the  eyeballs,  is  highly 
characteristic  of  certain  lesions  of  the  pons.  In  such  cases  the  internal  rectus 
may  still  be  capable  of  functioning  on  convergence,  or  when  the  eye  to  which 
it  belongs  is  tested  independently  of  that  in  which  the  external  rectus  is  paral- 
yzed. This  form  of  paralysis  is  found,  as  a  rule,  only  when  the  lesion  lies  just 
.'n  front  of  the  abducens  or  involves  the  nucleus  itself,  or  includes,  besides  the 
root  fibres  of  the  abducens,  that  portion  of  the  formatio  reticularis  that  lies 
between  them  and  the  fasciculus  longitudinalis  medialis  (von  Monakow).  The 
cases  of  conjugate  paralysis  just  referred  to  may  be  complicated  by  other  dis- 
turbances of  the  eye-muscle  movements,  in  which  case  the  interpretation  of 
the  symptoms  may  be  rendered  difficult.  The  facial  nerve  is  often  involved  in 
these  paralyses. 

In  lesions  of  the  pons  the  patient  often  has  a  tendency  to  fall  toward  the 
side  on  which  the  lesion  is,  probably  on  account  of  implication  of  the  middle 
peduncle  of  the  cerebellum  (brachium  pontis).  Still  more  frequent  is  the 
simple  motor  hemi-ataxia  consequent  upon  lesion  of  the  medial  lemniscus,  and 
perhaps  of  longitudinal  bundles  in  the  formatio  reticularis.  This  is  often 
accompanied  by  a  dissociated  sensory  disturbance,  pain  and  temperature  being 
affected,  while  touch  remains  normal.  The  muscular  sense  may  also  be  in- 
volved. Only  when  the  lesion  is  very  extensive  are  there  disturbances  of  hear- 
ing (involvement  of  the  lateral  lemniscus  or  corpus  trapezoideum) . 

The  symptoms  produced  by  involvement  of  the  different  cerebral  nerves 
will  be  considered  in  detail  in  another  section. 

Cerebellum.  — The  functions  of  this  part  of  the  brain  are  still  under  con- 
sideration. Luciani,  whose  monograph  is  exhaustive,  regards  it  as  "an  end 
organ,  directly  or  indirectly  related  to  certain  peripheral  sensory  organs  and 
in  direct  efferent  relationship  with  certain  ganglia  of  the  cerebro-spinal  axis, 
and  indirectly  with  the  motor  apparatus  in  general.  It  is  functionally  homo- 
geneous, each  part  exercising  the  functions  of  the  whole,  but  having  special 
relations  to  the  muscles  of  the  corresponding  side  of  the  body"  (Krauss). 

Lesions  of  the  lateral  lobes  affect  the  corresponding  side  of  the  body,  while 
lesions  of  the  middle  lobe  (vermis)  affect  both  sides.  Partial  removal  is  fol- 
lowed by  transient  muscular  weakness;  complete  removal  by  extreme  inco- 
ordi  nation.  Its  one  important  function  would  appear  to  be  the  coordination 
of  the  muscular  movements. 

•  In  monkeys  the  symptoms  differ  much  at  different  periods  after  the  opera- 
tion. During  the  first  five  or  six  days  irritation  phenomena  predominate. 
According  to  Luciani,  there  are  asthenia,  atony  of  the  muscles,  and  astasia  on 
the  side  of  the  body  operated  upon.  The  animal  can  not  stand  or  walk.  All 
these  symptoms  may  gradually  disappear  in  the  course  of  a  few  months. 

The  experiments  of  Risien  Russell  do  not  entirely  confirm  the  observations 
of  Luciani.  In  the  first  place,  the  occurrence  of  asthenia  is  not  constant,  and 
as  to  atony,  while  the  patellar  tendon  reflexes  are  sometimes  absent,  they  are, 
as  a  rule,  intact  in  pure  cerebellar  lesions.  There  may  be  even'  muscular 
rigidity  instead  of  atony.  Russell's  experiments  make  it  seem  likely  that  the 


TOPICAL   DIAGNOSIS  975 

serebellar  hemisphere  of  one  side  exercises  constantly  an  inhibitory  effect  upon 
the  activities  of  the  cerebral  hemisphere  of  the  opposite  side  (probably  by  way 
of  the  brachium  conjunctivum).  Thus,  after  removal  of  one  cerebellar  hemi- 
sphere, he  found  that  movements  of  the  arm  and  leg  could  be  caused  by  a 
faradic  stimulation  of  the  contralateral  motor  area,  much  milder  than  that 
necessary  to  stimulate  the  homolateral  motor  area.  The  epileptic  seizures  fol- 
lowing the  administration  of  absinthe  were  far  greater  on  the  side  of  ablation. 
It  is  not  impossible  that  the  explanation  of  the  epileptiform  attacks  by  no 
means  rare  in  cerebellar  disease  is  here  to  be  sought. 

W.  C.  Krauss  has  analyzed  the  lesions  and  symptoms  in  100  cases  of  dis- 
ease of  this  part.  The  morbid  conditions  were  as  follows:  Sarcoma  in  22 
cases ;  tubercle  in  22 ;  glioma  in  18 ;  abscess  in  10 ;  tumor  of  unspecified  origin 
in  13 ;  cyst  in  7;  and  1  case  each  of  softening,  endothelioma,  cyst  and  sarcoma, 
cancer,  gumma,  fibroma,  and  haemorrhage.  The  left  lobe  was  affected  32  times, 
the  right  lobe  32  times,  and  the  middle  lobe  17  times.  Thus,  tumor  constituted 
by  far  the  most  important  affection.  There  may  be  no  symptoms  whatever 
if  it  is  in  one  hemisphere  only  and  does  not  involve  the  middle  lobe.  There 
are  instances  not  only  of  complete  absence  of  one  whole  hemisphere  from  arrest 
of  growth,  but  also  of  extensive  bilateral  disease,  which  throughout  life  has 
yielded  no  noticeable  symptoms.  Only  when  lesions  are  comparatively  sudden 
do  the  symptoms  resemble  the  early  experimental  states  in  animals.  Other 
portions  of  the  brain  appear  to  be  able  to  take  on  the  functions  normally  per- 
formed by  the  cerebellum.  The  most  common  symptoms  in  tumor  of  the  cere- 
bellum are  as  follows: 

Vertigo,  which  is  more  constant  in  this  than  in  affections  of  any  other 
region  of  the  brain.  Some  believe  this  to  be  due  to  involvement  of  the  nervus 
vestibularis  or  its  nuclei  of  termination,  by  means  of  which  the  semicircular 
canals  are  connected  with  the  cerebellum.  The  symptom  was  present  in  48 
of  the  cases  of  Krauss'  collection,  not  reported  in  43.  The  vertigo  appears  to 
be  entirely  independent  of  the  ataxia.  Though  most  frequently  associated, 
either  symptom  may  be  present  without  the  other.  The  vertigo  of  cerebellar 
disease  is  often  associated  with  the  feeling  that  objects  are  revolving  about  the 
body,  or  that  the  body  itself  is  moving.  Headache  was  present  in  83  cases. 
Vomiting  occurred  in  69  cases,  not  reported  in  23.  Optic  neuritis  was  found 
in  G6  cases,  not  reported  in  23.  It  is  apt  to  appear  early,  and  is  probably 
brought  about  by  the  obstructive  internal  hydrocephalus  that  commonly  results 
from  subtentorial  growths  through  pressure  on  the  aqueductus  cerebri. 

Of  symptoms  which  are  designated  as  more  particularly  cerebellar,  ataxia, 
particularly  of  the  homolateral  limbs,  is  the  most  important.  In  cerebellar 
ataxia  the  gait  is  irregular  and  staggering,  often  zigzag,  and  in  attempting  to 
walk  the  patient  sways  to  and  fro  like  a  drunken  man  (demarche  d'ivresse  of 
the  French  writers).  As  a  rule,  the  patient  walks  and  tends  to  fall  toward  the 
affected  side,  but  the  rule  is  not  certain.  The  ataxia  of  cerebellar  disease  i°  to 
be  sharply  differentiated  from  the  ataxia  of  tabes  dorsalis,  from  cortical  ataxia, 
and  probably  from  the  ataxia  accompanying  diseases  of  the  tegmental  portion 
of  the  pons  and  cerebral  peduncle.  Cerebellar  ataxia  is  both  static  and  dy- 
namic. The  opening  or  closing  of  the  eyes  has  less  influence  than  in  spinal 
•ataxia.  Very  important  for  differential  diagnosis  is  the  fact  that  when  the 
patient  lies  in  bed  movements  tolerably  well  coordinated  can  be  carried  out. 


976  DISEASES    OF    THE    NERVOUS    SYSTEM 

The  coarse  nature  of  the  incoordination  distinguishes  cerebellar  ataxia  from 
that  due  to  lesion  of  the  cerebral  cortex.  In  the  latter  the  finer  movements 
(buttoning,  etc.)  are  especially  apt  to  be  involved,  and  there  is  usually  hemi- 
paresis  or  mono-paresis,  and  often  disturbance  of  muscular  sense  and  of  the 
stereognostic  sense  (von  Monakow).  Cerebellar  ataxia  may  depend  upon  the 
withdrawal  of  the  influence  of  the  cerebellum  upon  the  cerebrum.  Babinski 
has  pointed  out  that  the  affected  limb,  although  ataxic,  may  be  held  in  a  given 
position  more  steadily  than  normal,  and  also  that  repeated  movements  can  not 
be  as  quickly  performed  on  the  affected  as  on  the  normal  side  (dys-diado- 
chokinesia). 

Paresis,  especially  of  the  homolateral  trunk  muscles,  manifest  in  an  in- 
ability to  perform  the  movements  of  bending,  erection,  and  lateral  flexion  of 
the  trunk,  may  be  present.  Eisien  Russell  holds  that  the  paralysis  is  "probably 
directly  due  to  the  withdrawal  of  the  cerebellar  influence  from  the  muscles." 
A  peculiar  attitude  of  the  head  has  been  described,  in  which  the  face  looks 
upward  and  is  turned  away  from  the  side  occupied  by  the  growth.  Deficiency 
in  power  of  the  limbs  on  the  same  side  is  frequent. 

Other  less  constant  but  suggestive  symptoms  are  neuralgic  pains  in  the 
region  of  the  neck  and  occiput;  blocking  of  the  venae  Galeni  and  dilatation 
of  the  lateral  ventricles,  causing  in  children  hydrocephalus;  pressure  on  the 
mid-brain,  pons,  or  medulla  oblongata,  producing  paralysis  of  the  cerebral 
nerves  (most  commonly  the  sixth  cranial),  rhythmical  contractions  of  the  head 
or  extremities,  nystagmus  (particularly  when  looking  toward  the  side  of  the 
lesion),  tremor,  anarthria,  auditory  or  visual  disturbances.  There  may  be 
glycosuria,  and  bilateral  rigidity  from  pressure  on  the  motor  paths.  Sudden 
death  may  occur. 

The  reflexes,  though  variable,  are  apt  to  be  increased  on  the  side  of  the 
lesion,  and  if  internal  hydrocephalus  develops  they  may  be  exaggerated  on  both 
sides.  When  the  cerebellar  disease  involves  other  structures  directly,  or  indi- 
rectly through  action  at  a  distance,  the  reflexes  may  be  abolished. 

Symptoms  of  general  mental  disturbance  may  accompany  cerebellar  dis- 
ease, but  they  are  not  characteristic.  There  are  often  irritability,  enfeebled 
memory,  and  toward  the  end  sopor  and  coma. 


IT.    APHASIA 

Speech  disorders  give  important  information  as  to  the  position  of  lesions 
of  the  nervous  system,  and  it  is  for  this  reason  that  they  are  considered  here. 

The  studies  of  Boulliaud,  Dax,  Broca,  Bastian,  Kussmaul,  Lichtheim, 
Marie,  and  others  have  done  much  to  widen  our  knowledge  of  this  very  difficult 
subject.  The  student  is  referred  to  the  works  of  these  authors,  and  especially 
to  the  monograph  of  Moutier. 

As  in  all  other  voluntary  movements  speech  requires  not  only  a  motor  but 
a  sensory  apparatus,  and  we  have,  as  composing  the  speech  mechanism,  a 
sensory  or  receptive  part  as  well  as  a  motor  or  emissive  part.  These  two  parts 
are  associated  with  the  higher  centres  underlying  the  intellectual  process,  and 
are  controlled  by  them. 

The  muscles  which  are  used  in  the  production  of  articulate  speech  are  many 


APHASIA  977 

and  widely  distributed ;  thus,  the  respiratory  muscles,  the  muscles  of  the  larynx, 
the  pharynx,  the  tongue,  the  lips,  and  those  which  move  the  jaws  are  all 
brought  into  play  during  speech.  These  muscles  are  all  active  in  other  less 
complicated  movements;  for  instance,  respiration,  crying,  sucking,  etc.,  and 
these  comparatively  simple  movements  are  represented  in  the  gray  matter  of 
the  lower  motor  segment  in  the  pons,  medulla,  and  spinal  cord.  The  asso- 
ciation of  neurones  upon  which  these  movements  depend  is  made  during  fetal 
life,  and  is  in  good  working  order  at  the  time  of  birth. 

As  the  child's  brain  grows  and  takes  control  of  the  spinal  centres  through 
the  medium  of  the  pyramidal  tracts,  other  more  complex  movements  are  de- 
veloped and  special  neurones  are  set  apart  for  this  purpose.  There  is,  then, 
a  re-representation  (Hughlings  Jackson)  of  the  finer  movements  of  these  mus- 
cles in  the  upper  motor  segment.  They  are  localized  in  the  central  convolu- 
tions about  the  lower  part  of  the  Rolandic  fissure.  All  these  muscles  except 
those  of  the  tongue  and  lips  are  used  bilaterally,  and  so  their  movements  on 
each  side  of  the  body  are  represented  on  both  sides  of  the  brain. 

This  group  of  movements,  which  are  in  part  congenital  and  in  part  ac- 
quired during  the  early  months  of  life,  is  that  from  which  the  delicate  move- 
ments of  articulate  speech  are  developed.  The  structures  upon  which  these 
movements  depend  make  the  primary  or  elementary  speech  mechanism.. 

The  cortical  centres  are  in  the  lower  third  of  the  central  convolution  on 
both  sides  of  the  brain.  They  are  bilaterally  acting  centres,  and  a  lesion 
limited  to  either  one  should  not  produce  marked  or  permanent  defects  in 
speech.  This  is  true  for  the  right  side,  but  on  the  left  Broca's  convolution 
and  the  insula  are  so  closely  situated  that  they  are  usually  injured  at  the  same 
time,  and  motor  aphasia  results.  The  path  from  the  cortical  centres  is  made  up 
of  the  motor  fibres  which  go  to  the  nuclei  of  the  pons  and  medulla,  and  in  the 
internal  capsule  is  situated  near  the  knee.  As  in  the  cortex,  a  unilateral  lesion 
here  causes  only  slight  disturbances  of  speech  due  to  difficult  articulation, 
following  weakness  of  the  opposite  side  of  the  face  and  tongue.  On  the  left 
side,  if  the  lesion  is  so  near  the  cortex  as  to  involve  the  fibres  which  connect 
Broca's  convolution  with  the  primary  speech  mechanism,  sub  cortical  motor 
aphasia  is  produced.  Bilateral  lesions  (usually  in  the  internal  capsule,  but 
at  times  in  the  cortex)  cause  speechlessness,  with  paralysis  of  the  muscles  of 
articulation — pseudo-bulbar  paralysis.  To  these  speech  defects  Bastian  gives 
the  name  aphemia. 

The  lower  segment  of  the  primary  speech  mechanism  is  made  up  of  the 
motor  nuclei  in  the  medulla,  etc.,  and  the  peripheral  nerves  arising  from  them. 
Lesions  here,  if  extensive  enough — as,  for  instance,  in  progressive  bulbar  paral- 
ysis— may  cause  speechlessness — anarthria  (Bastian)  ;  but  usually  they  are 
more  limited,  giving  various  disturbances  of  articulation. 

The  Auditory  Speech  Centre. — As  the  child  learns  to  speak  there  is  devel- 
oped in  the  cortex  of  the  brain  an  association  of  centres  which  takes  control 
of  the  primary  speech  mechanism.  The  child  is  constantly  hearing  objects 
called  by  names,  and  he  learns  to  associate  certain  sounds  with  the  look,  feel, 
taste,  etc.,  of  certain  things.  When  he  hears  such  a  sound  he  gets  a 
more  or  less  clear  mental  picture  of  the  object,  or,  in  other  words,  he  has  devel- 
oped certain  auditory  memories.  These  memories  of  the  sounds  of  words  are 
stored  in  what  is  called  the  auditory  speech  centre.  This  centre,  which  in  the 


978  DISEASES    OF   THE    NERVOUS    SYSTEM 

majority  of  people  is  the  controlling  speech  centre,  is  situated  on  the  left  side 
in  right-handed  people,  and  on  the  right  side  in  those  who  are  left-handed. 
The  afferent  impressions  arising  in  the  ears  reach  the  transverse  gyri  of  the 
temporal  lobes,  those  from  each  ear  going  to  both  sides  of  the  brain.  From 
each  of  these  primary  auditory  centres  impulses  are  sent  to  the  auditory  speech 
centre  in  the  temporal  lobe  of  the  left  hemisphere.  The  exact  location  of  this 
so-called  centre  is  not  accurately  determined,  but  it  is  thought  to  occupy  the 
first  and  perhaps  part  of  the  second  temporal  convolutions.  Marie  in  his  work 
on  aphasia  denies  all  speech  centres,  but  places  the  cortical  region,  which  has 
to  do  with  the  intellectual  processes  underlying  language,  rather  vaguely  in  the 
left  temporo-parietal  lobe.  This  he  designates  "Wernicke's  zone,"  a  lesion  of 
which  alone  can  produce  aphasia.  The  child  endeavors,  and  by  repeated  efforts 
learns,  to  make  the  sounds  that  he  hears,  and  he  first  becomes  able  to  repeat 
words,  then  to  speak  voluntarily.  To  do  this,  he  has  had  to  learn  certain  very 
delicate  movements,  and  so  there  has  been  developed  under  the  control  of 
the  auditory  speech  centres  a  special  motor  centre  for  speech  in  which  these 
movements  are  localized. 

The  Motor  Speech  Centre. — This  was  placed  by  Broca,  and  those  who  im- 
mediately followed  him,  in  the  posterior  part  of  the  left  third  frontal  convolu- 
tion. It  is  around  this— Broca's  centre — that  the  discussion  started  by  Marie 
has  been  most  heated.  Marie  and  his  followers  deny  that  this  portion  of  the 
brain  has  anything  to  do  with  speech,  and  insist  that  the  so-called  motor  aphasia 
is  merely  a  "combination  of  aphasia"  (of  which  they  admit  but  one  type,  that 
due  to  lesions  of  Wernicke's  zone)  with  anarthria.  Anarthria  they  think  of 
as  a  speech  disturbance  without  any  intellectual  defect,  due  to  a  lesion  of  their 
lenticular  zone,  an  ill-defined  area  in  the  centre  of  the  brain. 

Marie's  position  has  been  much  discussed,  and  many  excellent  observers 
have  come  to  the  rescue  of  the  old  view  which  accepts  Broca's  convolution  as 
the  motor  speech  centre.  The  recent  studies  of  cases  of  apraxia,  which  seem 
to  have  determined  a  centre  in  the  left  frontal  lobe  for  certain  purposive  move- 
ments, as  in  the  use  of  objects,  gestures,  etc.,  have  lent  support  to  the  im- 
portance of  Broca's  convolution. 

The  motor  speech  centres  and  the  corresponding  area  in  the  right  brain 
are  connected  either  directly  by  special  motor  fibres  with  the  bulbar  nuclei, 
or,  as  is  more  probable,  indirectly,  through  the  medium  of  the  cortical  cen- 
tres of  the  primary  speech  mechanism  in  the  lower  part  of  the  Rolandic  region 
on  both  sides. 

The  speech  centres  are  in  close  connection  with  the  rest  of  the  brain  cor- 
tex, and  in  this  way  they  take  part  in  the  general  mental  activities,  of  which, 
indeed,  the  speech  processes  form  a  large  part.  Some  authors  have  assumed 
that  the  several  sensory  elements  which  go  to  make  a  concept  are  brought 
together  in  a  special  region  of  the  brain,  and  here,  as  it  were,  united  by  a 
name.  This  is  called  "the  centre  for  concepts,"  or  "naming  centre"  (Broad- 
bent),  but  most  writers  have  followed  Bastian  in  considering  that  the  suppo- 
sition of  such  a  centre  is  unnecessary. 

The  mechanism  which  has  been  described  is  that  which  is  developed  in 
uneducated  people  and  in  children  before  they  have  learned  to  read  and  write, 
and  is  of  primary  importance  in  all  speech  processes.  As  the  child  learns  to 
read  he  associates  certain  visual  impressions  with  the  speech  memories  he  has 


APHASIA  979 

already  acquired,  and  he  then  adds  to  his  concepts  the  visual  memories  of 
written  or  printed  symbols.  These  memories  are  stored  in  the  visual  speech 
centre. 

The  Visual  Speech  Centre.— This  is  placed  hy  nearly  all  authors  in  the 
angular  and  supramarginal  convolutions  on  the  left  side,  where  it  is  believed 
visual  impressions  from  both  occipital  lobes  are  combined  in  speech  memories. 
Von  Monakow  denies  such  a  special  centre,  but  holds  that  visual  speech  mem- 
ories are  dependent  upon  the  direct  connection  of  the  general  visual  centres 
in  both  occipital  lobes  with  the  speech  sphere.  That  speech  defects  result  from 
injury  to  the  angular  and  supramarginal  convolutions,  he  admits;  but  he 
thinks  these  are  due  to  an  interruption  of  fibre  tracts  which  lie  beneath  and 
not  to  a  destruction  of  a  cortical  centre.  The  distinction  is,  therefore,  of 
more  theoretical  than  practical  importance.  Marie  includes  this  region  in 
his  Wernicke's  zone. 

In  learning  to  write,  the  child  develops  certain  delicate  movements  of  the 
arm  and  hand,  and  thus  acquires  another  method  of  externalizing  his  speech 
activities.  Whether  or  not  this  requires  the  development  of  a  separate  writing 
centre,  apart  from  the  general  Eolandic  arm  centre,  or  is  brought  about  by  an 
evolution  of  the  latter  through  the  medium  of  Broca's  convolution,  is  a  vexed 
question.  Gordinier  has  recorded  a  remarkable  case  of  total  agraphia,  with 
no  sensory  or  motor  speech  aphasia,  in  which  a  tumor  occupying  the  foot  of 
the  second  left  frontal  convolution  was  found  at  autopsy.  Agraphia  is  a 
special  form  of  apraxia.  The  movements  of  writing  are  learned  under  the ' 
influence  of  visual  impressions  in  association  with  the  other  speech  memories, 
although  there  is  a  more  direct  path,  which  is  used  in  copying  unknown  char- 
acters. Just  as  the  movements  of  articulate  speech  are  constantly  under  the 
control  of  auditory  memories,  so  are  the  movements  of  writing  regulated  by 
visual  memories;  but  in  this  case  the  other  speech  memories  are  of  great 
importance. 

With  the  development  of  the  associations  which  underlie  reading  and 
writing,  the  speech  mechanism  may  be  said  to  be  complete,  although  its  activ- 
ities are  capable  of  practically  endless  extension,  as  when  music  or  foreign 
languages  are  learned. 

It  will  be  seen  that  the  cortical  speech  centres — the  speech  sphere  of  the 
French — occupy  the  part  of  the  brain  near  the  Sylvian  fissure,  and  that  they 
all  receive  their  blood  from  the  Sylvian  artery.  Speaking  broadly,  the  pos- 
terior part  of  this  region  is  sensory  and  the  anterior  is  motor.  The  sensory 
areas  are  near  the  optic  radiation  and  the  motor  are  near  the  general  motor 
tracts,  and  so?  with  lesions  of  the  posterior  part,  hemianopia  is  apt  to  be  asso- 
ciated with  the  speech  disturbance  while  hemiplegia  occurs  with  disease  of 
the  anterior  areas.  These  associations  often  help  to  distinguish  a  sensory  from 
a  motor  aphasia,  but  each  type  has  special  characteristics  which  must  be 
studied. 

Auditory  Aphasia. — Most  people  in  mentally  recalling  words  do  so  by 
means  of  their  auditory  speech  memories — i.  e.,  they  think  of  the 
sound  of  the  words,  and,  in  voluntary  speech,  it  is  probable  that  the 
will  acts  on  the  motor  centre  indirectly  through  the  auditory  centre. 
This  centre  is  also  necessary  for  reading  in  such  persons.  There  are 


980  DISEASES    OF    THE    NERVOUS    SYSTEM 

t 

certain  persons,  however,  in  whom  the  mental  processes  are  carried  on 
by  visual  memories,  and  in  these  rare  "visuals"  the  visual  speech  cen- 
tres take  the  predominant  place  in  speech  usually  occupied  by  the  auditory 
centres. 

Complete  abolition  of  all  the  auditory  speech  memories  by  destruction  of 
the  first  temporal  convolution  causes  the  most  extensive  disturbances  of  speech. 
Such  a  person  is  unable  to  comprehend  speech,  either  spoken  or  printed.  Vol- 
untary speech  is  much  disturbed,  and  although  at  first  he  may  talk,  his  speech 
is  nothing  but  a  jargon  of  misplaced  words,  and  he  soon  becomes  speechless. 
Writing  is  also  lost,  and  he  can  neither  repeat  words  nor  write  at  dictation. 
He  may  be  able  to  copy. 

Lesions  are  often  only  partial,  and  the  resultant  disturbance  may  be 
simply  a  difficulty  in  speech  due  to  the  loss  of  nouns  or  to  the  trans- 
position of  words  (paraphasia),  the  writing  showing  the  same  defect. 
The  patient  usually  understands  what  he  hears  and  reads,  and  can  re- 
peat words  and  write  at  dictation.  This  is  the  condition  Bastian  calls 
"amnesia  verbalis."  The  condition  may  be  so  pronounced  that  voluntary 
speech  and  writing  are  nearly  lost,  even  when  the  auditory  memories  can 
still  be  aroused  by  new  afferent  impressions  and  he  is  able  to  understand 
what  is  said  to  him  and  what  he  reads.  He  can  usually  repeat  and  read 
aloud. 

The  afferent  paths,  which  reach  the  auditory  speech  centre  from  the  two 
primary  auditory  centres,  may  be  destroyed.  A  lesion  to  do  this  must  be 
in  the  white  matter  beneath  the  first  temporal  convolution  on  the  left  side. 
Such  a  lesion  would  block  all  auditory  impressions  coming  to  the  cen- 
tre,- and  the  patient  would  not  be  able  to  understand  anything  that  was 
said  to  him,  could  not  repeat  words  nor  write  from  dictation.  As  the 
cortical  centres  are  not  disturbed,  and  the  auditory  speech  memories  are  still 
present,  there  is  no  disturbance  of  voluntary  speech  or  writing,  and  the  pa- 
tient can, read  perfectly.  This  is  pure  word-deafness  or  subcortical  sensory 
aphasia. 

Visual  Aphasia.  • — Destruction  of  the  visual  centre  in  the  angular  and 
supramarginal  convolutions  causes  a  loss  of  the  visual  speech  memories,  and 
the  patient  is  unable  to  read  printed  or  written  characters.  He  is  unable  to 
write — i.  e.,  there  is  agraphia — and  he  can  not  copy.  His  understanding  of 
spoken  words  is  good,  and  voluntary  speech  is  normal  or  only  slightly  par- 
aphasic. 

A  subcortical  lesion  involving  the  afferent  fibres  going  to  the  visual  speech 
centre  causes  pure  word-blindness  (subcortical  alexia) — i.  e.,  there  is  inability 
to  understand  written  or  printed  words.  Voluntary  speech  and  .writing  are 
good.  The  patient  can  not  read  his  own  writing  except  by  aid  of  muscle- 
sense  impression,  in  retracing  the  letters,  either  voluntarily  or  passively.  Asso- 
ciated with  this  is  always  hemianopia. 

Word-deafness  and  word-blindness  are  often  combined,  and  at  times  it 
is  not  only  the  tracts  that  connect  the  primary  auditory  and  visual  centres 
with  the  speech  spheres,  but  also  those  which  associate  them  with  the  other 
sensory  centres  in  the  formation  of  concepts,  that  are  diseased.  In  this  case 
the  patient  has  lost  not  only  his  auditory  and  visual  speech  memories,  but  also 
all  of  his  memories  which  have  to  do  with  hearing  and  sight,  and  he  has  mind- 


APHASIA  981 

deafness  and  mind-blindness — i.  e.,  he  is  unable  to  recognize  objects  when  he 
hears  or  when  he  sees  them.  Further  than  this,  there  may  be  a  dissociation 
of  all  the  sensory  centres  from  each  other  or  from  the  higher  psychical  centre, 
which  is  practically  the  same  thing,  in  which  case  the  patient  is  entirely  unable 
to  recognize  objects  and  to  use  them  properly — i.  e.,  he  has  sensory  aphasia  or 
agnosia. 

Motor  Aphasia. — Lesions  of  the  motor  speech  zone,  possibly  in  rare  cases 
of  Broca's  convolution  alone,  more  commonly  of  a  wider  area,  cause  loss  of 
the  power  of  speech.  The  patient  may  be  absolutely  dumb,  or  he  may  have 
retained  one  or  two  words  or  phrases,  which  is  believed  to  be  due  to  the  activ- 
ity of  the  corresponding  region  of  the  right  brain.  He  will  make  no  effort  to 
repeat  words.  His  mind  is  comparatively  clear,  and  he  understands  what 
is  said  to  him,  but  reads  poorly.  He  has  not  a  clear  mental  picture  of  words. 
This  is  tested  by  asking  him  to  squeeze  the  observer's  hand  or  to  make  expira- 
tory efforts  as  many  times  as  there  are  syllables  in  a  well-known  name. 

Voluntary  writing  is  usually  lost  in  cortical  motor  aphasia,  and  many 
authors  believe  that  writing  movements  are  controlled  from  this  centre. 
Others,  who  believe  that  there  is  a  special  writing  centre,  contend  that  a 
lesion  strictly  limited  to  the  motor  speech  centre  would  not  cause  agraphia, 
and  cite  cases  which  seem  to  support  their  view.  If  there  is  much  disturbance 
of  internal  speech,  writing  must  be  impaired. 

Subcortical  motor  aphasia  is  described  as  due  to  the  destruction  of  the 
fibres  which  join  Broca's  convolution  to  the  primary  speech  mechanism. 
Lesions  which  have  produced  this  type  of  aphasia  have  been  in  the  white  mat- 
ter of  the  left  hemisphere  near  Broca's  convolution.  These  would  be  within 
Marie's  lenticular  zone.  There  is  complete  loss  of  the  power  of  speech  without 
any  disturbance  of  internal  speech.  The  patient's  mental  processes  are  not 
disturbed,  and  he  can  write  perfectly  if  the  hand  is  not  paralyzed. 

Cases  of  aphasia  are  rarely  simple,  and  it  is  often  impossible  to  classify 
them  accurately.  The  problems  involved  are,  in  reality,  exceedingly  com- 
plicated, and  the  student  must  not  for  a  moment  suppose  that  cases  are  as 
straightforward  as  the  various  diagrams  at  first  sight  would  appear  to  indi- 
cate. A  majority  of  them  are  very  complex,  but  with  patience  the  diagnosis 
of  the  different  varieties  can  often  be  worked  out.  The  following  tests  should 
be  applied  in  each  case  of  aphasia,  after  the  presence  or  absence  of  paralysis 
has  been  determined  and  whether  the  patient  is  right-handed  or  left-handed : 
(1)  The  power  of  recognizing  the  nature,  uses,  and  relations  of  objects — 
i.  e.,  whether  agnosia  and  apraxia  are  present  or  not;  (2)  the  power  to  recall 
the  name  of  familiar  objects  seen,  smelled,  or  tasted,  or  of  a  sound  when 
heard,  or  of  an  object  touched;  (3)  the  power  to  understand  spoken  words; 
(4)  the  capability  of  understanding  printed  or  written  language;  (5)  the 
power  of  appreciating  and  understanding  music;  (6)  the  power  of  voluntary 
speech — in  this  it  is  to  be  noted  particularly  whether  he  misplaces  words  or 
not;  (7)  the  power  of  reading  aloud  and  of  understanding  what  he  reads; 
(8)  the  power  to  write  voluntarily  and  of  reading  what  he  has  written;  (9) 
the  power  to  copy;  (10)  the  power  to  write  at  dictation;  and  (11)  the  power 
of  repeating  words. 

The  medico-legal  aspects  of  aphasia  are  of  great  importanca  No  general 
principle  can  be  laid  down,  but  each  case  must  be  considered  on  its  merits 


982  DISEASES    OF    THE    NERVOUS    SYSTEM 

Langdon,  in  reviewing  the  whole  question,  concludes:  "Sanity  established, 
any  legal  document  should  be  recognized  when  it  can  be  proved  that  the 
person  making  it  can  understand  fully  its  nature  by  any  receptive  channel 
(viz.,  hearing,  vision,  or  muscular  sense),  and  can,  in  addition,  express  assent 
or  dissent  with  certainty  to  proper  witnesses,  whether  this  expression  be  by 
spoken  speech,  written  speech,  or  pantomime-" 

PROGNOSIS  AND  TREATMENT  OF  APHASIA 

In  young  persons  the  outlook  is  good,  and  the  power  of  speech  is  gradually 
restored  apparently  by  the  development  of  other  portions  of  the  brain.  The 
opposite  hemisphere  often  takes  part  in  this.  In  adults  the  condition  is  less 
hopeful,  particularly  in  the  cases  of  complete  motor  aphasia  with  right  hemi- 
plegia.  The  patient  may  remain  speechless,  though  capable  of  understanding 
everything,  and  attempts  at  re-education  may  be  futile.  Partial  recovery  may 
occur,  and  the  patient  may  be  able  to  talk,  but  misplaces  words.  In  sensory 
aphasia  the  condition  may  be  only  transient,  and  the  different  forms  rarely 
persist  alone  without  impairment  of  the  powers  of  expression. 

The  education  of  an  aphasic  person  requires  the  greatest  care  and  patience, 
particularly  if,  as  so  often  happens,  he  is  emotional  and  irritable.  It  is  best 
to  begin  by  the  use  of  detached  letters,  and  advance,  not  too  rapidly,  to  words 
of  only  one  syllable.  Children  often  make  rapid  progress,  but  in  adults  failure 
is  only  too  frequent,  even  after  the  most  painstaking  efforts.  In  the  cases  of 
right  hemiplegia  with  aphasia  the  patient  may  be  taught  to  write  with  the  left 
hand. 

in.  AFFECTIONS  OF  THE  BLOOD  VESSELS 

1.     CEREBRAL   CIRCULATION 

There  is  much  that  is  still  indefinite  in  the  physiology  of  the  circulation 
of  the  brain,  but  that  which  is  known  is  of  the  greatest  practical  moment  to 
the  physician. 

The  brain  receives  blood  from  the  internal  carotid  arteries,  the  vertebrals, 
and,  to  some  extent,  from  the  spinal  arteries.  These  anastomose  soon  after 
entering  the  skull  to  form  the  circle  of  Willis.  The  extent  of  this  intercom- 
munication is  subject  to  considerable  variation,  which  may  be  of  extreme 
importance  in  pathological  conditions.  Collected  by  the  veins,  the  blood  is 
emptied  into  large  venous  sinuses,  which  are,  to  a  great  extent,  protected  from 
pressure  changes  by  the  skull  and  dura  mater. 

The  cerebro-spinal  fluid  is  collected  in  the  meningeal  spaces  and  fills  the 
interstices  between  the  convolutions,  etc.  Under  normal  conditions  there  is 
but  a  small  quantity  of  this  fluid  within  the  skull,  which  is  entirely  filled 
with  brain,  blood,  and  the  cerebro-spinal  fluid.  Practically  a  closed  box,  with 
contents  uninfluenced  by  atmospheric  pressure,  the  quantity  of  blood  within 
the  skull  under  normal  circumstances  is  almost  constant,  for  the  brain  sub- 
stance itself  can  not  be  compressed,  so  that  the  only  increase  or  decrease 
is  that  which  compensates  for  the  small  quantity  of  cerebro-spinal  fluid  that 
can  pass  between  the  cranial  and  spinal  cavities. 

Although  the  quantity  of  blood  does  not  change  materially,  its  rapidity 
of  flow  may,  and  does,  show  marked  variations,  and  thus  the  relation  between 


AFFECTIONS    OF    THE    BLOOD   VESSELS  983 

arterial  and  venous  blood  is  subject  to  change.  The  circulation  within  the 
skull  not  only  differs  from  the  circulation  in  other  parts  in  its  freedom  from 
the  effects  of  atmospheric  pressure,  but  apparently  it  is  not  under  local  vaso- 
motor  control  and  is  in  an  organ  that  can  only  expand  slightly.  Although 
nerve  fibres  have  been  demonstrated  in  the  walls  of  the  small  arteries  of  the 
brain,  it  has  not  been  proved  that  they  cause  dilatation  or  contraction  under 
influences  from  the  vaso-motor  centres;  indeed,  there  is  little  experimental 
evidence  that  speaks  for,  and  much  that  speaks  against,  this  view. 

Under  ordinary  circumstances,  the  circulation  of  the  brain  follows  pas- 
sively the  general  bodily  conditions.  When  anything  increases  the  force  with 
which  the  blood  enters  the  skull — i.  e.,  when  blood  pressure  is  raised,  either  by 
increase  in  the  heart's  action  or  by  general  vaso-motor  effects — more  blood 
passes  through  the  brain  in  a  given  time,  and  it  is,  as  it  were,  flooded  with 
blood.  This  active  hypersemia  must  occur  under  many  circumstances,  but 
it  is  doubtful  whether  it  causes  any  symptoms;  in  fact,  it  is  difficult  to  see 
how  it,  in  itself,  can  do  anything  but  good. 

Although  without  direct  vaso-motor  control,  the  circulation  of  the  brain 
is  regulated  by  the  action  of  the  vaso-motor  centre 'on  the  splanchnic  areas 
and  skin.  This  centre  itself  shares  with  the  respiratory  and  cardiac  centres 
the  same  circulatory  conditions  as  prevail  throughout  the  brain. 

Consciousness  depends  upon  a  due  blood  supply  to  the  brain,  particularly 
to  the  cortex,  and  life  itself  depends  upon  the  circulation  in  the  medullary 
centres.  When  the  blood  circulating  about  these  centres  is  poor  in  oxygen — 
i.  e.,  when  there  is  a  lack  of  arterial  blood — the  arterioles  within  the  splanch- 
nic and  skin  areas  contract  under  vaso-motor  influences,  the  blood  pressure  is 
raised,  and  the  blood  enters  the  brain  with  unusual  force  and  supplies  the 
capillaries  with  arterial  blood.  The  extent  to  which  this  regulating  mechan- 
ism can  counteract  an  obstruction  to  the  circulation  through  these  centres 
has  been  well  shown  experimentally  by  Harvey  Gushing.  When  the  general 
intracranial  pressure  was  raised  to  arterial  blood  pressure,  instead  of  the  circu- 
lation being  blocked  and  the  animal  dying  from  anaemia  of  the  brain,  as  has 
been  stated,  he  showed  that  the  vaso-motor  centres  responded  with  a  sufficient 
rise  of  blood  pressure  to  overcome  the  impediment,  and  so  restore  the  circula- 
tion. With  every  repeated  increase  of  intracranial  pressure,  there  was  an 
answering  rise  of  blood  pressure,  until,  at  the  end  of  the  experiment,  the  brain 
was  acting  under  an  intracranial  pressure  much  above  the  arterial  pressure 
of  the  animal  at  the  beginning  of  the  experiment,  and  this  pressure  had  been 
correspondingly  raised  to  a  startling  extent.  The  interesting  clinical  deduc- 
tions which  Gushing  draws  from  this  experiment  will  be  referred  to  under 
cerebral  haemorrhage. 

When  this  regulating  mechanism  is  disturbed,  serious  results  may  follow. 
The  ordinary  fainting  fit  is  an  example :  Under  the  influence  of  emotion  the 
vaso-motor  centre  is  inhibited,  and,  in  consequence,  the  abdominal  blood  ves- 
sels become  dilated,  blood  pressure  falls,  and  the  heart  is  no  longer  able  to 
drive  the  blood  back  to  itself  against  the  force  of  gravity;  the  blood  accumu- 
lates in  the  abdominal  veins,  the  heart  empties,  cerebral  circulation  fails,  and 
unconsciousness  occurs.  A  similar  condition  may  follow  the  sudden  removal 
of  something  that  has  caused  pressure  on  the  abdominal  vessels  for  a  consider- 
able time,  as  the  withdrawal  of  the  ascitic  fluid.  In  this  case  the  vaso-motor 


984  DISEASES    OF    THE    NERVOUS    SYSTEM 

control  influences  have  not  been  called  on  for  some  time,  and  the  centre  itself 
has  taken  part  in  the  general  weakened  condition  of  the  individual,  so  that, 
when  a  sudden  demand  is  made  upon  it  to  compensate  for  the  accustomed 
external  support  to  the  blood  vessels,  it  is  entirely  unable  to  respond,  and  the 
blood  collects  in  the  splanchnic  vessels,  the  patient  becomes  unconscious  and 
may  die,  having  bled  to  death  into  his  own  veins. 

While  under  ordinary  circumstances  the  vaso-motor  mechanism  and  the 
tonicity  of  the  muscles  of  the  abdominal  walls  compensate  perfectly  for  the 
change  from  the  horizontal  to  the  upright  position — i.  e.,  for  the  effect  of 
gravity  upon  the  column  of  venous  blood  from  the  heart  to  the  feet,  in  asthenic 
states,  as  after  severe  illness,  the  compensation  may  be  very  imperfect.  When 
such  is  the  case,  if  the  patient  stands,  or,  at  times,  even  if  he  sits  up  in  bed, 
his  heart  beats  more  rapidly,  he  becomes  giddy  and  may  faint.  The  change 
in  the  pulse  rate,  with  a  change  in  position,  is  a  fair  indication  of  the  vaso- 
motor  control,  for  the  heart  itself  endeavors  to  make  up  for  this  incompetence. 

Chloroform  and,  to  a  less  extent,  ether  tend  to  induce  vaso-motor  paraly- 
sis, and  this  is  the  reason  why  position  is  such  an  important  factor  in  the 
safety  of  patients  during  anassthesia.  The  splanchnic  circulation,  under  these 
circumstances,  may,  to  a  certain  extent,  be  supported  by  bandaging  the  legs 
and  abdomen  and  elevating  the  foot  of  the  bed.  Crile's  pneumatic  operating 
suit,  in  which  the  patient  is  encased  below  the  chest  in  an  inflatable  suit,  by 
means  of  which  pressure  on  the  peripheral  and  abdominal  vessels  may  be 
varied,  is  an  attempt  to  establish  an  artificial  vaso-constructor  system  under 
the  control  of  the  operator,  which  can  compensate  for  the  paralyzing  effects* 
of  the  anesthetic,  and  obviate  the  necessity  of  considering  position. 

The  heart  itself  may  become  weak  from  various  causes  and  so  be  unable 
to  keep  the  brain  properly  supplied  with  arterial  blood.  The  extreme  example 
of  this  is  paralysis  of  the  heart  muscles  from  failure  of  the  coronary  circula- 
tion, which  is  immediately  followed  by  unconsciousness  and  death.  In  Stokes- 
Adams  disease  the  cerebral  symptoms,  attacks  of  unconsciousness,  convulsions, 
and  apoplectiform  seizures  are  due  to  cerebral  anaemia,  caused  by  the  tempo- 
rary cessation  of  the  ventricular  systole.  When  the  chest  is  forcibly  com- 
pressed the  heart  may  be  unable  to  fill  itself  with  blood,  and  so  unconscious- 
ness, or  even  death,  may  follow  from  failure  of  the  cerebral  circulation. 

Eespiration  is  an  essential  part  of  circulation;  this  is  true  not  only  in  the 
primary  sense,  that  it  is  through  this  function  that  venous  is  changed  into 
arterial  blood,  but  also  in  a  more  truly  mechanical  sense.  With  every  inspira- 
tion the  blood  is  sucked  into  the  heart  from  the  veins,  and  the  descent  of  the 
diaphragm,  by  increasing  the  pressure  on  the  abdominal  veins,  tends  to  force 
the  blood  into  the  heart.  During  expiration  the  entrance  of  the  blood  into 
the  heart  is  impeded  by  the  increase  in  the  intra-thoracic  pressure".  Eespira- 
tion has  direct,  but  slight,  influence  upon  the  blood  pressure  within  the 
arteries. 

The  circulation  within  the  skull  is  very  intimately  related  to  respiration. 
The  blood  from  the  brain  sinuses  passes  through  the  jugular  veins  directly 
into  the  superior  vena  cava  and  the  columns  of  blood  appear  to  be  uninter- 
rupted by  competent  valves,  so  that  every  change  of  pressure  in  the  cava  is 
transmitted  directly  to  the  sinuses  and  veins  of  the  brain.  Intracranial  pres- 
sure has  been  shown  to  be  equal  to  venous  blood  pressure  within  the  sinuses 


AFFECTIONS    OF   THE   BLOOD   VESSELS  985 

and  to  follow  every  change  in  this.  The  brain  dilates  with  each  pulse-beat, 
but  relatively  much  more  with  each  expiration.  In  expiration  intrathoracic 
pressure  is  increased,  and  this  causes  an  increase  in  the  pressure  within  the 
cava,  the  jugular,  and  the  brain  sinuses.  The  blood  is,  as  it  were,  dammed 
back,  venous  congestion  occurs,  intracranial  pressure  rises,  and  the  brain 
receives  less  arterial  blood,  and  the  symptoms  of  cerebral  anaemia  may  follow. 
L'rcler  ordinary  conditions  these  effects  are  not  so  pronounced  or  protracted 
as  to  cause  marked  symptoms,  but  at  times  they  may  be,  as  when  a  crying 
child  holds  his  breath  until  he  becomes  unconscious.  Here  the  difficulty 
which  the  heart  has  in  filling  itself  with  blood  under  increased  thoracic  pres- 
sure is  also  a  factor.  When  the  superior  vena  cava  is  alone  obstructed,  as  by 
pressure  from  a  tumor,  there  may  be  not  the  slightest  disturbance  of  the  func- 
tions. This  depends  upon  the  freedom  of  the  cranio-vertebral  venous  anasto- 
mosis, and  other  paths  which  allow  the  blcod  to  reach  the  heart  through  the 
inferior  vena  cava.  Strong  respiratory  efforts  against  an  obstruction  may 
change  intrathoracic  pressure  very  greatly.  In  forced  expiration  with  the 
glottis  closed,  the  normal  negative  pressure  becomes  markedly  positive  and 
may  far  exceed  the  normal  pressure  on  the  intrathoracic  veins,  while  if  the 
glottis  be  closed  and  .a  strong  inspiratory  effort  be  made  the  pressure  may 
fall  far  below  atmospheric  pressure.  Intracranial  haemorrhages  not  in- 
frequently take  place  during  a  strong  effort  with  the  breath  held  as  when 
straining  at  stool,  or  when  lifting  a  heavy  weight,  or  during  a  severe  cough- 
ing spell,  all  conditions  in  which,  among  other  things,  the  flow  of  the  venous 
blood  from  the  brain  to  the  heart  is  impeded,  and  in  consequence  of  which 
intracranial  circulatory  conditions  are  altered  in  the  direction  of  a  rise  of 
venous  and  capillary  pressure.  The  importance  of  preventing,  as  far  as  possi- 
ble, any  obstruction  to  respiration  during  the  course  of  apoplexy  will  be 
referred  to  in  a  subsequent  paragraph. 

The  venous  outlets  from  the  skull  are  so  large  and  the  anastomoses  are  so 
free  that  they  must  all  be  obstructed  to  cause  any  marked  anaemia  of  the  brain, 
and  for  this  reason  thrombosis  or  ligature  of  one  of  the  sinuses  is  not  neces- 
sarily followed  by  any  symptoms.  If  all  the  veins  in  the  neck  are  compressed, 
as  by  a  tight  band  or  strong  flexion  of  the  neck,  the  circulation  may  be  im- 
peded to  a  considerable  extent,  and  this  is  of  definite  importance  under  patho- 
logical conditions. 

Any  one  of  the  arteries  may  be  tied  before  entering  the  skull,  with  but 
little  danger,  owing  to  the  freedom  of  the  anastomosis  in  the  circle  of  Willis, 
but,  as  this  is  subject  to  variation,  the  closure  should  be  made  slowly.  With 
this  precaution,  both  carotids  may  be  tied  if  an  interval  be  allowed  between 
the  operations. 

Obliteration  of  an  artery  beyond  the  circle  of  Willis  is  always  followed  by 
a  disturbance  of  function  of  the  part  of  the  brain  supplied  by  that  artery, 
and  is  considered  under  Embolism  and  Thrombosis. 

2.     HYPEE^EMIA   AND   ANAEMIA 

Less  and  less  stress  is  now  laid  on  active  hyperaemia  as  a  cause  of  symp- 
toms.   As  Leube  suggests,  the  symptoms  usually  referred  to  active  hyperamia 
in  the  infectious  diseases,  or  in  association  with  hypertrophy  of  the  heart  ae- 
64 


986  DISEASES    OF    THE    NERVOUS    SYSTEM 

companying  disease  of  the  kidney,  are  due  to  the  action  of  toxic  agents  rather 
than  to  changes  in  the  circulation.  On  the  other  hand,  venous  stasis  and  anae- 
mia of  the  brain  must  be  a  very  potent  cause  of  head  symptoms.  The  uncer- 
tainty which  exists  is  largely  due  to  the  fact  that  the  condition  of  the  blood 
vessels  as  seen  within  the  skull  after  death  may  bear  no  relation  to  that  which 
held  sway  during  life. 

The  anatomical  condition  of  the  brain  in  anaemia  is  very  striking.  The 
membranes  are  pale,  only  the  large  veins  are  full,  the  small  vessels  over  the 
gyri  are  empty,  and  an  unusual  amount  of  cerebro-spinal  fluid  is  present.  On 
section  both  the  gray  and  white  matter  look  extremely  pale  and  the  cut  surface 
is  moist.  Very  few  puncta  vasculosa  are  seen. 

The  effects  of  sudden  anaemia  of  the  brain  are  well  illustrated  by  the  ordi- 
nary fainting  fit,  and  have  been  described  above. 

Symptoms. — When  the  symptoms  are  the  result  of  hemorrhage,  there  are 
drowsiness,  giddiness,  inability  to  stand ;  flashes  of  light,  dark  spots  before  the 
eyes,  and  noises  in  the  ears ;  the  respiration  becomes  hurried ;  tire  skin  is  cool 
and  covered  with  sweat;  the  pupils  are  dilated,  there  may  be  vomiting,  head- 
ache, or  delirium,  and  gradually,  if  the  bleeding  continues,  consciousness  is 
lost  and  death  may  occur  with  convulsions.  In  the  more  chronic  forms  of 
brain  anaemia,  such  as  result  from  the  gradual  impoverishment  of  the  blood, 
as  in  protracted  illness  or  in  starvation,  the  condition  known  as  irritable  weak- 
ness results.  Mental  effort  is  difficult,  the  slightest  irritation  is  followed  by 
undue  excitement,  the  patient  complains  of  giddiness  and  noises  in  the  ears, 
or  there  may  be  hallucinations  or  delirium.  These  symptoms  are  met  with 
in  an  extreme  grade  as  a  result  of  prolonged  starvation,  and  a  very  similar 
condition  is  seen  in  certain  cases  of  arterio-sclerosis  where  the  brain  is  poorly 
nourished. 

An  interesting  set  of  symptoms,  to  which  the  term  hydrencephaloid  was 
applied  by  Marshall  Hall,  occurs  in  the  debility  produced  by  prolonged  diar- 
rhoea in  children.  The  child  is  in  a  semi-comatose  condition  with  the  eyes 
open,  the  pupils  contracted,  and  the  fontanelle  depressed.  In  the  earlier 
period  there  may  be  convulsions.  The  coma  may  gradually  deepen,  the  pupils 
become  dilated,  and  there  may  be  strabismus  and  even  retraction  of  the  head, 
symptoms  which  closely  simulate  those  of  basilar  meningitis. 

3.     (EDEMA  OF  THE  BKAIN 

Pathology. — In  the  pathology  of  brain  lesions  oedema  formerly  played  a 
role  almost  equal  in  importance  to  congestion.  It  occurs  under  the  following 
conditions :  In  general  atrophy  of  the  convolutions,  in  which  case  the  oedema 
is  represented  by  an  increase  in  the  cerebro-spinal  fluid  and  in  that  of  the 
meshes  of  the  pia.  In  extreme  venous  dilatation  from  obstruction,  as  in 
mitral  stenosis  or  in  tumors,  there  may  be  a  condition  of  congestive  oedema,  in 
which,  in  addition  to  great  filling  of  the  blood  vessels,  the  substance  of  the 
brain  itself  is  unusually  moist.  The  most  acute  oedema  is  a  local  process 
found  around  tumors  and  abscesses.  The  symptoms  of  compression  following 
concussion  or  contusion,  as  shown  by  Cannon,  are  frequently  attributable  to 
cerebral  oedema  due  to  change  in  osmotic  pressure.  An  intense  infiltration, 
local  or  general,  may  occur  in  Bright's  disease,  and  to  it,  as  Traube  suggested, 
certain  of  the  uraemic  symptoms  may  be  due. 


AFFECTIONS    OF   THE    BLOOD   VESSELS  987 

Anatomical  Changes. — The  anatomical  changes  are  not  unlike  those  of 
anaemia.  When  the  oedema  follows  progressive  atrophy,  the  fluid  is  chiefly 
within  and  beneath  the  membranes.  The  brain  substance  is  anaamic  and 
moist,  and  has  a  wet,  glistening  appearance,  which  is  very  characteristic.  In 
some  instances  the  oedema  is  more  intense  and  local,  and  the  brain  substance 
may  look  infiltrated  with  fluid.  The  amount  of  fluid  in  the  ventricles  is 
usually  increased. 

Symptoms. — The  symptoms  are  in  great  part  those  of  lessened  blood  flow, 
and  are  not  well  defined.  As  just  stated,  some  of  the  cerebral  features  of 
uremia  may  depend  upon  it.  Cases  have  been  reported  by  Eaymond,  Tenne- 
son,  and  Dercum,  in  which  unilateral  convulsions  or  paralysis  have  occurred 
in  connection  with  chronic  Bright's  disease,  and  in  which  the  condition  ap- 
peared to  be  associated  with  oedema  of  the  brain.-  The  older  writers  laid  great 
stress  upon  an  apoplexia  serosa,  which  may  really  have  been  a  general  oedema 
of  the  brain.  Inasmuch  as  the  instances  in  which  oedema  of  the  brain  occurs 
are  often  those  in  which  there  is  also  intoxication,  or  anemia,  or  both,  it  is 
probably  impossible  to  say  at  the  bedside  definitely  which  of  these  possible 
factors  is  responsible  for  the  symptoms  in  a  given  case. 

4.     CEEEBEAL  HEMORRHAGE 

The  bleeding  may  come  from  branches  of  either  of  the  two  great  groups 
of  cerebral  vessels — the  basal,  comprising  the  circle  of  Willis  and  the  central 
arteries  passing  from  it  and  from  the  first  portion  of  the  cerebral  arteries,  or 
the  cortical  group,  the  anterior,  middle,  and  the  posterior  cerebral  vessels.  In 
a  majority  of  the  cases  the  haemorrhage  is  from  the  central  branches,  more 
particularly  from  those  which  are  given  off  by  the  middle  cerebral  arteries  in 
the  anterior  perforated  spaces,  and  which  supply  the  corpora  striata  and  in- 
ternal capsules.  One  of  the  largest  of  these  branches  which  passes  to  the  third 
division  of  the  lenticular  nucleus  and  to  the  anterior  part  of  the  internal  cap- 
sule, the  lenticulo-striate  artery  of  Duret,  is  so  frequently  involved  in  haemor- 
rhage that  it  has  been  called  by  Charcot  the  artery  of  cerebral  haemorrhage. 
Haemorrhages  from  this  and  from  the  lenticulo-thalamic  artery  include  more 
than  60  per  cent,  of  all  cerebral  haemorrhages.  The  bleeding  may  be  into  the 
substance  of  the  brain,  to  which  alone  the  term  cerebral  apoplexy  is  applied,  or 
into  the  membranes,  in  which  case  it  is  termed  meningeal  haemorrhage ;  both, 
however,  are  usually  included  under  the  terms  intracranial  or  cerebral  haemor- 
rhage. 

Etiology.  • — The  conditions  which  produce  degeneration  of  the  blood  vessels 
play  the  important  part. 

AGE. — 'The  liability  increases  with  each  decade.  H.  M.  Thomas,  in  his 
analysis  of  the  United  States  Census  Eeport  for  1907,  states  that  the  greatest 
number  of  cases  occurred  in  the  seventh  and  eighth  decades.  Cerebral  haemor- 
rhage may  be  congenital.  One  of  the  only  recorded  instances  is  that  which  I 
reported  in  a  six-month  fetus  of  a  woman  dead  of  typhoid  fever.  The  clot 
was  in  the  left  hemisphere  and  had  broken  into  the  ventricle.  Apart  from 
meningeal  haemorrhage,  which  is  common  as  a  result  of  the  accidents  of  birth, 
haemorrhage  is  rare  in  children,  and  we  had  no  instance  at  the  Johns  Hopkins 
Hospital  during  my  term  of  service.  Before  the  fifth  decade  haemorrhage  is 


988  DISEASES    OF    THE    NERVOUS    SYSTEM 

rare;  then  in  the  fifth  and   sixth  decades  cases  progressively  increase   in 
number. 

SEX. — There  is  a  marked  preponderance  of  males. 

RACE. — In  the  United  States  the  death  rate  from  apoplexy  and  paralysis 
in  the  Report  of  1906  was  88.7  per  100,000  of  the  population.  In  England 
and  Wales  in  1909  the  deaths  from  apoplexy  were  502  per  million  living. 
Both  apoplexy  and  paralysis  seem  to  be  much  more  prevalent  among  the 
negroes. 

HEREDITY. — Formerly  thought  to  be  a  very  important  factor,  heredity 
influences  the  incidence  in  rendering  members  of  families  in  which  the 
blood  vessels  degenerate  early  more  liable  to  cerebral  haemorrhage.  What 
was  formerly  known  as  the  apoplectic  habitus,  or  build,  is  still  spoken  of, 
by  which  we  mean  a  stout,  plethoric  person  of  medium  size  with  a  short 
neck. 

SPECIAL  FACTORS. — Individuals  with  progressive  renal  disease  and  consecu- 
tive arterio-sclerosis  and  hypertrophy  of  the  heart  are  particularly  liable  to 
cerebral  haemorrhage.  The  causes  of  arterio-sclerosis,  such  as  alcohol,  im- 
moderate eating,  prolonged  muscular  exertion,  syphilis,  chronic  lead  poison- 
ing, and  gout,  are  antecedents  in  many  cases.  Endocarditis  may  lead  indi- 
rectly to  apoplexy  by  causing  embolism  and  aneurism  of  the  vessels  of  the 
brain.  Cerebral  haemorrhage  occurs  occasionally  in  the  specific  fevers  and  in 
such  profound  alterations  of  the  blood  as  are  met  with  in  leukaemia. 

The  actual  exciting  cause  is  not  always  evident.  The  attacks  may  be  sud- 
den without  any  preliminary  symptoms.  In  other  instances  violent  exertion, 
particularly  straining  efforts  or  overaction  of  the  heart  in  emotion,  may  cause 
a  rupture.  Many  cases  occur  during  sleep.  Some  instances  follow  slight 
trauma.  The  records  of  University  College  Hospital  analyzed  by  Ernest  Jones 
indicate  that  in  none  of  123  cases  did  the  attack  come  on  through  excessive 
bodily  effort. 

Morbid  Anatomy. — DIRECT  CHANGES. — The  lesions  causing  apoplexy  are 
almost  invariably  in  the  cerebral  arteries,  in  which  the  following  changes  may 
lead  directly  to  it : 

(a)  The  production  of  miliary  aneurisms,  rupture  of  which  is  the  most 
common  cause  of  cerebral  haemorrhage.  The  origin  of  the  miliary  aneurisms 
is  disputed.  Charcot  thought  they  resulted  from  changes  in  the  adventitia 
(periarteritis).  Others  find  the  primary  change  in  the  intima.  The  weight 
of  opinion  at  present,  however,  is  on  the  side  of  the  view  that  the  media  is 
first  degenerated.  They  occur  most  frequently  on  the  central  arteries,  but 
also  on  the  smaller  branches  of  the  cortical  vessels.  On  section  of  the  brain 
substance  they  may  be  seen  as  localized,  small  dark  bodies,  about  the  size  of 
a  pin's  head.  Sometimes  they  are  seen  in  numbers  upon  the  arteries  when 
carefully  withdrawn  from  the  anterior  perforated  spaces.  According  to  Char- 
chot  and  Bouchard,  who  have  described  them,  they  are  most  frequent  in  the 
central  ganglia.  In  apoplexy  after  the  fortieth  year  if  sought  for  they  are 
rarely  missed.  The  actual  miliary  aneurism,  which  by  its  rupture  has  oc- 
casioned the  haemorrhage,  may  be  difficult  to  fipd,  but  if  one  pours  water  care- 
fully on  the  area  of  haemorrhage,  or,  better  still,  submerges  the  apoplectic 
mass  for  a  time,  it  will  usually  be  found  possible  to  do  so,  and  even  to  find  the 
hole  in  its  wall. 


AFFECTIONS    OF    THE    BLOOD    VESSELS  989 

(&)  Aneurism  of  the  branches  of  the  circle  of  Willis.  These  are  by  no 
means  uncommon,  and  will  be  considered  subsequently. 

(c)  Endarteritis  and  periarteritis  in  the  cerebral  vessels  most  commonly 
lead  to  apoplexy  by  the  production  of  aneurisms,  either  miliary  or  coarse. 
There  are  instances  in  which  the  most  careful  search  fails  to  reveal  anything 
but  diffuse  degeneration  of  the  cerebral  vessels,  particularly  of  the  smaller 
.branches ;  so  that  we  must  conclude  that  spontaneous  rupture  may  occur  with- 
out the  previous  formation  of  aneurism. 

(d)  Increased  permeability  of  the  walls  of  the  vessels  may  account  for 
haemorrhages  by  diapedesis  without  actual  rupture.     Such  haemorrhages  are 
not  uncommon  in  cases  of  contracted  kidney,  grave  anaemia,  and  various  in- 
fections and  intoxications. 

(e)  In  persons  over  sixty  the  hemiplegia  may  depend  upon  small  areas  of 
softening  in  the  gray  matter — the  lacuna  of  Marie — areas  varying  in  size  from 
a  pin's  head  to  a  pea  or  a  small  bean,  grayish  red  in  tint.     The  lenticular 
nucleus  is  particularly  apt  to  be  involved.    The  blood  vessels  are  always  dis- 
eased. 

The  haemorrhage  may  be  meningeal,  cerebral,  or  intraventricular. 

Meningeal  hcemorrhage  may  be  outside  the  dura,  between  this  membrane 
and  the  bone,  or  between  the  dura  and  arachnoid,  or  between  the  arachnoid 
and  the  pia  mater.  The  following  are  the  chief  causes  of  this  form  of  haemor- 
rhage :  Fracture  of  the  skull,  in  which  case  the  blood  usually  comes  from  the 
lacerated  meningeal  vessels,  sometimes  from  the  torn  sinuses.  In  these  cases 
the  blood  is  usually  outside  the  dura  or  between  it  and  the  arachnoid.  The 
next  most  frequent  cause  is  rupture  of  aneurisms  on  the  larger  cerebral  ves- 
sels. The  blood  is  usually  subarachnoid.  An  intracerebral  haemorrhage  may 
burst  into  the  meninges.  A  special  form  of  meningeal  haemorrhage  is  found 
in  the  new-born,  associated  with  injury  during  birth.  And  lastly,  meningeal 
haemorrhage  may  occur  in  the  constitutional  diseases  and  fevers.  The  blood 
may  be  in  a  large  quantity  at  the  base ;  in  cases  of  ruptured  aneurism,  particu- 
larly, it  may  extend  into  the  cord  or  upon  the  cortex.  Owing  to  the  greater 
frequency  of  the  aneurisms  in  the  middle  cerebral  vessels,  the  Sylvian  fissures 
are  often  distended  with  blood. 

Intracerebral  hcemorrhage  is  most  frequent  in  the  neighborhood  of  the  cor- 
pus striatum,  particularly  toward  the  outer  section  of  the  lenticular  nucleus. 
The  haemorrhage  may  be  small  and  limited  to  the  lenticular  body,  the  thala- 
mus,  and  the  internal  capsule,  or  it  may  extend  to  the  insula.  Haemorrhages 
confined  to  the  white  matter — the  centrum  semiovale — are  rare.  Localized 
bleeding  may  occur  in  the  crura  or  in  the  pons.  Haemorrhage  into  the  cerebel- 
lum is  not  uncommon,  and  usually  comes  from  the  superior  cerebellar  artery. 
The  extravasation  may  be  limited  to  the  substance  or  may  rupture  into  the 
fourth  ventricle. 

Ventricular  Hcemorrhage. — This  is  rarely  primary,  coming  from  the  vessels 
of  the  plexuses  or  of  the  walls.  More  often  it  is  secondary,  following  haemor- 
rhage into  the  cerebral  substance.  It  is  not  infrequent  in  early  life  and  may 
occur  during  birth.  Of  94  cases  collected  by  Edward  Sanders,  7  occurred 
during  the  first  year,  and  14  under  the  twentieth  year.  In  the  cases  which 
I  have  seen  in  adults  it  has  almost  always  been  caused  by  rupture  of  a  vessel 
in  the  neighborhood  of  the  caudate  nucleus.  The  blood  may  be  found  in  one 


990  DISEASES    OF    THE    NEKVOTJS    SYSTEM 

ventricle  only,  but  more  commonly  it  is  in  both  lateral  ventricles,  and  may 
pass  into  the  third  ventricle  and  through  the  aqueduct  of  Sylvius  into  the 
fourth  ventricle,  forming  a  complete  mould  in  blood  01'  the  ventricular  sys- 
tem. In  these  cases  the  clinical  picture  may  be  that  of  "apoplexie  foudroy- 
anie." 

SUBSEQUENT  CHANGES. — The  blood  gradually  changes  in  color,  and  ulti- 
mately the  hemoglobin  is  converted  into  the  reddish  brown  hematoidin.  In- 
flammation occurs  about  the  apoplectic  area,  limiting  and  confining  it,  and 
ultimately  a  definite  wall  may  be  produced,  inclosing  a  cyst  with  fluid  contents. 
In  other  instances  a  cyst  is  not  formed,  but  the  connective  tissue  proliferates 
and  leaves  a  pigmented  scar.  In  meningeal  hemorrhage  the  effused  blood 
may  be  gradually  absorbed  and  leave  only  a  staining  of  the  membranes.  In 
other  cases,  particularly  in  infants,  when  the  effusion  is  cortical  and  abundant, 
there  may  be  localized  wasting  of  the  convolutions  and  the  production  of  a  cyst 
in  the  meninges.  Possibly  porencephaly  may  arise  in  this  way.  Secondary 
degeneration  follows,  varying  in  character  according  to  the  location  of  the 
hemorrhage  and  the  actual  damage  done  by  it  to  nerve  cells  or  their  medul- 
lated  axones.  Thus,  in  persons  dying  some  years  after  a  cerebral  apoplexy 
which  has  produced  hemiplegia  (lesion  of  the  motor  area  in  the  cortex  or 
of  the  pyramidal  tract  leading  from  it),  the  degeneration  may  be  traced 
through  the  cerebral  peduncle,  the  ventral  part  of  the  pons,  the  pyramids  of 
the  medulla,  the  fibres  of  the  direct  pyramidal  tract  of  the  cord  of  the  same 
side,  and  the  fibres  of  the  crossed  pyramidal  tract  on  the  opposite  side.  After 
haemorrhages  in  the  middle  and  inferior  frontal  gyri  there  follows  degenera- 
tion of  the  frontal  cerebro-cortico-pontal  path,  going  through  the  anterior 
limb  of  the  internal  capsule  and  the  medial  portion  of  the  basis  pedunculi  to 
the  nuclei  pontis;  also  degeneration  of  the  fibres  connecting  the  nucleus  me- 
dialis  thalami  and  the  anterior  part  of  the  nucleus  lateralis  thalami  with  the 
cortex. 

When  the  temporal  gyri  or  their  white  matter  are  destroyed  by  a  hemor- 
rhage the  lateral  segment  of  the  basis  pedunculi  degenerates.  Cerebellar 
hemorrhage,  especially  if  it  injure  the  nucleus  dentatus,  may  lead  to  degen- 
eration of  the  brachium  conjunctivum. 

There  may  be  slow  degeneration  in  the  lemniscus  medialis,  extending  as 
far  as  the  nuclei  on  the  opposite  side  of  the  medulla  oblongata,  after  hemor- 
rhages in  the  central  gyri,  hypothalamic  region,  or  dorsal  part  of  the  pons. 
Hemorrhages  destroying  the  occipital  cortex,  or  subcortical  hemorrhages  in- 
juring the  optic  radiations,  occasion  slow  degeneration  (cellulipetal)  of  the 
radiations  from  the  lateral  geniculate  body,  and  after  a  time  cause  marked 
atrophy  or  even  disappearance  of  its  ganglion  cells. 

Symptoms. — These  may  be  divided  into  primary,  or  those  connected  with 
the  onset,  and  secondary,  or  those  which  develop  later,  after  the  early  mani- 
festations have  passed  away. 

PRIMARY  SYMPTOMS. — Premonitory  indications  are  rare.  As  a  rule,  the 
patient  is  seized  while  in  full  health  or  about  the  performance  of  some  every 
day  action,  occasionally  an  action  requiring  strain  or  extra  exertion.  Now  and 
then  instances  are  found  in  which  there  are  sensations  of  numbness  or  tingling 
or  pains  in  the  limbs,  or  even  choreiform  movements  in  the  muscles  of  the 
opposite  side,  the  so-called  prehemiplegic  chorea.  In  other  cases  temporary 


AFFECTION'S    OF   THE-  BLOOD   VESSELS  991 

disturbances  of  vision  and  of  associated  movements  of  the  eye-muscles  have 
been  noted,  but  none  of  the  prodromata  of  apoplexy  (the  so-called  "warn- 
ings") are  characteristic.  The  onset  of  the  apoplexy,  as  the  symptoms  of 
cerebral  haemorrhage  are  usually  called,  varies  greatly.  There  may  be  sudden 
loss  of  consciousness  and  complete  relaxation  of  the  extremities.  In  such  in- 
stances the  name  apoplectic  stroke  is  particularly  appropriate.  In  other  cases 
the  onset  is  more  gradual  and  the  loss  of  consciousness  may  not  occur  for  a 
few  minutes  after  the  patient  has  fallen,  or  after  the  paralysis  of  the  limbs 
is  manifest.  In  the  typical  apoplectic  attack  the  condition  is  as  follows: 
There  is  deep  unconsciousness;  the  patient  can  not  be  roused.  The  face  is 
injected,  sometimes  cyanotic,  or  of  an  ashen  gray  hue.  The  pupils  vary;  usu- 
ally they  are  dilated,  sometimes  unequal,  and  always,  in  deep  coma,  inactive. 
If  the  haemorrhage  be  so  located  that  it  can  irritate  the  nucleus  of  the  third 
nerve  the  pupils  are  contracted  (haemorrhages  into  the  pons  or  ventricles). 
The  respirations  are  slow,  noisy,  and  accompanied  with  stertor.  Sometimes 
the  Cheyne-Stokes  rhythm  may  be  present.  The  chest  movements  on  the 
paralyzed  side  may  be  restricted,  in  rare  instances  on  the  opposite  side.  The 
cheeks  are  often  blown  out  during  expiration,  with  spluttering  of  the  lips. 
The  pulse  is  usually  full,  slow,  and  of  increased  tension.  The  temperature  may 
be  normal,  but  is  often  found  subnormal,  and,  as  in  a  case  reported  by  Bastian, 
may  sink  below  95°.  In  cases  of  basal  haemorrhage  the  temperature,  on  the 
other  hand,  may  be  high.  The  urine  and  faeces  are  usually  passed  involun- 
tarily. Convulsions  are  not  common.  It  may  be  difficult  to  decide  whether 
the  condition  is  apoplexy  associated  with  hemiplegia  or  sudden  coma  from 
other  causes.  An  indication  of  hemiplegia  may  be  discovered  in  the  difference 
in  the  tonus  of  the  muscles  on  the  two  sides.  If  the  arm  or  the  leg  is  lifted, 
it  drops  "dead"  on  the  affected  side,  while  on  the  other  it  falls  more  slowly. 
The  lack  of  muscular  tone  of  the  paralyzed  limb  may  be  determined  by  in- 
spection. In  this  condition  the  muscle  mass  of  the  thigh  acts  like  a  semi- 
fluid sac  and  takes  the  shape  determined  by  gravity.  In  a  patient  lying  or 
sitting  on  a  firm  support,  the  thigh  of  the  paralyzed  limb  is  broadened  or  flat- 
tened, while  that  on  the  normal  side  has  a  more  rounded  contour.  Eigidity 
also  may  be  present.  In  watching  the  movements  of  the  facial  muscles  in  the 
stertorous  respiration  it  will  be  seen  that  on  the  paralyzed  side  the  relaxation 
permits  the  cheek  to  be  blown  out  in  a  more  marked  manner.  The  head  and 
eyes  may  be  turned  strongly  to  one  side — conjugate  deviation.  In  such  an 
event  the  turning  is  toward  the  side  of  the  haemorrhage. 

In  other  cases,  in  which  the  onset  is  not  so  abrupt,  the  patient  may  not 
lose  consciousness,  but  in  the  course  of  a  few  hours  there  is  loss  of  power, 
unconsciousness  gradually  develops,  and  deepens  into  profound  coma.  This 
is  sometimes  termed  ingravescent  apoplexy.  The  attack  may  occur  during 
sleep.  The  patient  may  be  found  unconscious,  or  wakes  to  find  that  the  power 
is  lost  on  one  side.  Small  haemorrhages  in  the  territory  of  the  central  arteries 
may  cause  hemiplegia  without  loss  of  consciousness.  In  old  persons  the  hemi- 
plegia may  be  slight  and  follow  a  transient  loss  of  consciousness,  and  is  usu- 
ally most  marked  in  the  leg,  which  is  dragged.  It  may  be  quite  slight  ond 
difficult  to  make  out.  It  is  associated  with  other  senile  changes.  This  is  the 
form  very  often  due  to  the  presence  of  lacunar  softening. 

Usually  within  forty  eight  hours  after  the  onset  of  an  attack,  sometimes 


992  DISEASES    OF    THE    NERVOUS    SYSTEM 

within  from  two  to  six  hours,  there  are  febrile  reaction  and  more  or  less  con- 
stitutional disturbance  associated  with  inflammatory  changes  about  the  haem- 
orrhage and  absorption  of  the  blood.  The  period  of  inflammatory  reaction 
may  continue  for  from  one  week  to  two  months.  The  patient  may  die  in  this 
reaction,  or,  if  consciousness  has  been  regained,  there  may  be  delirium  or 
recurrence  of  the  coma.  At  this  period  the  so-called  early  rigidity  may  develop 
in  the  paralyzed  limbs.  The  so-called  trophic  changes  may  occur,  such  as 
sloughing  or  the  formation  of  vesicles.  The  most  serious  of  these  is  the 
sloughing  eschar  of  the  lower  part  of  the  back,  or  on  the  paralyzed  side,  which 
may  appear  within  forty  eight  hours  of  the  onset  and  is  usually  of  grave  sig- 
nificance. The  congestion  at  the  bases  of  the  lungs  so  common  in  apoplexy  is 
regarded  by  some  as  a  trophic  change. 

Conjugate  Deviation. — In  a  right  hemiplegia  the  eyes  and  head  may  be 
turned  to  the  left  side ;  that  is  to  say,  the  eyes  look  toward  the  cerebral  lesion. 
This  is  almost  the  rule  in  the  conjugate  deviation  of  the  head  and  eyes  which 
occurs  early  in  hemiplegia.  When,  however,  convulsions  or  spasm  occur  or 
the  state  of  so-called  early  rigidity  in  hemiplegia,  the  conjugate  deviation 
of  the  head  and  eyes  may  be  in  the  opposite  direction ;  that  is  to  say,  the  eyes 
look  away  from  the  lesion  and  the  head  is  rotated  toward  the  eonvulsed  side. 
This  symptom  may  be  associated  with  cortical  lesions,  particularly,  according 
to  some  authors,  wh'en  in  the  neighborhood  of  the  supramarginal  and  angular 
gyri.  It  may  also  occur  in  a  lesion  of  the  internal  capsule  or  in  the  pons,  but 
in  the  latter  situation  the  conjugate  deviation  is  the  reverse  of  that  which 
occurs  in  other  cases,  as  the  patient  looks  away  from  the  lesion,  and  in  spasm 
or  convulsion  looks  toward  the  lesion. 

Hemiplegia. — In  cases  in  which  consciousness  is  restored  and  the  patient 
improves,  a  unilateral'  paralysis  may  persist  due  to  the  destruction  of  the 
motor  area  or  the  pyramidal  tract  in  any  part  of  its  course.  Hemiplegia  is 
complete  when  it  involves  face,  arm,  and  leg,  or  partial  when  it  involves  only 
one  or  other  of  these  parts.  This  may  be  the  result  of  a  lesion  (a)  of  the 
motor  cortex;  (&)  of  the  pyramidal  fibres  in  the  corona  radiata  and  in 
the  internal  capsule;  (c)  of  a  lesion  in  the  cerebral  peduncle;  or  (d)  in  the 
pons  Varolii.  The  situation  of  the  lesions  and  their  effects  are  given  in  Fig. 
18.  Haemorrhage  is  perhaps  the  most  common  cause,  but  tumors  and  spots  of 
softening  may  also  induce  it.  The  special  details  of  the  hemiplegia  may  here 
be  considered.  The  face  (except  in  lesions  in  the  lower  part  of  the  pons)  is 
involved  on  the  same  side  as  the  arm  and  leg.  This  results  from  the  fact  that 
the  facial  muscles  stand  in  precisely  the  same  relation  to  the  cortical  centres 
as  those  of  the  arm  and  leg,  the  fibres  of  the  upper  motor  segment  of  the  facial 
nerve  from  the  cortex  decussating  just  as  do  those  of  the  nerves  of  the  limbs. 
The  signs  of  the  facial  paralysis  are  usually  well  marked.  There  may  be  a 
slight  difficulty  in  elevating  the  eyebrows  or  in  closing  the  eye  on  the  paralyzed 
side,  or  in  rare  cases  the  facial  paralysis  is  complete,  but  the  movements  may 
be  present  with  emotion,  as  laughing  or  crying.  The  facial  paralysis  is  par- 
tial, involving  only  the  lower  portion  of  the  nerve,  so  that  the  orbicularis  oculi 
and  the  frontalis  muscles  are  much  less  involved  than  the  lower  branch.  The 
hypoglossal  nerve  also  is  involved.  In  consequence,  the  patient  can  not  put 
out  the  tongue  straight,  but  it  deviates  toward  the  paralyzed  side,  inasmuch 
as  the  genio-hyo-glossus  of  the  sound  side  is  unopposed.  In  a  few  cases  the 


993 

protrusion  is  toward  the  side  of  the  lesion,  a  fact  not  easily  explained  in  the 
present  state  of  our  knowledge  of  the  nervous  control  of  the  tongue.  With 
right  hemiplegia  there  may  be  aphasia.  Even  without  marked  aphasia  diffi- 
culty in  speaking  and  slowness  are  common. 

The  arm  is,  as  a  rule,  more  completely  paralyzed  than  the  leg.  The  loss 
of  power  may  be  absolute  or  partial.  In  severe  cases  it  is  at  first  complete. 
In  others,  when  the  paralysis  in  the  face  and  arm  is  complete,  that  of  the  leg 
is  only  partial.  The  face  and  arm  may  alone  be  paralyzed,  while  the  leg 
escapes.  Less  commonly  the  leg  is  more  affected  than  the  arm,  and  the  face 
may  be  only  slightly  involved. 

Certain  muscles  escape  in  hemiplegia,  particularly  those  associated  in 
symmetrical  movements,  as  those  of  the  thorax  and  abdomen,  a  fact  which 
Broadbent  explains  by  supposing  that  as  the  spinal  nuclei  controlling  these 
movements  on  both  sides  constantly  act  together  they  may,  by  means  of  this 
intimate  connection,  be  stimulated  by  impulses  coming  from  only  one  side 
of  the  brain.  Hughlings  Jackson  pointed  out  that  in  quiet  respiration  the 
muscles  on  the  paralyzed  side  acted  more  strongly  than  the  corresponding, 
muscles,  but  that  in  forced  respiration  the  reverse  condition  was  true.  The 
degree  of  permanent  paralysis  after  a  hemiplegic  attack  varies  much  in  dif- 
ferent cases.  When  the  restitution  is  partial,  it  is  always  certain  groups  of 
muscles  which  recover  rather  than  others.  Thus  in  the  leg  the  residual  par- 
alysis concerns  the  flexors  of  the  leg  and  the  dorsal  flexors  of  the  foot — i.  e., 
the  muscles  which  are  active  in  the  second  period  of  walking,  shortening  the 
leg,  and  bringing  it  forward  while  it  swings.  The  muscles  which  lift  the  body 
when  the  foot  rests  upon  the  ground,  those  used  in  the  first  period  of  walking, 
include  the  extensors  of  the  leg  and  the  plantar  flexors  of  the  foot.  These 
"lengtheners"  of  the  leg  often  recover  almost  completely  in  cases  in  which 
the  paralysis  is  due  to  lesions  of  the  pyramidal  tract.  In  the  arms  the  residual 
.paralysis  usually  affects  the  muscle  'groups  which  oppose  the  thumb,  those 
which  rotate  the  arm  outward,  and  the  openers  of  the  hand. 

As  a  rule,  there  is  at  first  no  wasting  of  the  paralyzed  limbs. 

Crossed  Hemiplegia. — A  paralysis  in  which  there  is  loss  of  function  in  a 
cerebral  nerve  on  one  side  with  loss  of  power  (or  of  sensation)  on  the  opposite 
Bide  of  the  body  is  called  a  crossed  or  alternate  hemiplegia.  It  is  met  with 
in  lesions,  commonly  hemorrhage,  in  the  crus,  the  pons,  and  the  medulla 
(Figs.  18,  12  and  13). 

(a)  Crus. — The  bleeding  may  extend  from  vessels  supplying  the  corpus 
striatum,  internal  capsule,  and  optic  thalamus,  or  the  haemorrhage  may  be 
primarily  in  the  crus.  In  the  classical  case  of  Weber,  on  section  of  the  lower 
part  of  the  left  crus,  an  oblong  clot  15  mm.  in  length  lay  just  below  the  medial 
and  inferior  surface.  The  characteristic  features  of  a  lesion  in  this  locality 
are  paralysis  of  arm,  face,  and  leg  of  the  opposite  side,  and  oculo-motor  paral- 
ysis of  the  same  side — the  syndrome  of  Weber.  Sensory  changes  may  also 
be  present.  Haemorrhage  into  the  tegmentum  is  not  necessarily  associated 
with  hemiplegia,  but  there  may  be  incomplete  paralysis  of  the  oculo-motor 
nerve,  with  disturbance  of  sensation  and  ataxia  on  the  opposite  side  of  the 
body.  The  optic  tract  or  the  lateral  geniculate  body  lying  on  the  lateral  side 
of  the  crus  may  be  compressed,  in  which  event  there  will  be  hemianopia. 

(6)  Pons  and  Medulla. — Lesions  may  involve  the  pyramidal  tract  and  one 


DISEASES    OF   THE    NEKVOUS    SYSTEM 


PIG.  18. — DIAGRAM  OP  MOTOR  PATH  FROM  LEFT  BRAIN.  The  upper  segment  is  black, 
the  lower  red.  The  nuclei  of  the  motor  cerebral  nerves  are  shown  on  the  right 
side;  on  the  left  side  the  cerebral  nerves  of  that  side  are  indicated.  A  lesion  at  1 
would  cause  upper  segment  paralysis  in  the  arm  of  the  opposite  side — cerebral 
monoplegia;  at  2,  upper  segment  paralysis  of  the  whole  opposite  side  of  the  body — 
hemiplegia;  at  3  (in  the  crus),  upper  segment  paralysis  of  the  opposite  face,  arm, 
and  leg,  and  lower  segment  paralysis  of  the  eye-muscles  on  the  same  side — crossed 
paralysis;  at  4  (in  the  lower  part  of  the  pons),  upper  segment  paralysis  of  the 
opposite  arm  and  leg,  and  lower  segment  paralysis  of  the  face  and  external  rectus 
on  the  same  side — crossed  paralysis;  at  5,  upper  segment  paralysis  of  all  muscles 
represented  below  lesion,  and  lower  segment  paralysis  of  muscles  represented  at 
level  of  lesion — spinal  paraplegia;  at  6,  lower  segment  paralysis  of  muscles  local' 
ized  at  seat  of  lesion — anterior  poliomyelitis.  (Van  Gehuchten,  modified.) 


AFFECTIONS    OF   THE    BLOOD    VESSELS  995 

or  more  of  the  cerebral  nerves.  If  at  the  lower  aspect  of  the  pons,  the  facial 
nerve  may  be  involved,  causing  paralysis  of  the  face  on  the  same  side  and 
hemiplegia  on  the  opposite  side.  The  fifth  nerve  may  be  involved,  with  the 
fillet  (the  sensory  tract),  causing  loss  of  sensation  in  the  area  of  distribution 
of  the  fifth  on  the  same  side  as  the  lesion  and  loss  of  sensation  on  the  opposite 
side  of  the  body.  The  sensory  disturbance  here  is  apt  to  be  dissociated,  of 
the  syringomyelic  type,  affecting  particularly  the  sense  of  pain  and  tem- 
perature. 

Sensory  Disturbances  Resulting  from  Cerebral  Hemorrhage. — These  are 
variable.  Hemianaesthesia  may  coexist  with  hemiplegia,  but  in  many  instances 
there  is  only  slight  numbing  of  sensation.  When  the  hemianaesthesia  is 
marked,  it  is  usually  the  result  of  a  lesion  in  the  internal  capsule  involving 
the  retrolenticular  portion  of  the  posterior  limb.  In  C.  L.  Dana's  study  of 
sensory  localization  he  found  that  anaesthesia  of  organic  cortical  origin  was 
always  limited  or  more  pronounced  in  certain  parts,  as  the  face,  arm,  or  leg, 
and  was  generally  incomplete.  Total  anaesthesia  was  either  of  functional  or 
subcortical  origin.  Marked  anaesthesia  was  much  more  common  in  softening 
than  in  haemorrhage.  Complete  hemi anaesthesia  is  certainly  rare  in  haemor- 
rhage. Disturbance  of  the  special  senses  is  not  common.  Hemianopia  may 
exist  on  the  same  side  as  the  paralysis,  and  there  may  be  diminution  in 
the  acuteness  of  the  senses  of  hearing,  taste,  and  smell.  Gowers  thinks  that 
homonymous  hemianopia  of  the  halves  of  the  visual  fields  opposite  to  the 
lesion  is  very  frequent  shortly  after  the  onset,  though  often  overlooked. 

Psychic  disturbances,  variable  in  nature  and  degree,  may  result  from  cere- 
bral haemorrhage. 

The  Reflexes  in  Apoplectic  Cases. — During  the  apoplectic  coma  all  the 
reflexes  are  abolished,  but  immediately  on  recovery  of  consciousness  they 
return,  first  on  the  non-hemiplegic  side,  later,  sometimes  only  after  weeks, 
on  the  paralyzed  side.  As  to  the  time  of  return,  especially  of  the  patellar 
reflexes,  marked  differences  are  observable  in  individual  cases.  The  deep 
reflexes  later  are  increased  on  the  paralyzed  side,  and  ankle  clonus  may  be 
present.  Plantar  stimulation  usually  gives  an  extensor  response  in  the  great 
toe  (Babinski's  reflex).  This  may  occur  very  early  and  is  an  important  indi- 
cation of  the  paralyzed  side.  The  other  superficial  reflexes  are  usually  dimin- 
ished. The  sphincters  are  not  affected. 

The  course  of  the  disease  depends  upon  the  situation  and  extent  of  the 
lesion.  If  slight,  the  hemiplegia  may  disappear  completely  within  a  few  days 
or  a  few  weeks.  In  severe  cases  the  rule  is  that  the  leg  gradually  recovers 
before  the  arm,  and  the  muscles  of  the  shoulder  girdle  and  upper  arm  before 
those  of  the  forearm  and  hand.  The  face  may  recover  quickly. 

Except  in  the  very  slight  lesions,  in  which  the  hemiplegia  is  transient, 
changes  take  place  which  may  be  grouped  as 

SECONDARY  SYMPTOMS. — These  correspond  to  the  chronic  stage.  In  a 
case  in  which  little  or  no  improvement  takes  place  within  eight  or  ten  weeks 
it  will  be  found  that  the  paralyzed  limbs  undergo  certain  changes.  The  leg, 
as  a  rule,  recovers  enough  power  to  enable  the  patient  to  get  about,  although 
the  foot  is  dragged.  Occasionally  a  recurrence  of  severe  symptoms  is  seen, 
even  without  a  new  haemorrhage  having  taken  place.  In  both  arm  and  leg 
the  condition  of  secondary  contraction  or  late  rigidity  comes  on  and  is  always 


996  DISEASES    OF    THE    NERVOUS    SYSTEM 

most  marked  in  the  upper  extremity.  The  arm  becomes  permanently  flexed 
at  the  elbow  and  resists  all  attempts  at  extension.  The  wrist  is  flexed  upon 
the  forearm  and  the  fingers  upon  the  hand.  The  position  of  the  arm  and 
hand  is  very  characteristic.  There  is  frequently,  as  the  contractures  develop, 
a  great  deal  of  pain.  In  the  leg  the  contracture  is  rarely  so  extreme.  The 
loss  of  power  is  most  marked  in  the  muscles  of  the  foot  and,  to  prevent  the 
toes  from  dragging,  the  knee  in  walking  is  much  flexed,  or  more  commonly 
the  foot  is  swung  round  in  a  half  circle. 

The  reflexes  are  at  this  stage  greatly  increased.  These  contractures  are 
permanent  and  incurable,  and  are  associated  with  a  secondary  descending 
sclerosis  of  the  motor  path.  There  are  instances,  however,  in  which  rigidity 
and  contracture  do  not  occur,  but  the  arm  remains  flaccid,  the  leg  having 
regained  its  power.  This  h-emipUgie  flasque  of  Bouchard  is  found  most  com- 
monly in  children.  Among  other  secondary  changes  in  late  hemiplegia  may 
be  mentioned  the  following:  Tremor  of  the  affected  limbs,  post-paralytic 
chorea,  the  mobile  spasm  known  as  athetosis,  arthropathies  in  the  joints  of 
the  affected  side,  and  muscular  atrophy.  Athetosis  and  post-hemiplegic  chorea 
will  be  considered  in  the  hemiplegia  of  children.  The  cool  surface  and  thin 
glossy  skin  of  a  hemiplegic  limb  are  familiar  to  all.  A  word  may  here  be 
said  upon  the  subject  of  muscular  atrophy  of  cerebral  origin. 

As  a  rule,  atrophy  is  not  a  marked  feature  in  hemiplegia,  but  in  some 
instances  it  does  occur.  It  has  been  thought  to  be  due  in  some  cases  to 
secondary  alterations  in  the  gray  matter  of  the  ventral  horns;  but  atrophy 
may  follow  as  a  direct  result  of  the  cerebral  lesion,  the  ventral  horns  remain- 
ing intact.  In  Quincke's  case  atrophy  of  the  arm  followed  the  development 
of  a  glioma  in  the  anterior  central  convolution.  The  gray  matter  of  the 
ventral  horns  was  normal.  These  atrophies  are  most  common  in  cortical 
lesions  involving  the  domain  of  the  third  main  branch  of  the  Sylvian  artery, 
and  in  central  lesions  involving  the  lenticulo-thalamic  region.  Their  explana- 
tion is  not  clear.  The  wasting  of  cerebral  origin,  which  occurs  most  fre- 
quently in  children,  and  leads  to  hemiatrophy  of  the  muscles  along  with 
stunted  growth  of  the  bones  and  joints,  is  to  be  sharply  separated  from  the 
hemiatrophy  of  the  muscles  of  the  adult  following  within  a  relatively  short 
time  upon  the  hemiplegia. 

Diagnosis. — There  are  three  groups  of  cases  which  offer  increasing  diffi- 
culty in  recognition. 

(1)  Cases  in  which  the  onset  is  gradual,  a  day  or  two  elapsing  before 
the  paralysis  is  fully  developed  and  consciousness  completely  lost,  are  readily 
recognized,  though  it  may  be  difficult  to  determine  whether  the  lesion  is  due 
to  thrombosis  or  to  hemorrhage. 

(2)  In  the  sudden  apoplectic  stroke  in  which  the  patient  rapidly  loses 
consciousness  the  difficulty  in  diagnosis  may  be   still  greater,   particularly 
if  the  patient  is  in  deep  coma  when  first  seen. 

The  first  point  to  be  decided  is  the  existence  of  hemiplegia.  This  may 
be  difficult,  although,  as  a  rule,  even  in  deep  coma  the  limbs  on  the  para- 
lyzed side  are  more  flaccid  and  drop  instantly  when  lifted;  whereas  on  the 
non-paralyzed  side  the  muscles  retain  some  degree  of  tonus.  The  reflexes  may 
be  decreased  or  lost  on  the  affected  side  ond  there  may  be  conjugate  devia- 
tion of  the  head  and  eyes.  Rigidity  in  the  limbs  on  one  side  is  in  favor  of  a 


AFFECTIONS    OF    THE    BLOOD    VESSELS  997 

hemiplegic  lesion.     It  is  practically  impossible  in  a  majority  of  these  cases 
to  say  whether  the  lesion  is  due  to  haemorrhage,  embolism,  or  thrombosis. 

(3)  Large  haemorrhage  into  the  ventricles  or  into  the  pons  may  produce 
sudden  loss  of  consciousness  with  complete  relaxation,  so  that  the  condition 
may  simulate  coma  from  uremia,  diabetes,  alcoholism,  opium  poisoning,  or 
epilepsy. 

The  previous  history  and  the  mode  of  onset  may  give  valuable  information. 
In  epilepsy  convulsions  have  preceded  the  coma;  in  alcoholism  there  is  a 
history  of  constant  drinking,  while  in  opium  poisoning  the  coma  develops 
more  gradually;  but  in  many  instances  the  difficulty  is  practically  very  great, 
and  on  more  than  one  occasion  I  have  seen  mortifying  post  mortem  disclosures 
under  these  circumstances.  With  diabetic  coma  the  breath  often  smells  of 
acetone.  In  ventricular  haemorrhage  the  coma  is  sudden  and  comes  on  rapidly. 
The  hemiplegic  symptoms  may  be  transient,  quickly  giving  place  to  complete 
relaxation.  Convulsions  occur  in  many  cases,  and  may  be  the  very  symptom 
to  lead  astray — as  in  a  case  of  ventricular  haemorrhage  which  occurred  in  a 
puerperal  patient,  in  whom,  naturally  enough,  the  condition  was  thought  to  be 
uraemic.  Rigidity  is  often  present.  In  haemorrhage  into  the  pons  convulsions 
are  frequent.  The  pupils  may  be  strongly  contracted,  conjugate  deviation  may 
occur,  and  the  temperature  is  apt  to  rise  rapidly.  The  contraction  of  the 
pupils  in  pontine  haemorrhage  naturally  suggests  opium  poisoning.  The  dif- 
ference in  temperature  in  the  two  conditions  is  a  valuable  diagnostic  point. 
The  apoplectiform  seizures  of  general  paresis  have  usually  been  preceded  by 
abnormal  mental  symptoms,  and  the  associated  hemiplegia  is  seldom  per- 
manent. 

It  may  be  impossible  at  first  to  give  a  definite  diagnosis.  In  admissions 
to  hospitals  or  in  emergency  cases  the  physician  should  be  particularly  careful 
about  the  following  points :  The  examination  of  the  head  for  injury  or  frac- 
ture ;  the  urine  should  be  tested  for  albumin,  examined  for  sugar,  and  studied 
microscopically;  a  careful  examination  should  be  made  of  the  limbs  with  ref- 
erence to  their  degree  of  relaxation  or  the  presence  of  rigidity,  and  the  con- 
dition of  the  reflexes ;  the  state  of  the  pupils  -should  be  noted  and  the  tem- 
perature taken.  The  odor  of  the  breath  (alcohol,  acetone,  chloroform,  etc.) 
should  be  remarked.  The  most  serious  mistakes  are  made  in  the  case  of 
patients  who  are  drunk  at  the  time  of  the  attack,  a  combination  by  no  means 
uncommon  in  the  class  of  patients  admitted  to  hospital.  Under  these  circum- 
stances the  case  may  erroneously  be  looked  upon  as  one  of  alcoholic  coma.  It 
is  best  to  regard  each  case  as  serious  and  to  bear  in  mind  that  this  is  a 
condition  in  which,  above  all  others,  mistakes  are  common. 

Prognosis.  — From  cortical  haemorrhage,  unless  very  extensive,  the  recovery 
may  be  complete  without  a  trace  of  contracture.  This  is  more  common  when 
the  hemorrhage  follows  injury  than  when  it  results  from  disease  of  the 
arteries.  Infantile  meningeal  haemorrhage,  on  the  other  hand,  is  a  condition 
which  may  produce  idiocy  or  spastic  diplegia. 

Large  haemorrhages  into  the  corona  radiata,  and  especially  those  which 
rupture  into  the  ventricles,  rapidly  prove  fatal. 

The  hemiplegia  which  follows  lesions  of  the  internal  capsule,  the  result 
of  rupture  of  the  lenticulo-striate  artery,  is  usually  persistent  and  followed 
by  contracture.  When  the  retro-lenticular  fibres  of  the  internal  capsule  are 


998  DISEASES    OF    THE    NEKVOUS    SYSTEM 

involved  there  may  be  hemianassthesia,  and  later,  especially  if  the  thalamus 
be  implicated,  hemichorea  or  athetosis.  In  any  case  of  cerebral  apoplexy  the 
following  symptoms  are  of  grave  omen:  persistence  or  deepening  of  the  coma 
during  the  second  and  third  day;  rapid  rise  in  temperature  within  the  first 
forty-eight  hours  after  the  initial  fall.  In  the  reaction  which  takes  place  on 
the  second  or  third  day  the  temperature  usually  rises,  and  its  gradual  fall 
on  the  third  or  fourth  day  with  return  of  consciousness  is  a  favorable  indica- 
tion. The  rapid  formation  of  bed-sores,  particularly  the  malignant  decubitus 
of  Charcot,  is  a  fatal  indication.  The  occurrence  of  albumin  and  sugar,  if 
abundant,  in  the  urine  is  an  unfavorable  symptom. 

When  consciousness  returns  and  the  patient  is  improving,  the  question  is 
anxiously  asked  as  to  the  paralysis.  The  extent  of  this  can  not  be  determined 
for  some  weeks.  With  slight  lesions  it  may  pass  off  entirely.  If  persistent  at 
the  end  of  a  month  some  grade  of  permanent  palsy  is  certain  to  remain,  and 
gradually  the  late  rigidity  supervenes. 

5.     EMBOLISM    AND    THEOMBOSIS 
(Cerebral  Softening) 

Embolism. — The  embolus  usually  enters  the  carotid,  rarely  the  verte- 
bral artery.  In  the  great  majority  of  cases  it  comes  from  the  left  heart  and 
is  either  a  vegetation  of  a  fresh  endocarditis  or,  more  commonly,  of  a  recurring 
endocarditis,  or  from  the  segments  involved  in  an  ulcerative  process.  Less 
often  the  embolus  is  a  portion  of  a  clot  which  has  formed  in  the  auricular 
appendix.  Portions  of  clot  from  an  aneurism,  thrombi  from  atheroma  of  the 
aorta,  or  from  the  territory  of  the  pulmonary  veins,  may  also  cause  blocking 
of  the  branches  of  the  circle  of  Willis.  In  the  puerperal  condition  cerebral 
embolism  is  not  infrequent.  It  may  occur  in  women  with  heart  disease,  but 
in  other  instances  the  heart  is  uninvolved,  and  the  condition  has  been  thought 
to  be  associated  with  the  development  of  heart  clots,  owing  to  increased  coagu- 
lability of  the  blood.  A  majority  of  cases  of  embolism  occur  in  heart  disease, 
89  per  cent.  (Saveliew).  Cases  are  rare  in  the  acute  endocarditis  of  rheuma- 
tic fever,  chorea,  and  febrile  conditions.  It  is  much  more  common  in  the  sec- 
ondary recurring  endocarditis  which  attacks  old  sclerotic  valves.  The  embolus 
most  frequently  passes  to  the  left  middle  cerebral  artery,  as  it  enters  the  left 
carotid  oftener  than  the  right  because  of  the  more  direct  course  of  the  blood 
in  the  former.  The  posterior  cerebral  and  the  vertebral  are  less  often  af- 
fected. A  large  plug  may  lodge  at  the  bifurcation  of  the  basilar.  Embolism 
of  the  cerebellar  vessels  is  rare. 

Embolism  occurs  more  frequently  in  women,  owing,  no  doubt,  to  the  greater 
frequency  of  mitral  stenosis.  Contrary  to  this  general  statement,  Newton 
Pitt's  statistics  of  79  cases  at  Guy's  Hospital  indicate,  however,  that  males  are 
more  frequently  affected ;  as  in  this  series  there  were  44  males  and  35  females. 
Saveliew  gives  54  per  cent,  in  women. 

Thrombosis. — Clotting  of  blood  in  the  cerebral  vessels  occurs  (1)  about 
an  embolus,  (2)  as  the  result  of  a  lesion  of  the  arterial  wall  (either  endar- 
teritis  with  or  without  atheroma  or,  particularly,  the  syphilitic  arteritis),  (3) 
in  aneurisms,  both  coarse  and  miliary,  and  (4)  very  rarely  as  a  direct  result 
of  abnormal  conditions  of  the  blood.  Thrombosis  occasionally  follows  ligation 


AFFECTIONS    OF   THE    BLOOD   VESSELS  999 

of  the  carotid  artery.  The  thrombosis  is  most  common  in  the  middle  cerebral 
and  in  the  basilar  arteries.  According  to  Kolisko,  softening  of  limited  areas, 
sufficient  to  induce  hemiplegia,  may  be  caused  by  sudden  collapse  of  certain 
cerebral  arteries  from  cardiac  weakness. 

Anatomical  Changes. — Degeneration  and  softening  of  the  territory  sup- 
plied by  the  vessels  are  the  ultimate  result  in  both  embolism  and  thrombosis. 
Blocking  in  a  terminal  artery  may  be  followed  by  infarction,  in  which  the 
territory  may  either  be  deeply  infiltrated  with  blood  (haemorrhagic  infarction) 
or  be  simply  pale,  swollen,  and  necrotic  (anaemic  infarction).  Gradually  the 
process  of  softening  proceeds,  the  tissue  is  infiltrated  with  serum  and  is  moist, 
the  nerve  fibres  degenerate  and  become  fatty.  The  neuroglia  is  swollen  and 
cedematous.  The  color  of  the  softened  area  depends  upon  the  amount  of  blood. 
The  haemoglobin  undergoes  gradual  transformation,  and  the  early  red  color 
may  give  place  to  yellow.  Formerly  much  stress  was  laid  upon  the  difference 
between  red,  yellow,  and  white  softening.  The  red  and  yellow  are  seen  chiefly 
on  the  cortex.  Sometimes  the  red  softening  is  particularly  marked  in  cases 
of  embolism  and  in  the  neighborhood  of  tumors.  The  gray  matter  shows  many 
punctiform  haemorrhages — capillary  apoplexy.  There  is  a  variety  of  yellow 
softening — the  plaques  jaunes — common  in  elderly  persons,  which  occurs  in 
the  gray  matter  of  the  convolutions.  The  spots  are  from  1  to  2  cm.  in  diam- 
eter, sometimes  are  angular  in  shape,  the  edges  cleanly  cut,  and  the  softened 
area  is  represented  by  either  a  turbid,  yellow  material,  or  in  some  instances 
there  is  a  space  crossed  by  fine  trabeculae,  in  the  meshes  of  which  there  is  fluid. 
White  softening  occurs  most  frequently  in  the  white  matter,  and  is  seen  best 
about  tumors  and  abscesses.  Inflammatory  changes  are  common  in  and  about 
the  softened  areas.  When  the  embolus  is  derived  from  an  infected  focus,  as 
in  ulcerative  endocarditis,  suppuration  may  follow.  The  final  changes  vary 
very  much.  The  degenerated  and  dead  tissue  elements  are  gradually  but 
slowly  removed,  and  if  the  region  is  small  may  be  replaced  by  a  growth  of 
connective  tissue  and  the  formation  of  a  scar.  If  large,  the  resorption  results 
in  the  formation  of  a  cyst.  It  is  surprising  for  how  long  an  area  of  softening 
may  persist  without  much  change. 

The  position  and  extent  of  the  softening  depend  upon  the  obstructed  artery. 
An  embolus  which  blocks  the  middle  cerebral  at  its  origin  involves  not  only 
the  arteries  to  the  anterior  perforated  space,  but  also  the  cortical  branches,  and 
in  such  a  case  there  is  softening  in  the  neighborhood  of  the  corpus  striatum, 
as  well  as  in  part  of  the  region  supplied  by  the  cortical  vessels.  The  freedom 
of  anastomosis  between  these  branches  varies  a  good  deal.  Thus,  there  are 
instances  of  embolism  of  the  middle  cerebral  artery  in  which  the  softening 
has  involved  only  the  territory  of  the  central  branches,  in  which  case  blood  has 
reached  the  cortex  through  the  anterior  and  posterior  cerebrals.  When  the 
middle  cerebral  is  blocked  (as  is  perhaps  oftenest  the  case)  beyond  the  point 
of  origin  of  the  central  arteries,  one  or  other  of  its  branches  is  usually  most 
involved.  The  embolus  may  lodge  in  the  vessel  passing  to  the  third  frontal 
convolution,  or  in  the  artery  of  the  ascending  frontal  or  ascending  parietal; 
or  it  may  lodge  in  the  branch  passing  to  the  supramarginal  and  angular  gyri, 
or  it  may  enter  the  lowest  branch  which  is  distributed  to  the  upper  convolu- 
tions of  the  temporal  lobe.  These  are  practically  terminal  arteries,  and  in- 
stances frequently  occur  of  softening  limited  to  a  part,  at  any  rate,  of  the 


1000  DISEASES    OF    THE   NERVOUS    SYSTEM 

territory  supplied  by  them.  Some  of  the  most  accurate  focalizing  lesions  are 
produced  in  this  way. 

Symptoms.— Extensive  thrombotic  softening  may  exist  without  any  symp- 
toms. It  is  not  uncommon  in  the  post  mortem  examination  of  the  bodies  of 
elderly  persons  to  find  the  plaques  jaunes  scattered  over  the  convolutions.  So, 
too,  softening  may  take  place  in  the  "silent"  regions,  as  they  are  termed, 
without  exciting  any  symptoms.  When  the  central  or  cortical  branches  of  the 
middle  cerebral  arteries  are  involved  the  symptoms  are  similar  to  those  of 
haemorrhage  from  the  same  arteries.  Permanent  or  transient  hemiplegia  re- 
sults. When  the  central  arteries  are  involved  the  softening  in  the  internal 
capsule  is  commonly  followed  by  permanent  hemiplegia.  There  are  certain 
peculiarities  associated  with  embolism  and  with  thrombosis  respectively. 

In  embolism  the  patient  is  usually  the  subject  of  heart  trouble,  or  there 
exist  some  of  the  conditions  already  mentioned.  The  onset  is  sudden,  without 
premonitory  symptoms  but  sometimes  with  intense  headache.  When  the 
embolus  blocks  the  left  middle  cerebral  artery  the  hemiplegia  is  associated  with 
aphasia.  In  thrombosis,  on  the  other  hand,  the  onset  is  more  gradual;  the 
patient  has  previously  complained  of  headache,  vertigo,  tingling  in  the  fingers ; 
the  speech  may  have  been  embarrassed  for  some  days ;  the  patient  has  had  loss 
of  memory  or  is  incoherent,  or  paralysis  begins  at  one  part,  as  the  hand,  and 
extends  slowly,  and  the  hemiplegia  may  be  incomplete  or  variable.  Abrupt 
loss  of  consciousness  is  much  less  common,  and  when  the  lesion  is  small  con- 
sciousness is  retained.  Thus,  in  thrombosis  due  to  syphilitic  disease,  the  hemi- 
plegia may  come  on  gradually  without  the  slightest  disturbance  of  conscious- 
ness. 

The  hemiplegia  following  thrombosis  or  embolism  has  practically  the  char- 
acteristics, both  primary  and  secondary,  described  under  hemorrhage. 

The  following  may  be  the  effects  of  blocking  the  different  vessels:  (a) 
Vertebral. — The  left  branch  is  more  frequently  plugged.  The  effects  are  in- 
volvement of  the  nuclei  in  the  medulla  and  symptoms  of  acute  bulbar  paralysis. 
It  rarely  occurs  alone ;  more  commonly  with 

(.&)  Blocking  of  the  basilar  artery.  When  this  is  entirely  occluded,  there 
may  be  bilateral  paralysis  from  involvement  of  both  motor  paths.  Bulbar 
symptoms  may  be  present;  rigidity  or  spasm  may  occur.  The  temperature 
may  rise  rapidly.  The  symptoms,  in  fact,  are  those  of  apoplexy  of  the  pons. 

(c)  The  posterior  cerebral  supplies  the  occipital  lobe  on  its  medial  surface 
and  the  greater  part  of  the  temporo-sphenoidal  lobe.     If  the  main  stem  be 
thrombosed  there  is  hemianopia  with  sensory  aphasia.     Localized  areas  of 
softening  may  exist  without  symptoms.    Blocking  of  the  main  occipital  branch 
(arteria  occipitalis  of  Duret),  or  of  the  arteria  calcarina,  passing  to  the  cuneus 
may  be  followed  by  hemianopia.     Hemianaesthesia  may  result  from  involve- 
ment of  the  posterior  part  of  the  internal  capsule.    Not  infrequently  symmet- 
rical thrombosis  of  the  occipital  arteries  of  the  two  sides  occurs,  as  in  Forster's 
well-known  case.     Still  more  frequent  is  the  occurrence  of  thrombosis  of  a 
branch  of  the  posterior  cerebral  of  one  hemisphere  and  a  branch  of  the  middle 
cerebral  of  the  other.    It  is  in  such  cases  that  the  most  pronounced  instances 
of  apraxia  are  met  with. 

(d)  Internal  Carotid. — The  symptoms  are  variable.    As  is  well  known,  the 
vessel  is  in  a  majority  of  cases  ligated  without  risk.    In  other  instances  tran- 


AFFECTIONS    OF   THE   BLOOD   VESSELS  1001 

sient  hemiplegia  follows ;  in  others  again  the  hemiplegia  is  permanent.  These 
variations  depend  on  the  anastomoses  in  the  circle  of  Willis.  If  these  are 
large  and  free,  no  paralysis  follows,  but  in  cases  in  which  the  posterior  com- 
municating and  the  anterior  communicating  vessels  are  small  or  absent  the 
paralysis  may  persist.  In  Xo.  7  of  my  Elwyn  series  of  cases  of  infantile  hemi- 
plegia, the  woman,  aged  twenty  four,  when  six  years  old,  had  the  right  carotid 
ligated  for  abscess  following  scarlet  fever,  with  the  result  of  permanent  hemi- 
plegia. Blocking  of  the  internal  carotid  within  the  skull  by  thrombosis  or 
embolism  is  followed  by  hemiplegia,  coma,  and  usually  death.  The  clot  is 
rarely  confined  to  the  carotid  itself,  but  spreads  into  its  branches  and  may 
involve  the  ophthalmic  artery. 

(e)  Middle  Cerebral. — This  is  the  vessel  most  commonly  involved,  and,  as 
already  mentioned,  if  plugged  before  the  central  arteries  are  given  off,  perma- 
nent hemiplegia  usually  follows  from  softening  of  the  internal  capsule.  Block- 
ing of  the  branches  beyond  this  point  may  be  followed  by  hemiplegia,  which 
is  more  likely  to  be  transient,  involves  chiefly  the  arm  and  face,  and  if  the 
lesion  be  on  the  left  side  is  associated  with  aphasia.  There  may  be  plugging 
of  the  individual  branches  passing  to  the  inferior  frontal  (producing  typical 
motor  aphasia  if  the  disease  be  on  the  left  side),  to  the  anterior  and  posterior 
central  gyri  (usually  causing  total  hemiplegia),  to  the  supramarginal  and 
angular  gyri  (giving  rise,  if  the  thrombosis  be  on  the  left  side,  probably  with- 
out exception  to  the  so-called  visual  aphasia  (alexia),  usually  also  to  right- 
sided  hemionopsia),  or  to  the  temporal  gyri  (in  which  event  with  left-sided 
thrombosis  word-deafness  results). 

(/)  Anterior  Cerebral. — No  symptoms  may  follow,  and  even  when  the 
branches  which  supply  the  paracentral  lobule  and  the  top  of  the  ascending 
convolutions  are  plugged  the  branches  from  the  middle  cerebral  are  usually 
able  to  effect  a  collateral  circulation  in  these  parts.  Monoplegia  of  the  leg 
may,  however,  result.  Hebetude  and  dullness  of  intellect  may  occur  with 
obstruction  of  the  vessel. 

There  is  unquestionably  greater  freedom  of  communication  in  the  cortical 
branches  of  the  different  arteries  than  is  usually  admitted,  although  it  is  not 
possible,  for  example,  to  inject  the  posterior  cerebral  through  the  middle  cere- 
bral, or  the  middle  cerebral  from  the  anterior;  but  the  absence  of  softening 
in  some  instances  in  which  smaller  branches  are  blocked  shows  how  complete 
may  be  the  compensation,  probably  by  way  of  the  capillaries.  The  dilatation 
of  the  collateral  branches  may  take  place  very  rapidly;  thus  a  patient  with 
chronic  nephritis  died  about  twenty  four  hours  after  the  hemiplegic  attack. 
There  were  recent  vegetations  on  the  mitral  valve  and  an  embolus  in  the  right 
middle  cerebral  artery  just  beyond  the  first  two  branches.  The  central  portion 
of  the  hemisphere  was  swollen  and  cedematous.  The  right  anterior  cerebral 
was  greatly  dilated,  and  by  measurement  its  diameter  was  found  to  be  nearly 
three  times  that  of  the  left. 

Treatment  of  Cerebral  Haemorrhage  and  of  Softening. — The  chief  diffi- 
cultv  in  deciding  upon  a  method  of  treatment  is  to  determine  whether  the 
apoplexy  is  due  to  hemorrhage  or  to  thrombosis  or  embolism.  The  patient 
should  be  placed  in  bed,  with  his  head  moderately  elevated  and  the  neck  free. 
He  should  be  kept  absolutely  quiet.  If  there  are  dyspnoea,  stertor,  and  signs  of 
mechanical  obstruction  to  respiration,  he  should  be  turned  on  his  side,  as  rec- 
65 


1002  DISEASES   OF   THE   NERVOUS    SYSTEM 

ommended  by  Bowles.  This  procedure  also  lessens  the  liability  to  congestion 
of  the  lungs.  If  the  signs  of  intracranial  hemorrhage  are  certain,  and  if  the 
arterial  tension  is  high,  measures  may  be  taken  for  its  reduction.  Of  these  the 
most  rapid  and  satisfactory  is  venesection,  which  in  many  cases  seems  to  do 
good.  However,  as  Gushing  has  shown  experimentally,  a  rapid  and  increasing 
rise  of  arterial  tension  usually  indicates  an  endeavor  of  the  vasomotor  centres 
to  counteract  an  increasing  intracranial  pressure,  in  this  case  due  to  a  con- 
tinuing haemorrhage.  The  indication  under  these  circumstances  is  the  relief 
of  the  intracranial  pressure  by  craniotomy  and  removal  of  the  clot,  if  this  is 
possible.  This  is  particularly  applicable  in  subdural  haemorrhage.  Horsley 
and  Spencer  have  recently,  on  experimental  grounds,  recommended  the  prac- 
tice, formerly  employed  empirically,  of  compression  of  the  carotid,  particu- 
larly in  the  ingravescent  form;  or  even,  in  suitable  cases,  passing  a  ligature 
round  the  vessel.  An  ice-bag  may  be  placed  on  the  head  and  hot  bottles  to  the 
feet.  The  bowels  should  be  freely  opened,  either  by  calomel,  elaterium,  or 
elaterin.  Counter-irritation  to  the  neck  or  to  the  feet  is  not  necessary.  Cathe- 
terization  of  the  bladder  may  be  necessary,  especially  if  the  patient  remains 
long  unconscious. 

Special  care  should  be  taken  to  avoid  bed-sores;  and  if  bottles  are  used 
to  the  feet,  they  should  not  be  too  hot,  since  blisters  may  be  readily  caused 
by  a  much  lower  temperature  than  in  health.  In  the  fever  of  reaction  aconite 
may  be  indicated,  but  should  be  cautiously  used.  Stimulants  are  not  necessary, 
unless  the  pulse  becomes  feeble  and  signs  of  collapse  supervene.  No  digitalis 
is  to  be  given.  During  recovery  the  patient  should  be  still  kept  entirely  at  rest, 
even  in  the  mildest  attacks  remaining  in  bed  for  at  least  fourteen  days.  The 
ice-bag  should  still  be  kept  to  the  head.  The  diet  should  be  light  and  no 
medicine  other  than  some  placebo  should  be  administered,  at  least  during  the 
first  month  after  the  haemorrhage.  Attention  should  be  paid  to  the  position 
occupied  by  the  paralyzed  limb  or  limbs,  which  if  swollen  may  be  wrapped  in 
cotton  batting  or  flannel. 

The  treatment  of  softening  from  thrombosis  or  embolism  is  very  unsatis- 
factory. Venesection  is  not  indicated,  as  it  lowers  the  tension  and  rather 
promotes  clotting.  If,  as  is  often  the  case,  the  heart's  action  is  feeble  and 
irregular,  stimulants  and  small  doses  of  digitalis  may  be  given  with,  if  neces- 
sary, ether  or  ammonia.  The  bowels  should  be  kept  open,  but  it  is  not  well 
to  purge  actively,  as  in  haemorrhage. 

In  the  thrombosis  which  follows  syphilitic  disease  of  the  arteries,  and  which 
is  met  with  most  frequently  in  men  between  twenty  and  forty  (in  whom  the 
hemiplegia  often  sets  in  without  loss  of  consciousness),  the  iodide  of  potassium 
should  be  freely  used,  giving  from  20  to  30  grains  (1.3  to  2  gm.)  three  times 
a  day,  or,  if  necessary,  larger  doses.  If  the  syphilis  has  been  recent,  mercurials 
by  inunction  are  also  indicated.  Practically  these  are  the  only  cases  of  hemi- 
plegia in  which  we  see  satisfactory  results  from  treatment. 

Very  little  can  be  done  for  the  hemiplegia  which  remains.  The  damage 
is  too  often  irreparable  and  permanent,  and  it  is  very  improbable  that  iodide 
of  potassium,  or  any  other  remedy,  hastens  in  the  slightest  degree  Nature's 
dealing  with  the  blood  clot. 

The  paralyzed  limbs  may  be  gently  rubbed  once  or  twice  a  day,  and  this 
should  be  systematically  carried  out,  in  order  to  maintain  the  nutrition  of  the 


AFFECTIONS    OF   THE   BLOOD   VESSELS  1003 

muscles  and  to  prevent,  if  possible,  contractures.  The  massage  should  not, 
however,  be  begun  until  at  least  ten  days  after  the  attack.  The  rubbing  should 
be  tou-ard  the  body,  and  should  not  be  continued  for  more  than  fifteen  minutes 
at  a  time.  After  the  lapse  of  a  fortnight,  or  in  severe  cases  a  month,  the  mus- 
cles may  be  stimulated  by  the  f aradic  current ;  f aradic  stimulation  alternating 
with  massage,  especially  if  applied  to  the  antagonists  of  the  muscles  which 
ordinarily  undergo  contracture,  is  of  very  great  service,  even  in  cases  where 
there  can  be  but  little  hope  of  any  return  of  voluntary  movement.  When  con- 
tractures occur,  electricity  properly  applied  at  intervals  may  still  be  of  some 
benefit  along  with  the  passive  movements  and  frictions,  and  it  has  been  sug- 
gested that  tendon  transplantation,  or  indeed  cross  suture  of  nerves,  may  cause 
some  improvement. 

In  a  case  of  complete  hemiplegia  the  friends  should  at  the  outset  be 
frankly  told  that  the  chances  of  full  recovery  are  slight.  Power  is  usually  re- 
stored in  the  leg  sufficient  to  enable  the  patient  to  get  about,  but  in  the  major- 
ity of  instances  the  finer  movements  of  the  hand  are  permanently  lost.  The 
general  health  should  be  looked  after,  the  bowels  regulated,  and  the  secretions 
of  the  skin  and  kidneys  kept  active.  In  permanent  hemiplegia  in  persons 
above  the  middle  period  of  life,  more  or  less  mental  weakness  is  apt  to  follow 
the  attack,  and  the  patient  may  become  irritable  and  emotional. 

And,  lastly,  when  hemiplegia  has  persisted  for  more  than  three  months  and 
contractures  have  developed,  it  is  the  duty  of  the  physician  to  explain  to  the 
patient,  or  to  his  friends,  that  the  condition  is  past  relief,  that  medicines  and 
electricity  will  do  no  good,  and  that  there  is  no  possible  hope  of  cure. 

6.     ANEUEISM  OF  THE  CEEEBEAL  AETEEIES 

Miliary  aneurisms  are  not  included,  but  reference  is  made  only  to  aneurism 
of  the  larger  branches.  The  condition  is  not  uncommon.  There  were  12 
instances  in  my  first  800  autopsies  in  Montreal.  This  is  a  considerably  larger 
proportion  than  in  Newton  Pitt's  collection  from  Guy's  Hospital,  19  times  in 
9,000  inspections. 

Etiology. — Males  are  more  frequently  affected  than  females.  Of  my  12 
cases  7  were  males.  The  disease  is  most  common  at  the  middle  period  of  life. 
One  of  my  cases  was  a  lad  of  six.  Pitt  describes  one  at  the  same  age.  The 
chief  causes  are  (a)  endarteritis,  either  simple  or  syphilitic,  which  leads  to 
weakness  of  the  wall  and  dilatation;  and  (&)  embolism.  These  aneurisms  are 
often  found  with  endocarditis.  Pitt,  in  his  study  of  the  subject,  concludes  that 
it  is  exceptional  to  find  cerebral  aneurism  unassociated  with  fungating  endo- 
carditis. The  embolus  disappears,  and  dilatation  follows  the  secondary  in- 
flammatory changes  in  the  coats  of  the  vessel. 

Morbid  Anatomy.  — The  middle  cerebral  branches  are  most  frequently  in- 
volved. In  my  12  cases  the  distribution  on  the  arteries  was  as  follows :  Inter- 
nal carotid,  1 ;  middle  cerebral,  5 ;  basilar,  3 ;  anterior  communicating,  3.  Ex- 
cept in  one  case  they  were  saccular  and  communicated  with  the  lumen  of  the 
vessel  by  an  orifice  smaller  than  the  circumference  of  the  sac.  In  the  154 
cases  which  make  up  the  statistics  of  Lebert,  Durand,  and  Bartholow  the  mid- 
dle cerebral  was  involved  in  44,  the  basilar  in  41,  internal  carotid  in  23,  ante- 
rior cerebral  in  14,  posterior  communicating  in  8,  anterior  communicating  in  8; 


1004  DISEASES   OF   THE    NEKVOUS    SYSTEM 

vertebral  in  7,  posterior  cerebral  in  6,  inferior  cerebellar  in  3  (Gowers).  The 
size  of  the  aneurism  varies  from  that  of  a  pea  to  that  of  a  walnut.  The  haem- 
orrhage may  be  entirely  meningeal  with  very  slight  laceration  of  the  brain 
substance,  but  the  bleeding  may  be,  as  Coats  has  shown,  entirely  within  the 
substance. 

Symptoms.- — The  aneurism  may  attain  considerable  size  and  cause  no 
symptoms.  In  a  majority  of  the  cases  the  first  intimation  is  the  rupture  and 
the  fatal  apoplexy.  Distinct  symptoms  are  most  frequently  caused  by  aneu- 
rism of  the  internal  carotid,  which  may  compress  the  optic  nerve  or  the  com- 
missure, causing  neuritis  or  paralysis  of  the  third  nerve.  A  murmur  may  be 
audible  on  auscultation  of  the  skull.  Aneurism  in  this  situation  may  give  rise 
to  irritative  and  pressure  symptoms  at  the  base  of  the  brain  or  to  hemianopia. 
In  the  remarkable  case  reported  by  Weir  Mitchell  and  Dercum  an  aneurism 
compressed  the  chiasma  and  produced  bilateral  temporal  hemianopia. 

Aneurism  of  the  vertebral  or  of  the  basilar  may  involve  the  nerves  from 
the  fifth  to  the  twelfth.  A  large  sac  at  the  termination  of  the  basilar  may 
compress  the  third  nerves  or  the  crura. 

The  diagnosis  is,  as  a  rule,  impossible.  The  larger  sacs  produce  the  symp- 
toms of  tumor,  and  their  rupture  is  usually  fatal. 

7.     ENDARTERITIS 

In  no  group  of  vessels  do  we  more  frequently  see  chronic  degenerative 
changes  than  in  those  of  the  circle  of  Willis.  The  condition  occurs  as : 

Arterio-sclerosis,  producing  localized  or  diffused  thickening  of  the  intima 
with  the  formation  of  atheromatous  patches  or  areas  of  calcification.  In  the 
later  stages,  as  seen  in  elderly  people,  the  arteries  of  the  circle  of  Willis  may  be 
dilated,  stiff,  or  almost  universally  calcified. 

Syphilitic  Endarteritis. — As  already  mentioned  under  the  section  of  syph- 
ilis, gummatous  endarteritis  is  specially  prone  to  attack  the  cerebral  vessels. 
It  has  in  itself  no  specific  characters — that  is  to  say,  it  is  impossible  in  given 
sections  to  pick  out  an  endarteritis  syphilitica  from  an  ordinary  endarteritis 
obliterans.  On  the  other  hand,  as  already  stated,  the  nodular  periarteritis 
is  never  seen  except  in  syphilis. 

8.     THROMBOSIS  OP  THE  CEREBRAL  SINUSES  AND  VEINS 

The  condition  may  be  primary  or  secondary.  Lebert  (1854)  and  Tonnele 
were  among  the  first  to  recognize  the  condition  clinically. 

Primary  thrombosis  of  the  sinuses  and  veins  is  rare.  It  occurs  (a)  in 
children,  particularly  during  the  first  six  months  of  life,  usually  in  connec- 
tion with  diarrhoea.  Gowers  believes  that  it  is  of  frequent  occurrence,  and 
that  thrombosis  of  the  veins  is  not  an  uncommon  cause  of  infantile  hemiplegia. 

(&)  In  connection  with  chlorosis  and  anaemia,  the  so-called  autochthonous 
sinus-thrombosis.  Of  82  cases  of  thrombosis  in  chlorosis,  78  were  in  the  veins 
and  32  in  the  cerebral  sinuses.  The  longitudinal  sinus  is  most  frequently 
involved.  The  thrombosis  is  usually  associated  with  venous  thromboses  in 
other  parts  of  the  body,  and  the  patients  die,  as  a  rule,  in  from  one  to  three 
weeks,  but  both  Bristowe  and  Buzzard  report  recoveries. 


AFFECTION'S    OF    THE    BLOOD   VESSELS  1005 

(e)  In  the  terminal  stages  of  cancer,  phthisis,  and  other  chronic  diseases 
thrombosis  may  gradually  occur  in  the  sinuses  and  cortical  veins.  To  the 
coagulum  developing  in  these  conditions  the  term  marantic  thrombus  is 
applied. 

Secondary  thrombosis  is  much  more  frequent  and  follows  extension  of 
inflammation  from  contiguous  parts  to  the  sinus  wall.  The  common  causes 
are  disease  of  the  internal  ear,  fracture,  compression  of  the  sinuses  by  tumor, 
or  suppurative  disease  outside  the  skull,  particularly  erysipelas,  carbuncle,  and 
parotitis.  In  secondary  cases  the  lateral  sinus  is  most  frequently  involved. 
Of  57  fatal  cases  in  which  ear  disease  caused  death  with  cerebral  lesions,  there 
were  22  in  which  thrombosis  existed  in  the  lateral  sinuses  (Pitt).  Tubercu- 
lous caries  of  the  temporal  bone  is  often  directly  responsible.  The  thrombus 
may  be  small,  or  may  fill  the  entire  sinus  and  extend  into  the  internal  jugular 
vein.  In  more  than  one  half  of  these  instances  the  thrombus  was  suppurat- 
ing. The  disease  spreads  directly  from  the  necrosis  on  the  posterior  wall  of 
the  tympanum.  According  to  Voltolini,  the  inflammation  extends  by  way  of 
the  petroso-mastoid  canal.  It  is  not  so  common  in  disease  of  the  mastoid 
cells. 

Symptoms. — Primary  thrombosis  of  the  longitudinal  sinus  may  occur  with- 
out exciting  symptoms  and  is  found  accidentally  at  the  post  mortem.  There 
may  be  mental  dullness  with  headache.  Convulsions  and  vomiting  may  occur. 
In  other  instances  there  is  nothing  distinctive.  In  the  chlorosis  cases  the  head 
symptoms  have,  as  a  rule,  been  marked.  Ball's  patient  was  dull  and  stupid, 
had  vomiting,  dilatation  of  the  pupils,  and  double  choked  disks.  Slight 
paresis  of  the  left  side  occurred.  An  interesting  feature  in  this  case  was  the 
development  of  swelling  of  the  left  leg.  In  the  cases  reported  by  Andrews, 
Church,  Tuckwell,  Isambard  Owen,  and  Wilks  the  patients  had  headache, 
vomiting,  and  delirium.  Paralysis  was  not  present.  In  Douglas  Powell's 
case,  with  similar  symptoms,  there  was  loss  of  power  on  the  left  side. 
Bristowe  reports  a  case  of  great  interest  in  an  anemic  girl  of  nine- 
teen, who  had  convulsions,  drowsiness,  and  vomiting.  Tenderness  and 
swelling  developed  in  the  position  of  the  right  internal  jugular  vein,  and  a 
few  days  later  on  the  opposite  side.  The  diagnosis  was  rendered  definite 
by  the  occurrence  of  phlebitis  in  the  veins  of  the  right  leg.  The  patient 
recovered. 

The  onset  of  such  symptoms  as  have  been  mentioned  in  an  anaemic  or 
chlorotic  girl  should  lead  to  the  suspicion  of  cerebral  thrombosis.  In  infants 
the  diagnosis  can  rarely  be  made.  Involvement  of  the  cavernous  sinus  may 
cause  oedema  about  the  eyelids  or  prominence  of  the  eyes. 

In  the  secondary  thrombi  the  symptoms  are  commonly  those  of  septi- 
caemia.. For  instance,  in  over  70  per  cent,  of  Pitt's  cases  the  mode  of  death 
was  by  pulmonary  pyaemia.  This  author  draws  the  following  important  con- 
clusions: (1)  The  disease  spreads  oftener  from  the  posterior  wall  of  the 
middle  ear  than  from  the  mastoid  cells.  (2)  The  otorrhcea  is  generally  of 
some  standing,  but  not  always.  (3)  The  onset  is  sudden,  the  chief  symp- 
toms being  pyrexia,  rigors,  pains  in  the  occipital  region  and  in  the  neck, 
associated  with  a  septicsemic  condition.  (4)  Well-marked  optic  neuritis  may 
be  present.  (5)  The  appearance  of  acute  local  pulmonary  mischief  or  of 
distant  suppuration  is  almost  conclusive  of  thrombosis.  (6)  The  average 


1006  DISEASES    OF    THE    NERVOUS    SYSTEM 

duration  is  about  three  weeks,  and  death  is  generally  from  pulmonary  pyaemia. 
The  chief  points  in  the  diagnosis  may  be  gathered  from  these  statements. 

Associated  with  thrombosis  of  the  lateral  sinus  there  may  be  venous  stasis 
and  painful  cedema  behind  the  ear  and  in  the  neck.  The  external  jugular 
vein  on  the  diseased  side  may  be  less  distended  than  on  the  opposite  side, 
since  owing  to  the  thrombus  in  the  lateral  sinus  the  internal  jugular  vein  is 
less  full  than  on  the  normal  side,  and  the  blood  from  the  external  jugular  can 
flow  more  easily  into  it. 

Treatment. — In  marantic  individuals  roborants  and  stimulants  are  in- 
dicated. The  position  assumed  in  bed  should  favor  both  the  arterial  and 
venous  circulation.  The  clothing  should  not  restrict  the  neck,  and  care  should 
be  taken  to  avoid  bending  of  the  neck.  The  internal  administration  of  potas- 
sium iodide  and  calomel  has  been  recommended  in  the  autochthonous  forms, 
but  no  treatment  is  likely  to  be  of  any  avail. 

The  secondary  forms,  especially  those  following  upon  disease  of  the  middle 
ear,  are  often  amenable  to  operation,  and,  especially  recently,  many  lives  have 
been  saved  by  surgical  intervention  after  extensive  sinus  thrombosis. 

9.     HEMIPLEGIA    IN   CHILDEEN 

Etiology. — Of  135  cases,  60  were  in  boys  and  75  in  girls.  Right  hemi- 
plegia  occurred  in  79,  left  in  56.  In  15  cases  the  condition  was  said  to  be 
congenital. 

In  a  great  majority  the  disease  sets  in  during  the  first  or  second  year; 
thus  of  the  total  number  of  cases,  95  were  under  two.  Cases  above  the  fifth 
year  are  rare,  only  10  in  my  series.  Neither  alcoholism  nor  syphilis  in  the 
parents  appears  to  play  an  important  role  in  this  affection.  Difficult  or  abnor- 
mal labor  is  responsible  for  certain  of  the  cases,  particularly  injury  with  the 
forceps.  Trauma,  such  as  falls  or  puncturing  wounds,  is  more  rare.  The 
condition  followed  ligation  of  the  common  carotid  in  one  case. 

Infectious  diseases.  All  the  authors  lay  special  stress  upon  this  factor.  In 
19  cases  in  my  series  the  disease  came  on  during  or  just  after  one  of  the  spe- 
cific fevers.  I  saw  one  case  in  which  during  the  height  of  vaccination  con- 
vulsions occurred,  followed  by  hemiplegia.  The  organism  of  anterior  polio- 
myelitis (Heine-Medin  disease)  is  probably  responsible  for  a  considerable 
share  of  the  cases.  In  a  great  majority  the  disease  sets  in  with  a  convulsion, 
in  which  the  child  may  remain  for  several  hours  or  longer,  and  after  recovery 
the  paralysis  is  noticed. 

Morbid  Anatomy. — In  an  analysis  which  I  have  made  of  90  autopsies 
reported  in  the  literature,  the  lesions  may  be  grouped  under  three  headings : 

(a)  Embolism,  thrombosis,  and  haemorrhage,  comprising  16  cases,  in  7  of 
which  there  was  blocking  of  a  Sylvian  artery,  and  in  9  haemorrhage.  A  strik- 
ing feature  in  this  group  is  the  advanced  age  of  onset.  Ten  of  the  cases 
occurred  in  children  over  six  years  old. 

(6)  Atrophy  and  sclerosis,  comprising  50  cases.  The  wasting  is  either  of 
groups  of  convolutions,  an  entire  lobe,  or  the  whole  hemisphere.  The  meninges 
are  usually  closely  adherent  over  the  affected  region,  though  sometimes  they 
look  normal.  The  convolutions  are  atrophied,  firm,  and  hard,  contrasting 
strongly  with  the  normal  gyri.  The  sclerosis  may  be  diffuse  and  widespread 


1007 

over  a  hemisphere,  or  there  may  be  nodular  projections — the  hypertrophic  scle- 
rosis. Some  of  the  cases  show  remarkable  unilateral  atrophy  of  the  hemi- 
sphere. In  one  of  my  cases  the  atrophied  hemisphere  weighed  169  grams 
and  the  normal  one  653  grams.  The  brain  tissue  may  be  a  mere  shell  over 
a  dilated  ventricle. 

(c)  Porencephalus,  which  was  present  in  24  of  the  90  autopsies.  This  term 
was  applied  by  Heschel  (1868)  to  a  loss  of  substance  in  the  form  of  cavities 
and  cysts  at  the  surface  of  the  brain,  either  opening  into  and  bounded  by  the 
arachnoid,  and  even  passing  deeply  into  the  hemisphere,  or  reaching  to  the 
ventricle.  In  the  study  by  Audrey  of  103  cases  of  porencephalus,  hemiplegia 
was  mentioned  in  68  cases. 

Practically,  then,  in  infantile  hemiplegia  cortical  sclerosis  and  porenceph- 
alus are  the  important  anatomical  conditions.  The  primary  change  in  the 
majority  of  these  cases  is  still  unknown.  Porencephalus  may  result  from  a 
defect  in  development  or  from  haemorrhage  at  birth.  The  etiology  is  clear  in 
the  limited  number  of  cases  of  haemorrhage,  embolism,  and  thrombosis,  but 
there  remains  the  large  group  in  which  the  final  change  is  sclerosis  and  atro- 
phy. What  is  the  primary  lesion  in  these  instances?  The  clinical  history 
shows  that  in  nearly  all  these  cases  the  onset  is  sudden,  with  convulsions — 
often  with  slight  fever.  Striimpell  believes  that  this  condition  is  due  to  an 
inflammation  of  the  gray  matter — poliencephalitis.  A  certain  number  of  the 
cases  represent  the  cerebral  sporadic  form  of  epidemic  polio-myeloencephalitis. 
The  clinical  picture  of  cases  described  in  the  Swedish  and  other  epidemics  is 
identical  with  that  with  which  we  are  only  too  familiar  in  this  disease. 

Symptoms. — (a)  THE  ONSET. — 'The  disease  may  set  in  suddenly  without 
spasms  or  loss  of  consciousness.  In  more  than  half  the  cases  the  child  is 
attacked  with  partial  or  general  convulsions  and  loss  of  consciousness,  which 
may  last  from  a  few  hours  to  many  days.  This  is  one  of  the  most  striking 
features  in  the  disease.  Fever  is  usually  present.  The  hemiplegia,  noticed  as 
the  child  recovers  consciousness,  is  generally  complete.  Sometimes  the  paraly- 
sis is  not  complete  at  first,  but  occurs  after  subsequent  convulsions.  The 
right  side  is  more  frequently  affected  than  the  left.  The  face  is  commonly  not 
involved. 

(&)  RESIDUAL  SYMPTOMS. — In  some  cases  the  paralysis  gradually  disap- 
pears and  leaves  scarcely  a  trace  as  the  child  grows  up.  The  leg,  as  a  rule, 
recovers  more  rapidly  and  more  fully  than  the  arm,  and  the  paralysis  may  be 
scarcely  noticeable.  In  a  majority  of  cases,  however,  there  is  a  characteristic 
hemiplegic  gait.  The  paralysis  is  most  marked  in  the  arm,  which  is  usually 
wasted ;  the  forearm  is  flexed  at  right  angles,  the  hand  is  flexed,  and  the  fingers 
are  contracted.  Motion  may  be  almost  completely  lost ;  in  other  instances  the 
arm  can  be  lifted  above  the  head.  Late  rigidity,  which  almost  always  develops, 
is  the  symptom  which  suggested  the  name  hemiplegia  spastica  cerebralis  to 
Heine,  the  orthopaedic  surgeon,  who  first  accurately  described  these  cases.  It 
is,  however,  not  constant.  The  limbs  may  be  quite  relaxed  even  years  after 
the  onset.  The  reflexes  are  usually  increased.  In  several  instances,  however, 
I  have  known  them  to  be  absent.  Sensation,  as  a  rule,  is  not  disturbed. 

Aphasia  is  a  not  uncommon  symptom,  and  occurred  in  16  cases  of  my 
series. 

Mental  Defects. — One  of  the  most  serious  consequences  of  infantile  hemi- 


1008  DISEASES    OF    THE    NERVOUS    SYSTEM 

plegia  is  the  failure  of  mental  development.  A  considerable  number  of  these 
cases  drift  into  the  institutions  for  feeble  minded  children.  Three  grades 
may  be  distinguished — idiocy,  which  is  most  common  when  the  hemiplegia 
has  existed  from  birth;  imbecility,  which  often  increases  with  the  develop- 
ment of  epilepsy;  and  feeble  mindedness,  a  retarded  rather  than  an  arrested 
development. 

Epilepsy. — Of  the  cases  in  my  series,  41  were  subject?  of  convulsive  seiz- 
ures, one  of  the  most  distressing  sequels  of  the  disease.  The  seizures  may  be 
either  transient  attacks  of  petit  mal,  true  Jacksonian  fits,  beginning  in  and 
confined  to  the  affected  side,  or  general  convulsions. 

Post-hemiplegic  Movements. — It  was  in  cases  of  this  sort  that  Weir 
Mitchell  first  described  the  post-hemiplegic  movements.  They  are  extremely 
common,  and  were  present  in  34  of  my  series.  There  may  be  either  slight 
tremor  in  the  affected  muscles,  or  incoordinate  choreiform  movements — the 
so-called  post-hemiplegic  chorea — or,  lastly, 

Athetosis. — In  this  condition,  described  by  Hammond,  there  are  remark- 
able spasms  of  the  paralyzed  extremities,  chiefly  of  the  fingers  and  toes,  and 
in  rare  instances  of  the  muscles  of  the  mouth.  The  movements  are  involun- 
tary and  somewhat  rhythmical ;  in  the  hand,  movements  of  adduction  or  abduc- 
tion and  of  supination  and  pronation  follow  each  other  in  orderly  sequence. 
There  may  be  hyperextension  of  the  fingers,  during  which  they  are  spread 
wide  apart.  This  condition  is  much  more  frequent  in  children  than  in  adults. 
In  the  latter  it  may  be  combined  with  hemianaesthesia,  and  the  lesion  is  not 
cortical,  but  basic,  in  the  neighborhood  of  the  thalamus.  The  movements  are 
sometimes  increased  by  emotion.  They  usually  persist  during  sleep. 

Treatment.' — The  possibility  of  injury  to  the  brain  in  protracted  labor  and 
in  forceps  cases  should  be  borne  in  mind  by  the  practitioner.  The  former 
entails  the  greater  risk.  In  infantile  hemiplegia  the  physician  at  the  outset 
sees  a  case  of  ordinary  convulsions,  perhaps  more  protracted  and  severe  than 
usual.  These  should  be  checked  as  rapidly  as  possible  by  the  use  of  the 
bromides,  the  application  of  cold  or  heat,  and  a  brisk  purge.  During  convul- 
sions chloroform  may  be  administered  with  safety  even  to  the  youngest  chil- 
dren. When  the  paralysis  is  established  not  much  can  be  hoped  from  medi- 
cines. In  only  rare  instances  does  the  paralysis  entirely  disappear.  When  the 
recovery  is  partial  the  "residual  paralysis"  is  similar  to  that  seen  in  other 
lesions  of  the  upper  motor  segment.  Thus  in  the  lower  extremity  it  is  the 
flexors  of  the  leg  and  the  dorsal  flexors  of  the  foot  which  are  most  often  per- 
manently paralyzed  (Wernicke).  The  indications  are  to  favor  the  natural 
tendency  to  improve  by  maintaining  the  general  nutrition  of  the  child,  to 
lessen  the  rigidity  and  contractures  by  massage  and  passive  motion,  and  if 
necessary  to  correct  deformities  by  mechanical  or  surgical  measures.  Much 
may  be  done  by  careful  manipulation  and  rubbing  and  the  application  of  a 
proper  apparatus.  In  children  the  aphasia  usually  disappears.  The  epi- 
lepsy is  a  distressing  and  obstinate  symptom,  for  which  a  cure  can  rarely  be 
anticipated.  Prolonged  periods  of  quiescence  are,  however,  not  uncommon.  In 
the  Jacksonian  fits  the  bromides  rarely  do  good,  unless  there  is  much  irritabil- 
ity and  excitement.  Operative  measures  in  favorable  cases  of  this  particular 
form  of  epilepsy  may  often  prove  beneficial  in  reducing  the  number  and  sever- 
ity of  the  seizures,  but  it  is  very  unusual  for  them  to  be  completely  or  per- 


TUMORS,    INFECTIONS,    GRAXULOMATA,    ETC.          1009 

manently  checked.  The  liability  to  feeble  mindedness  is  the  most  serious 
outlook  in  the  infantile  cerebral  palsies.  In  many  cases  the  damage  is  irrep- 
arable, and  idiocy  and  imbecility  result.  With  patient  training  and  with 
care  many  of  the  children  reach  a  fair  measure  of  intelligence  and  self-reliance. 


IV.     TUMORS,    INFECTIONS,    GRANULOMATA,    AND    CYSTS    OF 

THE    BRAIN 

The  following  are  the  most  common  varieties  of  new  growths  within  the 
cranium : 

Infectious  Granulomata.  —  (a)  Tubercle,  which  may  form  large  or  small 
growths,  usually  multiple.  Tuberculosis  of  the  glands  or  bones  may  be  co- 
existent, but  the  tuberculous  disease  of  the  brain  may  occur  in  the  absence 
of  other  clinically  recognizable  tuberculous  lesions.  The  disease  is  most  fre- 
quent early  in  life.  Three-fourths  of  the  cases  occur  under  twenty,  and  one- 
half  of  the  patients  are  under  ten  years  of  age  (Gowers).  Of  300  cases  of 
tumor  in  persons  under  nineteen  collected  from  various  sources  by  Starr,  152 
were  tubercle.  The  nodules  are  most  numerous  in  the  cerebellum  and  about 
the  base. 

(&)  Syphiloma  is  most  commonly  found  on  the  cortex  cerebri  or  about  the 
pons.  The  tumors  are  superficial,  attached  to  the  arteries  or  the  meninges, 
and  rarely  grow  to  a  large  size,  although  they  may  do  so.  They  may  be 
multiple.  A  gummatous  meningitis  of  the  base  is  common  and  in  this  process 
the  oculomotor  nerves  are  often  affected.  The  motor  nerves  of  the  eye  are 
particularly  prone  to  syphilitic  infiltration,  and  ptosis  and  the  ordinary  forms 
of  squint  are  common.  It  is  common  for  the  pituitary  body  to  be  involved  with 
symptoms  suggestive  of  diabetes  insipidus. 

Tumors. — (c)  Glioma  and  Neuroglioma. — These  vary  greatly  in  appear- 
ance. They  may  be  firm  and  hard,  almost  like  an  area  of  sclerosis,  and  are  not 
sharply  denned  from  the  surrounding  brain  substance.  They  may  be  soft  and 
very  vascular,  and  haemorrhages  are  common.  They  persist  remarkably  for 
many  years.  Klebs  has  called  attention  to  the  occurrence  of  elements  in  them 
not  unlike  ganglion-cells.  Tumors  of  this  character  may  contain  the  "Spin- 
nen"  or  spider  cells;  enormous  spindle-shaped  cells  with  single  large  nuclei; 
cells  like  the  ganglion-cells  of  nerve-centres  with  nuclei  and  one  or  more  proc- 
esses ;  and  translucent,  band-like  fibres,  tapering  at  each  end,  which  result  from 
a  vitreous  or  hyaline  transformation  of  the  large  spindle-cells.  A  separate 
type  is  also  recognizable,  in  which  the  cells  resemble  the  ependymal  epithelium. 

(d)  Fibrosarcoma   (endothelioma)   occurs  most  commonly  in  the  mem- 
branes covering  the  hemispheres  or  brain  stem,  and  for  a  long  time  may  cause 
injury  by  its  compression  effects  alone.    Tumors  of  this  kind  are  particularly 
common  in  the  cerebello-pontine  recess.     When  sarcoma  originates  in  the 
brain  substance  it  may  become  one  of  the  largest  and  most  diffusely  infiltrating 
of  intracranial  growths.     When  meningeal  in  origin,  it  is  the  form  of  tumor 
most  amenable  to  surgical  treatment. 

(e)  Carcinoma  not  infrequently  is  secondary  to  cancer  in  other  parts.     It 
is  seldom  primary.     Occasionally  cancerous  tumors  have  been  found  in  sym- 
metrical parts  of  the  brain. 


1010  DISEASES    OF   THE    NEEVOUS    SYSTEM 

(/)  Other  varieties  occur,  such  as  fibroid  growths,  which  usually  develop 
from  the  membranes;  bony  tumors,  which  grow  sometimes  from  the  falx, 
psammona,  cholesteatoma,  and  angioma.  Fatty  tumors  are  occasionally  found 
on  the  corpus  callosum. 

Cysts. — These  occur  between  the  membranes  and  the  brain,  as  a  result  of 
haemorrhage  or  of  softening.  Porencephalus  is  a  sequel  of  congenital  atrophy 
or  of  haemorrhage,  or  may  be  due  to  a  developmental  defect.  Hydatid  cysts  have 
been  referred  to  in  the  section  on  parasites.  An  interesting  variety  of  cyst  is 
that  which  follows  severe  injury  to  the  skull  in  early  life.  Gliomata  often 
undergo  cystic  degeneration.  Dermoid  cyst  has  been  described. 

Site. — A  majority  of  all  tumors  occur  in  the  cerebrum  and  especially  in 
the  centrum  ovale.  The  cerebellum,  pons,  and  membranes  are  next  most  often 
involved.  Glioma  is  more  common  in  the  hemispheres  and  grows  slowly.  It 
is  usually  single.  Tubercles  are  usually  multiple.  Secondary  sarcoma  and 
carcinoma  are  often  mutiple. 

Symptoms. — GENERAL. — The  following  are  the  most  important:  Head- 
ache., either  dull,  aching,  and  continuous,  or  sharp,  stabbing,  and  paroxysmal. 
It  may  be  diffused  over  the  entire  head;  sometimes  it  is  limited  to  the  back 
or  front.  When  in  the  back  of  the  head  it  may  extend  down  the  neck 
(especially  in  tumors  in  the  posterior  fossa),  and  when  in  the  front  it  may 
be  accompanied  with  neuralgic  pains  in  the  face.  Occasionally  the  pain  may 
be  very  localized  and  associated  with  tenderness  on  pressure. 

Choked  disk  (optic  neuritis)  occurs  in  four  fifths  of  all  the  cases  (Gowers). 
It  should  be  looked  for  in  every  patient  presenting  cerebral  symptoms,  for  it 
may  be  present  in  high  degree  without  impairment  of  vision.  Loss  of  visual 
acuity  usually  indicates  that  optic  atrophy  has  set  in.  It  is  usually  double, 
but  occasionally  is  found  in  only  one  eye.  A  growth  may  develop  slowly  and 
attain  considerable  size  without  producing  optic  neuritis.  On  the  other  hand, 
it  may  occur  with  a  very  small  tumor,  when  this  tumor  is  so  situated  as  to 
cause  internal  hydrocephalus.  J.  A.  Martin,  from  an  extensive  analysis  of  the 
literature  with  reference  to  the  localizing  value,  concludes:  When  there  is  a 
difference  in  the  amount  of  the  neuritis  in  each  eye  it  is  more  than  twice  as 
probable  that  the  tumor  is  on  the  side  of  the  most  marked  neuritis.  It  is  con- 
stant in  tumors  of  the  corpora  quadrigemina,  present  in  89  per  cent,  of  cere- 
bellar  tumors,  and  absent  in  nearly  two  thirds  of  the  cases  of  tumor  of  the 
pons,  medulla,  and  of  the  corpus  callosum.  It  is  least  frequent  in  cases  of 
tuberculous  tumor;  most  common  in  cases  of  glioma  and  cystic  tumors. 

Paton  and  Holmes,  who  reported  upon  the  eyes  of  700  cases  of  cerebral 
tumor,  concluded  that  the  essential  feature  of  the  associated  optic  neuritis  is 
oadema,  and  in  60  eyes  examined  histologically  the  one  unfailing  change  was 
acute  oedema,  the  origin  of  which  they  attribute  to  the  venous  engorgement. 

Vomiting  is  a  common  feature  and,  with  headache  and  optic  neuritis, 
makes  up  the  characteristic  clinical  picture  of  cerebral  tumor.  An  important 
point  is  the  absence  of  definite  relation  to  the  meals.  A  chemical  examination 
shows  that  the  vomiting  is  independent  of  digestive  disturbances.  It  may 
be  very  obstinate,  particularly  in  growths  of  the  cerebellum  and  the  pons. 

Giddiness  is  often  an  early  symptom.  The  patient  complains  of  vertigo 
on  rising  suddenly  or  on  turning  quickly. 

Mental  Disturbance. — The  patient  may  act  in  an  odd,  unnatural  manner, 


TUMORS,    INFECTIONS,    GRANULOMATA,    ETC.          1011 

or  there  may  be  stupor  and  heaviness.  The  patient  may  become  emotional 
or  silly,  or  there  are  symptoms  resembling  hysteria. 

Convulsions,  either  general  and  resembling  true  epilepsy  or  localized  ( Jack- 
sonian)  in  character.  Seizures  beginning  with  a  gustatory  or  olfactory  aura 
are  particularly  common  with  tumors  originating  in  the  infundibular  region. 
There  may  be  slowing  of  the  pulse,  as  in  all  cases  of  increased  intracranial 
pressure. 

LOCALIZING  SYMPTOMS. — Focal  symptoms  often  occur,  but  it  must  not  be 
forgotten  that  these  may  be  indirectly  produced.  The  smaller  the  tumor  and 
the  less  marked  the  general  symptoms  of  cerebral  compression  the  more  likely 
is  it  that  any  focal  symptoms  occurring  are  of  direct  origin. 

(a)  Central  Motor  Area. — The  symptoms  are  either  irritative  or  destruc- 
tive in  character.  Irritation  in  the  lower  third  may  produce  spasm  in  the 
/•muscles  of  the  face,  in  the  angle  of  the  mouth,  or  in  the  tongue.  The  spasm 
with  tingling  may  be  strictly  limited  to  one  muscle  group  before  extending  to 
others,  and  this  Seguin  terms  the  signal  symptom.  The  middle  third  of  the 
motor  area  contains  the  centres  controlling  the  arm,  and  here,  too,  the  spasm 
may  begin  in  the  fingers,  in  the  thumb,  in  the  muscles  of  the  wrist,  or  in  the 
shoulder.  In  the  upper  third  of  the  motor  areas  the  irritation  may  produce 
spasm  beginning  in  the  toes,  in  the  ankles,  or  in  the  muscles  of  the  leg.  In 
many  instances  the  patient  can  determine  accurately  the  point  of  origin  of 
the  spasm,  and  there  are  important  sensory  disturbances,  such  as  numbness 
and  tingling,  which  may  be  felt  first  at  the  region  affected. 

In  all  cases  it  is  important  to  determine,  first,  the  point  of  origin,  the 
signal  symptom;  second,  the  order  or  march  of  the  spasm;  and  third,  the 
subsequent  condition  of  the  parts  first  affected,  whether  it  is  a  state  of  paresis 
or  anaesthesia. 

Destructive  lesions  in  the  motor  zone  cause  paralysis,  which  is  often  pre- 
ceded by  local  convulsive  seizures ;  there  may  be  a  monoplegia,  as  of  the  leg, 
and  convulsive  seizures  in  the  arm,  often  due  to  irritation  in  these  centres. 
Tumors  in  the  neighborhood  of  the  motor  area  may  cause  localized  spasms  and 
subsequently,  as  the  centres  are  invaded  by  the  growth,  paralysis  occurs.  When 
tumors  are  situated  in  the  left  hemisphere  the  speech  mechanism  is  apt  to  be 
involved  if  the  transverse  temporal  gyrus  or  the  third  frontal  convolution  and 
their  connecting  path  are  implicated. 

(&)  Prefrontal  Region. — Neither  motor  nor  sensory  disturbance  may  be 
present.  The  general  symptoms  are  often  well  marked.  The  most  striking 
feature  of  growths  in  this  region  is  mental  torpor  and  gradual  imbecility. 
Particularly  when  the  left  side  is  involved  mental  characteristics  may  be 
greatly  altered.  In  its  extension  downward  the  tumor  may  involve  on  the  left 
side  the  lower  frontal  convolution  and  produce  aphasia,  or  in  its  progress 
backward  cause  irritative  or  destructive  lesions  of  the  motor  area.  Exophthal- 
mos  on  the  side  of  the  tumor  may  occur  and  be  helpful  in  diagnosis. 

(c)  Tumors  in  the  parieto-occipital  lobe,  particularly  on  the  right  side,  may 
grow  to  a  large  size  without  causing  any  symptoms.     There  may  be  word- 
blindness  and  mind-blindness  when  the  left  angular  gyrus  and  its -underlying 
white  matter  are  involved,  and  paraphasia.     Astereognosis  may  accompany 
growths  in  the  superior  parietal  region. 

(d)  Tumors  of  the  occipital  lobe  produce  hemianopia,  and  a  bilateral 


1012  DISEASES    OF    THE    NERVOUS    SYSTEM 

lesion  may  produce  blindness.  Tumors  in  this  region  on  the  left  hemisphere 
may  be  associated  with  word-blindness  and  mind-blindness.  In  all  cases  of 
tumor  a  careful  study  should  be  made  of  the  fields  of  vision.  In  addition  to 
the  lateral  hemianopia  there  may  be  remarkable  visual  hallucinations,  and  in 
tumors  of  the  left  occipital  lobe  dissociation  of  the  color  sense  and  inability 
to  find  the  proper  colors  of  various  objects  presented. 

(e)  Tumors  in  the  temporal  lobe  may  attain  a  large  size  without  produc- 
ing symptoms.  In  their  growth  they  involve  the  lower  motor  centres.  On 
the  left  side  involvement  of  the  transverse  temporal  gyri  (auditory  sense  area) 
may  be  associated  with  word-deafness. 

(/)  Tumors  growing  in  the  neighborhood  of  the  basal  ganglia  produce 
hemiplegia  from  involvement  of  the  internal  capsule.  Limited  growths  in 
either  the  nucleus  caudatus  or  the  nucleus  lentiformis  of  the  corpus  striatum 
do  not  necessarily  cause  paralysis.  Tumors  in  the  thalamus  opticus  may 
also,  when  small,  cause  no  symptoms,  but,  increasing,  they  may  involve  the 
fibres  of  the  sensory  portion  of  the  internal  capsule,  producing  hemianopia 
and  sometimes  hemiansesthesia.  Growths  in  this  situation  are  apt  to  cause 
early  optic  neuritis,  and,  growing  into  the  third  ventricle,  may  cause  a  dis- 
tention  of  the  lateral  ventricles.  What  has  been  termed  the  thalamic  syndrome 
may  be  present — hemianaesthesia  to  pain,  touch  and  temperature,  with  the 
loss  of  deep  sensibility.  With  this  there  may  be  a  very  remarkable  type  of 
pain,  involving  the  hand  and  arm  and  the  foot  and  leg,  on  the  affected  side, 
a  sense  of  burning  discomfort  rather  than  sharp  pain.  Ataxic  features  are 
usually  present  and  astereognosis.  Motor  hemiplegia  may  be  present,  and 
it  is  unaccompanied  by  contractures  (Dana). 

Growths  in  the  corpora  quadrigemina  are  rarely  limited,  but  most  com- 
monly involve  the  crura  cerebri  as  well.  Ocular  symptoms  are  marked.  The 
pupil  reflex  is  lost  and  there  is  nystagmus.  In  the  gradual  growth  the  third 
nerve  is  involved  as  it  passes  through  the  crus,  in  which  case  there  will  be 
oculo-motor  paralysis  on  one  side  and  hemiplegia  on  the  other,  a  combination 
almost  characteristic  of  unilateral  disease  of  the  crus. 

(g)  Tumors  of  the  pons  and  medulla.  The  symptoms  are  chiefly  those 
of  pressure  upon  the  nerves  emerging  in  this  region.  In  disease  of  the  pons 
the  nerves  may  be  involved  alone  or  with  the  pyramidal  tract.  Of  52  cases 
analyzed  by  Mary  Putnam  Jacobi,  there  were  13  in  which  the  cerebral  nerves 
were  involved  alone,  13  in  which  the  limbs  were  affected,  and  26  in  which 
there  were  hemiplegia  and  involvement  of  the  nerves.  Twenty-two  of  the  latter 
had  what  is  known  as  alternate  paralysis — i.  e.,  involvement  of  the  nerves  on 
one  side  and  of  the  limbs  on  the  opposite  side.  In  4  cases  there  were  no  motor 
symptoms.  In  tuberculosis  (or  syphilis)  a  growth  at  the  inferior  and  inner 
aspects  of  the  crus  may  cause  paralysis  of  the  third  nerve  on  one  side,  and  of 
the  face,  tongue,  and  limbs  on  the  opposite  side  (syndrome  of  Weber).  A 
tumor  growing  in  the  lower  part  of  the  pons  usually  involves  the  sixth  nerve, 
producing  internal  strabismus,  the  seventh  nerve,  producing  facial  paralysis, 
and  the  auditory  nerve,  causing  deafness.  Conjugate  deviation  of  the  eyes 
to  the  side  opposite  that  on  which  there  is  facial  paralysis  also  occurs.  When 
the  motor  cerebral  nerves  are  involved  the  paralyses  are  of  the  peripheral 
type  (lower  segment  paralyses). 

Tumors  of  the  medulla  may  involve  the  cerebral  nerves  alone  or  cause 


TUMORS,   INFECTIONS,   GRANtJLOMATA,   ETC.         1013 

in  some  instances  a  combination  of  hemiplegia  with  paralysis  of  the  nerves. 
Paralyses  of  the  nerves  are  helpful  in  topical  diagnosis,  but  the  fact  must  not 
be  overlooked  that  one  or  more  of  the  cerebral  nerves  may  be  paralyzed  as 
a  result  of  a  much  increased  general  intraCranial  pressure.  Signs  of  irritation 
in  the  ninth,  tenth,  and  eleventh  nerves  are  usually  present,  and  produce 
difficulty  in  swallowing,  irregular  action  of  the  heart,  irregular  respiration, 
vomiting,  and  sometimes  retraction  of  the  head  and  neck.  The  hypoglossal 
nerve  is  least  often  affected.  The  gait  may  be  unsteady  or,  if  there  is  pressure 
on  the  cerebellum,  ataxic.  Occasionally  there  are  sensory  symptoms,  numb- 
ness, and  tingling.  Toward  the  end  convulsions  may  occur. 

(h)  Tumors  of  the  cerebellum  may  be  latent,  but  they  usually  give  rise  to 
very  characteristic  symptoms,  headache  in  the  occipital  region,  giddiness,  inco- 
ordination,  but  there  is  nothing  definite  in  the  direction  of  the  swaying,  and 
early  optic  neuritis.  They  may  be  intracerebellar  or  extracerebellar. 

Tumors  or  enlargements  of  the  pituitary  gland  itself,  or  growths  from  a 
congenital  anlage  in  its  neighborhood  which  implicate  the  pituitary  gland 
secondarily,  are  very  common.  The  congenital  tumors  arise  presumably  from 
developmental  faults,  and  show  either  a  teratomatous  character  or  are  solid 
or  cystic  tumors  with  squamous  epithelium,  often  attaining  adamantine  char- 
acteristics. The  most  common  tumor  is  a  so-called  struma  (malignant 
adenoma)  of  the  gland  proper.  There  are  characteristic  signs  of  pressure 
upon  the  neighborhood  structures,  bitemporal  hemianopia  being  a  frequent 
though  not  invariable  feature.  These  lesions  may  occur  in  patients  who  have 
suffered  from  acromegaly,  or  in  those  who  show  signs  of  glandular  deficiency 
or  dyspituitarism,  and  in  whom  there  may  or  may  not  be  suggestive  acrome- 
galic  tendencies.  The  X-rays  are  most  useful  in  diagnosis. 

Diagnosis.  — From  the  general  symptoms  alone  the  existence  of  tumor  may 
be  determined,  for  the  combination  of  headache,  optic  neuritis,  and  vomiting 
is  distinctive.  As  pointed  out  by  R.  T.  Williamson,  progressive  hemiplegia, 
without  other  symptoms,  a  paralysis,  which  gradually  becomes  more  marked 
day  by  day  and  week  by  week,  is  almost  pathognomic,  even  in  the  absence  of 
optic  neuritis,  headache,  and  vomiting.  The  two  exceptions  to  this  rule  appear 
to  be  in  cerebral  abscess,  and  in  rare  instances  a  polioencephalitis.  It  must 
not  be  forgotten  that  severe  headache  and  neuro-retinitis  may  be  caused  by 
Bright's  disease.  The  localization  must  be  gathered  from  the  consideration 
of  the  symptoms  above  detailed  and  from  the  data  given  in  the  section  on 
Topical  Diagnosis  of  Diseases  of  the  Brain.  Mistakes  are  most  likely  to 
occur  in  connection  with  uraemia,  hysteria,  .vascular  lesions,  abscess,  serous 
meningitis,  hydrocephalus,  and  general  paralysis;  but  careful  consideration 
of  all  the  circumstances  of  the  case  usually  enables  the  practitioner  to  avoid 
error. 

Prognosis. — 'Syphilitic  tumors  alone  are  amenable  to  medical  treatment. 
Tuberculous  growths  occasionally  cease  to  grow  and  become  calcified.  The 
gliomata  and  fibromata,  particularly  when  the  latter  grow  from  the  membranes, 
may  last  for  years.  I  have  described  a  case  of  small,  hard  glioma,  in  which 
the  Jacksonian  epilepsy  persisted  for  fourteen  years.  Hughlings  Jackson  has 
reported  cases  of  glioma  in  which  the  symptoms  lasted  for  over  ten  years.  The 
more  rapidly  growing  sarcomata  usually  prove  fatal  in  from  six  to  eighteen 
months.  Death  may  be  sudden,  particularly  in  growths  near  the  medulla; 


1014  DISEASES    OF   THE    NERVOUS    SYSTEM 

more  commonly  it  is  due  to  coma  in  consequence  of  gradual  increase  in  the 
intracranial  pressure. 

Treatment. — (a)  MEDICAL. — A  Wassermann  test  of  the  blood  and  cere- 
brospinal  fluid  should  always  be  made  before  antiluetic  measures  are  insti- 
tuted. It  must  not  be  overlooked  that  vigorous  treatment  with  potassium 
iodide  often  causes  a  temporary  amelioration  of  pressure  symptoms  due  to  a 
glioma,  so  that  the  therapeutic  test  is  not  entirely  a  dependable  one.  If  syphilis 
is  proved  the  iodide  of  potassium  and  mercury  should  be  given.  Salvarsan  is 
sometimes  given  in  repeated  small  doses.  Nowhere  do  we  see  more  brilliant 
therapeutical  effects  than  in  certain  cases  of  cerebral  gummata.  The  iodide 
should  be  given  in  increasing  doses.  In  tuberculous  tumors  the  outlook  is  less 
favorable,  though  instances  of  cure  are  reported,  and  there  is  post  mortem 
evidence  to  show  that  the  solitary  tuberculous  tumors  may  undergo  changes 
and  become  obsolete.  A  general  tonic  treatment  is  indicated  in  these  cases. 
The  headache  usually  demands  prompt  treatment.  The  iodide  of  potassium 
in  full  doses  sometimes  gives  marked  relief.  An  ice-cap  for  the  head  or,  in 
the  occipital  headache,  the  application  of  the  Paquelin  cautery  may  be  tried. 
The  bromides  are  not  of  much  use  in  the  headache  from  this  cause,  and,  as 
the  last  resort,  morphia  must  be  given.  For  the  convulsions  bromide  of 
potassium  is  of  little  service. 

(&)  SURGICAL. — Scores  of  tumors  of  the  brain  have  now  been  successfully 
removed.  Though  the  percentage  of  cases  in  which  total  enucleation  is  pos- 
sible is  doubtless  small,  yet  in  all  cases  marked  amelioration  of  the  pressure 
symptoms  is  possible  by  modern  surgical  measures.  It  is  important  that  they 
should  be  instituted  early,  even  in  the  absence  of  localizing  symptoms,  for 
the  sake  of  preserving  vision.  The  most  advantageous  cases  are  the  localized 
fibromata  and  sarcomata  growing  from  the  dura  and  only  compressing  the 
brain  substance.  Of  late  years  there  have  been  numerous  successful  operations 
with  removal  of  growths  from  the  cerebellum  and  cerebello-pontine  recess. 
The  safety  with  which  the  exploratory  operation  can  be  made  warrants  it  in  all 
doubtful  cases.  For  two  objects  the  so-called  decompression  operation  may 
be  performed,  to  relieve  the  headache,  which  it  sometimes  does  promptly  and 
permanently,  and  to  save  sight.  It  is  now  very  generally  practised  by  sur- 
geons, and  the  reduction  of  the  greatly  increased  intracranial  pressure  may 
cause  the  choked  disk  to  subside  and  the  risk  of  subsequent  atrophy  is  much 
diminished. 

V.    INFLAMMATION   OF   THE    BRAIN 

1.     ACUTE  ENCEPHALITIS 

A  focal  or  diffuse  inflammation  of  the  brain  substance,  usually  of  the  gray 
matter  (poliencephalitis),  is  met  with  (a)  as  a  result  of  trauma;  (&)  in  cer- 
tain intoxications,  alcohol,  food  poisoning,  and  gas  poisoning;  (c)  follow- 
ing the  acute  infections;  and  (d)  as  one  of  the  varieties  of  the  poliomyelo- 
encephalitis  (Heine-Medin  disease).  The  anatomical  features  are  those  of  an 
acute  hasmorrhagic  poliencephalitis,  corresponding  in  histological  details  with 
acute  polio-myelitis.  Focal  forms  are  seen  in  ulcerative  endocarditis,  in  which 
the  gray  matter  may  present  deeply  haemorrhagic  areas,  firmer  than  the  sur- 


1015 

rounding  tissue.  In  the  fevers  there  may  be  more  extensive  regions,  involving 
two  or  three  convolutions.  This  acute  haemorrhagic  poliencephalitis  superior 
is  thought  by  Striimpell  to  be  the  essential  lesion  in  infantile  hemiplegia,  and* 
it  seems  probable  that  many  of  the  cases  represent  the  sporadic  form  (cere- 
bral variety  of  the  Heine-Medin  disease).  Localizing  symptoms  are  usually 
present,  though  they  may  be  obscured  in  the  severity  of  the  general  infection. 
The  most  typical  encephalitis  accompanies  the  meningitis  in  cerebro-spinal 
fever. 

In  acute  mania,  in  delirium  tremens,  in  chorea  insaniens,  in  the  maniacal 
form  of  exophthalmic  goitre,  and  in  the  so-called  cerebral  forms  of  the  malig- 
nant fevers  the  gray  cortex  is  deeply  congested,  moist,  and  swollen,  and  with 
the  recent  finer  methods  of  research  will  probably  show  changes  which  may 
be  classed  as  encephalitis. 

The  symptoms  are  not  very  definite.  In  severe  forms  they  are  those  of 
an  acute  infection;  some  cases  have  been  mistaken  for  typhoid  fever.  The 
onset  may  be  abrupt  in  an  individual  apparently  healthy.  Other  cases  have 
occurred  in  the  convalescence  from  the  fevers,  particularly  influenza.  One  of 
J.  J.  Putnam's  cases  followed  mumps.  The  general  symptoms  are  those  which 
accompany  all  severe  acute  affections  of  the  brain — headache,  somnolence, 
coma,  delirium,  vomiting,  etc.  The  local  symptoms  are  very  varied,  depend- 
ing on  the  extent  of  the  lesions,  and  may  be  irritative  or  paralytic.  Usually 
fatal  within  a  few  weeks,  cases  may  drag  on  for  weeks  or  months  and  recover, 
generally  with  paralysis. 

2.     ABSCESS    OF   THE    BEAIN 

Definition. — Purulent  encephalitis  with  abscess  formation  the  result  of 
infection  by  micro-organisms. 

Etiology. — Suppuration  of  the  brain  substance  is  rarely  if  ever  primary, 
but  results,  as  a  rule,  from  extension  of  inflammation  from  neighboring  parts 
or  infection  from  a  distance  through  the  blood.  The  question  of  idiopathic 
brain  abscess  need  scarcely  be  considered,  though  occasionally  instances  occur 
in  which  it  is  extremely  difficult  to  assign  a  cause.  There  are  three  important 
etiological  factors. 

(a)  Trauma.  Falls  upon  the  head  or  blows,  with  or  without  abrasion  of 
the  skin.  More  commonly  it  follows  fracture  or  punctured  wounds.  In  this 
group  meningitis  is  frequently  associated  with  the  abscess.  As  Bergmann  says, 
simple  trauma  or  concussion  can  never  produce  abscess  but  organisms  may 
enter  through  a  laceration  of  the  base  opening  one  of  the  many  sinuses. 

(&)  By  far  the  most  important  infective  foci  are  those  which  arise  in 
direct  extension  from  disease  of  the  middle  ear,  of  the  mastoid  cells,  or  of  the 
frontal  sinuses.  From  the  roof  of  the  -mastoid  antrum  the  infection  readily 
passes  to  the  sigmoid  sinus  and  induces  an  infective  thrombosis.  In  other 
instances  the  dura  becomes  involved,  and  a  subdural  abscess  is  formed,  which 
may  readily  involve  the  arachnoid  or  the  pia  mater.  In  another  group  the 
inflammation  extends  along  the  lymph  spaces,  or  the  thrombosed  veins,  into 
the  substance  of  the  brain  and  causes  suppuration.  Macewen  thinks  that  with- 
out local  areas  of  meningitis  the  infective  agents  may  be  carried  through  the 
lymph  and  blood  channels  into  the  cerebral  substance.  Infection  which  ex- 


1016  DISEASES    OF    THE    NERVOUS    SYSTEM 

tends  from  the  roof  of  the  tympanic  cavity  is  most  likely  to  be  followed  by 
abscess  in  the  temporal  lobe,  while  infection  extending  from  the  mastoid  cells 
•causes  most  frequently  sinus  thrombosis  and  cerebellar  abscess. 

(c)  In  septic  processes.  Abscess  of  the  brain  is  not  often  found  in  pyae- 
mia. In  ulcerative  endocarditis  multiple  foci  of  suppuration  are  common. 
Localized  bone  disease  and  suppuration  in  the  liver  are  occasional  causes.  Cer- 
tain inflammations  in  the  lungs,  particularly  bronchiectasis,  as  already  referred 
to  in  connection  with  Schorstein's  researches,  may  be  followed  by  abscess.  It 
is  an  occasional  complication  of  empyema.  Abscess  of  the  brain  may  follow 
the  specific  fevers.  Bristowe  has  called  attention  to  its  occurrence  as  a  sequel 
of  influenza.  The  largest  number  of  cases  occur  between  the  twentieth  and 
fortieth  years,  and  the  condition  is  more  frequent  in  men  than  in  'women. 
Holt  has  collected  25  cases  in  children  under  five  years  of  age,  the  chief  causes 
of  which  were  otitis  media  and  trauma. 

Morbid  Anatomy. — The  abscess  may  be  solitary  or  multiple,  diffuse  or  cir- 
cumscribed. Practically  any  one  of  the  different  varieties  of  pyogenic  bac- 
teria may  be  concerned.  The  bacteriological  examination  often  shows  a  mix- 
ture of  different  varieties.  Occasionally  cultures  are  sterile,  owing  to  death 
•)f  the  bacteria.  In  the  acute,  rapidly  fatal  cases  following  injury  the  suppura- 
tion is  not  limited;  but  in  long  standing  cases  the  abscess  is  inclosed  in  a 
definite  capsule,  which  may  have  a  thickness  of  from  2  to  5  mm.  The  pus 
varies  much  in  appearance,  depending  upon  the  age  of  the  abscess.  In  early 
cases  it  may  be  mixed  with  reddish  debris  and  softened  brain  matter,  but  in 
the  solitary  encapsulated  abscess  the  pus  is  distinctive,  having  a  greenish  tint, 
•in  acid  reaction,  and  a  peculiar  odor,  sometimes  like  that  of  sulphuretted 
hydrogen.  The  brain  substance  surrounding  the  abscess  is  usually  cedematous 
and  infiltrated.  The  size  varies  from  that  of  a  walnut  to  that  of  a  large 
orange.  There  are  cases  on  record  in  which  the  cavity  has  occupied  the  greater 
portion  of  a  hemisphere.  Multiple  abscesses  are  usually  small.  In  four  fifths 
of  all  cases  the  abscess  is  solitary.  Suppuration  occurs  most  frequently  in  the 
cerebrum,  and  the  temporal  lobe  is  more  often  involved  than  other  parts,  and 
always  on  the  side  of  the  ear  disease.  The  cerebellum  is  the  next  most  com- 
mon seat,  particularly  in  connection  with  ear  disease. 

Symptoms. — Following  injury  or  operation  the  disease  may  run  an  acute 
course,  with  fever,  headache,  delirium,  vomiting,  and  rigors.  The  symptoms 
are  those  of  suppurative  meningo-encephalitis,  and  it  may  be  very  difficult  to 
determine,  unless  there  are  localizing  symptoms,  whether  there  is  really  sup- 
puration in  the  brain  substance.  In  the  cases  following  ear  disease  the  symp- 
toms may  at  first  be  those  of  meningeal  irritation.  There  may  be  irritability, 
restlessness,  severe  headache,  and  aggravated  earache.  Other  striking  symp- 
toms, particularly  in  the  more  prolonged  cases,  are  drowsiness,  slow  cerebra- 
tion, vomiting,  and  optic  neuritis.  In  the  chronic  form  of  brain  abscess  which 
may  follow  injury,  otorrhoea,  or  local  lung  trouble,  there  may  be  a  latent 
period  ranging  from  one  or  two  weeks  to  several  months,  or  even  a  year  or 
more.  In  the  "silent"  regions,  when  the  abscess  becomes  encapsulated  there 
may  be  no  symptoms  whatever  during  the  latent  period.  During  all  this  time 
the  patient  may  be  under  careful  observation  and  no  suspicion  be  aroused  of 
the  existence  of  suppuration.  Then  severe  headache,  vomiting,  and  fever  set 
in,  perhaps  with  a  chill,  So?  too,  after  a  blow  upon  the  head  or  a  fracture 


INFLAMMATION    OF    THE    BRAIN  1017 

the  symptoms  of  the  lesion  may  be  transient,  and  months  afterward  cerebral 
symptoms  of  the  most  aggravated  character  may  develop. 

The  localization  of  the  lesion  is  often  difficult.  If  situated  in  or  near 
the  motor  region  there  may  be  convulsions  or  paralysis,  and  it  is  to  be  remem- 
bered that  an  abscess  in  the  temporal  lobe  may  compress  the  lower  part  of  the 
pre-central  convolution  and  produce  paralysis  of  the  arm  and  face,  and  on  the 
left  side  cause  aphasia.  A  large  abscess  may  exist  in  the  frontal  lobe  without 
causing  paralysis,  but  in  these  cases  there  is  almost  always  some  mental  dull- 
ness. In  the  temporal  lobe,  the  common  seat,  there  may  be  no  focalizing 
symptoms.  So  also  in  the  parieto-occipital  region;  though  here  early  exam- 
ination may  lead  to  the  detection  of  hemianopia.  In  abscess  of  the  cerebellum 
vomiting  is  common.  If  the  middle  lobe  is  affected  there  may  be  staggering 
— cerebellar  incoordination.  Localizing  symptoms  in  the  pons  and  other  parts 
are  still  more  uncertain. 

Diagnosis. — In  the  acute  cases  there  is  rarely  any  doubt.  A  consideration 
of  possible  etiological  factors  is  of  the  highest  importance.  The  history  of 
injury  followed  by  fever,  marked  cerebral  symptoms,  the  onset  of  rigors, 
delirium,  and  perhaps  paralysis,  make  the  diagnosis  certain.  In  chronic 
ear  disease,  such  cerebral  symptoms  as  drowsiness  and  torpor,  with  irregular 
fever,  supervening  upon  the  cessation  of  a  discharge,  should  excite  the  sus- 
picion of  abscess.  Cases  in  which  suppurative  processes  exist  in  the  orbit, 
nose,  or  naso-pharynx,  or  in  which  there  has  been  subcutaneous  phlegmon  of 
the  head  or  neck,  a  parotitis,  a  facial  erysipelas,  or  tuberculous  or  syphilitic 
disease  of  the  bones  of  the  skull,  should  be  carefully  watched,  and  immediately 
investigated  should  cerebral  symptoms  appear.  It  is  particularly  in  the 
chronic  cases  that  difficulties  arise.  The  symptoms  resemble  those  of  tumor 
of  the  brain;  indeed,  they  are  those  of  tumor  plus  fever.  Choked  disk,  how- 
ever, so  commonly  associated  with  tumor,  is  very  frequently  absent  in  abscess 
of  the  brain.  In  a  patient  with  a  history  of  trauma  or  with  localized  lung 
or  pleural  trouble,  who  for  weeks  or  months  has  had  slight  headache  or  dizzi- 
ness, the  onset  of  a  rapid  fever,  especially  if  it  be  intermittent  and  associated 
with  rigors,  intense  headache,  and  vomiting,  points  strongly  to  abscess.  The 
pulse  rate  in  cases  of  cerebral  abscess  is  usually  accelerated,  but  cases  are  not 
rare  in  which  it  is  slowed.  Macewen  lays  stress  upon  the  value  of  percussion 
of  the  skull  as  an  aid  in  diagnosis.  The  note,  which  is  uniformly  dull,  be- 
comes much  more  resonant  when  the  lateral  ventricles  are  distended  in  cere- 
bellar abscess  and  in  conditions  in  which  the  venae  Galeni  are  compressed. 

It  is  not  always  easy  to  determine  whether  the  meninges  are  involved  with 
the  abscess.  Often  in  ear  disease  the  condition  is  that  of  meningo-encepha- 
litis.  Sometimes  in  association  with  acute  ear  disease  the  symptoms  may 
simulate  closely  cerebral  meningitis  or  even  abscess.  Indeed,  Gowers  states 
that  not  only  may  these  general  symptoms  be  produced  by  ear  disease,  but 
even  distinct  optic  neuritis. 

Treatment. — A  remarkable  advance  has  been  made  of  late  years  in  dealing 
with  these  cases,  owing  to  the  impunity  with  which  the  brain  can  be  explored. 
In  ear  disease  free  discharge  of  the  inflammatory  products  should  be  promoted 
and  careful  disinfection  practiced.  The  treatment  of  injuries  and  fractures 
comes  within  the  scope  of  the  surgeon.  The  acute  symptoms,  such  as  fever, 
headache,  and  delirium,  must  be  treated  by  rest,  an  ice-cap,  and,  if  necessary, 
66 


1018  DISEASES    OF    THE    NERVOUS    SYSTEM 

local  depletion.  In  all  cases,  when  a  reasonable  suspicion  exists  of  the  occur- 
rence of  abscess,  the  brain  should  be  explored.  The  cases  following  ear  dis- 
ease, in  which  the  suppuration  is  in  the  temporal  lobe  or  in  the  cerebellum, 
offer  the  most  favorable  chances  of  recovery.  The  localization  can  rarely  be 
made  accurately  in  these  cases,  and  the  operator  must  be  guided  more  by  gen- 
eral anatomical  and  pathological  knowledge.  In  cases  of  injury  the  trephine 
should  be  applied  over  the  seat  of  the  blow  or  the  fracture.  In  ear  disease 
the  suppuration  is  most  frequent  in  the  temporal  lobe  or  in  the  cerebellum, 
and  the  operation  should  be  performed  at  the  points  most  accessible  to  these 
regions.  Crowe's  discovery  of  the  secretion  of  hcxamethylenamine  into  the 
cerebro-spinal  fluid  suggests  its  administration  in  every  case  in  which  menin- 
geal  infection  is  threatened  or  has  occurred. 


VI.     HYDROCEPHALUS 

Definition. — A  condition,  congenital  or  acquired,  in  which  there  is  a  great 
accumulation  of  fluid  within  the  ventricles  of  the  brain. 

The  term  hydrocephalus  has  also  been  applied  to  the  collection  of  fluid 
between  the  cortex  of  the  brain  and  the  skull,  known  in  this  situation  as 
hydrocephalus  externus  or  hydrocephalus  ex  vacuo,  a  condition  common  in 
cases  of  atrophy  of  the  brain  substance,  met  with  in  old  age,  after  hasmor- 
rhages,  softenings,  or  scleroses,  in  lingering  and  cachectic  diseases,  as  cancer, 
chronic  nephritis,  chronic  alcoholism,  and  sometimes  in  rickets.  Occasionally 
the  disease  is  caused  by  meningeal  cysts.  A  true  dropsy,  however,  of  the  arach- 
noid sac  probably  does  not  occur. 

The  cases  may  be  divided  into  three  groups — idiopathic  internal  hydro- 
cephalus (serous  meningitis),  congenital  or  infantile,  and  secondary  or  ac- 
quired. 

Serous  Meningitis  (Quincke)  (Idiopathic  Internal  Hydrocephalus;  An- 
gio-neurotic  Hydrocephalus). — This  remarkable  form,  described  by  Quincke, 
is- very  important,  since  a  knowledge  of  the  condition  may  explain  very  anom- 
alous and  puzzling  cases.  It  is  an  ependymitis  causing  a  serous  effusion  into 
the  ventricles,  with  distention  and  pressure  effects.  It  may  be  compared  to  the 
serous  exudates  in  the  pleura  or  in  synovial  membranes.  It  is  not  certain 
that  the  process  is  inflammatory,  and  Quincke  likens  it  to  the  angio-neurotic 
osdema  of  the  skin.  In  very  acute  cases  the  ependyma  may  be  smooth  and 
natural  looking;  in  more  chronic  cases  it  may  be  thickened  and  sodden.  The 
exudate  does  not  differ  from  the  normal,  and  if  on  lumbar  puncture  a  fluid  is 
removed  of  a  specific  gravity  above  1.009,  with  albumin  above  two  tenths  per 
cent.,  the  condition  is  more  likely  to  be  hydrocephalus  from  stasis,  secondary 
to  tumor,  etc. 

Both  children  and  adults  are  affected,  the  latter  more  frequently.  In  the 
acute  form  the  condition  is  mistaken  for  tuberculous  or  purulent  meningitis. 
There  are  headache,  retraction  of  the  neck,  and  signs  of  increased  intracranial 
pressure,  choked  -disks,  slow  pulse,  etc.  Fever  is  usually  absent,  but  I  have 
seen  one  case  with  recurring  paroxysms  of  fever,  and  Morton  Prince  has 
described  a  similar  one.  In  both  the  exudate  was  clear  and  the  ependyma  not 
acutely  inflamed.  Quincke  has  reported  cases  of  recovery.  In  the  chronic 


HYDROCEPHALUS  1019 

form  the  symptoms  are  those. of  tumor — general,  such  as  headache,  slight  fever, 
somnolence,  and  delirium;  and  local,  as  exophthalmos,  optic  neuritis,  spasms, 
and  rigidity  of  muscles  and  paralysis  of  the  cerebral  nerves.  Remarkable  ex- 
acerbations occur,  and  the  symptoms  vary  in  intensity  from  day  to  day. 
Recovery  may  follow  after  an  illness  of  many  weeks,  and  some  of  the  re- 
ported cases  of  disappearance  of  all  symptoms  of  brain  tumor  belong  in  this 
category. 

Congenital  Hydrocephalus. -^The  enlarged  head  may  obstruct  labor;  more 
frequently  the  condition  is  noticed  some  time  after  birth.  The  cause  is  un- 
known. It  has  occurred  in  several  members  of  the  same  family. 

The  anatomical  condition  in  these  cases  offers  no  clew  to  the  nature  of 
the  trouble.  The  lateral  ventricles  are  enormously  distended,  but  the  epen- 
dyma  is  usually  clear,  sometimes  a  little  thickened  and  granular,  and  the  veins 
large.  The  choroid  plexuses  are 'vascular,  sometimes  sclerotic,  but  often  nat- 
ural looking.  The  third  ventricle  is  enlarged,  the  aqueduct  of  Sylvius  dilated, 
and  the  fourth  ventricle  may  be  distended.  The  quantity  of  fluid  may  reach 
several  litres.  It  is  limpid  and  contains  a  trace  of  albumin  and  salts.  The 
changes  in  consequence  of  this  enormous  ventricular  distention  are  remarkable. 
The  cerebral  cortex  is  greatly  stretched,  and  over  the  middle  region  the  thick- 
ness may  amount  to  no  more  than  a  few  millimetres  without  a  trace  of  the 
sulci  or  convolutions.  The  basal  ganglia  are  flattened.  The  skull  enlarges, 
and  the  circumference  of  the  head  of  a  child  of  three  or  four  years  may  reach 
25  or  even  30  inches.  The  sutures  widen,  Wormian  bones  develop  in  them, 
and  the  bones  of  the  cranium  become  exceedingly  thin.  The  veins  are  marked 
beneath  the  skin.  A  fluctuation  wave  may  sometimes  be  obtained,  and 
Fisher's  brain  murmur  may  be  heard.  The  orbital  plates  of  the  frontal  bone 
are  depressed,  causing  exoplithalmos,  so  that  the  eyeballs  can  not  be  covered 
by  the  eyelids.  The  small  size  of  the  face,  widening  somewhat  above,  is  strik- 
ing in  comparison  with  the  enormously  expanded  skull. 

Convulsions  may  occur.  The  reflexes  are  increased,  the  child  learns  to 
walk  late,  and  ultimately  in  severe  cases  the  legs  become  feeble  ond  sometimes 
spastic.  Sensation  is  much  less  affected  than  motility.  Choked  disk  is  not 
uncommon.  The  mental  condition  is  variable;  the  child  may  be  bright,  but, 
as  a  rule,  there  is  some  grade  of  imbecility.  The  congenital  cases  usually  die 
within  the  first  four  or  five  years.  The  process  may  be  arrested  and  the 
patient  may  reach  adult  life.  Cases  of  this  sort  are  not  very  uncommon. 
Even  when  extreme,  the  mental  faculties  may  be  retained,  as  in  Bright's  cele- 
brated patient,  Cardinal,  who  lived  to  the  age  of  twenty-nine,  and  whose  head 
was  translucent  when  the  sun  was  shining  behind  him.  Care  must  be  taken 
not  to  mistake  the  rachitic  head  for  hydrocephalus. 

Acquired  Chronic  Hydrocephalus. — This  is  stated  to  be  occasionally  pri- 
mary (idiopathic) — that  is  to  say,  it  comes  on  spontaneously  in  the  adult 
without  observable  lesion.  Dean  Swift  is  said  to  have  died  of  hydrocephalus, 
but  this  seems  very  unlikely.  It  is  based  upon  the  statement  that  "he  (Mr. 
Whiteway)  opened  the  skull  and  found  much  water  in  the  brain,"  a  condition 
no  doubt  of  hydrocephalus  ex  vacua,  due  to  the  wasting  associated  with  his 
prolonged  illness  and  paralysis.  In  nearly  all  cases  there  is  either  a  tumor  at 
the  base  of  the  brain  or  in  the  third  ventricle,  which  compresses  the  venae 
Galeni.  The  passage  from  the  third  to  the  fourth  ventricle  may  be  closed, 


1020  DISEASES    OF   THE    NERVOUS    SYSTEM 

either  by  a  tumor  or  by  parasites.  More  rarely  the  foramen  of  Magendie, 
through  which  the  ventricles  communicate  with  the  cerebro-spinal  meninges, 
becomes  closed  by  meningitis.  Chronic  inflammations  of  the  ependyma  may 
in  similar  fashion  block  the  foramina  of  exit  of  the  ventricular  fluid.  There 
may  be  unilateral  hydrocephalus  from  closure  of  one  of  the  foramina  of  Monro. 
In  cerebro-spinal  fever,  particularly  in  the  sporadic  form,  the  foramina  of 
exit  of  the  fluid  may  be  occluded,  with  great  distention  of  the  ventricles. 
These  conditions,  occurring  in  adults,  may  produce  the  most  extreme  hydro- 
cephalus without  any  enlargement  of  the  head.  Even  when  the  tumor  begins 
early  in  life  there  may  be  no  expansion  of  the  skull.  In  the  case  of  a  girl 
aged  sixteen,  blind  from  her  third  year,  the  head  was  not  unusually  large, 
the  ventricles  were  enormously  distended,  and  in  the  Rolandic  region  the  brain 
substance  was  only  5  mm.  in  thickness.  A  tumor  occupied  the  third  ventricle. 
In  a  case  of  cholesteatoma  of  the  floor  of  the  third  ventricle,  in  which  the 
symptoms  persisted  at  intervals  for  eight  or  nine  years,  the  ventricles  were 
enormously  distended  without  enlargement  of  the  skull.  In  other  instances 
the  sutures  separate  and  the  head  gradually  enlarges. 

The  symptoms  of  hydrocephalus  in  the  adult  are  curiously  variable.  In 
the  first  case  mentioned  there  were  early  headaches  and  gradual  blindness; 
then  a  prolonged  period  in  which  she  was  able  to  attend  to  her  studies.  Head- 
aches again  supervened,  the  gait  became  irregular  and  somewhat  ataxic. 
Death  occurred  suddenly.  In  the  other  case  there  were  prolonged  attacks  of 
coma  with  a  slow  pulse,  and  on  one  occasion  the  patient  remained  unconscious 
for  more  than  three  months.  Gradually  progressing  optic  neuritis  without 
focalizing  symptoms,  headache,  and  attacks  of  somnolence  or  coma  are  sug- 
gestive symptoms.  These  cases  of  acquired  chronic  hydrocephalus  can  not 
be  certainly  diagnosed  during  life,  though  in  certain  instances  the  condition 
may  be  suspected.  They  simulate  tumor  very  closely. 

Treatment.- — Very  little  can  be  done  to  relieve  hydrocephalus.  Medicines 
are  powerless  to  cause  the  absorption  of  the  fluid.  In  the  meningitis  serosa 
Quincke  advises  the  use  of  mercury.  Many  operative  procedures  have  been 
devised,  tapping  of  the  ventricles,  lumbar  puncture,  making  communications 
between  the  ventricles  and  the  subarachnoid  spaces,  into  the  extracranial  tis- 
sues, or  into  the  retro-peritoneal  tissues  and  through  the  body  of  the  fifth 
lumbar  vertebra;  and  Gushing  has  practiced  an  anastomosis  by  means  of  a 
transplanted  vein  between  the  external  jugular  and  the  subdural  space.  Bra- 
mann  claims  beneficial  results  from  puncture  of  the  corpus  callosum. 


F.    DISEASES  OF  THE  PERIPHERAL  NERVES 

I.    NEURITIS 

(Inflammation  of  the  Bundles  of  Nerve  Fibres) 

Neuritis  may  be  localized  in  a  single  nerve,  or  general,  involving  a  large 
number  of  nerves,  in  which  case  it  is  usually  known  as  multiple  neuritis  or 
polyneuritis. 

Etiology. — Localized  neuritis  arises  from  (a)  cold,  which  is  a  very  fre- 


NEUEITIS  1021 

quent  cause,  as,  for  example,  in  the  facial  nerve.  This  is  sometimes  known 
as  rheumatic  neuritis.  (6)  Traumatism — wounds,  blows,  direct  pressure  on 
the  nerves,  the  tearing  and  stretching  which  follow  a  dislocation  or  a  frac- 
ture, and  the  hypodermic  injection  of  ether.  Under  this  section  come  also 
the  professional  palsies,  due  to  pressure  in  the  exercise  of  certain  occupations. 
(c)  Extension  of  inflammation  from  neighboring  parts,  as  in  a  neuritis  of  the 
facial  nerve  due  to  caries  in  the  temporal  bone,  or  in  that  met  with  in  syphi- 
litic disease  of  the  bones,  disease  of  the  joints,  and  occasionally  in  tumors. 

Multiple  neuritis  has  a  very  complex  etiology,  the  causes  of  which  may 
be  classified  as  follows:  (a)  The  poisons  of  infectious  diseases,  as  in  leprosy, 
diphtheria,  typhoid  fever,  small-pox,  scarlet  fever,  and  occasionally  in  other 
forms;  (6)  the  organic  poisons,  comprising  the  diffusible  stimulants,  such 
as  alcohol  and  ether,  bisulphide  of  carbon  and  naphtha,  and  the  metallic 
bodies,  such  as  lead,  arsenic,  and  mercury;  (c)  cachectic  conditions,  such  as 
occur  in  anaemia,  cancer,  tuberculosis,  or  marasmus  from  any  cause;  (d)  the 
endemic  neuritis  or  beri-beri;  and  (e)  lastly,  there  are  cases  in  which  none 
of  these  factors  prevail,  but  the  disease  sets  in  suddenly  after  overexertion  or 
exposure  to  cold. 

Morbid  Anatomy. — In  neuritis  due  to  the  extension  of  inflammation  the 
nerve  is  usually  swollen,  infiltrated,  and  red  in  color.  The  inflammation  may 
be  chiefly  perineural  or  it  may  pass  into  the  deeper  portion — interstitial  neu- 
ritis— in  which  form  there  is  an  accumulation  of  lymphoid  elements  between 
the  nerve  bundles.  The  nerve  fibres  themselves  may  not  appear  involved,  but 
there  is  an  increase  in  the  nuclei  of  the  sheath  of  Schwann.  The  myelin  is 
fragmented,  the  nuclei  of  the  internodal  cells  are  swollen,  and  the  axis-cylin- 
ders present  varicosities  or  undergo  granular  degeneration.  Ultimately  the 
nerve  fibres  may  be  completely  destroyed  and  replaced  by  a  fibrous  connective 
tissue  in  which  much  fat  is  sometimes  deposited — the  lipomatous  neuritis  of 
Le)den. 

In  other  instances  the  condition  is  termed  parenchymatous  neuritis,  in 
which  the  changes  are  like  those  met  with  in  the  secondary  or  Wallerian 
degeneration,  which  follows  when  the  nerve  fibre  is  cut  off  from  the  cell  body 
of  the  neurone  to  which  it  belongs.  The  medullary  substance  and  the  axis- 
cylinders  are  chiefly  involved,  the  interstitial  tissue  being  but  little  altered  or 
only  affected  secondarily.  The  muscles  connected  with  the  degenerated  nerves 
usually  show  marked  atrophic  changes,  and  in  some  instances  the  change  in 
the  nerve  sheath  appears  to  extend  directly  to  the  interstitial  tissue  of  the 
muscles — the  neuritis  fascians  of  Eichhorst. 

Symptoms. — LOCALIZED  NEURITIS. — As  a  rule,  the  constitutional  disturb- 
ances are  slight.  The  most  important  symptom  is  pain  of  a  boring  or  stabbing 
character,  usually  felt  in  the  course  of  the  nerve  and  in  the  parts  to  which  it  is 
distributed.  The  nerve  itself  is  sensitive  to  pressure,  probably,  as  Weir  Mitchell 
suggests,  owing  to  the  irritation  of  its  nervi  nervorum.  The  skin  may  be 
slightly  reddened  or  even  cedematous  over  the  seat  of  the  inflammation. 
Mitchell  has  described  increase  in  the  temperature  and  sweating  in  the  affected 
region,  and  such  atrophic  disturbances  as  effusion  into  the  joints  and  herpes. 
The  function  of  the  muscle  to  which  the  nerve  fibres  are  distributed  is  im- 
paired, motion  is  painful,  and  there  may  be  twitchings  or  contractions.  The 
tactile  sensation  of  the  part  may  be  somewhat  deadened,  even  when  the  pain 


1022  DISEASES    OF    THE    NEEVOUS    SYSTEM 

is  greatly  increased.  In  the  more  chronic  cases  of  local  neuritis,  such,  for 
instance,  as  follow  the  dislocation  of  the  humerus,  the  localized  pain,  which 
at  first  may  he  severe,  gradually  disappears,  though  some  sensitiveness  of  the 
brachial  plexus  may  persist  for  a  long  time,  and  the  nerve  cords  may  be  felt 
to  be  swollen  and  firm.  The  pain  is  variable — sometimes  intense  and  distress- 
ing; at  others  not  causing  much  inconvenience.  Numbness  and  formication 
may  be  present  and  the  tactile  sensation  may  be  greatly  impaired.  The  motor 
disturbances  are  marked.  Ultimately  there  is  extreme  atrophy  of  the  muscles. 
Contractures  may  occur  in  the  fingers.  The  skin  may  be  reddened  or  glossy, 
the  subcutaneous  tissue  cedematous,  and  the  nutrition  of  the  nails  may  be 
defective.  In  the  rheumatic  neuritis  subcutaneous  fibroid  nodules  may  de- 
velop. 

A  neuritis  limited  at  first  to  a  peripheral  nerve  may  extend  upward — • 
the  so-called  ascending  or  migratory  neuritis — and  involve  the  larger  nerve 
trunks,  or  even  reach  the  spinal  cord,  causing  subacute  myelitis  (Gowers). 
The  condition  is  rarely  seen  in  the  neuritis  from  cold,  or  in  that  which  fol- 
lows fevers ;  but  it  occurs  most  frequently  in  traumatic  neuritis. 

J.  K.  Mitchell,  in  his  monograph  on  injuries  of  nerves,  concludes  that  the 
larger  nerve  trunks  are  most  susceptible,  and  that  the  neuritis  may  spread 
either  up  or  down,  the  former  being  the  most  common.  The  paralysis  second- 
ary to  visceral  disease,  as  of  the  bladder,  may  be  due  to  an  ascending  neuritis. 
The  inflammation  may  extend  to  the  nerves  of  the  other  side,  either  through 
the  spinal  cord  or  its  membranes,  or  without  any  involvement  of  the  nerve- 
centres,  the  so-called  sympathetic  neuritis.  The  electrical  changes  in  localized 
neuritis  vary  a  great  deal,  depending  upon  the  extent  to  which  the  nerve  is 
injured.  The  lesion  may  be  so  slight  that  the  nerve  and  the  muscles  to  which 
it  is  distributed  may  react  normally  to  both  currents;  or  it  may  be  so  severe 
that  the  typical  reaction  of  degeneration  develops  within  a  few  days — i.  e., 
the  nerve  does  not  respond  to  stimulation  by  either  current,  while  the  muscle 
reacts  only  to  the  galvanic  current  and  in  a  peculiar  manner.  The  contraction 
caused  is  slow  and  lazy,  instead  of  sharp  and  quick  as  in  the  normal  mus- 
cle, and  the  AC  contraction  is  usually  stronger  than  the  KG  contraction. 
Between  these  two  extremes  there  are  many  different  grades,  and  a  care- 
ful electrical  examination  is  most  important  as  an  aid  to  diagnosis  and 
prognosis. 

The  duration  varies  from  a  few  days  to  weeks  or  months.  A  slight  trau- 
matic neuritis  may  pass  off  in  a  day  or  two,  while  the  severer  cases,  such  as 
follow  unreduced  dislocation  of  the  humerus  mair  persist  for  months  or  never 
be  completely  relieved. 

MULTIPLE  NEUKITIS. — The  following  are  the  most  important  groups  of 
cases : 

(a)  Acute  Febrile  Polyneuritis. — The  attack  follows  exposure  to  cold  or 
overexertion,  or,  in  some  instances,  comes  on  spontaneously.  The  onset  resem- 
bles that  of  an  acute  infectious  disease.  There  may  be  a  definite  chill,  pains 
in  the  back  and  limbs  or  joints,  so  that  the  case  may  be  thought  to  be  rheu- 
matic fever.  The  temperature  rises  rapidly  and  may  reach  103°  or  104°  F. 
There  are  headache,  loss  of  appetite,  and  the  general  symptoms  of  acute  in- 
fection. The  limbs  and  back  ache.  Intense  pain  in  the  nerves,  however,  is 
by  no  means  constant.  Tingling  and  formication  are  felt  in  the  fingers  and 


NEURITIS  1023 

toes,  and  there  is  increased  sensitiveness  of  the  nerve  trunks  or  of  the  entire 
limb.  Loss  of  muscular  power,  first  marked,  perhaps,  in  the  legs,  gradually 
comes  on  and  extends  with  the  features  of  an  ascending  paralysis.  In  other 
cases  the  paralysis  begins  in  the  arms.  The  extensors  of  the  wrists  and  the 
flexors  of  the  ankles  are  early  affected,  so  that  there  is  foot  and  wrist  drop. 
In  severe  cases  there  is  general  loss  of  muscular  power,  producing  a  flabby 
paralysis,  which  may  extend  to  the  muscles  of  the  face  and  to  the  intercostals, 
and  respiration  may  be  carried  on  by  the  diaphragm  alone.  The  muscles 
soften  and  waste  rapidly.  There  may  be  only  hyperaesthesia  with  soreness  and 
stiffness  of  the  limbs;  in  some  cases,  increased  sensitiveness  with  anesthesia; 
in  other  instances  the  sensory  disturbances  are  slight.  The  Argyll-Robertson 
pupil  may  be  present  and  the  pupils  may  be  unequal.  Involvement  of  the 
cranial  nerves  is  rare,  but  the  oculo-motor,  the  facial,  and  the  fifth  have  been 
involved.  The  vagus  may  be  attacked  and  the  quickening  of  the  pulse  is 
usually  attributed  to  this  cause.  Involvement  of  the  bladder  and  rectum  is 
rare,  but  it  does  occur  in  undoubted  cases  and  does  not  necessarily  mean  in- 
volvement of  the  cord.  The  -clinical  picture  is  not  to  be  distinguished,  in 
many  cases,  from  Landry's  paralysis;  in  others,  from  the  subacute  myelitis 
of  Duchenne. 

The  course  is  variable.  In  the  most  intense  forms  the  patient  may  die  in 
a  week  or  ten  days,  with  involvement  of  the  respiratory  muscles  or  from 
paralysis  of  the  heart.  As  a  rule,  in  cases  of  moderate  severity,  after  persist- 
ing for  five  or  six  weeks,  the  condition  remains  stationary  and  then  slow 
improvement  begins.  The  paralysis  in  some  muscles  may  persist  for  many 
months  and  contractures  may  occur  from  shortening  of  the  muscles,  but  even 
when  this  occurs  the  outlook  is,  as  a  rule,  good,  although  the  paralysis  may 
have  lasted  for  a  year  or  more. 

(6)  Recurring  Multiple  Neuritis. — Under  the  term  polyneuritis  recurrens 
Mary  Sherwood  has  described  from  Eichhorst's  clinic  2  cases  in  adults — in 
one  case  involving  the  nerves  of  the  right  arm,  in  the  other  both  legs.  In 
one  patient  there  were  three  attacks,  in  the  other  two,  the  distribution  in  the 
various  attacks  being  identical. 

(c)  Alcoholic  Neuritis. — This,  perhaps  the  most  important  form  of  mul- 
tiple neuritis,  was  graphically  described  in  1822  by  James  Jackson,  Sr.,  of 
Boston.  Wilks  recognized  it  as  alcoholic  paraplegia,  but  the  starting  point 
of  the  recent  researches  on  the  disease  dates  from  the  observations  of  Dumenil, 
of  Rouen.  It  occurs  most  frequently  in  women,  particularly  in  steady,  quiet 
tipplers.  Its  appearance  may  be  the  first  revelation  to  the  physician  or  to  the 
family  of  habits  of  secret  drinking.  The  onset  is  usually  gradual,  and  may 
be  preceded  for  weeks  or  months  by  neuralgic  pains  and  tingling  in  the  feet 
and  hands.  Convulsions  are  not  uncommon.  Fever  is  rare.  The  paralysis 
gradually  sets  in,  at  first  in  the  feet  and  legs,  and  then  in  the  hands  and  fore- 
arms. The  extensors  are  affected  more  than  the  flexors,  so  that  there  is  wrist- 
drop  and  foot-drop.  The  paralysis  may  be  thus  limited  and  not  extend  higher 
in  the  limbs.  In  other  instances  there  is  paraplegia  alone,  while  in  the  most 
extreme  cases  all  the  extremities  are  involved.  In  rare  instances  the  facial 
muscles  and  the  sphincters  are  also  affected.  The  sensory  symptoms  are  very 
variable.  There  are  cases  in  which  there  are  numbness  and  tingling  only, 
without  great  pain.  In  other  cases  there  are  severe  burning  or  boring  pains, 


1024  DISEASES    OF    THE    NERVOUS    SYSTEM 

the  nerve  trunks  are  sensitive,  and  the  muscles  are  sore  when  grasped.  The 
hands  and  feet  are  frequently  swollen  and  congested,  particularly  when  held 
down  for  a  few  moments.  The  cutaneous  reflexes,  as  a  rule,  are  preserved. 
The  deep  reflexes  are  usually  lost. 

The  course  of  these  alcoholic  cases  is,  as  a  rule,  favorable,  and  after  per- 
sisting for  weeks  or  months  improvement  gradually  begins,  the  muscles  regain 
their  power,  and  even  in  the  most  desperate  cases  recovery  may  follow.  The 
extensors  of  the  feet  may  remain  paralyzed  for  some  time,  and  give  to  the 
patient  a  distinctive  walk,  the  so-called  steppage  gait,  characteristic  of  pe- 
ripheral neuritis.  It  is  sometimes  known  as  the  pseudo-tabetic  gait,  although 
in  reality  it  could  not  well  he  mistaken  for  the  gait  of  ataxia.  The  foot  is 
thrown  forcibly  forward,  the  toe  lifted  high  in  the  air  so  as  not  to  trip  upon  it. 
The  entire  foot  is  slapped  upon  the  ground  as  a  flail.  It  is  an  awkward,  clumsy 
gait,  and  gives  the  patient  the  appearance  of  constantly  stepping  over  obsta- 
cles. Among  the  most  striking  features  of  alcoholic  neuritis  are  the  mental 
symptoms.  Delirium  is  common,  and  there  may  be  hallucinations  with  ex- 
travagant ideas,  resembling  somewhat  those  of  general  paralysis.  In  some 
cases  the  picture  is  that  of  ordinary  delirium  tremens,  but  the  most  peculiar 
and  almost  characteristic  mental  disorder  is  that  so  well  described  by  Wilks,  in 
which  the  patient  loses  all  appreciation  of  time  and  place,  and  describes  with 
circumstantial  details  long  journeys  which,  he  says,  he  has  recently  taken,  or 
tells  of  persons  whom  he  has  just  seen.  This  is  the  so-called  Korsakoff's 
syndrome. 

(d)  Multiple  Neuritis  in  the  Infectious  Diseases. — This  has  been  already 
referred  to,  particularly  in  diphtheria,  in  which  it  is  most  common.     The 
peripheral  nature  of  the  lesion  in  these  instances  has  been  shown  by  post 
mortem  examination.    The  outlook  is  usually  favorable  and,  except  in  diph- 
theria, fatal  cases  are  uncommon.    Multiple  neuritis  in  tuberculosis,  diabetes, 
and  syphilis  is  of  the  same  nature,  being  probably  due  to  toxic  materials 
absorbed  into  the  blood. 

(e)  The  Metallic  Poisons. — Neuritis  from  arsenic  may  follow:    (1)   The 
medicinal  use  particularly  of  Fowler's  solution.     I  have  reported  a  case  of 
Hodgkin's  disease  in  which  general  neuritis  was  caused  by  §  j  3  ij  of  the 
solution.    In  chorea  a  good  many  cases  have  been  reported.     Changes  in  the 
nails  are  not  uncommon,  chiefly  the  transverse  ridging.     In  one  case  in  my 
wards,  of  a  young  woman  who  had  taken  rough-on-rats,  there  were  remarkable 
white  lines— the  leuconychia — running  across  the  nails,  without  any  special 
ridging.    C.  J.  Aldrich  finds  that  this  is  not  uncommon  in  chronic  arsenical 
poisoning.    (2)  The  accidental  contamination  of  food  or  drink.     Chrome  yel- 
low may  be  used  to  color  cakes,  as  in  the  cases  recorded  by  D.  D.  Stewart. 
A  remarkable  epidemic  of  neuritis  occurred  in  the  Midland  Counties  of  Eng- 
land, which  was  traced  to  the  use  of  beer  containing  small  quantities  of 
arsenic,   a  contamination  from  the  sulphuric  acid  used  in  making  glucose. 
Reynolds,  who  studied  these  cases,  believes  that  most  of  the  instances  of 
neuritis  in  drinkers  are  arsenical,  but  admits  that  the  slight  cases  may  be 
due  to  the  alcohol  itself.     Pigmentation  of  the  skin  is  an  important  distin- 
guishing sign.     The  general  features  have  been  referred  to  under  arsenical 
poisoning.     Lead  is  a  much  more  frequent  cause.     Neuritis  has  followed  the 
use  of  mercurial  inunctions.    Zinc  is  a  rare  cause.    I  saw  a  case  with  Urban 


NEURITIS  1025 

Smith  -which  followed  the  use  of  two  grains  of  the  sulpho-carbolate  taken  daily 
for  three  years.     Tea,  coffee,  and  tobacco  are  mentioned  as  rare  causes. 

(/)   Endemic  neuritis,  heri-heri,  has  been  considered  elsewhere. 

ANAESTHESIA  PARALYSIS. — Here  perhaps  may  most  appropriately  be  con- 
sidered the  forms  of  paralysis  following  the  use  of  anaesthetics,  or  of  too 
long-continued  compression  during  operations.  Much  has  been  written  in  the 
past  few  years  upon  this  subject.  There  are  two  groups  of  cases : 

(a)  During  an  operation  the  nerves  may  be  compressed,  either  the  brachial 
plexus  by  the  humerus  or  the  musculo-spiral  by  the  table.  The  pressure  most 
frequently  occurs  when  the  arm  is  elevated  alongside  the  head,  as  in  laparot- 
omy  done  in  the  Trendelenburg  position,  or  held  out  from  the  body,  as  in 
breast  amputations.  Instances  of  paralysis  of  the  crural  nerves  by  leg-holders 
are  also  reported.  The  too  firm  application  of  a  tourniquet  may  be  followed 
by  a  severe  paralysis. 

(&)  Paralysis  from  cerebral  lesions  during  etherization.  In  one  of  Gar- 
rigues'  cases  paralysis  followed  the  operation,  and  at  the  autopsy,  seven  weeks 
later,  softening  of  the  brain  was  found.  Apoplexy  or  embolism  may  occur 
during  anaesthesia.  In  Montreal  a  cataract  operation  was  performed  on  an 
old  man.  He  did  not  recover  from  the  anaesthetic;  I  found  post  mortem  a 
cerebral  haemorrhage.  A  man  was  admitted  to  the  Philadelphia  Hospital, 
completely  comatose,  who  on  the  previous  day  had  been  given  ether  for  a 
minor  operation.  He  never  recovered  consciousness,  but  remained  deeply  com- 
atose, with  great  muscular  relaxation,  low  temperature,  97.5°,  and  noisy 
respirations;  he  died  two  days  later.  There  was,  unfortunately,  no  autopsy. 
Epileptic  convulsions  may  occur  during  the  anaesthesia,  and  may  even  prove 
fatal.  The  possibility  has  to  be  considered  of  paralysis  from  loss  of  blood  in 
prolonged  operations,  though  I  have  no  personal  knowledge  of  any  such  cases. 

And,  lastly,  a  paralysis  might  result  from  the  toxic  effects  of  the  ether  in 
a  very  protracted  administration. 

Diagnosis.  — The  electrical  condition  in  multiple  neuritis  is  thus  described 
by  Allen  Starr :  "The  excitability  is  very  rapidly  and  markedly  changed ;  but 
the  conditions  which  have  been  observed  are  quite  various.  Sometimes  there 
is  a  simple  diminution  of  excitability,  and  then  a  very  strong  faradic  or  gal- 
vanic current  is  needed  to  produce  contractions.  Frequently  all  faradic  ex- 
citability is  lost  and  then  the  muscles  contract  to  a  galvanic  current  only. 
In  this  condition  it  may  require  a  very  strong  galvanic  current  to  produce 
contraction,  and  thus  far  it  is  quite  pathognomonic  of  neuritis.  For  in  an- 
terior polio-myelitis,  where  the  muscles  respond  to  galvanism  only,  it  does  not 
require  a  strong  current  to  cause  a  motion,  until  some  months  after  the 
invasion. 

"The  action  of  the  different  poles  is  not  uniform.  In  many  cases  the  con- 
traction of  the  muscle  when  stimulated  with  the  positive  pole  is  greater  than 
when  stimulated  with  the  negative  pole,  and  the  contractions  may  be  sluggish. 
Then  the  reaction  of  degeneration  is  present.  But  in  some  cases  the  normal 
condition  is  found  and  the  negative  pole  produces  stronger  contractions  than 
the  positive  pole.  A  loss  of  faradic  irritability  and  a  marked  decrease  in  the 
galvanic  irritability  of  the  muscle  and  nerve  are  therefore  important  symp- 
toms of  multiple  neuritis." 

There  is  rarely  any  difficulty  in  distinguishing  the  alcohol  cases.     The 


1026  DISEASES    OF    THE    NERVOUS    SYSTEM 

combination  of  wrist  and  foot  drop  with  congestion  of  the  hands  and  feet, 
and  the  peculiar  delirium  already  referred  to,  are  quite  characteristic.  The 
rapidly  advancing  cases  with  paralysis  of  all  extremities,  often  reaching  to 
the  face  and  involving  the  sphincters,  are  more  commonly  regarded  as  of 
spinal  origin,  but  the  general  opinion  seems  to  point  strongly  to  the  fact  that 
all  such  cases  are  peripheral.  The  less  acute  cases,  in  which  the  paralysis 
gradually  involves  the  legs  and  arms  with  rapid  wasting,  simulate  closely  and 
are  usually  confounded  with  the  subacute  atrophic  spinal  paralysis  of  Du- 
chenne.  The  diagnosis  from  locomotor  ataxia  is  rarely  difficult.  The  stoppage 
gait  is  entirely  different  from  that  of  tabes.  There  is  rarely  positive  incoor- 
dination.  The  patient  can  usually  stand  well  with  the  eyes  closed.  Foot-drop 
is  not  common  in  locomotor  ataxia.  The  lightning  pains  are  absent  and  there 
are  usually  no  pupillary  symptoms.  The  etiology,  too,  is  of  moment.  The 
patient  is  recovering  from  a  paralysis  which  has  been  more  extensive,  or  from 
arsenical  poisoning,  or  he  has  diabetes. 

Treatment. — Eest  in  bed  is  essential.  In  the  acute  cases  with  fever  the 
salicylates  and  antipyrin  are  recommended.  To  allay  the  intense  pain  mor- 
phia or  the  hot  applications  of  lead  water  and  laudanum  are  often  required. 
Great  care  must  be  exercised  in  treating  the  alcoholic  form,  and  the  physician 
must  not  allow  himself  to  be  deceived  by  the  statements  of  the  relatives.  It 
is  sometimes  exceedingly  difficult  to  get  a  history  of  spirit  drinking.  In  the 
alcoholic  form  it  is  well  to  reduce  the  stimulants  gradually.  If  there  is  any 
tendency  to  bed-sores  an  air-bed  should  be  used  or  the  patient  placed  in  a 
continuous  bath.  Gentle  friction  of  the  muscles  may  be  applied  from  the  out- 
set, and  in  the  later  stages,  when  the  atrophy  is  marked  and  the  pains  have 
lessened,  massage  is  probably  the  most  reliable  means  at  our  command.  Con- 
tractures  may  be  gradually  overcome  by  passive  movements  and  extension. 
Often  with  the  most  extreme  deformity  from  contracture,  recovery  is,  in  time, 
still  possible.  The  interrupted  current  is  useful  when  the  acute  stage  is 
passed. 

Of  internal  remedies,  strychnia  is  of  value  and  may  be  given  in  increasing 
doses.  Arsenic  also  may  be  employed,  and  if  there  is  a  history  of  syphilis  the 
iodide  of  potassium  and  mercury  may  be  given. 


H.    NEUROMATA 

Tumors  situated  on  nerve  fibres  may  consist  of  nerve  substance  proper,  the 
true  neuromata,  or  of  fibrous  tissue,  the  false  neuromata.  The  true  neuroma 
usually  contains  nerve  fibres  only,  or  in  rare  instances  ganglion  cells.  Cases 
of  ganglionic  or  medullary  neuroma  are  extremely  rare;  some  of  them,  as 
Lancereaux  suggests,  are  undoubtedly  instances  of  malformation  of  the  brain 
substance.  In  other  instances  the  tumor  is,  in  all  probability,  a  glioma  with 
cells  closely  resembling  those  of  the  central  nervous  system.  The  growths  are 
often  intermediate  in  their  anatomical  structure  between  the  true  and  the 
false. 

Plexiform  Neuroma. — In  this  remarkable  condition  the  various  nerve  cords 
may  be  occupied  by  many  hundreds  of  tumors.  The  cases  are  often  hereditary 
and  usually  congenital.  The  tumors  may  occur  in  all  the  nerves  of  the  body, 


NEUROMATA  1027 

and,  as  numbers  of  them  may  be  made  out  on  palpation,  the  diagnosis  is  usu- 
ally easy.  One  of  the  most  remarkable  cases  is  that  described  by  Prudden, 
the  specimens  of  which  are  in  the  medical  museum  of  Columbia  College,  New 
York.  There  were  over  1,182  distinct  tumors  distributed  on  the  nerves  of  the 
body.  These  tumors  rarely  are  painful,  but  may  cause  symptoms  through 
pressure  on  neighboring  structures. 

Generalized  Neuro-fibromatosis :  von  Recklinghausen's  Disease. — Special 
attention  was  first  directed  to  this  particular  form  of  multiple  neuroma  by 
von  Recklinghausen  in  1882.  The  disease  presents  four  essential  features: 

(a)  Soft,  fibrous  nodules,  some  sessile,  others  pedunculated,  varying 
greatly  in  size  and  number,  are  scattered  over  the  surface  of  the  body.  These 
subcutaneous  growths  at  times  may  be  diffuse  and  reach  an  enormous  size,  pro- 
ducing a  condition  called  "Elephantiasis  Neuromatosa." 

(&)  Tumors  resembling  those  of  plexiform  neuroma  may  be  present  on 
any  part  of  the  nerve  trunks  from  their  central  origin  to  the  periphery.  Their 
variable  situation  may  lead  to  a  variety  of  symptoms,  more  especially  as  they 
may  arise  from  the  nerve  roots  within  the  spinal  canal  or  cranium.  Super- 
ficial painful  nodules  may  also  be  present. 

(c)  Patches  of  brownish  pigmentation  of  the  skin,  either  as  small  spots 
or  large  areas,  are  always  present.    Congenital  naevi  are  a  frequent  accompani- 
ment of  the  disease. 

(d)  There  are  many  variable  sensory  or  motor  phenomena  resulting  from 
the  presence  of  the  nerve  tumors,  but  peculiar  mental  changes,  with  loss  of 
intellectual  power  and  sometimes  difficulty  in  speaking,  are  especially  charac- 
teristic of  the  disease. 

Three  generations  have  been  affected.  A  sarcomatous  change  has  been 
present  in  some  tumors,  and  in  a  few  cases  associated  brain  tumors,  as  glio- 
mata,  have  been  present.  The  tumors  are  believed  to  originate  in  the  sheath  of 
Schwann,  in  confirmation  of  which  is  the  interesting  point  that  the  optic  and 
olfactory  nerves  which  are  devoid  of  this  sheath  have  never  been  found  af- 
fected with  neuromatosis. 

The  prognosis  depends  on  the  possibility  of  successful  removal  of  such 
tumors  as  are  causing  greatest  inconvenience. 

"Tubercula  Dolorosa." — Multiple  neuromata  may  especially  affect  the  ter- 
minal cutaneous  branches  of  the  sensory  nerves  and  lead  to  small  subcutaneous 
painful  nodules,  often  found  on  the  face,  breast,  or  about  the  joints.  They 
may  be  associated  with  tumors  of  the  nerve  trunks. 

"Amputation  Neuromata." — These  bulbous  swellings  may  form  on  the 
central  ends  of  nerves  which  have  been  divided  in  injuries  or  operations.  They 
are  especially  common  after  amputations.  They  are  due  to  the  tangled  coil 
of  axis-cylinder  processes  growing  down  from  the  central  stump  in  an  effort 
to  reach  their  former  end  structures.  They  are  very  painful  and  usually  re- 
quire surgical  removal,  but  often  recur. 


1028       DISEASES  OF  THE  NERVOUS  SYSTEM 

III.  DISEASES  OF  THE  CEREBRAL  NERVES 

OLFACTORY  NERVES  AND  TRACTS 

The  functions  of  the  olfactory  nerves  may  be  disturbed  at  their  origin, 
in  the  nasal  mucous  membrane,  at  the  bulb,  in  the  course  of  the  tract,  or 
at  the  centres  in  the  brain.  The  disturbances  may  be  manifested  in  sub- 
jective sensations  of  smell,  complete  loss  of  the  sense,  and  occasionally  in 
hyperassthesia. 

Subjective  Sensations;  Parosmia. — Hallucinations  of  this  kind  are  found 
in  the  insane  and  in  epilepsy.  The  aura  may  be  represented  by  an  unpleasant 
odor,  described  as  resembling  chloride  of  lime,  burning  rags,  or  feathers.  In 
a  few  cases  with  these  subjective  sensations  tumors  have  been  found  in  the 
hippocampi.  In  rare  instances,  after  injury  of  the  head,  the  sense  is  per- 
verted— odors  of  the  most  different  character  may  be  alike,  or  the  odor  may 
be  changed,  as  in  a  patient  noted  by  Morell  Mackenzie,  who  for  some  time 
could  not  touch  cooked  meat,  as  it  smelt  to  her  exactly  like  stinking  fish. 

Increased  sensitiveness  (hyperosmia)  occurs  chiefly  in  nervous,  hysterical 
women,  in  whom  it  may  sometimes  be  developed  so  greatly  that,  like  a  dog, 
they  can  recognize  the  difference  between  individuals  by  the  odor  alone. 

Anosmia;  loss  of  the  Sense  of  Smell.— This  may  be  produced  by:  (a)  Af- 
fections of  the  origin  of  the  nerves  in  the  mucous  membrane,  which  is  perhaps 
the  most  frequent  cause.  It  is  by  no  means  uncommon  in  association  with 
chronic  nasal  catarrh  and  polypi.  In  paralysis  of  the  fifth  nerve,  the  sense 
of  smell  may  be  lost  on  the  affected  side,  owing  to  interference  with  the  secre- 
tion. 

It  is  doubtful  whether  the  cases  of  loss  of  smell  following  the  inhalations 
of  very  foul  or  strong  odors  should  come  under  this  or  under  the  central 
division.- 

(&)  Lesions  of  the  bulbs  or  of  the  tracts.  In  falls  or  blows,  in  caries 
of  the  bones,  and  in  meningitis  or  tumor,  the  bulbs  or  the  olfactory  tracts 
may  be  involved.  After  an  injury  to  the  head  the  loss  of  smell  may  be  the 
only  symptom.  Mackenzie  notes  a  case  of  a  surgeon  who  was  thrown  from 
his  gig  and  lighted  on  his  head.  The  injury  was  slight,  but  the  anosmia 
which  followed  was  persistent.  In  locomotor  ataxia  the  sense  of  smell  may 
be  lost,  possibly  owing  to  atrophy  of  the  nerves. 

(c)  Lesions  of  the  olfactory  centres.  There  are  congenital  cases  in  which 
the  structures  have  not  been  developed.  Cases  have  been  reported  by  Beevor, 
Hughlings  Jackson,  and  others,  in  which  anosmia  has  been  associated  with 
disease  in  the  hemisphere. 

To  test  the  sense  of  smell  the  pungent  bodies,  such  as  ammonia,  which 
act  upon  the  fifth  nerve,  should  not  be  used,  but  such  substances  as  cloves, 
peppermint,  and  musk.  This  sense  is  readily  tested  as  a  routine  matter  in 
brain  cases  by  having  two  or  three  bottles  containing  the  essential  oils.  In 
all  instances  a  rhinoscopic  examination  should  be  made,  as  the  condition  may 
be  due  to  local,  not  central  causes.  The  treatment  is  unsatisfactory  even  in 
the  cases  due  to  local  lesions  in  the  nostrils. 


1029 


OPTIC   NERVE    AND    TRACT 
(1)  Lesions  of  the  Retina 

These  are  of  importance  to  the  physician,  and  information  of  the  great- 
est value  may  be  obtained  by  a  systematic  examination  of  the  eye  grounds. 
Only  a  brief  reference  can  here  be  made  to  the  more  important  of  the  appear- 
ances. 

Retinitis.  — This  occurs  in  certain  general  affections,  more  particularly  in 
Bright's  disease,  syphilis,  leukaemia,  and  anaemia.  The  common  feature  in  all 
these  states  is  the  occurrence  of  haemorrhage  and  the  development  of  opacities. 
There  may  also  be  a  diffuse  cloudiness  due  to  effusion  of  serum.  The  haemor- 
rhages are  in  the  layer  of  nerve  fibres.  They  vary  greatly  in  size  and  form, 
but  often  follow  the  course  of  vessels.  When  recent  the  color  is  bright  red, 
but  they  gradually  change  and  old  haemorrhages  are  almost  black.  The  white 
spots  are  due  either  to  fibrinous  exudate  or  to  fatty  degeneration  of  the  retinal 
elements,  and  occasionally  to  accumulation  of  leucocytes  or  to  a  localized 
sclerosis  of  the  retinal  elements.  The  more  important  of  the  forms  of  retinitis 
to  be  recognized  are: 

ALBUMINURIC  RETINITIS,  which  occurs  in  chronic  nephritis,  particularly  in 
the  interstitial  or  contracted  form.  The  percentage  of  cases  affected  is  from 
15  to  25.  There  are  instances  in  which  these  retinal  changes  are  associated 
with  the  granular  kidney  at  a  stage  when  the  amount  of  albumin  may  be 
slight  or  transient ;  but  in  all  such  instances  it  will  be  found  that  there  is  a 
marked  arterio-sclerosis.  Gowers  recognizes  a  degenerative  form  (most  com- 
mon), in  which,  with  the  retinal  changes,  there  may  be  scarcely  any  alteration 
in  the  disk;  a  hagmorrhagic  form,  with  many  haemorrhages  and  but  slight 
signs  of  inflammation;  and  an  inflammatory  form,  in  which  there  is  much 
swelling  of  the  retina  and  obscuration  of  the  disk.  It  is  noteworthy  that  in 
some  instances  the  inflammation  of  the  optic  nerve  predominates  over  the 
retinal  changes,  and  one  may  be  in  doubt  for  a  time  whether  the  condition  is 
really  associated  with  the  renal  changes  or  dependent  upon  intracranial  disease. 

SYPHILITIC  EETINITIS. — In  the  acquired  form  this  is  less  common  than 
choroiditis.  In  inherited  syphilis  retinitis  pigmentosa  is  sometimes  met  with. 

EETINITIS  IN  ANEMIA. — It  has  long  been  known  that  a  patient  may  be- 
come blind  after  a  large  haemorrhage,  either  suddenly  or  within  two  or  three 
days,  and  in  one  or  both  eyes.  Occasionally  the  loss  may  be  permanent  and 
complete.  In  some  of  these  instances  a  neuro-retinitis  has  been  found,  prob- 
ably sufficient  to  account  for  the  symptoms.  In  the  more  chronic  anaemias, 
particularly  in  the  pernicious  (f orm,  retinitis  is  common,  as  determined  first 
by  Quincke. 

In  MALARIA  retinitis  or  neuro-retinitis  may  be  present,  as  noted  by  Stephen 
Mackenzie.  It  is  seen  only  in  the  chronic  cases  with  anaemia,  and  in  my 
experience  is  not  nearly  so  common  proportionately  as  in  pernicious  anaemia. 

LEUK^IMIC  EETINITIS. — In  this  affection  the  retinal  veins  are  large  and 
distended;  there  is  also  a  peculiar  retinitis,  as  described  by  Liebreich.  It  is 
not  very  common.  There  are  numerous  haemorrhages  and  white  or  yellow 
areas,  which  may  be  large  and  prominent.  In  one  of  my  cases  the  retina  post 


1030  DISEASES    OF    THE    NERVOUS    SYSTEM 

mortem  was  dotted  with  many  small,  opaque,  white  spots,  looking  like  little 
tumors,  the  larger  of  which  had  a  diameter  of  nearly  2  mm. 

Retinitis  is  also  found  occasionally  in  diabetes,  in  purpura,  in  chronic 
lead  poisoning,  and  sometimes  as  an  idiopathic  affection. 

Functional  Disturbances  of  Vision.  —  (a)  Toxic  AMAUROSIS. — This  occurs 
in  uraemia  and  may  follow  convulsions  or  come  on  independently.  The  con- 
dition, as  a  rule,  persists  only  for  a  day  or  two.  This  form  of  amaurosis 
occurs  in  poisoning  by  lead,  alcohol,  and  occasionally  by  quinine.  It  seems 
more  probable  that  the  poisons  act  on  the  centres  and  not  on  the  retina. 

(&)  TOBACCO  AMBLYOPIA. — The  loss  of  sight  is  usually  gradual,  equal  in 
both  eyes,  and  affects  particularly  the  centre  of  the  field  of  vision.  The  eye- 
grounds  may  be  normal,  but  occasionally  there  is  congestion  of  the  disks. 
On  testing  the  color  fields  a  central  scotoma  for  red  and  green  is  found  in  all 
cases.  Ultimately,  if  the  use  of  tobacco  is  continued,  organic  changes  may 
develop  with  atrophy  of  the  disk. 

(c)  HYSTERICAL  AMAUROSIS. — More  frequently  this  is  loss  of  acuteness  of 
vision — amblyopia — but  the  loss  of  sight  in  one  or  both  eyes  may  apparently 
be  complete.    The  condition  will  be  mentioned  subsequently  under  hysteria. 

(d)  NIGHT-BLINDNESS — NYCTALOPIA — the  condition  in  which  objects  are 
clearly  seen  during  the  day  or  by  strong  artificial  light,  but  become  invisible  in 
the  shade  or  in  twilight,  and  hemeralopia,  in  which  objects  can  not  be  clearly 
seen  without  distress  in  daylight  or  in  a  strong  artificial  light,  but  are  readily 
seen  in  a  deep  shade  or  in  twilight,  are  functional  anomalies  of  vision  which 
rarely  come  under  the  notice  of  the  physician.     It  may  occur  in  epidemic 
form. 

(e)  RETINAL  HYPER^STHESIA  is  sometimes  seen  in  hysterical  women,  but 
is  not  found  frequently  in  actual  retinitis.    I  have  seen  it  once,  however,  in 
albuminuric  retinitis,  and  once,  in  a  marked  degree,  in  a  patient  with  aortic 
insufficiency,  in  whose  retina  there  were  no  signs  other  than  the  throbbing 
arteries. 

(2)  Lesions  of  the  Optic  Nerve 

Optic  Neuritis  (Papillitis;  Choked  Disk) . — In  the  first  stage  there  is  con- 
gestion of  the  disk  and  the  edges  are  blurred  and  striated.  In  the  second 
stage  the  congestion  is  more  marked;  the  swelling  increases,  the  striation 
also  is  more  visible.  The  physiological  cupping  disappears  and  haemorrhages 
are  not  uncommon.  The  arteries  present  little  change,  the  veins  are  dilated, 
and  the  disk  may  swell  greatly.  In  slight  grades  of  inflammation  the  swelling 
gradually  subsides  and  occasionally  the  nerve  recovers  completely.  In  in- 
stances in  which  the  swelling  and  exudate  are  very  great  the  subsidence  is 
slow,  and  when  it  finally  disappears  there  is  complete  atrophy  of  the  nerve. 
The  retina  not  infrequently  participates  in  the  inflammation,  which  is  then 
a  neuro-retinitis. 

This  condition  is  of  the  greatest  importance  in  diagnosis.  It  may  exist 
in  its  early  stages  without  any  disturbance  of  vision,  and  even  with  exten- 
sive papillitis  the  sight  may  for  a  time  be  good. 

Optic  neuritis  is  seen  occasionally  in  anemia  and  lead  poisoning,  more 
commonly  in  Bright's  disease  as  neuro-retinitis.  It  occurs  occasionally  as 
a  primary  idiopathic  affection.  The  frequent  connection  with  intracranial 


DISEASES    OF   THE    CEREBRAL   NERVES  1031 

disease,  particularly  tumor,  makes  its  presence  of  great  value  to  practition- 
ers. The  nature  of  the  growth  is  without  influence.  In  over  90  per  cent, 
of  such  instances  the  papillitis  is  bilateral.  It  is  also  found  in  meningitis, 
either  the  tuberculous  or  the  simple  form.  In  meningitis  it  is  easy  to  see 
how  the  inflammation  may  extend  down  the  nerve  sheath.  In  the  case  of 
tumor,  however,  it  is  probable  that  mechanical  conditions,  especially  the 
venous  stasis,  are  alone  responsible  for  the  oedematous  swelling.  It  often  sub- 
sides very  rapidly  after  a  palliative  craniectomy  has  been  performed. 

Optic  Atrophy. — This  may  be:  (a)  A  primary  affection.  There  is  an 
hereditary  form,  in  which  the  disease  has  developed  in  all  the  males  of  a 
family  shortly  after  puberty.  A  large  number  of  the  cases  of  primary  atrophy 
are  associated  with  spinal  disease,  particularly  locomotor  ataxia.  Other  causes 
which  have  been  assigned  for  the  primary  atrophy  are  cold,  sexual  excesses, 
diabetes,  the  specific  fevers,  methyl  alcohol,  and  lead. 

(6)  Secondary  atrophy  results  from  cerebral  diseases,  pressure  on  the 
chiasma  or  on  the  nerves,  or,  most  commonly  of  all,  as  a  sequence  of  papillitis. 

The  ophthalmoscopic  appearances  are  different  in  the  cases  of  primary 
and  secondary  atrophy.  In  the  former  the  disk  has  a  gray  tint,  the  edges 
are  well  defined,  and  the  arteries  look  almost  normal;  whereas  in  the  con- 
secutive atrophy  the  disk  has  a  staring  opaoue  white  aspect,  with  irregular 
outlines,  and  the  arteries  are  very  small. 

The  symptom  of  optic  atrophy  is  loss  of  sight,  proportionate  to  the  dam- 
age in  the  nerve.  The  change  is  in  three  directions:  "(1)  Diminished  acuity 
of  vision;  (2)  alteration  in  the  field  of  vision;  and  (3)  altered  perception  of 
solor"  (Growers).  The  outlook  in  primary  atrophy  is  bad. 

(3)  Affections  of  the  Chiasma  and  Tract. 

At  the  chiasma  the  optic  nerves  undergo  partial  decussation.  Each  optic 
tract,  as  it  leaves  the  chiasma,  contains  nerve  fibres  which  originate  in  the 
retinae  of  both  eyes.  Thus,  of  the  fibres  of  the  right  tract,  part  have  come 
through  the  chiasma  without  decussating  from  the  temporal  half  of  the  right 
retina,  the  other  and  larger  portion  of  the  fibres  of  the  tract  have  decussated 
in  the  chiasma,  coming  as  they  do  from  the  left  optic  nerve  and  the  nasal  half 
of  the  retina  on  the  left  side.  The  fibres  which  cross  are  in  the  middle  por- 
tion of  the  chiasma,  while  the  direct  fibres  are  on  each  side.  The  following 
are  the  most  important  changes  which  ensue  in  lesions  of  the  tract  and  of  the 
chiasma : 

Unilateral  Affection  of  Tract. — If  on  the  right  side,  this  produces  loss 
of  function  in  the  temporal  half  of  the  retina  on  the  right  side,  and  in  the 
nasal  half  of  the  retina  on  the  left  side,  so  that  there  is  only  half  vision, 
and  the  patient  is  blind  to  objects  on  the  left  side.  This  is  termed  homony- 
mous  hemianopia  or  lateral  hemianopia.  The  fibres  passing  to  the^  right 
half  of  each  retina  being  involved,  the  patient  is  blind  to  objects  in  the 
left  half  of  each  visual  field.  The  hemianopia  may  be  partial  and  only  a 
portion  of  the  half  field  may  be  lost.  The  unaffected  visual  fields  may  have 
the  normal  extent,  but  in  some  instances  there  is  considerable  reduction. 
When  the  left  half  of  one  field  and  the  right  half  of  the  other,  or  vice  versa, 
are  blind,  the  condition  is  known  as  heteronymous  hemianopia. 


1032  DISEASES    OF    THE    NERVOUS    SYSTEM 

Disease  of  the  Chiasma. — (a)  A  lesion  involves,  as  a  rule,  chiefly  the 
central  portion,  in  which  the  decussating  fibres  pass  which  supply  the  inner 
or  nasal  halves  of  the  retinae,  producing  in  consequence  loss  of  vision  in 
the  outer  half  of  each  field,  or  what  is  known  as  temporal  hemianopia. 

(6)  If  the  lesion  is  more  extensive  it  may  involve  not  only  the  central  por- 
tion, but  also  the  direct  fibres  on  one  side  of  the  commissure,  in  which  case 
there  would  be  total  blindness  in  one  eye  and  temporal  hemianopia  in  the 
other. 

(c)  Still  more  extensive  disease  is  not  infrequent  from  pressure  of  tumors 
in  this  region,  the  whole  chiasma  is  involved,  and  total  blindness  results.    The 
different  stages  in  the  process  may  often  be  traced  in  a  single  case  from  tem- 
poral hemianopia,  then  complete  blindness  in  one  eye  with  temporal  hemi- 
anopia in  the  other,  and  finally  complete  blindness. 

(d]  A  limited  lesion  of  the  outer  part  of  the  chiasma  involves  only  the 
direct  fibres  passing  to  the  temporal  halves  of  the  retinae  and  inducing  blind- 
ness in  the  nasal  field,  or,  as  it  is  called,  nasal  hemianopia.    This,  of  course,  is 
extremely  rare.     Double  nasal  hemianopia  may  occur  as  a  manifestation  of 
tabes  and  in  tumors  involving  the  outer  fibres  of  each  tract. 

(4)  Affections  of  the  Tract  and  Centres 

The  optic  tract  crosses  the  crus  (cerebral  peduncle)  to  the  hinder  part 
of  the  optic  thalamus  and  divides  into  two  portions,  one  of  which  (the  lateral 
root)  goes  to  the  pulvinar  of  the  thalamus,  the  lateral  geniculate  body,  and 
to  the  anterior  quadrigeminal  body  (superior  colliculus).  From  these  parts, 
in  which  the  lateral  root  terminates,  fibres  pass  into  the  posterior  part  of  the 
internal  capsule  and  enter  the  occipital  lobe,  forming  the  fibres  of  the  optic 
radiation,  which  terminate  in  and  about  the  cuneus,  the  region  of  the  visual 
perceptive  csntre.  The  fibres  of  the  medial  division  of  the  tract  pass  to  the 
medial  geniculate  body  and  to  the  posterior  quadrigeminal  body.  The  medial 
root  contains  the  fibres  of  the  commissura  inferior  of  v.  Gudden,  which  are 
believed  to  have  no  connection  with  the  retina.  It  is  still  held  by  some  physi- 
ologists that  the  cortical  visual  centre  is  not  confined  to  the  occipital  lobe  alone, 
hut  embraces  the  occipito-angular  region. 

A  lesion  of  the  fibres  of  the  optic  path  anywhere  between  the  cortical  cen- 
tre and  the  chiasma  will  produce  hemianopia.  The  lesion  may  be  situated: 
(a)  In  the  optic  tract  itself.  (&)  In  the  region  of  the  thalamus,  lateral 
geniculate  body,  and  the  corpora  quadrigemina,  into  which  the  larger  part  of 
each  tract  enters,  (c)  A  lesion  of  the  fibres  passing  from  the  centres  just 
mentioned  to  the  occipital  lobe.  This  may  be  either  in  the  hinder  part  of  the 
internal  capsule  or  the  white  fibres  of  the  optic  radiation,  (d)  Lesion  of  the 
cuneus.  Bilateral  disease  of  the  cuneus  may  result  in  total  blindness,  (e) 
There  is  clinical  evidence  to  show  that  lesion  of  the  angular  gyrus  may  be 
associated  with  visual  defect,  not  so  often  hemianopia  as  crossed  amblyopia, 
dimness  of  vision  in  the  opposite  eye,  and  great  contraction  in  the  field  of 
vision.  Lesions  in  this  region  are  associated  with  mind-blindness,  a  condition 
in  which  there  is  failure  to  recognize  the  nature  of  objects. 

The  effects  of  lesions  in  the  optic  nerve  in  different  situations  from  the  reti- 
nal expansion  to  the  brain  cortex  are  as  follows :  (1)  Of  the  optic  nerve — total 


DISEASES    OF   THE    CEREBRAL   NERVES 


1033 


blindness  of  the  corresponding  eye:  (2)  of  the  optic  chiasma,  either  temporal 
hemianopia,  if  the  central  part  alone  is  involved,  or  nasal  hemianopia,  if  the 
lateral  region  of  each  chiasma  is  involved;  (3)  lesion  of  the  optic  tract 
between  the  chiasma  and  the  lateral  geniculate  body  produces  lateral  hemian- 
opia; (4)  lesion  of  the  central  fibres  of  the  nerve  between  the  geniculate 


M& 


FIG.  19. — DIAGRAM  OF  VISUAL  PATHS.  (From  Vialet,  modified.)  OP.  N.,  Optic  tierve, 
OP.  C.,  Optic  chiasm.  OP.  T.,  Optic  tract.  OP.  E.,  Optic  radiations.  EXT. 
GEN.,  External  geniculate  body.  THO.,  Optic  thalamus.  C.  QU.,  Corpera  quad- 
rigemina.  C.  C.,  Corpus  callosum.  V.  S.,  Visual  speech  centre.  A.  S.,  Auditory 
speech  centre.  M.  S.,  Motor  speech  centre.  A  lesion  at  1  causes  blindness  of  that 
eye;  at  2,  bi-temporal  hemianopia;  at  3,  nasal  hemianopia.  Symmtrical  lesions 
at  3  and  3'  would  cause  bi-nasal  hemianopia;  at  4,  hemianopia  of  both  eyes,  with 
hemianopic  pupillary  inaction;  at  5  and  6,  hemianopia  of  both  eyes,  pupillary 
reflexes  normal;  at  7,  amblyopia,  especially  of  opposite  eye;  at  8,  on  left  side, 
word-blindness. 

bodies  and  the  cerebral  cortex  produces  lateral  hemianopia;  (5)  lesion  of  the 
cuneus  causes  lateral  hemianopia;  and  (6)  lesion  of  the  angular  gyrus  may 
be  associated  with  hemianopia,  sometimes  crossed  amblyopia,  and  the  con- 
dition known  as  mind-blindness.  (See  Fig.  19,  with  accompanying  explana* 
tion.) 

67 


1034  DISEASES    OF    THE    NERVOUS    SYSTEM 

Diagnosis  of  Lesions  of  the  Optic  Nerve  and  Tract. — Having  determined 
the  presence  of  hemianopia,  the  question  arises  as  to  the  situation  of  the 
lesion,  whether  in  the  tract  between  the  chiasma  and  the  geniculate  bodies 
or  in  the  central  portion  of  the  fibres  between  these  bodies  and  the  visual 
centres.  This  can  be  determined  in  some  cases  by  the  test  known  as  Wcr- 
nicke's  hemiopic  pupillary  inaction.  The  pupil  reflex  depends  on  the  in- 
tegrity of  the  retina  or  receiving  membrane,  on  the  fibres  of  the  optic  nerve 
and  tract  which  transmit  the  impulse,  and  the  nerve-centre  at  the  termination 
of  the  optic  tract  which  receives  the  impression  and  transmits  it  to  the  third 
nerve  along  which  the  motor  impulses  pass  to  the  iris.  If  a  bright  light  is 
thrown  into  the  eye  and  the  pupil  reacts,  the  integrity  of  this  reflex  arc  is 
demonstrated.  It  is  possible  in  cases  of  lateral  hemianopia  so  to  throw  the 
light  into  the  eye  that  it  falls  upon  the  blind  half  of  the  retina.  If  when  this 
is  done  the  pupil  contracts,  the  indication  is  that  the  reflex  arc  above  referred 
to  is  perfect,  by  which  we  mean  that  the  optic  nerve  fibres  from  the  retinal 
expansion  to  the  centre,  the  centre  itself,  and  the  third  nerve  are  uninvolved. 
In  such  a  case  the  conclusion  would  be  justified  that  the  cause  of  the  hemi- 
anopia was  central;  that  is,  situated  beyond  the  geniculate  body,  either  in  the 
fibres  of  the  optic  radiation  or  in  the  visual  cortical  centres.  If,  on  the  other 
hand,  when  the  light  is  carefully  thrown  on  the  hemiopic  half  of  the  retina 
the  pupil  remains  inactive,  the  conclusion  is  justifiable  that  there  is  interrup- 
tion in  the  path  between  the  retina  and  the  nucleus  of  the  third  nerve,  and  that 
the  hemianopia  is  not  central,  but  dependent  upon  a  lesion  situated  in  the 
optic  tract.  This  test  of  Wernicke's  is  sometimes  difficult  to  obtain.  It  is 
best  performed  as  follows :  "The  patient  being  in  a  dark  or  nearly  dark  room 
with  the  lamp  or  gas-light  behind  his  head  in  the  usual  position,  I  bid  him 
look  over  to  the  other  side  of  the  room,  so  as  to  exclude  accommodative  iris 
movements  (which  are  not  necessarily  associated  with  the  reflex).  Then  I 
throw  a  faint  light  from  a  plane  mirror  or  from  a  large  concave  mirror,  held 
well  out  of  focus,  upon  the  eye  and  note  the  size  of  the  pupil.  With  my  other 
hand  I  now  throw  a  beam  of  light,  focussed  from  the  lamp  by  an  ophthalmo- 
scopic  mirror,  directly  into  the  optical  centre  of  the  eye;  then  laterally  in 
various  positions,  and  also  from  above  and  below  the  equator  of  the  eye,  noting 
the  reaction  at  all  angles  of  incidence  of  the  ray  of  light"  (Seguin). 

The  significance  of  hemianop'la  varies.  There  is  a  functional  hemianopia 
associated  with  migraine  and  hysteria.  In  a  considerable  proportion  of  all 
cases  there  are  signs  of  organic  brain  disease.  In  a  certain  number  of  in- 
stances of  slight  lesions  of  the  occipital  lobe  hemichromatopsia  has  been 
observed.  The  homonymous  halves  of  the  retina  as  far  as  the  fixation  point 
are  dulled,  or  blind  for  colors.  Hemiplegia  is  common.,  in  which  event  the 
loss  of  power  and  blindness  are  on  the  same  side.  Thus,  a  lesion  in  the  left 
hemisphere  involving  the  motor  tract  produces  right  hemiplegia,  and  when 
the  fibres  of  the  optic  radiation  are  involved  in  the  internal  capsule  there  is 
also  lateral  hemianopia,  so  that  objects  in  the  field  of  vision  to  the  right  are 
not  perceived.  Hemiansesthesia  is  not  uncommon  in  such  cases,  owing  to  the 
close  association  of  the  sensory  and  visual  tracts  at  the  posterior  part  of  the 
internal  capsule.  Certain  forms  of  aphasia  also  occur  in  many  of  the  cases. 

The  optic  aphasia  of  Freund  may  be  mentioned  here.  The  patient,  after 
an  apoplectic  attack,  though  able  to  recognize  ordinary  objects  shown  to  him, 


DISEASES    OF    THE    CEREBRAL    NERVES  1035 

is  unable  to  name  them  correctly.  If  he  be  permitted  to  touch  the  object  he 
may  be  able  to  name  it  quickly  and  correctly.  Freund's  optic  aphasia  differs 
from  mind-blindness,  since  in  the  latter  affection  the  objects  seen  are  not 
recognized.  Optic  aphasia,  like  word-blindness,  never  occurs  alone,  but  is 
always  associated  with  hemianopia,  or  mind-blindness,  and  often  also  with 
word-deafness.  In  the  cases  which  have  thus  far  come  to  autopsy  there  has 
always  been  a  lesion  in  the  white  matter  of  the  occipital  lobe  on  the  left  side. 

MOTOE  NERVES  OF  THE  EYEBALL 

Third  Nerve  (Nervus  oculomotorius] . — The  nucleus  of  origin  of  this  nerve 
is  situated  in  the  floor  of  the  aqueduct  of  Sylvius;  the  nerve  passes  through 
the  crus  at  the  side  of  which  it  emerges.  Passing  along  the  wall  of  the  cav- 
ernous sinus,  it  enters  the  orbit  through  the  sphenoidal  fissure  and  supplies, 
by  its  superior  branch,  the  levator  palpebraa  superioris  and  the  superior  rectus, 
and  by  its  inferior  branch  the  internal  and  inferior  recti  muscles  and  the  infe- 
rior oblique.  Branches  pass  to  the  ciliary  muscle  and  the  constrictor  of  the 
iris.  Lesions  may  affect  the  nucleus  or  the  nerve  in  its  course  and  cause  either 
paralysis  or  spasm. 

PARALYSIS. — A  nuclear  lesion  is  usually  associated  with  disease  of  the 
centres  for  the  other  eye  muscles,  producing  a  condition  of  general  ophthal- 
moplegia.  More  commonly  the  nerve  itself  is  involved  in  its  course,  either  by 
meningitis,  gummata,  or  aneurism,  or  is  attacked  by  a  neuritis,  as  in  diph- 
theria and  locomotor  ataxia.  Complete  paralysis  of  the  third  nerve  is  accom- 
panied by  the  following  symptoms : 

Paralysis  of  all  the  muscles,  except  the  superior  oblique  and  external  rec- 
tus, by  which  the  eye  can  be  moved  outward  and  a  little  downward  and  inward. 
There  is  divergent  strabismus.  There  is  ptosis  or  drooping  of  the  upper  eye- 
lid, owing  to  paralysis  of  the  levator  palpebraB.  The  pupil  is  usually  dilated. 
It  does  not  contract  to  light,  and  the  power  of  accommodation  is  lost.  The 
most  striking  features  of  this  paralysis  are  the  external  strabismus,  with 
diplopia  or  double  vision,  and  the  ptosis.  In  very  many  cases  the  affection 
of  the  third  nerve  is  partial.  Thus  the  levator  palpebraa  and  the  superior 
rectus  may  be  involved  together,  or  the  ciliary  muscles  and  the  iris  may  be 
affected  and  the  external  muscles  may  escape. 

There  is  a  remarkable  form  of  recurring  oculo-motor  paralysis  affecting 
chiefly  women,  and  involving  all  the  branches  of  the  nerve.  In  some  cases 
the  attacks  have  come  on  at  intervals  of  a  month;  in  others  a  much  longer 
period  has  elapsed.  The  attacks  may  persist  throughout  life.  They  are  some- 
times associated  with  pain  in  the  head  and  sometimes  with  migraine.  Mary 
Sherwood  has  collected  from  the  literature  23  cases. 

PTOSIS  is  a  common  and  important  symptom  in  nervous  affections.  We 
may  here  briefly  refer  to  the  conditions  under  which  it  may  occur:  (a)  A  con- 
genital, incurable  form,  which  is  frequently  seen;  (&)  the  form  associated 
with  definite  lesion  of  the  third  nerve,  either  in  its  course  or  at  its  nucleus. 
This  may  come  on  with  paralysis  of  the  superior  rectus  alone  or  with  paralysis 
of  the  internal  and  inferior  recti  as  well,  (c)  There  are  instances  of  com- 
plete or  partial  ptosis  associated  with  cerebral  lesions  without  any  other  branch 
of  the  third  nerve  being  paralyzed.  The  exact  position  of  the  cortical  centre 


1036  DISEASES    OF    THE    NERVOUS    SYSTEM 

or  centres  is  as  yet  unknown,  (d)  Hysterical  ptosis,  which  is  double  and 
occurs  with  other  hysterical  symptoms,  (e)  Pseudo-ptosis,  due  to  affection 
of  the  sympathetic  nerve,  is  associated  with  symptoms  of  vaso-motor  palsy, 
such  as  elevation  of  the  temperature  on  the  affected  side  with  redness  and 
cedema  of  the  skin.  Contraction  of  the  pupil  exists  on  the  same  side  and  the 
eyeball  appears  rather  to  have  shrunk  into  the  orbit.  (/)  In  idiopathic  mus- 
cular atrophy,  when  the  face  muscles  are  involved,  there  may  be  marked 
bilateral  ptosis.  And,  lastly,  in  weak,  delicate  women  there  is  often  to  be 
seen  a  transient  ptosis,  particularly  in  the  morning. 

Among  the  most  important  of  the  symptoms  of  the  third-nerve  paralysis 
are  those  which  relate  to  the  ciliary  muscle  and  iris. 

CYCLOPLEGIA,  paralysis  of  the  ciliary  muscle,  causes  loss  of  the  power  of 
accommodation.  Distant  vision  is  clear,  but  near  objects  can  not  be  prop- 
erly seen.  In  consequence  the  vision  is  indistinct,  but  can  be  restored  by  the 
use  of  convex  glasses.  This  may  occur  in  one  or  in  both  eyes;  in  the  latter 
case  it  is  usually  associated  with  disease  in  the  nuclei  of  the  nerve.  Cyclo- 
plegia  is  an  early  and  frequent  symptom  in  diphtheritic  paralysis  and  occurs 
also  in  tabes. 

IRIDOPLEGIA,  or  paralysis  of  the  iris,  occurs  in  three  forms  (Gowers)  : 

(a)  Accommodation  iridoplegia,  in  which  the  pupil  does  not  diminish 
in  size  during  the  act  of  accommodation.  To  test  for  this  the  patient 
should  look  first  at  a  distant  and  then  at  a  near  object  in  the  same  line  of 
vision. 

(&)  Reflex  Iridoplegia. — The  path  for  the  iris  reflex  is  along  the  optic 
nerve  and  tract  to  its  termination,  then  to  the  nucleus  of  the  third  nerve, 
and  along  the  trunk  of  this  nerve  to  the  ciliary  ganglion,  and  so  through 
the  ciliary  nerves  to  the  eyes.  Each  eye  should  be  tested  separately,  the  other 
one  being  covered.  The  patient  should  look  at  a  distant  object  in  a  dark  part 
of  the  room;  then  a  light  is  brought  suddenly  in  front  of  the  eye  at  a  dis- 
tance of  three  or  four  feet,  so  as  to  avoid  the  effect  of  accommodation.  Loss 
of  this  iris  reflex  with  retention  of  the  accommodation  contraction  is  known 
as  the  Argyll-Robertson  pupil. 

(c)  Loss  of  the  Skin  Reflex. — If  the  skin  of  the  neck  is  pinched  or  pricked 
the  pupil  dilates  reflexly,  the  afferent  impulses  being  conveyed  along  the  cer- 
vical sympathetic.  Erb  pointed  out  that  this  skin  reflex  is  lost  usually  in 
association  with  the  reflex  contraction,  but  the  two  are  not  necessarily  con- 
joined. In  iridoplegia  the  pupils  are  often  small,  particularly  in  spinal  dis- 
ease, as  in  the  characteristic  small  pupils  of  tabes — spinal  myosis.  Irido- 
plegia may  coexist  with  a  pupil  of  medium  size. 

Inequality  of  the  pupils — anisocoria — is  not  infrequent  in  progressive  pare- 
sis and  in  tabes.  It  may  also  occur  in  perfectly  healthy  individuals. 

SPASM. — Occasionally  in  meningitis  and  in  hysteria  there  is  spasm  of  the 
muscles  supplied  by  the  third  nerve,  particularly  the  internal  rectus  and  the 
levator  palpebrae.  The  clonic  rhythmical  spasm  of  the  eye  muscles  is  known 
as  nystagmus,  in  which  there  is  usually  a  bilateral,  rhythmical,  involuntary 
movement  of  the  eyeballs.  The  condition  is  met  with  in  many  congenital 
and  acquired  brain  lesions,  in  albinism,  and  sometimes  in  coal  miners. 

Fourth  Nerve    (Nervus  trochlearis) . — This  supplies  the  superior  oblique 
muscle.     In  its  course  around  the  outer  surface  of  the  crus  and  in  its  pas- 


DISEASES    OF    THE    CEEEBKAL   NERVES  1037 

sage  into  the  orbit  it  is  liable  to  be  compressed  by  tumors,  by  aneurism,  or  in 
the  exudation  of  basilar  meningitis.  Its  nucleus  in  the  upper  part  of  the 
fourth  ventricle  may  be  involved  by  tumors  or  undergo  degeneration  with  the 
other  ocular  nuclei.  The  superior  oblique  muscle  acts  in  such  a  way  as  to 
direct  the  eyeball  downward  and  rotate  it  slightly.  The  paralysis  causes  de- 
fective downward  and  inward  movement,  often  too  slight  to  be  noticed.  The 
head  is  inclined  somewhat  forward  and  toward  the  sound  side,  and  there  is 
double  vision  when  the  patient  looks  down. 

Sixth  Nerve  (Nervus  dbducens}. — This  nerve  emerges  at  the  junction  of 
the  pons  and  medulla,  then,  passing  forward,  it  enters  the  orbit  and  supplies 
the  external  rectus  muscle.  Owing  to  its  long  course  and  exposed  position  it 
is  more  commonly  injured  than  any  other  cranial  nerve.  It  is  affected  by 
meningitis  at  the  base,  by  gummata  or  other  tumors,  and  sometimes  by  cold. 
There  is  internal  strabismus,  and  the  eye  can  not  be  turned  outward.  Diplopia 
occurs  on  looking  toward  the  paralyzed  side. 

"When  the  nucleus  is  affected  there  is,  in  addition  to  paralysis  of  the 
external  rectus,  inability  of  the  internal  rectus  of  the  opposite  eye  to  turn  that 
eye  inward.  As  a  consequence  of  this  the  axes  of  the  eyes  are  kept  parallel, 
and  both  are  conjugately  deviated  to  the  opposite  side,  away  from  the  side 
of  lesion.  The  reason  of  this  is  that  the  nucleus  of  the  sixth  nerve  sends 
fibres  up  in  the  pons  to  that  part  of  the  nucleus  of  the  opposite  third  nerve 
which  supplies  the  internal  rectus.  We  thus  have  paralysis  of  the  internal 
rectus  without  the  nucleus  of  the  third  nerve  being  involved,  owing  to  its 
receiving  its  nervous  impulses  for  parallel  movement  from  the  sixth  nucleur 
of  the  opposite  side.  As  the  sixth  nucleus  is  in  such  proximity  to  the  facial 
nerve  in  the  substance  of  the  pons,  it  is  frequently  found  that  the  whole  of 
the  face  on  the  same  side  is  paralyzed,  and  gives  the  electrical  reaction  of 
degeneration,  so  that  with  a  lesion  of  the  left  sixth  nucleus  there  is  conjugate 
deviation  of  both  eyes  to  the  right — i.  e.,  paralysis  of  the  left  external  and  the 
right  internal  rectus,  and  sometimes  complete  paralysis  of  the  left  side  of  the 
face"  (Beevor). 

General  Features  of  Paralysis  of  the  Motor  Nerves  of  the  Eye. — Gowers 
divides  them  into  five  groups: 

(a)  Limitation  of  Movem&nt. — Thus,  in  paralysis  of  the  external  rectus, 
the  eyeball  can  not  be  moved  outward.  When  the  paralysis  is  incomplete 
the  movement  is  deficient  in  proportion  to  the  degree  of  the  palsy. 

(6)  Strabismus. — The  axes  of  the  eyes  do  not  correspond.  Thus,  paral- 
ysis of  the  internal  rectus  causes  a  divergent  squint;  of  the  external  rectus, 
a  convergent  squint.  At  first  this  is  evident  only  when  the  eyes  are  moved 
m  the  direction  of  the  action  of  the  weak  muscle,  but  may  become  con- 
stant by  the  contraction  of  the  opposing  muscle.  The  deviation  of  the  axis 
of  the  affected  eye  from  parallelism  with  the  other  is  called  the  primary 
deviation. 

(c)  Secondary  Deviation. — If,  while  the  patient  is  looking  at  an  object, 
the  sound  eye  is  covered,  so  that  he  fixes  the  object  looked  at  with  the  affected 
eye  only,  the  sound  eye  is  moved  still  further  in  the  same  direction — e.  g., 
outward,  when  there  is  paralysis  of  the  opposite  internal  rectus.  This  is  known 
as  secondary  deviation.  It  depends  upon  the  fact  that,  if  two  muscles  are 
acting  together,  when  one  is  weak  and  an  effort  is  made  to  contract  it,  the 


1038  DISEASES    OF    THE    NERVOUS    SYSTEM 

increased  effort — innervation — acts  powerfully  upon  the  other  muscle,  causing 
an  increased  contraction. 

(d)  Erroneous  Projection. — "We  judge  of  the  relation  of  external  ob- 
jects to  each  other  by  the  relation  of  their  images  on  the  retina;  but  we  judge 
of  their  relation  to  our  own  body  by  the  position  of  the  eyeball  as  indicated 
to  us  by  the  innervation  we  give  to  the  ocular  muscles"   (Gowers).     With 
the  eyes  at  rest  in  the  mid-position,  an  object  at  which  we  are  looking  is 
directly  opposite  our  face.     Turning  the  eyes  to  one  side,  we  recognize  that 
object  in  the  middle  of  the  field  or  to  the  side  of  this  former  position.     We 
estimate  the  degree  by  the  amount  of  movement  of  the  eyes,  and  when  the 
object  moves  and  we  follow  it  we  judge  of  its  position  by  the  amount  of  move- 
ment of  the  eyeballs.    When  one  ocular  muscle  is  weak  the  increased  inner- 
vation gives  the  impression  of  a  greater  movement  of  the  eye  than  has  really 
taken  place.    The  mind,  at  the  same  time,  receives  the  idea  that  the  object  is 
further  on  one  side  than  it  really  is,  and  in  an  attempt  to  touch  it  the  finger 
may  go  beyond  it.     As  the  equilibrium  of  the  body  is  in  a  large  part  main- 
tained by  a  knowledge  of  the  relation  of  external  objects  to  it  obtained  by  the 
action  of  the  eye  muscles,  this  erroneous  projection  resulting  from  paralysis 
disturbs  the  harmony  of  these  visual  impressions  and  may  lead  to  giddiness — 
ocular  vertigo. 

(e)  Double  Vision. — This  is  one  of  the  most  disturbing  features  of  paral- 
ysis of  the  eye  muscles.    The  visual  axes  do  not  correspond,  so  that  there  is 
a  double  image — diplopia.     That  seen  by  the  sound  eye  is  termed  the  true 
image;  that  by  the  paralyzed  eye,   tho  false.     In  simple   or  homonymous 
diplopia  the  false  image  is  "on  the  same  side  of  the  other  as  the  eye  by  which 
it  is  seen."    In  crossed  diplopia  it  is  on  the  other  side.    In  convergent  squint 
the  diplopia  is  simple ;  in  divergent  it  is  crossed. 

Ophthalmoplegia. — Under  this  term  is  described  a  chronic  progressive 
paralysis  of  the  ocular  muscles.  Two  forms  are  recognized — ophthalmoplegia 
externa  and  ophthalmoplegia  interna.  The  conditions  may  occur  separately 
or  together  and  are  described  by  Gowers  under  nuclear  ocular  palsy. 

OPHTHALMOPLEGIA  EXTERNA. — The  condition  is  one  of  more  or  less  com- 
plete palsy  of  the  external  muscles  of  the  eyeball,  due  usually  to  a  slow  degen- 
eration in  the  nuclei  of  the  nerves,  but  sometimes  to  pressure  of  tumors  or  to 
basilar  meningitis.  It  is  often,  but  riot  necessarily,  associated  with  ophthal- 
moplegia interna.  Of  62  cases  analyzed  by  Siemerling  in  only  11  could 
syphilis  be  positively  determined.  The  levator  muscles  of  the  eyelids  and  the 
superior  recti  are  first  involved,  and  gradually  the  other  muscles,  so  that  the 
eyeballs  are  fixed  and  the  eyelids  droop.  There  is  sometimes  slight  protrusion 
of  the  eyeballs.  The  disease  is  essentially  chronic  and  may  last  for  many  years. 
It  is  found  particularly  in  association  with  general  paralysis,  locomotor  ataxia, 
and  in  progressive  muscular  atrophy.  Mental  disorders  were  present  in  11  of 
the  62  cases.  With  it  may  be  associated  atrophy  of  the  optic  nerve  and  af- 
'fections  of  other  cerebral  nerves.  Occasionally,  as  noted  by  Bristowe,  it  may 
be  functional. 

OPHTHALMOPLEGIA  INTERNA. — Jonathan  Hutchinson  applied  this  term  to 
a  progressive  paralysis  of  the  internal  ocular  muscles,  causing  loss  of  pupil- 
lary action  and  the  power  of  accommodation.  When  the  internal  and  ex- 
ternal muscles  are  involved  the  affection  is  known  as  total  ophthalmoplegia, 


DISEASES    OF    THE    CEREBRAL    NERVES  1039 

and  in  a  majority  of  the  cases  the  two  conditions  are  associated.  In 
some  instances  the  internal  form  may  depend  upon  disease  of  the.  ciliary 
ganglion. 

While,  as  a  rule,  ophthalmoplegia  is  a  chronic  process,  there  is  an  acute 
form  associated  with  haemorrhagic  softening  of  the  nuclei  of  the  ocular  mus- 
cles. There  is  usually  marked  cerebral  disturbance.  It  was  to  this  form  that 
Wernicke  gave  the  name  poliencephalitis  superior. 

Treatment  of  Ocular  Palsies. — It  is  important  to  ascertain,  if  possible, 
the  cause.  The  forms  associated  with  locomotor  ataxia  are  obstinate,  and 
resist  treatment.  Occasionally,  however,  a  palsy,  complete  or  partial,  may 
pass  away  spontaneously.  The  group  of  cases  associated  with  chronic  degen- 
erative changes,  as  in  progressive  paresis  and  bulbar  paralysis,  is  little  affected 
by  treatment.  On  the  other  hand,  in  syphilitic  cases,  mercury  and  iodide  of 
potassium  are  indicated  and  are  often  beneficial.  Arsenic  and  strychnia,  the 
latter  hypodermically,  may  be  employed.  In  any  case  in  which  the  onset  is 
acute,  with  pain,  hot  fomentations  and  counter-irritation  or  leeches  applied 
to  the  temple  give  relief.  The  direct  treatment  by  electricity  has  been  exten- 
sively employed,  but  probably  without  any  special  effect.  The  diplopia  may 
be  relieved  by  the  use  of  prisms,  or  it  may  be  necessary  to  cover  the  affected  eye 
with  an  opaque  glass. 

FIFTH  NEEVE 

(Nervus  trigeminus) 

Etiology. — Paralysis  may  result  from:  (a)  Disease  of  the  pons,  particu- 
larly haemorrhage  or  patches  of  sclerosis.  (&)  Injury  or  disease  at  the  base  of 
the  brain.  Fracture  rarely  involves  the  nerve ;  on  the  other  hand,  meningitis, 
acute  or  chronic,  and  caries  of  the  bone  are  not  uncommon  causes,  (c)  The 
branches  may  be  affected  as  they  pass  out — the  first  division  by  tumors  press- 
ing on  the  cavernous  sinus  or  by  aneurism ;  the  second  and  third  divisions  by 
growths  which  invade  the  spheno-maxillary  fossa,  (d)  Primary  neuritis, 
which  is  rare. 

Symptoms. — (a)  SENSORY  PORTION. — Disease  of  the  fifth  nerve  may  cause 
loss  of  sensation  in  the  parts  supplied,  including  the  half  of  the  face,  the  cor- 
responding side  of  the  head,  the  conjunctiva,  the  mucosa  of  the  lips,  tongue, 
hard  and  soft  palate,  and  of  the  nose  of  the  same  side.  The  anaesthesia  may 
be  preceded  by  tingling  or  pain.  The  muscles  of  the  face  are  also  insensible 
and  the  movements  may  be  slower.  The  sense  of  smell  is  interfered  with, 
owing  to  dryness  of  the  mucous  membrane.  There  may  be  disturbance  of 
the  sense  of  taste.  The  salivary,  lachrymal,  and  buccal  secretions  may  be 
lessened,  and  the  teeth  may  become  loose.  Unless  properly  guarded  from 
injury  an  ulcerative  inflammation  of  the  eye  may  follow.  This  was  formerly 
supposed  to  be  due  to  nutritional  changes  from  paralysis  of  so-called  trophic 
nerve  fibres.  This  idea  has  of  late  years  been  overthrown  by  the  large  number 
of  cases  in  which  the  Gasserian  ganglion  has  been  removed  for  obstinate 
neuralgia  without  consequent  inflammation  of  the  eye.  Herpes  may  occur 
in  the  region  supplied  by  the  nerve,  usually  the  upper  branch,  and  is  asso- 
ciated with  much  pain,  which  may  be  peculiarly  enduring,  lasting  for 
months  or  years  (Gowers).  In  herpes  zoster  with  the  neuritis  there  may  b§ 


1040  DISEASES    OF    THE    NERVOUS    SYSTEM 

slight  enlargement  of  the  cervical  glands.  (See  under  Neuralgia  for  Tic 
Douloureux.) 

(6)  MOTOR  PORTION. — The  inability  to  use  the  muscles  of  mastication  on 
the  affected  side  is  the  distinguishing  feature  of  paralysis  of  this  portion  of 
the  nerve.  It  is  recognized  by  placing  the  finger  on  the  masseter  and  tem- 
poral muscles,  and,  when  the  patient  closes  the  jaw,  the  feebleness  of  their 
contraction  is  noted.  If  paralyzed,  the  external  pterygoid  can  not  move  the 
jaw  toward  the  unaffected  side;  and  when  depressed,  the  jaw  deviates  to  the 
paralyzed  side.  The  motor  paralysis  of  the  fifth  nerve  is  almost  invariably  a 
result  of  involvement  of  the  nerve  after  it  has  left  the  nucleus.  Cases,  how- 
ever, have  been  associated  with  cortical  lesions.  The  cortical  motor  centre  for 
the  tngeminus,  or  for  movements  effecting  closure  of  the  jaw,  lies  below  that 
for  movements  of  the  face  at  the  lower  part  of  the  anterior  central  convolu- 
tion. 

Spasm  of  the  Muscles  of  Mastication. — Trismus,  the  masticatory  spasm 
*  f  Eomberg,  may  be  tonic  or  clonic,  and  is  either  an  associated  phenomenon 
in  general  convulsions  or,  more  rarely,  an  independent  affection.  In  the  tonic 
form  the  jaws  are  kept  close  together — lock-jaw — or  can  be  separated  only  for 
a  short  space.  The  muscles  of  mastication  can  be  seen  in  contraction  and 
felt  to  be  hard;  the  spasm  is  often  painful.  "This  tonic  contraction  is  an 
early  symptom  in  tetanus,  and  is  sometimes  seen  in  tetany.  A  form  of  this 
tonic  spasm  occurs  in  hysteria.  Occasionally  trismus  follows  exposure  to  cold, 
and  is  said  to  be  due  to  reflex  irritation  from  the  teeth,  the  mouth,  or  caries 
of  the  jaw.  It  may  also  be  a  symptom  of  organic  disease  due  to  irritation 
near  the  motor  nucleus  of  the  fifth  nerve. 

Clonic  spasm  of  the  muscles  supplied  by  the  fifth  occurs  in  the  form  of 
rapidly  repeated  contractions,  as  in  "chattering  teeth."  This  is  rare  apart 
from  general  conditions,  though  cases  are  on  record,  usually  in  women  late 
in  life,  in  whom  this  isolated  clonic  spasm  of  the  muscles  of  the  jaw  ha1?  been 
found.  In  another  form  of  clonie  spasm  sometimes  seen  in  chorea  there  are 
forcible  single  contractions.  Gowers  mentions  an  instance  of  its  occurrence  a-s 
an  isolated  affection. 

(c)  GUSTATORY. — Complete  or  partial  loss  of  the  sense  of  taste  ever  the 
anterior  two-thirds  of  the  tongue  has  been  supposed  by  some  to  follow  paralysis 
of  the  fifth  nerve.  There  are  two  views  concerning  the  course  of  the  fibres  that 
carry  gustatory  impulse  from  this  part  of  the  tongue.  According  to  some 
they  take  a  devious  path,  passing  with  the  chorda  tympani  to  the  geniculate 
ganglion,  thence  by  the  great  superficial  petrosal  nerve  to  Meckel's  ganglion, 
and  this  they  leave  to  reach  the  maxillary  nerve,  which  they  follow  through  the 
trigeminal  nerve  to  the  brain.  A  study  of  clinical  cases  of  disease  of  the  fifth 
nerve  has  led  to  this  view.  It  seems  more  probable,  however,  from  the  fact 
that  a  large  number  of  the  trigeminal  neurectomies  are  not  followed  by  loss  of 
taste,  that  the  fibres  pass  to  the  brain  directly  from  the  geniculate  ganglion 
by  the  nervus  intermedius  of  Wrisberg.  Possibly  there  may  be  more  than  one 
course  for  these  fibres. 

The  diagnosis  of  disease  of  the  trifacial  nerve  is  rarely  difficult.  It  must 
be  remembered  that  the  preliminary  pain  and  hyperassthesia  are  sometimes 
mistaken  for  ordinary  neuralgia.  The  loss  of  sensation  and  the  palsy  of  the 
muscles  of  mastication  are  readily  determined. 


DISEASES    OF    THE    CEREBRAL    NERVES  1041 

Treatment. — When  the  pain  is  severe  morphia  may  be  required  and  local 
applications  are  useful.  If  there  is  a  suspicion  of  syphilis,  appropriate  treat- 
ment should  be  given.  Faradization  is  sometimes  beneficial. 

FACIAL  NERVE 

Paralysis  (Bell's  Palsy). — ETIOLOGY. — The  facial  or  seventh  may  be  para- 
lyzed by  (a)  lesions  of  the  cortex — supranuclear  palsy;  (&)  lesions  of  the 
nucleus  itself;  or  (c)  involvement  of  the  nerve  trunk  in  its  tortuous  course 
within  the  pons  and  through  the  wall  of  the  skull. 

(a)  Supranuclear  paralysis,  due  to  lesion  of  the  cortex  or  of  the  facial 
fibres  in  the  corona  radiata  or  internal  capsule,  is,  as  a  rule,  associated  with 
hemiplegia.  It  may  be  caused  by  tumors,  abscess,  chronic  inflammation,  or 
softening  in  the  cortex  or  in  the  region  of  the  internal  capsule.  It  is  distin- 
guished from  the  peripheral  form  by  well  marked  characters — the  persistence 
of  the  normal  electrical  excitability  of  both  nerves  and  muscles  and  the  fre- 
quent absence  of  involvement  of  the  upper  branches  of  the  nerve,  so  that  the 
orbicularis  palpebrarum,  frontalis,  and  corrugator  muscles  are  spared.  In  rare 
instances  these  muscles  are  paralyzed.  In  this  form  the  voluntary  movements 
are  more  impaired  than  the  emotional.  Isolated  paralysis — monoplegia 
facialis — due  to  involvement  of  the  cortex  or  of  the  fibres  in  their  path  to 
the  nucleus,  is  uncommon.  In  the  great  majority  of  cases  supranuclear  facial 
paralysis  is  part  of  a  hemiplegia.  Paralysis  is  on  the  same  side  as  that  of  the 
arm  and  leg  because  the  facial  muscles  bear  precisely  the  same  relation  to  the 
cortex  as  the  spinal  muscles.  The  nuclei  of  origin  on  either  side  of  the  middle 
line  in  the  medulla  are  united  by  decussating  fibres  with  the  cortical  centre 
on  the  opposite  side  (see  Fig.  18).  A  few  fibres  reach  the  nucleus  from  the 
cerebral  cortex  of  the  same  side,  and  this  uncrossed  path  may  innervate  the 
upper  facial  muscles. 

(&)  The  nuclear  paralysis  caused  by  lesions  of  the  nerve  centres  in  the 
medulla  is  not  common  alone ;  but  is  seen  occasionally  in  tumors,  chronic  soft- 
ening, and  ha?morrhage.  It  may  be  involved  in  anterior  polio-myelitis.  In 
diphtheria  this  centre  may  also  be  attacked.  The  symptoms  are  practically 
similar  to  those  of  an  affection  of  the  nerve  fibre  itself — infranuclear  paralysis. 

(c)  Involvement  of  the  Nerve  Trunk. — Paralysis  may  result  from: 

(1)  Involvement  of  the  nerve  as  it  passes  through  the  pons — that  is,  be- 
tween its  nucleus  in  the  floor  of  the  fourth  ventricle  and  the  point  of  emer- 
gence in  the  postero-lateral  aspect  of  the  pons.  The  specially  interesting 
feature  in  connection  with  involvement  of  this  part  is  the  production  of  what 
is  called  alternating  or  crossed  paralysis,  the  face  being  involved  on  the  same 
side  as  the  lesion,  and  the  arm  and  leg  on  the  opposite  side,  since  the  motor 
path  is  involved  above  the  point  of  decussation  in  the  medulla  (Fig.  18).  This 
occurs  only  when  the  lesion  is  in  the  lower  section  of  the  pons.  A  lesion  in 
the  upper  half  of  the  pons  involves  the  fibres  not  of  the  outgoing  nerve  on  the 
same  side,  but  of  the  fibres  from  the  hemispheres  before  they  have  crossed  to 
the  nucleus  of  the  opposite  side.  In  this  case  there  would  of  course  be,  as 
in  hemiplegia,  paralysis  of  the  face  and  limbs  on  the  side  opposite  to  the 
lesion.  The  palsy,  too,  would  resemble  the  cerebral  form,  involving  only  the 
lower  fibres  of  the  facial  nerve. 


1042  DISEASES    OF    THE    NERVOUS    SYSTEM 

(2)  The  nerve  may  be  involved  at  its  point  of  emergence  by  tumors,  par- 
ticularly by  the  cerebello-pontine  growths,  by  gummata,  meningitis,  or  occa- 
sionally it  may  be  injured  in  fracture  of  the  base. 

(3)  In  passing  through  the  Fallopian  canal  the  nerve  may  be  involved 
in  disease  of  the  ear,  particularly  by  caries  of  the  bone  in  otitis  media.     This 
is  a  common  cause  in  children.     I  have  seen  two  instances  follow  otitis  in 
puerperal  fever. 

(4)  As  the  nerve  emerges  from  the  styloid  foramen  it  is  exposed  to  in- 
juries and  blows  which  not  infrequently  cause  paralysis.     The  fibres  may  be 
cut  in  the  removal  of  tumors  in  this  region,  or  the  paralysis  may  be  caused  by 
pressure  of  the  forceps  in  an  instrumental  delivery. 

(5)  Exposure  to  cold  is  the  most  common  cause  of  facial  paralysis  (Bell's 
palsy),  inducing  a  neuritis  of  the  nerve  within  the  Fallopian  canal.    Reik  be- 
lieves that  in  most  of  these  cases  there  is  an  acute  otitis  media  from  which 
the  nerve  is  involved. 

(6)  Syphilis  is  not  an  infrequent  cause,  and  the  paralysis  may  appear 
early  with  the  secondary  symptoms. 

(7)  It  may  occur  in  association  with  herpes. 

Facial  diplegia  is  a  rare  condition  occasionally  found  in  affections  at  the 
base  of  the  brain,  lesions  in  the  pons,  simultaneous  involvement  of  the  nerves 
in  ear-disease,  and  in  diphtheritic  paralysis.  Disease  of  the  nuclei  or  sym- 
metrical involvement  of  the  cortex  might  also  produce  it.  It  may  occur  as 
a  congenital  affection.  H.  M.  Thomas  has  described  two  cases  in  one  family. 

SYMPTOMS. — In  the  peripheral  facial  paralysis  all  the  branches  of  the 
nerve  are  involved.  The  face  on  the  affected  side  is  immobile  and  can  neither 
be  moved  at  will  nor  participate  in  any  emotional  movements.  The  skin  is 
smooth  and  the  wrinkles  are  effaced,  a  point  particularly  noticeable  on  the 
forehead  of  elderly  persons.  The  eye  can  not  be  closed,  the  lower  lid  droops, 
and  the  eye  waters.  On  the  affected  side  the  angle  of  the  mouth  is  lowered, 
and  in  drinking  the  lips  are  not  kept  in  close  apposition  to  the  glass,  v  so  that 
the  liquid  is  apt  to  run  out.  In  smiling  or  laughing  the  contrast  is  most 
striking,  as  the  affected  side  does  not  move,  which  gives  a  curious  unequal 
appearance  to  the  two  sides  of  the  face.  The  eye  can  not^be  closed  nor  can 
the  forehead  be  wrinkled.  In  long  standing  cases,  when  the  reaction  of 
degeneration  is  present,  if  the  patient  tries  to  close  the  eyes  while  looking 
fixedly  at  an  object  the  lids  on  the  sound  side  close  firmly,  but  on  the  paralyzed 
side  there  is  only  a  slight  inhibitory  droop  of  the  upper  lid,  and  the  eye  is 
turned  upward  and  outward  by  the  inferior  oblique.  On  asking  the  patient 
to  show  his  upper  teeth,  the  angle  of  the  mouth  is  not  raised.  In  all  these 
movements  the  face  is  drawn  to  the  sound  side  by  the  action  of  the  muscles. 
Speaking  may  be  slightly  interfered  with,  owing  to  the  imperfection  in  the 
formation  of  the  labial  sounds.  Whistling  can  not  be  performed.  In  chew- 
ing the  food,  owing  to  the  paralysis  of  the  buccinator,  particles  collect  on  the 
affected  side.  The  paralysis  of  the  nasal  muscles  is  seen  on  asking  the  patient 
to  sniff.  Owing  to  the  fact  that  the  lips  are  drawn  to  the  sound  side,  the 
tongue,  when  protruded,  looks  as  if  it  were  pushed  to  the  paralyzed  side;  but 
on  taking  its  position  from  the  incisor  teeth,  it  will  be  found  to  be  in  the  mid- 
dle line..  The  reflex  movements  are  lost  in  this  peripheral  form.  It  is  usually 
stated  that  the  palate  is  partially  paralyzed  on  the  same  side  and  that  the 


DISEASES    OF    THE    CEREBRAL    XERYES  1043 

uvula  deviates.  Both  Gowers  and  Hughlings  Jackson  deny  the  existence  of 
this  involvement  in  the  great  majority  of  cases,  and  Horsley  and  Beevor  have 
shown  that  these  parts  are  innervated  hy  the  accessory  nerve  to  the  vagus. 

The  sensory  functions  of  the  facial  nerve,  to  which  much  attention  has 
been  paid  of  late  by  Gushing,  Mills  and  others,  are  ministered  to  by  the  genic- 
ulate  ganglion,  the  intermediary  nerve  of  Wrisberg,  and  the  chorda  tympani, 
•which  last  has  chiefly  gustatory  functions.  It  seems  likely  that  deep  sensi- 
bility with  sense  of  pressure,  position  and  passive  movement  runs  in  a  sep- 
arate afferent  system  in  the  motor  nerve  of  the  face.  Cutaneous  sensibility, 
both  epicritic,  by  which  we  localize  light  touch,  and  protopathic,  by  which  we 
recognize  degrees  of  heat  and  cold,  is  not  ministered  to  by  the  facial  nerve 
proper.  There  are  observations  that  would  indicate,  however,  that  the  an- 
terior part  of  the  tongue  and  possibly  a  little  strip  of  the  skin  of  the  auricle 
have  a  vestigial  supply  from  this  nerve. 

When  the  nerve  is  involved  within  the  canal  between  the  genu  and  the 
origin  of  the  chorda  tympani,  the  sense  of  taste  is  lost  in  the  anterior  part  of 
the  tongue  on  the  affected  side.  When  the  nerve  is  damaged  outside  the  skull 
the  sense  of  taste  is  unaffected.  Hearing  is  often  impaired  in  facial  paralysis, 
most  commonly  by  preceding  ear  disease.  The  paralysis  of  the  stapedius 
muscle  may  lead  to  increased  sensitiveness  to  musical  notes.  Herpes  is 
sometimes  associated  with  facial  paralysis.  Pain  is  not  common,  but 
there  may  be  neuralgia  about  the  ear.  The  face  on  the  affected  side  may  be 
swollen. 

The  electrical  reactions,  which  are  those  of  a  peripheral  palsy,  have  con- 
siderable importance  from  a  prognostic  standpoint.  Erb's  rules  are  as  fol- 
lows :  If  there  is  no  change,  either  faradic  or  galvanic,  the  prognosis  is  good 
and  recovery  takes  place  in  from  fourteen  to  twenty  days.  If  the  faradic 
and  galvanic  excitability  of  the  nerve  is  only  lessened  and  that  of  the  muscle 
increased  to  the  galvanic  current  and  the  contraction  formula  altered  (the 
contraction  sluggish  AC<KC),  the  outlook  is  relatively  good  and  recovery 
will  probably  take  place  in  from  four  to  six  weeks;  occasionally  in  from  eight 
to  ten.  When  the  reaction  of  degeneration  is  present — that  is,  if  the  faradic 
and  galvanic  excitability  of  the  nerves  and  the  faradic  excitability  of  the  mus- 
cles are  lost  and  the  galvanic  excitability  of  the  muscle  is  quantitatively  in- 
creased and  qualitatively  changed,  and  if  the  mechanical  excitability  is  altered 
— the  prognosis  is  relatively  unfavorable  and  the  recovery  may  not  occur  for 
two,  six,  eight,  or  even  fifteen  months. 

COURSE. — The  course  of  facial  paralysis  is  usually  favorable.  The  onset 
in  the  form  following  cold  is  very  rapid,  developing  perhaps  within  twenty- 
four  hours,  but  rarely  is  the  paralysis  permanent.  Now  and  again  the  par- 
alysis never  disappears ;  after  four  years  I  have  seen  only  slight  recovery.  Re- 
curring attacks  have  been  described;  Sinkler  mentions  five.  On  the  other 
hand,  in  the  paralysis  from  injury,  as  by  a  blow  on  the  mastoid  process,  the 
condition  may  remain.  When  permanent,  the  muscles  are  entirely  toneless. 
In  some  instances  contracture  develops  as  the  voluntary  power  returns,  and 
the  natural  folds  and  the  wrinkles  on  the  affected  side  may  be  deepened,  so 
that  on  looking  at  the  face  one  at  first  may  have  the  impression  that  the  af- 
fected side  is  the  sound  one.  This  is  corrected  at  once  on  asking  the  patient 
to  smile,  when  it  is  seen  which  side  of  the  face  has  the  most  active  movement. 


1044  DISEASES    OF    THE    NERVOUS    SYSTEM 

Aretaeus  noted  the  difficulty  sometimes  experienced  in  determining  which  side 
•was  affected  until  the  patient  spoke  or  laughed. 

DIAGNOSIS. — The  diagnosis  of  facial  paralysis  is  usually  easy.  The  dis- 
tinction between  the  peripheral  and  central  form  is  based  on  facts  already  men- 
tioned. 

TREATMENT. — In  the  cases  which  result  from  cold  and  are  probably  due 
to  neuritis  within  the  bony  canal,  hot  applications  first  should  be  made;  sub- 
sequently the  thermo-cautery  may  be  used  lightly  at  intervals  of  a  day  or  two 
over  the  mastoid  process,  or  small  blisters  applied.  If  the  ear  is  diseased, 
free  discharge  for  the  secretion  should  be  obtained.  The  galvanic  current  may 
be  employed  to  keep  up  the  nutrition  of  the  muscles.  The  positive  pole  should 
be  placed  behind  the  ear,  the  negative  one  along  the  zygomatic  and  other  mus- 
cles. The  application  can  be  made  daily  for  a  quarter  of  an  hour  and  the 
patient  can  readily  be  taught  to  make  it  himself  before  a  looking  glass. 
Massage  in  the  course  of  the  nerve  and  of  the  muscles  of  the  face  is  also 
useful.  A  course  of  iodide  of  potassium  may  be  given  even  when  there  is  no 
indication  of  syphilis. 

In  those  cases  in  which  the  nerve  has  been  destroyed  by  an  injury,  during 
an  operation  or  from  disease,  and  when  there  has  been  no  evidence  of  return- 
ing function  after  keeping  up  the  electric  treatment  for  a  few  months,  a  nerve 
anastomosis  should  be  performed.  For  this  purpose  either  the  spinal  acces- 
sory or  the  hypoglossal  nerve  may  be  used.  Though  the  normal  conditions 
may  never  be  completely  regained  after  such  an  operation,  the  motor  power 
will  be  largely  restored  to  the  paralyzed  muscles  and  the  obtrusive  deformity 
greatly  lessened.  This  procedure,  based  on  the  results  of  physiological  experi- 
mentation, makes  one  of  the  most  striking  of  modern  operations. 

Spasm. — The  spasm  may  be  limited  to  a  few  or  involve  all  the  muscles 
innervated  by  the  facial  nerve,  and  may  be  unilateral  or  bilateral. 

It  is  known  also  by  the  name  of  mimic  spasm  or  of  convulsive  tic.  Sev- 
eral different  affections  are  usually  considered  under  the  name  of  facial  or 
mimic  spasm,  but  we  shall  here  speak  only  of  the  simple  spasm  of  the  facial 
muscles,  either  primary  or  following  paralysis,  and  shall  not  include  the  cases 
of  habit  spasm  in  children,  or  the  tic  convulsif  of  the  French. 

Gowers  recognizes  two  classes — one  in  which  there  is  an  organic  lesion, 
and  an  idiopathic  form.  It  is  thought  to  be  due  also  to  reflex  causes,  such 
as  the  irritation  from  carious  teeth  or  the  presence  of  intestinal  worms.  The 
disease  usually  occurs  in  adults,  whereas  the  habit  spasm  and  the  tic  convulsif 
of  the  French,  often  confounded  with  it,  are  most  common  in  children.  True 
mimic  spasm  occasionally  comes  on  in  childhood  and  persists.  In  the  case  of 
a  school-mate  the  affection  was  marked  as  early  as  the  eleventh  or  twelfth  year 
and  still  continues.  When  the  result  of  organic  disease,  there  has  usually  been 
a  lesion  of  the  centre  in  the  cortex,  as  in  the  case  reported  by  Berkley,  or 
pressure  on  the  nerve  at  the  base  of  the  brain  by  aneurism  or  tumor. 

SYMPTOMS. — The  spasm  may  involve  only  the  muscles  around  the  eye — 
blepharospasm — in  which  case  there  is  constant,  rapid,  quick  action  of  the 
orbicularis  palpebrarum,  which,  in  association  with  photophobia,  may  be  tonic 
in  character.  More  commonly  the  spasm  affects  the  lateral  facial  muscles  with 
those  of  the  eye,  and  there  is  constant  twitching  of  tlio  side  of  the  face  with 
partial  closure  of  the  eye.  The  frontalis  is  rarely  involved.  In  aggravated 


DISEASES    OF    THE    CEREBRAL    NERVES  1045 

cases,  the  depressors  of  the  angle  of  the  mouth,  the  levator  menti,  and  the 
platysma  myoides  are  affected.  This  spasm  is  confined  to  one  side  of  the  face 
in  a  majority  of  cases,  though  it  may  extend  and  become  bilateral.  It  is 
increased  by  emotional  causes  and  by  voluntary  movements  of  the  face.  As 
a  rule,  it  is  painless,  but  there  may  be  tender  points  over  the  course  of  the  fifth 
nerve,  particularly  the  supraorbital  branch.  Tonic  spasm  of  the  facial  mus- 
cle may  follow  paralysis,  and  is  said  to  result  occasionally  from  cold. 

The  outlook  in  facial  spasm  is  always  dubious.  A  majority  of  the  cases 
persist  for  years  and  are  incurable. 

TREATMENT. — Sources  of  irritation  should  be  looked  for  and  removed. 
When  a  painful  spot  is  present  over  the  fifth  nerve,  blistering  or  the  appli- 
cation of  the  thermo-cautery  may  relieve  it.  Hypodermic  injections  of  strych- 
nia may  be  tried,  but  are  of  doubtful  benefit.  Weir  Mitchell  recommends  the 
freezing  of  the  cheek  for  a  few  minutes  daily  or  every  second  day  with  the 
spray,  and  this,  in  some  instances,  is  beneficial.  Often  the  relief  is  transient; 
the  cases  return,  and  at  every  clinic  may  be  seen  half  a  dozen  or  more  of  such 
patients  who  have  run  the  gamut  of  all  measures  without  material  improve- 
ment. Severe  cases  may  require  surgical  interference.  The  nerve  may  be 
divided  near  the  stylomastoid  foramen  and  an  anastomosis  made  between  it 
and  the  spinal  accessory. 

AUDITOEY  NERVE 

The  eighth,  known  also  as  portio  mollis  of  the  seventh  pair,  passes  from 
the  ear  through  the  internal  auditory  meatus,  and  in  reality  consists  of  two 
separate  nerves — the  cochlear  and  vestibular  roots.  These  two  roots  have  en- 
tirely different  functions,  and  may  therefore  be  best  considered  separately. 
The  cochlear  nerve  is  the  one  connected  with  the  organ  of  Corti,  and  is  con- 
cerned in  hearing.  The  vestibular  nerve  is  connected  with  the  vestibule  and 
semicircular  canals,  and  has  to  do  with  the  maintenance  of  equilibrium. 

The  Cochlear  Nerve 

The  cortical  centre  for  hearing  is  in  the  temporo-sphenoidal  lobe.  Primary 
disease  of  the  auditory  nerve  in  its  centre  or  intracranial  course  is  uncommon. 
More  frequently  the  terminal  branches  are  affected  within  the  labyrinth. 

Affection  of  the  Cortical  Centre. — The  'superior  temporal  gyrus  represents 
the  centre  for  hearing.  In  man  destruction  of  this  gyrus  on  the  left  side 
results  in  word-deafness,  which  may  be  defined  as  an  inability  to  understand 
the  meaning  of  words,  though  they  may  still  be  heard  as  sounds.  The  central 
auditory  path  extending  to  the  cortical  centre  from  the  terminal  nuclei  of  the 
cochlear  nerve  may  be  involved  and  produce  deafness.  This  may  result  from 
involvement  of  the  lateral  lemniscus,  from  the  presence  of  a  tumor  in  the 
/corpora  quadrigemina,  especially  if  it  involve  the  posterior  quadrigeminal 
bodies,  from  a  lesion  of  the  internal  geniculate  body,  or  it  may  be  associated 
with  a  lesion  of  the  internal  capsule. 

Lesions  of  the  nerve  at  the  base  of  the  brain  may  result  from  the  pressure 
of  tumors,  meningitis  (particularly  the  cerebro-spinal  form),  haemorrhage,  or 
traumatism.  A  primary  degeneration  of  the  nerve  may  occur  in  locomotor 
ataxia.  Primary  disease  of  the  terminal  nuclei  of  the  cochlear  nerve  (nucleus 


1046  DISEASES    OF    THE    NERVOUS    SYSTEM 

nervi  cochlearis  dorsalis  and  nucleus  nervi  cochlearis  ventralis)  Is  rare.  Bj 
far  the  most  interesting  form  results  from  epidemic  cerebro-spinal  meningitis, 
in  which  the  nerve  is  frequently  involved,  causing  permanent  deafness.  In 
young  children  the  condition  results  in  deaf-mutism. 

Internal  Ear. — In  a  majority  of  the  cases  associated  with  auditory  nerve 
symptoms  the  lesion  is  in  the  internal  ear,  either  primary  or  the  result  of  ex- 
tension of  disease  of  the  middle  ear.  Two  groups  of  symptoms  may  be  pro- 
duced— hyperassthesia  and  irritation,  and  diminished  function  or  nervous  deaf- 
ness. 

(a)  HYPER^STHESIA  AND  IRRITATION. — This  may  be  due  to  altered  func- 
tion of  the  centre  as  well  as  of  the  nerve  ending.  True  hyperaasthesia — hyper- 
acusis — is  a  condition  in  which  sounds,  sometimes  even  those  inaudible  to 
other  persons,  are  heard  with  great  intensity.  It  occurs  in  hysteria  and  oc- 
casionally in  cerebral  disease.  As  already  mentioned,  in  paralysis  of  the 
stapedius  low  notes  may  be  heard  with  intensity.  In  dysaesthesia,  or  dysacusis, 
ordinary  sounds  cause  an  unpleasant  sensation,  as  commonly  happens  in  con- 
nection with  headache,  when  ordinary  noises  are  badly  borne. 

Tinnitus  aurium  is  a  term  employed  to  designate  certain  subjective  sensa- 
tions of  ringing,  roaring,  tickling,  and  whirring  noises  in  the  ear.  It  is  a 
very  common  and  often  a  distressing  symptom.  It  is  associated  with  many 
forms  of  ear  disease  and  may  result  from  pressure  of  wax  on  the  drum.  It  is 
rare  in  organic  disease  of  the  central  connections  of  the  nerve.  Sudden  in- 
tense stimulation  of  the  nerve  may  cause  it.  A  form  not  uncommonly  met 
with  in  medical  practice  is  that  in  which  the  patient  hears  a  continual  bruit 
in  the  ear,  and  the  noise  has  a  systolic  intensification,  usually  on  one  side.  I 
have  twice  been  consulted  by  physicians  for  this  condition  under  the  belief 
that  they  had  an  internal  aneurism.  A  systolic  murmur  may  be  heard  occa- 
sionally on  auscultation.  It  occurs  in  conditions  of  anaemia  and  neurasthenia. 
Subjective  noises  in  the  ear  may  precede  ah  epileptic  seizure  and  are  sometimes 
present  in  migraine.  In  whatever  form  tinnitus  exists,  though  slight  and 
often  regarded  as  trivial,  it  occasions  great  annoyance  and  often  mental  dis- 
tress, and  has  even  driven  patients  to  suicide. 

The  diagnosis  is  readily  made ;  but  it  is  often  extremely  difficult  to  deter- 
mine upon  what  condition  the  tinnitus  depends.  The  relief  of  constitutional 
states,  such  as  anemia,  neurasthenia,  or  gout,  may  result  in  cure.  A  careful 
local  examination  of  the  ear  should  always  be  made.  One  of  the  most  worry- 
ing forms  is  the  constant  clicking,  sometimes  audible  many  feet  away  from 
the  patient,  and  due  probably  to  clonic  spasm  of  the  muscles  connected  with 
the  Eustachian  tube  or  of  the  levator  palati.  The  condition  may  persist  for 
years  unchanged,  and  then  disappear  suddenly.  The  pulsating  forms  of  tinni- 
tus, in  which  the  sound  is  like  that  of  a  systolic  bruit,  are  almost  invariably 
subjective,  and  it  is  very  rare  to  hear  anything  with  the  stethoscope.  It  is 
to  be  remembered  that  in  children  there  is  a  systolic  brain  murmur,  best 
heard  over  the  ear,  and  in  some  instances  appreciable  in  the  adult. 

(6)  DIMINISHED  FUNCTION  OR  NERVOUS  DEAFNESS. — In  testing  for  nerv- 
ous deafness,  if  the  tuning  fork  can  not  be  heard  when  placed  near  the  meatus, 
but  the  vibrations  are  audible  by  placing  the  foot  of  the  tuning  fork  against 
the  temporal  bone,  the  conclusion  may  be  drawn  that  the  deafness  is  not  due 
to  involvement  of  the  nerve.  The  vibrations  are  conveyed  through  the  tern- 


DISEASES    OF    THE    CEREBRAL    NERVES  1047 

poral  bone  to  the  cochlea  and  vestibule.  The  watch  may  be  used  for  the  same 
purpose,  and  if  the  meatus  is  closed  and  the  watch  is  heard  better  in  contact 
with  the  mastoid  process  than  when  opposite  the  open  meatus,  the  deafness 
is  probably  not  nervous.  Disturbance  of  the  function  of  the  auditory  nerve 
is  not  a  very  frequent  symptom  in  brain  disease,  but  in  all  cases  the  function 
of  the  nerve  should  be  carefully  tested. 

The  Vestibular  Nerve 

The  most  frequent  symptoms  met  with  in  association  with  disease  of  the 
vestibular  nerve  and  its  central  connections  are  vertigo,  nystagmus,  and  loss 
of  coordination  of  the  muscles  of  the  head,  neck,  and  eyes. 

Auditory  Vertigo — Meniere's  Disease.— In  1861  Meniere,  a  French  phy- 
sician, described  an  affection  characterized  by  noises  in  the  ear,  vertigo  (which 
might  be  associated  with  loss  of  consciousness),  vomiting,  and,  in  many  cases, 
progressive  loss  of  hearing.  Barany,  of  Vienna,  has  thrown  much  light  on 
this  subject.  He  groups  the  conditions  in  which  the  labyrinth  may  be  af- 
fected under  the  following  heads:  (a)  Acute  infectious  diseases,  influenza, 
cerebro-spinal  meningitis,  mumps,  etc.  (&)  Chronic  infectious  diseases,  syph- 
ilis particularly,  (c)  Constitutional  conditions  and  auto-intoxications.  Hem- 
orrhage into  the  labyrinth  (in  leukaemia,  purpura  haamorrhagica,  pernicious 
anaemia)  ;  chlorosis,  thyroid  intoxications,  arterio-sclerosis,  etc.  (d)  Tumors 
and  diseases  of  the  central  nervous  system;  tumors  of  the  acoustic  nerve, 
cerebellum,  pons,  and  fourth  ventricle,  meningitis,  cerebellar  abscess,  multiple 
sclerosis,  tabes,  etc.  (e)  Traumatic  injuries,  fracture  of  the  base,  etc.  (f) 
Hereditary  degenerative  diseases  and  malformations  of  the  internal  ear.  (g) 
Intoxications,  alcohol,  nicotine,  quinine,  salicylic  acid  group,  arsenic  (sal- 
varsan?). 

SYMPTOMS. — The  attack  usually  sets  in  suddenly  with  a  buzzing  noise  in 
the  ears  and  the  patient  feels  as  if  he  was  reeling  or  staggering.  He  may  feel 
himself  to  be  reeling,  or  the  objects  about  him  may  seem  to  be  turning,  or  the 
phenomena  may  be  combined.  The  attack  is  often  so  abrupt  that  the  patient 
falls,  though,  as  a  rule,  he  has  time  to  steady  himself  by  grasping  some  neigh- 
boring object.  Consciousness  is  generally  maintained,  but  may  be  momenta- 
rily lost.  Ocular  symptoms  are  usually  present.  Jerking  of  the  eyeballs,  or 
nystagmus,  occurs.  The  patient  becomes  pale  and  nauseated,  a  clammy  sweat 
breaks  out  on  the  face,  and  vomiting  may  follow.  The  duration  of  the  attack 
varies  greatly.  At  times  it  may  be  very  short,  but  it  usually  causes  the 
patient  to  lie  quietly  for  some  time,  as  any  movement  of  the  head  brings  on 
another  attack. 

Labyrinthine  vertigo  is  usually  paroxysmal,  coming  on  at  irregular  inter- 
vals, sometimes  of  weeks  or  months ;  or  several  attacks  may  occur  in  a  day. 

The  disturbances  of  equilibrium,  including  the  vertigo,  are  dependent  upon 
a  disturbance  of  the  functions  of  the  vestibular  nerve  or  of  the  organs  with 
which  this  nerve  is  connected,  either  in  its  peripheral  distribution  or  by  means 
of  its  central  connection.  The  auditory  symptoms  often  accompanying  it  are 
doubtless  always  due  to  involvement  of  the  cochlear  nerve  or  its  peripheral 
or  central  connections. 

DIAGNOSIS. — The  combination  of  tinnitus  with  giddiness,  with  or  without 


1048  DISEASES    OF   THE    NERVOUS    SYSTEM 

gastric  disturbance,  is  sufficient  to  establish  a  diagnosis.  There  are  other 
forms  of  vertigo  from  which  it  must  bo  distinguished.  The  form  known  as 
gastric  vertigo,  which  is  associated  with  dyspepsia  and  occurs  most  commonly 
in  persons  of  middle  age,  is,  as  a  rule,  readily  distinguished  by  the  absence 
of  tinnitus  or  evidences  of  disturbance  in  the  function  of  the  auditory  nerve. 
This  variety  of  vertigo  is  much  less  common  than  Trousseau's  description 
would  lead  us  to  believe.  It  is  important  to  note  the  close  connection  of 
vertigo  with  ocular  defects. 

The  cardio-vascular  vertigo,  one  of  the  most  common  forms,  occurs  in 
cases  of  valvular  disease,  particularly  aortic  insufficiency,  and  as  frequently 
in  arterio-sclerosis. 

Aural  vertigo  must  be  carefully  distinguished  from  attacks  of  petit  mal, 
or,  indeed,  of  definite  epilepsy.  It  is  rare  in  petit  mal  to  have  noises  in  the 
ear  or  actual  giddiness,  but  in  the  aura  preceding  an  epileptic  attack  the 
patient  may  feel  giddy.  Giddiness  and  transient  loss  of  consciousness  may 
be  associated  with  organic  disease  of  the  brain,  more  particularly  with  tumor. 
Vomiting  also  may  be  present.  A  careful  investigation  will  usually  lead  to  a 
correct  diagnosis.  Barany's  special  tests  for  the  functional  activity  of  the  ves- 
tibular  nerve  are  of  great  use  in  the  hands  of  a  skilled  observer,  particularly 
his  caloric  test  (irrigation  of  the  external  meatus  with  cold  or  warm  water, 
and  observing  its  effect  on  the  production  of  nystagmus). 

PROGNOSIS. — The  outlook  in  Meniere's  disease  is  uncertain.  While  many 
cases  recover  completely,  in  others  deafness  results  and  the  attacks  recur  at 
shorter  intervals.  In  aggravated  cases  the  patient  constantly  suffers  from 
vertigo,  and  may  even  be  confined  to  his  bed. 

TREATMENT. — Bromide  of  potassium,  in  20  grain  (1.3  gm.)  doses  three 
times  a  day,  is  sometimes  beneficial.  If  there  is  a  history  of  syphilis  the 
iodides  should  be  administered.  The  salicylates  are  recommended,  and  Charcot 
advises  quinine  to  cinchonism.  In  cases  in  which  there  is  increase  in  the 
arterial  tension  nitroglycerin  may  be  given,  at  first  in  very  small  doses,  but 
increasing  gradually.  It  is  not  specially  valuable  in  Meniere's  disease,  but  in 
the  cases  of  giddiness  in  middle  aged  men  and  women  associated  with  arterio- 
sclerosis it  sometimes  acts  very  satisfactorily.  Correction  of  errors  of  refrac- 
tion is  sometimes  followed  by  prompt  relief  of  the  vertigo. 

Endemic  Paralytic  Vertigo. — In  parts  of  Switzerland  and  France  there  is 
a  remarkable  form  of  vertigo  described  by  Gerlier,  which  is  characterized  by 
attacks  of  paretic  weakness  of  the  extremities,  falling  of  the  eyelids,  remark- 
able depression,  but  with  retention  of  consciousness.  It  occurs  also  in  northern 
Japan,  where  Miura  says  it  develops  paroxysmally  among  the  farm  laborers 
of  both  sexes  and  all  ages.  It  is  known  there  as  kubisagari. 

GLOSSO-PHARYNGEAL    NERVE 
(Nervus  glossopharyngeus) 

The  ninth  nerve  contains  both  motor  and  sensory  fibres  and  is  also  a  nerve 
of  the  special  sense  of  taste  to  the  tongue.  It  supplies,  by  its  motor  branches, 
the  stylo-pharyngeus  and  the  middle  constrictor  of  the  pharynx.  The  sensory 
fibres  are  distributed  to  the  upper  part  of  the  pharynx. 


DISEASES    OF   THE    CEREBRAL   NERVES  1049 

Symptoms. — Of  nuclear  disturbance  we  know  very  little.  The  pharyngeal 
symptoms  of  bulbar  paralysis  are  probably  associated  with  involvement  of  the 
nuclei  of  this  nerve.  Lesion  of  the  nerve  trunk  itself  is  rare,  but  it  may  be 
compressed  by  tumors  or  involved  in  meningitis.  Disturbance  of  the  sense  of 
taste  may  result  from  loss  of  function  of  this  nerve,  in  which  case  it  is  chiefly 
in  the  posterior  part  of  the  tongue  and  soft  palate. 

The  general  disturbances  of  the  sense  of  taste  may  here  be  briefly  referred 
to.  Loss  of  the  sense  of  taste — ageusia — may  be  caused  by  disturbance  of  the 
peripheral  end  organs,  as  in  affections  of  the  mucosa  of  the  tongue.  This  is 
very  common  in  the  dry  tongue  of  fever  or  the  furred  tongue  of  dyspepsia, 
under  which  circumstances,  as  the  saying  is,  everything  tastes  alike.  Strong 
irritants,  too,  such  as  pepper,  tobacco,  or  vinegar,  may  dull  or  diminish  the 
sense  of  taste.  Complete  loss  may  be  due  to  involvement  of  the  nerves  either 
in  their  course  or  in  the  centres.  Perversion  of  the  sense  of  taste — parageusis 
— is  rarely  found,  except  as  an  hysterical  manifestation  and  in  the  insane. 
Increased  sensitiveness  is  still  more  rare.  There  are  occasional  subjective 
sensations  of  taste,  occurring  as  an  aura  in  epilepsy  or  as  part  of  the  hallu- 
cinations in  the  insane. 

To  test  the  sense  of  taste  the  patient's  eyes  should  be  closed  and  small 
quantities  of  various  substances  applied  to  the  protruded  tongue.  The  sensa- 
tion should  be  perceived  before  the  tongue  is  withdrawn.  The  following  are 
the  most  suitable  tests :  For  bitterness,  quinine ;  for  sweetness,  a  strong  solu- 
tion of  sugar  or  saccharin;  for  acidity,  vinegar;  and  for  the  saline  test,  com- 
mon salt.  One  of  the  most  important  tests  is  the  feeble  galvanic  current, 
which  gives  the  well-known  metallic  taste. 

PNEUMOGASTEIC    NEEVE 
(Nervus  vagus) 

The  tenth  nerve  has  an  important  and  extensive  distribution,  supplying 
the  pharynx,  larynx,  lungs,  heart,  oesophagus,  and  stomach.  The  nerve  may 
be  involved  at  its  nucleus  along  with  the  spinal  accessory  and  the  hypoglossal, 
forming  what  is  known  as  bulbar  paralysis.  It  may  be  compressed  by  tumors 
or  aneurism,  or  in  the  exudation  of  meningitis,  simple  or  syphilitic.  In  its 
course  in  the  neck  the  trunk  may  be  involved  by  tumors  or  in  wounds.  It  has 
been  tied  in  ligature  of  the  carotid,  and  has  been  cut  in  the  removal  of  deep- 
seated  tumors.  The  trunk  may  be  attacked  by  neuritis. 

The  affections  of  the  vagus  are  best  considered  in  connection  with  the 
distribution  of  the  separate  nerves. 

Pharyngeal  Branches. — In  combination  with  the  glosso-pharyngeal  the 
branches  from  the  vagus  form  the  pharyngeal  plexus,  from  which  the  muscles 
and  mucosa  of  the  pharynx  are  supplied.  In  paralysis  due  to  involvement  of 
this  either  in  the  nuclei,  as  in  bulbar  paralysis,  or  in  the  course  of  the  nerve, 
as  in  diphtheritic  neuritis,  there  is  difficulty  in  swallowing  and  the  food  is  not 
passed  on  into  the  oesophagus.  If  the  nerve  on  one  side  only  is  involved  the 
deglutition  is  not  much  impaired.  In  these  cases  the  particles  of  food  fre- 
quently pass  into  the  larynx,  and,  when  the  soft  palate  is  involved,  into  the 
posterior  nares. 
68 


1050  DISEASES    OF   THE   NERVOUS- SYSTEM 

SPASM  of  the  pharynx  is  always  a  functional  disorder,  usually  occurring 
in  hysterical  and  nervous  people.  Gowers  mentions  a  case  of  a  gentleman 
who  could  not  eat  unless  alone,  on  account  of  the  inability  to  swallow  in  the 
presence  of  others  from  spasm  of  the  pharynx.  This  spasm  is  a  well  marked 
feature  in  hydrophobia,  and  it  occurs  also  in  pseudo-hydrophobia. 

Laryngeal  Branches. — The  superior  laryngeal  nerve  supplies  the  mucous 
membrane  of  the  larynx  above  the  cords  and  the  crico-thyroid  muscle.  The 
inferior  or  recurrent  laryngeal  curves  around  the  arch  of  the  aorta  on 
the  left  side  and  the  subclavian  artery  on  the  right  passes  along  the  trachea 
and  supplies  the  mucosa  below  the  cords  and  all  the  muscles  of  the  larynx 
except  the  crico-thyroid  and  the  epiglottidean.  Experiments  have  shown  that 
these  motor  nerves  of  the  pneumogastric  are  all  derived  from  the  spinal 
accessory.  The  remarkable  course  of  the  recurrent  laryngeal  nerves  renders 
them  liable  to  pressure  by  tumors  within  the  thorax,  particularly  by  aneurism. 
The  following  are  the  most  important  forms  of  paralysis : 

(a)  BILATERAL  PARALYSIS  OF  THE  ABDUCTORS. — In  this  condition  the 
posterior  crico-arytenoids  are  involved  and  the  glottis  is  not  opened  during 
inspiration.  The  cords  may  be  close  together  in  the  position  of  phonation, 
and  during  inspiration  may  be  brought  even  nearer  together  by  the  pressure 
of  air,  so  that  there  is  only  a  narrow  •chink  through  which  the  air  whistles 
with  a  noisy  stridor.  This  dangerous  form  of  laryngeal  paralysis  occurs  occa- 
sionally as  a  result  of  cold,  or  may  follow  a  laryngeal  catarrh.  The  posterior 
muscles  have  been  found  degenerated  when  the  others  were  healthy.  The  con- 
dition may  be  produced  by  pressure  upon  both  vagi,  or  upon  both  recurrent 
nerves.  As  a  central  affection  it  occurs  in  tabes  and  bulbar  paralysis,  but  may 
be  seen  also  in  hysteria.  The  characteristic  symptoms  are  inspiratory  stridor 
with  unimpaired  phonation.  Possibly,  as  Gowers  suggests,  many  cases  of 
so-called  hysterical  spasm  of  the  glottis  are  in  reality  abductor  paralysis. 

(6)  UNILATERAL  ABDUCTOR  PARALYSIS. — This  frequently  results  from  the 
pressure  of  tumors  or  involvement  of  one  recurrent  nerve.  Aneurism  is  by 
far  the  most  common  cause,  though  on  the  right  side  the  nerve  may  be  in- 
volved in  thickening  of  the  pleura.  The  symptoms  are  hoarseness  or  roughness 
of  the  voice,  such  as  is  so  common  in  aneurism.  Dyspnoea  is  not  often  present. 
The  cord  on  the  affected  side  does  not  move  in  inspiration.  Subsequently  the 
adductors  mav  also  become  involved,  in  which  case  the  phonation  is  still  more 
impaired. 

(c)  ADDUCTOR  PARALYSIS. — This  results  from  involvement  of  the  lateral 
crico-arytenoid  and  the  arytenoid  muscle  itself.     It  is  common  in  hysteria, 
particularly  of  women,  and  causes  the  hysterical  aphonia,  which  may  come  on 
suddenly.     It  may  result  from  catarrh  of  the  larynx  or  from  overuse  of  the 
voice.    In  laryngoscopic  examination  it  is  seen,  on  attempting  phonation,  that 
there  is  no  power  to  bring  the  cords  together. 

(d)  SPASM  OF  THE  MUSCLES  OF  THE  LARYNX. — In  this  the  adductor  mus- 
cles are  involved.    It  is  not  an  uncommon  affection  in  children,  and  has  al- 
ready been  referred  to  as  laryngismus   stridulus.      Paroxysmal   attacks   of 
laryngeal  spasm  are  rare  in  the  adult,  but  cases  are  described  in  which  the 
patient,  usually  a  young  girl,  wakes  at  night  in  an  attack  of  intense  dyspncea, 
which  may  persist  long  enough  to  produce  cyanosis.     Liveing  states  that  they 
may  replace  attacks  of  migraine.    They  occur  in  a  characteristic  form  in  loco- 


DISEASES    OF    THE    CEREBRAL    NERVES  1051 

motor  ataxia,  forming  the  so-called  laryngeal  crises.  There  is  a  condition 
known  as  spastic  aphonia,  in  which,  when  the  patient  attempts  to  speak,  pho- 
nation  is  completely  prevented  by  a  spasm. 

Disturbance  of  the  sensory  nerves  of  the  larynx  is  rare. 

(e)  ANESTHESIA  may  occur  in  bulbar  paralysis  and  in  diphtheritic  neuritis 
— a  serious  condition,  as  portions  of  food  may  enter  the  windpipe.  It  is  usu- 
ally associated  with  dysphagia  and  is  sometimes  present  in  hysteria.  Hyper- 
sesthesia  of  the  larynx  is  rare. 

Cardiac  Branches. — The  cardiac  plexus  is  formed  by  the  union  of  branches 
of  the  vagi  and  of  the  sympathetic  nerves.  The  vagus  fibres  subserve  motor, 
sensory,  and  probably  trophic  functions. 

MOTOR. — The  fibres  which  inhibit,  control,  and  regulate  the  cardiac  action 
pass  in  the  vagi.  Irritation  may  produce  slowing  of  the  action.  Czermak 
could  slow  or  even  arrest  the  heart's  action  for  a  few  beats  by  pressing  a  small 
tumor  in  his  neck  against  one  pneumogastric  nerve,  and  it  is  said  that  the 
same  can  be  produced  by  forcible  bilateral  pressure  on  the  carotid  canal. 
There  are  instances  in  which  persons  appear  to  have  had  voluntary  control 
over  the  action  of  the  heart.  Cheyne  mentions  the  case  of  Colonel  Townshend, 
"who  could  die  or  expire  when  he  pleased,  and  yet  by  an  effort  or  somehow 
come  to  life  again,  which  it  seems  he  had  sometimes  tried  before  he  had  sent 
for  us."  Retardation  of  the  heart's  action  has  also  followed  accidental  liga- 
ture of  one  vagus.  Irritation  of  the  nuclei  may  also  be  accompanied  with  a 
neurosis  of  this  nerve.  On  the  other  hand,  when  there  is  complete  paralysis 
of  the  vagi,  the  inhibitory  action  may  be  abolished  and  the  acceleratory  influ- 
ences have  full  sway.  The  heart's  action  is  then  greatly  increased.  This  is 
seen  in  some  instances  of  diphtheritic  neuritis  and  in  involvement  of  the  nerve 
by  tumors,  or  its  accidental  removal  or  ligature.  Complete  loss  of  function 
of  one  vagus,  however,  may  not  be  followed  by  any  symptoms. 

SENSORY  symptoms  on  the  part  of  the  cardiac  branches  are  very  varied. 
Normally,  the  heart's  action  proceeds  regularly  without  the  participation  of 
consciousness,  but  the  unpleasant  feelings  and  sensations  of  palpitation  and 
pain  are  conveyed  to  the  brain  through  this  nerve.  How  far  the  fibres  of  the 
pneumogastric  are  involved  in  angina  it  is  impossible  to  say.  The  various 
disturbances  of  sensation  are  described  under  the  cardiac  neuroses. 

Pulmonary  Branches. — We  know  very  little  of  the  pulmonary  branches 
of  the  vagi.  The  motor  fibres  are  stated  to  control  the  action  of  the  bronchial 
muscles,  and  it  has  long  been  held  that  asthma  may  be  a  neurosis  of  these 
fibres.  The  various  alterations  in  the  respiratory  rhythm  are  probably  due 
more  to  changes  in  the  centre  than  in  the  nerves  themselves. 

Gastric  and  (Esophageal  Branches. — The  muscular  movements  of  these 
parts  are  presided  over  by  the  vagi  and  vomiting  is  induced  through  them, 
usually  reflexly,  but  also  by  direct  irritation,  as  in  meningitis.  Spasm  of  the 
oesophagus  generally  occurs  with  other  nervous  phenomena.  Gastralgia  may 
sometimes  be  due  to  cramp  of  the  stomach,  but  is  more  commonly  a  sensory 
disturbance  of  this  nerve,  due  to  direct  irritation  of  the  peripheral  ends,  or 
is  a  neuralgia  of  the  terminal  fibres.  Hunger  is  said  to  be  a  sensation  aroused 
by  the  pneumogastric,  and  some  forms  of  nervous  dyspepsia  probably  depend 
upon  disturbed  function  of  this  nerve.  The  severe  gastric  crises  which  occur 
in  locomotor  ataxia  are  due  to  central  irritation  of  the  nuclei. 


1052  DISEASES    OF    THE    NERVOUS    SYSTEM 

SPINAL    ACCESSORY    NERVE 
(Nervus  accessorius) 

Paralysis. — The  smaller  or  internal  part  of  this  nerve  joins  the  vagus  and 
is  distributed  through  it  to  the  laryngeal  muscles.  The  larger  external  part 
is  distributed  to  the  sterno-mastoid  and  trapezius  muscles. 

The  nuclei  of  the  nerve,  particularly  of  the  accessory  part,  may  be  in- 
volved in  bulbar  paralysis.  The  nuclei  of  the  external  portion,  situated  as 
they  are  in  the  cervical  cord,  may  be  attacked  in  progressive  degeneration  of 
the  motor  nuclei  of  the  cord.  The  nerve  may  be  involved  in  the  exudation  of 
meningitis,  or  be  compressed  by  tumors,  or  in  caries.  The  symptoms  of  paraly- 
sis of  the  accessory  portion  which  joins  the  vagus  have  already  been  given  in 
the  account  of  the  palsy  of  the  laryngeal  branches  of  the  pneumogastric.  Dis- 
ease or  compression  of  the  external  portion  is  followed  by  paralysis  of  the 
sterno-mastoid  and  of  the  trapezius  on  the  same  side.  In  paralysis  of  one 
sterno-mastoid  the  patient  rotates  the  head  with  difficulty  to  the  opposite 
side,  but  there  is  no  torticollis,  though  in  some  cases  the  head  is  held  obliquely. 
As  the  trapezius  is  supplied  in  part  from  the  cervical  nerves,  it  is  not  com- 
pletely paralyzed,  but  the  portion  which  passes  from  the  occipital  bone  to  the 
acromion  is  functionless.  The  paralysis  of  the  muscle  is  well  seen  when  the 
patient  draws  a  deep  breath  or  shrugs  the  shoulders.  The  middle  portion  of 
the  trapezius  is  also  weakened,  the  shoulder  droops  a  little,  and  the  angle 
of  the  scapula  is  rotated  inward  by  the  action  of  the  rhomboids  and  the  levator 
anguli  scapulae.  Elevation  of  the  arm  is  impaired,  for  the  Irapezius  does  not 
fix  the  scapula  as  a  point  from  which  the  deltoid  can  work. 

In  progressive  muscular  atrophy  we  sometimes  see  bilateral  paralysis  of 
these  muscles.  Thus,  if  the  sterno-mastoids  are  affected,  the  head  tends  to 
fall  back;  when  the  trapezii  are  involved,  it  falls  forward,  a  characteristic 
attitude  of  the  head  in  many  cases  of  progressive  muscular  atrophy.  Gowers 
suggests  that  lesions  of  the  accessory  in  difficult  labor  may  account  for  those 
cases  in  which  during  the  first  year  of  life  the  child  has  great  difficulty  in 
holding  up  the  head.  In  children  this  drooping  of  the  head  is  an  important 
symptom  in  cervical  meningitis,  the  result  of  caries. 

The  TREATMENT  of  the  condition  depends  much  upon  the  cause.  In  the 
central  nuclear  atrophy  but  little  can  be  done.  In  paralysis  from  pressure 
the  symptoms  may  gradually  be  relieved.  The  paralyzed  muscles  should  be 
stimulated  by  electricity  and  massage. 

Accessory  Spasm  (Torticollis;  Wryneck). — The  forms  of  spasm  affecting 
the  cervical  muscles  are  best  considered  here,  as  the  muecles  supplied  by  the 
accessory  are  chiefly,  though  not  solely,  responsible  for  the  condition.  The 
following  forms  may  be  described  in  this  section : 

(a)  CONGENITAL  TORTICOLLIS. — This  condition,  also  known  as  fixed  torti- 
collis, depends  upon  the  shortening  and  atrophy  of  the  sterno-mastoid  on 
one  side.  It  occurs  in  children  and  may  not  be  noticed  for  several  years  on 
account  of  the  shortness  of  the  neck,  the  parents  often  alleging  that  it  has 
only  recently  come  on.  It  affects  the  right  side  almost  exclusively.  A  re- 
markable circumstance  in  connection  with  it  is  the  existence  of  facial  asym- 
metry noted  by  Wilks,  which  appears  to  be  an  essential  part  of  this  congenital 


DISEASES    OF    THE    CEREBRAL    NERVES  1053 

,/orm.  In  congenital  wryneck  the  sterno-mastoid  is  shortened,  hard  and  firm, 
and  in  a  condition  of  more  or  less  advanced  atrophy.  This  must  be  distin- 
guished from  the  local  thickening  in  the  sterno-mastoid  due  to  rupture,  which 
may  occur  at  the  time  of  birth  and  produce  an  induration  or  muscle  callus. 
Although  the  sterno-mastoid  is  almost  always  affected,  there  are  rare  cases 
in  which  the  fibrous  atrophy  affects  the  trapezius.  This  form  of  wryneck  in 
itself  is  unimportant,  since  it  is  readily  relieved  by  tenotomy,  but  Golding- 
Bird  states  that  the  facial  asymmetry  persists,  or,  indeed,  may,  as  shown  by 
photographs  in  my  case,  become  more  evident.  With  reference  to  the  pathology 
of  the  affection,  Golding-Bird  concludes  that  the  facial  asymmetry  and  the  tor- 
ticollis are  integral  parts  of  one  affection  which  has  a  central  origin,  and  is 
the  counterpart  in  the  head  and  neck  of  infantile  paralysis  with  talipes  in 
the  foot. 

(&)  SPASMODIC  WRYNECK. — Two  varieties  of  this  spasm  occur,  the  tonic 
and  the  clonic,  which  may  alternate  in  the  same  case;  or,  as  is  most  common, 
they  are  separate  and  remain  so  from  the  outset.  The  disease  is  most  frequent 
in  adults  and,  according  to  Gowers,  more  common  in  females.  In  America 
it  is  certainly  more  frequent  in  males.  In  females  it  may  be  an  hysterical 
manifestation.  There  may  be  a  marked  neurotic  family  history,  but  it  is 
usually  impossible  to  fix  upon  any  definite  etiological  factor.  Some  cases 
have  followed  cold ;  others  a  blow.  Brissaud  has  described  what  he  calls  men- 
tal torticollis.  It  is  usually  met  with  in  neurasthenic  patients  and  in  elderly 
persons,  and  consists  of  a  clonic  spasm  of  the  rotators  of  the  head. 

The  symptoms  are  well  defined.  In  the  tonic  form  the  contracted  sterno- 
mastoid  draws  the  occiput  toward  the  shoulder  of  the  affected  side;  the  chin 
is  raised,  and  the  face  rotated  to  the  other  shoulder.  The  sterno-mastoid  may 
be  affected  alone  or  in  association  with  the  trapezius.  When  the  latter  is 
implicated  the  head  is  depressed  still  more  toward  the  same  side.  In  long- 
standing cases  these  muscles  are  prominent  and  very  rigid.  There  may  be 
some  curvature  of  the  spine,  the  convexity  of  which  is  toward  the  sound  side. 
The  cases  in  which  the  spasm  is  clonic  are  much  more  distressing  and  serious. 
The  spasm  is  rarely  limited  to  a  single  muscle.  The  sterno-mastoid  is  almost 
always  involved  and  rotates  the  head  so  as  to  approximate  the  mastoid  proc- 
ess to  the  inner  end  of  the  clavicle,  turning  the  face  to  the  opposite  side  and 
raising  the  chin.  When  with  this  the  trapezius  is  affected,  the  depression  of 
the  head  toward  the  same  side  is  more  marked.  The  head  is  drawn  somewhat 
backward ;  the  shoulder,  too,  is  raised  by  its  action.  According  to  Gowers,  the 
splenius  is  associated  with  the  sterno-mastoid  about  half  as  frequently  as  the 
trapezius.  Its  action  is  to  incline  the  head  and  rotate  it  slightly  toward 
the  same  side.  Other  muscles  may  be  involved,  such  as  the  scalenus  and 
platysma  myoides ;  and  in  rare  cases  the  head  may  be  rotated  by  the  deep  cervi- 
cal muscles,  the  rectus  and  obliquus.  There  are  cases  in  which  the  spasm  is 
bilateral,  causing  a  backward  movement— the  retro-collie  spasm.  This  may 
be  either  tonic  or  r.lom'c,  and  in  extreme  cases  the  face  is  horizontal  and  looks 
upward. 

These  clonic  contractions  may  come  on  without  warning,  or  be  precede! 
for  a  time  by  irregular  pains  or  stiffness  of  the  neck.    The  jerking  movements 
recur  every  few  moments,  and  it  is  impossible  to  keep  the  head  still  for  more 
than  s  minute  or  two.    In  time  the  muscles  undergo  hypertrophy  and  may  be 


1054  DISEASES    OF    THE    NERVOUS    SYSTEM 

distinctly  larger  on  one  side  than  the  other.  In  some  cases  the  pain  is  consid- 
erable; in  others  there  is  simply  a  feeling  of  fatigue.  The  spasms  cease  dur- 
ing sleep.  Emotion,  excitement,  and  fatigue  increase  them.  The  spasm  may 
extend  from  the  muscles  of  the  neck  and  involve  those  of  the  face  or  the 
arms. 

The  disease  varies  much  in  its  course.  Cases  occasionally  get  well,  but 
the  great  majority  of  them  persist,  and,  even  if  temporarily  relieved,  the 
disease  frequently  recurs.  The  affection  is  usually  regarded  as  a  functional 
neurosis,  but  it  is  possibly  due  to  disturbance  of  the  cortical  centres  presiding 
over  the  muscles. 

Treatment. — Temporary  relief  is  sometimes  obtained;  a  permanent  cure 
is  exceptional.  Various  drugs  have  been  used,  but  rarely  with  benefit.  Occa- 
sionally, large  doses  />f  bromide  will  lessen  the  intensity  of  the  spasm.  Mor- 
phia, subcutaneously,  has  been  successful  in  some  reported  cases,  but  there 
is  the  great  danger  of  establishing  the  morphia  habit.  Galvanism  may  be 
tried.  Counter-irritation  is  probably  useless.  Fixation  of  the  head  mechan- 
ically can  rarely  be  borne  by  the  patient.  These  obstinate  cases  fall  ultimately 
into  the  hands  of  the  surgeon,  and  the  operations  of  stretching,  division,  and 
excision  of  the  accessory  nerve  and  division  of  the  muscles  have  been  tried. 
Temporary  relief  may  follow,  but,  as  a  rule,  the  condition  returns.  Risien 
Russell  thinks  that  resection  of  the  posterior  branches  of  the  upper  cervical 
nerves  is  most  likely  to  give  relief,  and  this  has  been  done  by  Keen  and 
others. 

(c)  The  NODDING  SPASM  of  children  may  here  be  mentioned  as  involving 
chiefly  the  muscles  innervated  by  the  accessory  nerve.  It  may  be  a  simple  trick, 
a  form  of  habit  spasm,  or  a  phenomenon  of  epilepsy  (E.  nutans),  in  which 
case  it  is  associated  with  transient  loss  of  consciousness.  A  similar  nodding 
spasm  may  occur  in  o]der  children.  In  women  it  sometimes  occurs  as  an  hys- 
terical manifestation,  jommonly  as  part  of  the  so-called  salaam  convulsion. 

HYPOGLOSSAL   NEBVE 

This  is  the  motor  nerve  of  the  tongue  and  for  most  of  the  muscles  attached 
to  the  hyoid  bone.  Its  cortical  centre  is  probably  the  lower  part  of  the  ante- 
rior central  gyrus. 

Paralysis. — (a)  CORTICAL  LESION. — The  tongue  is  often  involved  in  hemi- 
plegia,  and  the  paralysis  may  result  from  a  lesion  of  the  cortex  itself,  or  of 
the  fibres  as  they  pass  to  the  medulla.  It  does  not  occur  alone  and  is  consid- 
ered with  hemiplegia.  There  is  this  difference,  however,  between  the  cortical 
and  other  forms,  that  the  muscles  on  both  sides  of  the  tongue  may  be  more  or 
less  affected  but  do  not  waste,  nor  are  their  electrical  reactions  disturbed. 

(6)  NUCLEAR  and  INFRA-NUCLEAR  lesions  of  the  hypoglossal  result  from 
slow  progressive  degeneration,  as  in  bulbar  paralysis  or  in  locomotor  ataxia; 
occasionally  there  is  acute  softening  from  obstruction  of  the  vessels.  The 
nuclei  of  both  nerves  are  usually  affected  together,  but  may  be  attacked  sepa- 
rately. Trauma  and  lead  poisoning  have  also  been  assigned  as  causes.  The 
fibres  may  be  damaged  by  a  tumor,  and  at  the  base  by  meningitis ;  or  the  nerve 
is  sometimes  involved  in  the  condylar  foramen  by  disease  of  the  skull.  It  may 
be  involved  in  its  course  in  a  scar,  as  in  Birkett's  case,  or  compressed  by  a 


DISEASES    OF    THE    SPINAL  NERVES  1055 

tumor  in  the  parotid  region.  As  a  result,  there  is  loss  of  function  in  the 
nerve  fibres  and  the  tongue  undergoes  atrophy  on  the  affected  side.  It  is 
protruded  toward  the  paralyzed  side  and  may  show  fibrillary  twitching. 

The  symptoms  of  involvement  of  one  hypoglossal,  either  at  its  centre  or  in 
its  course,  are  those  of  unilateral  paralysis  and  atrophy  of  the  tongue.  When 
protruded,  it  is  pushed  toward  the  affected  side,  and  there  are  fibrillary  twitch- 
ings.  The  atrophy  is  usually  marked  and  the  mucous  membrane  on  the  af- 
fected side  is  thrown  into  folds.  Articulation  is  not  much  impaired  in  the 
unilateral  affection.  There  is  a  remarkable  triad  of  symptoms,  to  which 
Hughlings  Jackson  first  called  attention — unilateral  hemi-atrophy  of  the 
tongue,  loss  of  power  in  the  palate  muscle,  with  paralysis  of  the  larynx  on 
the  same  side.  When  the  disease  is  bilateral,  the  tongue  lies  almost  motion- 
less in  the  floor  of  the  mouth;  it  is  atrophied,  and  can  not  be  protruded. 
Speech  and  mastication  are  extremely  difficult  and  deglutition  may  be  im- 
paired. If  the  seat  of  the  disease  is  above  the  nuclei,  there  may  be  little  or 
no  wasting.  The  condition  is  seen  in  progressive  bulbar  paralysis  and  occa- 
sionally in  progressive  muscular  atrophy. 

The  diagnosis  is  readily  made  and  the  situation  of  the  lesion  can  usually 
be  determined,  since  when  supra-nuclear  there  is  associated  hemiplegia  and 
no  wasting  of  the  muscles  of  the  tongue.  Nuclear  disease  is  only  occasionally 
unilateral ;  most  commonly  bilateral  and  part  of  a  bulbar  paralysis.  It  should 
be  borne  in  mind  that  the  fibres  of  the  hypoglossal  may  be  involved  within  the 
medulla  after  leaving  their  nuclei.  In  such  a  case  there  may  be  paralysis  of 
the  tongue  on  one  side  and  paralysis  of  the  limbs  on  the  opposite  side,  and  the 
tongue,  when  protruded,  is  pushed  toward  the  sound  side. 

Spasm. — This  rare  affection  may  be  unilateral  or  bilateral.  It  is  most 
frequently  a  part  of  some  other  convulsive  disorder,  such  as  epilepsy,  chorea, 
or  spasm  of  the  facial  muscles.  In  some  cases  of  stuttering,  spasm  of  the 
tongue  precedes  the  explosive  utterance  of  the  words.  It  may  occur  in  hys- 
teria, and  is  said  to  follow  reflex  irritation  in  the  fifth  nerve.  The  most 
remarkable  cases  are  those  of  paroxysmal  clonic  spasm,  in  which  the  tongue 
is  rapidly  thrust  in  and  out,  as  many  as  forty  or  fifty  times  a  minute.  The 
prognosis  is  usually  good. 


IV.    DISEASES   OF   THE    SPINAL   NERVES 

CERVICAL  PLEXUS 

Occipito-cervical  Neuralgia. — This  involves  the  nerve  territory  supplied 
by  the  occipitalis  major  and  minor,  and  the  auricularis  magnus  nerves.  The 
pains  are  chiefly  in  the  back  of  the  head  and  neck  and  in  the  ear.  The  condi- 
tion may  follow  cold  and  is  sometimes  associated  with  stiffness  of  the  neck 
or  torticollis.  Unless  connected  with  it  there  exists  disease  of  the  bones  or 
unless  it  is  due  to  pressure  of  tumors,  the  outlook  is  usually  good.  There 
are  tender  points  midway  between  the  mastoid  process  and  the  spine  and  just 
above  the  parietal  eminence,  and  between  the  sterno-mastoid  and  the  trapezius. 
The  affection  may  be  due  to  direct  pressure  in  carrying  heavy  weights. 

Affections  of  the  Phrenic  Nerve.— Paralysis  may  follow  a  lesion  in  the 


1056  DISEASES    OF    THE    NERVOUS    SYSTEM 

anterior  horns  at  the  level  of  the  third  and  fourth  cervical  nerves,  or  may  be 
due  to  compression  of  the  nerve  by  tumors  or  aneurism.  More  rarely  paralysis 
results  from  neuritis,  diphtheritic  or  saturnine. 

When  the  diaphragm  is  paralyzed  respiration  is  carried  on  by  the  inter- 
costal and  accessory  muscles.  When  the  patient  is  quiet  and  at  rest  little  may 
be  noticed,  but  the  abdomen  retracts  in  inspiration  and  is  forced  out  in  expira- 
tion. On  exertion  or  even  on  attempting  to  move  there  may  be  dyspnoea.  If 
the  paralysis  sets  in  suddenly  there  may  be  dyspncea  and  lividity,  which  is 
usually  temporary  (W.  Pasteur).  Intercurrent  attacks  of  bronchitis  seriously 
aggravate  the  condition.  Difficulty  in  coughing,  owing  to  the  impossibility  of 
drawing  a  full  breath,  edds  greatly  to  the  danger  of  this  complication. 

WThen  the  phrenic  nerve  is  paralyzed  on  one  side  the  paralysis  may  be 
scarcely  noticeable,  but  careful  inspection  shows  that  the  descent  of  the  dia- 
phragm is  much  less  on  the  affected  side. 

The  diagnosis  of  paralysis  is  not  always  easy,  particularly  in  women,  who 
habitually  use  this  muscle  less  than  men,  and  in  whom  the  diaphragmatic 
breathing  is  less  conspicuous.  Immobility  of  the  diaphragm  is  not  uncom- 
mon, particularly  in  diaphragmatic  pleurisy,  in  large  effusions,  and  in  ex- 
tensive emphysema.  The  muscle  itself  may  be  degenerated  and  its  power 
impaired. 

Owing  to  the  lessened  action  of  the  diaphragm,  there  is  a  tendency  to 
accumulation  of  blood  at  the  bases  of  the  lungs,  and  there  may  be  impaired 
resonance  and  signs  of  oedema.  As  a  rule,  however,  the  paralysis  is  not  con- 
fined to  this  muscle,  but  is  part  of  a  general  neuritis  or  an  anterior  polio- 
myelitis, and  there  are  other  symptoms  of  value  in  determining  its  presence. 
The  outlook  is  usually  serious.  Pasteur  states  that  of  15  cases  following  diph- 
theria only  8  recovered.  The  treatment  is  that  of  the  neuritis  or  polio- 
myelitis. 

Hiccough. — Here  may,  perhaps,  best  be  considered  this  remarkable  symp- 
tom, caused  by  intermittent,  sudden  contraction  of  the  diaphragm.  The  mech- 
anism, however,  is  complex,  and  while  the  afferent  impressions  to  the  respira- 
tory centre  may  be  peripheral  or  central  the  efferent  are  distributed  through 
the  phrenic  nerve  to  the  diaphragm,  causing  the  intermittent  spasm,  and 
through  the  laryngeal  branches  of  the  vagus  to  the  glottis,  causing  sudden 
closure  as  the  air  is  rapidly  inspired.  There  are  various  groups: 

(a)  INFLAMMATORY,  seen  particularly  in  affections  of  the  abdominal  vis- 
cera, gastritis,  peritonitis,  hernia,  internal  strangulation,  appendicitis,  suppu- 
rative  pancreatitis,  and  in  the  severe  forms  of  typhoid  fever. 

(&)  IRRITATIVE,  as  in  the  direct  stimulation  of  the  diaphragm  when  very 
hot  substances  are  swallowed,  in  disease  of  the  oesophagus  near  the  diaphragm, 
and  in  many  conditions  of  gastric  and  intestinal  disorder,  more  particularly 
those  associated  with  flatus. 

(c)  SPECIFIC,  or,  perhaps  more  properly,  idiopathic,  in  which  no  evident 
causes  are  present.    In  these  cases  there  is  usually  some  constitutional  taint, 
as  gout,  diabetes,  or  chronic  Bright's  disease.     I  have  seen  several  instances 
of  obstinate  hiccough  in  the  later  stages  of  chronic  interstitial  nephritis. 

(d)  NEUROTIC,  cases  in  which  the  primary  cause  is  in  the  nervous  system; 
hysteria,  epilepsy,  shock,  or  cerebral  tumors.     Of  these  cases  the  hysterical 
are,  perhaps,  the  most  obstinate. 


DISEASES   OF   THE    SPIRAL   NERVES  105? 

The  TREATMENT  is  often  very  unsatisfactory.  Sometimes  in  the  milder 
fcrms  a  sudden  reflex  irritation  will  check  it  at  once.  Eeaders  of  Plato's 
Symposium  will  remember  that  the  physician  Eryximachus  recommended  to 
Aristophanes,  who  had  hiccough  from  eating  too  much,  either  to  hold  his 
breath  (which  for  trivial  forms  of  hiccough  is  very  satisfactory)  or  to  gargle 
with  a  little  water;  but  if  it  still  continued,  "tickle  your  nose  with  something 
and  sneeze;  and  if  you  sneeze  once  or  twice  even  the  most  violent  hiccough 
is  sure  to  go."  The  attack  must  have  been  of  some  severity,  as  it  is  stated 
subsequently  that  the  hiccough  did  not  disappear  until  Aristophanes  had 
resorted  to  the  sneezing. 

Ice,  a  teaspoonful  of  salt  and  lemon  juice,  or  salt  and  vinegar,  or  a  tea- 
spoonful  of  raw  spirits  may  be  tried.  When  the  hiccough  is  due  to  gastric 
irritation,  lavage  is  sometimes  promptly  curative.  I  saw  a  case  of  a  week's 
duration  cured  by  a  hypodermic  injection  of  gr.  %  (0.008  gm.)  of  apomor- 
phia.  In  obstinate  cases  the  various  antispasmodics  have  been  used  in  suc- 
cession. Pilocarpine  has  been  recommended.  The  ether  spray  on  the  epigas- 
trium may  be  promptly  curative.  Hypodermics  of  morphia,  inhalations  of 
chloroform,  the  use  of  nitrite  of  amyl  and  of  nitroglycerin  have  been  bene- 
ficial in  some  cases.  Galvanism  over  the  phrenic  nerve,  or  pressure  on  the 
nerves,  applied  between  the  heads  of  the  sterno-cleido-mastoid  muscles  may  be 
used.  Strong  traction  upon  the  tongue  may  give  immediate  relief.  Of  all 
measures  morphia  used  freely  is  the  best. 


BRACHIAL  PLEXUS 

Cervical  Rib  Pressure. — Symptoms  from  pressure  of  this  anomaly  are  by 
no  means  rare.  It  is  usually  bilateral,  but  the  rib  may  be  much  longer  on  one 
side  than  on  the  other.  The  rib  may  be  short  and  straight  with  the  subclavian 
artery  and  brachial  plexus  in  front  of  it,  or  longer  and  curved  with  the  sub- 
clavian artery  on  its  upper  surface  in  a  groove,  in  which  case  the  artery  is 
lengthened  and  elevated  in  the  neck.  Only  about  5  or  10  per  cent,  of  the 
cases  have  any  trouble.  The  symptoms  are  either  from  pressure  on  the  artery 
or  on  the  nerve.  The  pulsation  of  the  abnormally  high  artery  may  be  mis- 
taken for  aneurism.  In  a  few  rare  instances  aneurism  has  occurred  at  the 
site  of  the  pressure,  and  there  have  been  cases  of  thrombosis  with  gangrene  of 
the  finger  tips.  I  have  seen  three  cases  in  which  on  exertion  the  arm  became 
swollen.,  red  and  hot  with  numbness  and  tingling,  but  when  quiet  and  at  rest 
there  was  no  inconvenience. 

Affections  of  the  nerves  are  more  frequent  and  important.  Pain  is  com- 
mon, corresponding,  as  a  rule,  to  the  distribution  of  the  eighth  cervical  and 
first  dorsal  roots,  extending  along  the  ulnar  border  of  the  forearm  to  the 
wrist  or  fingers.  In  other  cases  there  is  marked  pressure  on  the  brachial 
plexus  with  partial  paralysis  and  wasting  of  the  intrinsic  muscles  of  the  hand. 
There  may  be  anesthesia  or  hyperaesthesia  of  the  inner  aspect  of  the  arm  and 
the  ulna/ half  of  the  hand.  In  a  few  instances  there  has  been  pressure  on 
the  cervical  sympathetic  nerve. 

The  condition  is,  as  a  rule,  readily  recognized,  sometimes  by  palpation, 
always  with  the  X-ray  picture. 


1058  DISEASES    OP   THE    NERVOUS    SYSTEM 

Combined  Paralysis. — The  plexus  may  be  involved  in  tbe  supraclavicular 
region  by  compression  of  the  nerve  trunks  as  they  leave  the  spine,  or  by 
tumors  and  other  morbid  processes  in  the  neck.  Below  the  clavicle  lesions  are 
more  common  and  result  from  injuries  following  dislocation  or  fracture,  some- 
times from  neuritis.  A  cervical  rib  may  lead  to  a  pressure  paralysis  of  the 
lower  cord  of  the  plexus.  A  not  infrequent  form  of  injury  in  this  region 
follows  falls  or  blows  on  the  neck,  which  by  lateral  flexion  of  the  head  and 
depression  of  the  shoulder  seriously  stretch  the  plexus.  The  entire  plexus  may 
be  ruptured  and  the  arm  be  totally  paralyzed.  The  rupture  may  occiir  any- 
where between  the  vertebra?  and  the  clavicle,  and  involve  all  the  cords  of  the 
plexus,  or  only  the  upper  ones.  The  so-called  "obstetrical  palsy,"  due  to 
drawing  apart  of  the  head  and  the  shoulder  during  delivery,  is  an  instance 
of  this  sort  of  injury.  In  these  cases,  however,  the  rupture  of  the  plexus  is 
usually  only  a  partial  one,  involving  its  upper  cord  alone,  so  that  the  deltoid, 
biceps,  supra-  and  infra-spinati,  brachialis  anticus,  and  supinator  longus  mus- 
cles may  alone  be  affected.  When  the  entire  plexus  has  been  ruptured  a  com- 
plete motor  and  sensory  paralysis  of  the  arm  is  produced.  The  roots  may 
even  be  torn  away  from  the  spinal  cord.  The  pupil  will  then  be  contracted 
on  the  side  of  the  injury,  and  the  arm  hang  from  the  body  like  a  flail.  An- 
other common  cause  of  lesion  of  the  brachial  plexus  is  luxation  of  the  head 
of  the  humerus,  particularly  the  subcoracoid  form. 

A  primary  neuritis  of  the  brachial  plexus  is  rare.  More  commonly  the 
process  is  an  ascending  neuritis  from  a  lesion  of  a  peripheral  branch,  involving 
first  the  radial  or  ulnar  nerves,  and  spreading  upward  to  the  plexus,  producing 
gradually  complete  loss  of  power  in  the  arm. 

Lesions  of  Individual  Nerves  of  the  Plexus. — (a)  LONG  THORACIC  NERVE. 
— Serratus  paralysis  follows  injury  to  this  nerve  in  the  neck,  usually  by  direct 
pressure  in  carrying  loads,  and  is  very  common  in  soldiers.  It  may  be  due 
to  a  neuritis  following  an  acute  infection  or  exposure.  Isolated  serratus  par- 
alysis is  rare.  It  usually  occurs  in  connection  with  paralysis  of  other  mus- 
cles of  the  shoulder  girdle,  as  in  the  myopathies  and  in  progressive  muscular 
atrophy.  Concomitant  trapezius  paralysis  is  the  most  frequent.  In  the 
isolated  paralysis  there  is  little  or  no  deformity  with  the  hands  hanging  by 
the  sides.  There  are  slight  abnormal  obliquity  of  the  posterior  border  of  the 
scapula  and  prominence  of  the  inferior  angle,  but  when,  as  so  commonly  hap- 
pens, the  middle  part  of  the  trapezius  is  also  paralyzed  the  deformity  is 
marked.  The  shoulder  is  at  a  lower  level,  the  inferior  angle  of  the  scapula 
is  displaced  inward  and  upward,  and  the  superior  angle  projects  upward. 
When  the  arms  are  held  out  in  front  at  right  angles  to  the  body  the  scapula 
becomes  winged  and  stands  out  prominently.  The  arm  can  not,  as  a  rule, 
be  raised  above  the  horizontal.  The  outlook  of  the  cases  due  to  injury  or  to 
neuritis  is  good. 

(6)  CIRCUMFLEX  NERVE. — This  supplies  the  deltoid  and  the  teres  minor. 
The  nerve  is  apt  to  be  involved  in  injuries,  in  dislocations,  bruising  by  a 
crutch,  or  sometimes  by  extension  of  inflammation  from  the  joint.  Occasion- 
ally the  paralysis  arises  from  a  pressure  neuritis  during  an  illness.  As  a  con- 
sequence of  loss  of  power  in  the  deltoid,  the  arm  can  not  be  raised.  The  wast- 
ing is  usually  marked  and  changes  the  shape  of  the  shoulder.  Sensation  may 
also  be  impaired  in  the  skin  over  the  muscle.  The  joint  may  be  relaxed  and 


1059 

there  may  be  a  distinct  space  between  the  bead  of  the  humerus  and  the 
acromion. 

(c)  MUSCULO-SPIEAL  PARALYSIS;  RADIAL  PARALYSIS. — This  is  one  of  the 
most  common  of  peripheral  palsies,  and  results  from  the  exposed  position  of 
the  musculo-spiral  nerve.     It  is  often  bruised  in  the  use  of  the  crutch,  by 
injuries  of  the  arm,  blows,  or  fractures.     It  is  frequently  injured  when  a 
person  falls  asleep  with  the  arm  over  the  back  of  a  chair,  or  by  pressure  of 
the  body  upon  the  arm  when  a  person  is  sleeping  on  a  bench  or  on  the  ground. 
It  may  be  paralyzed  by  sudden  violent  contraction  of  the  triceps.    It  is  some- 
times involved  in  a  neuritis  from  cold,  but  this  is  uncommon  in  comparison 
with  other  causes.     The  paralysis  of  lead  poisoning  is  the  result  of  involve- 
ment of  certain  branches  of  this  nerve. 

A  lesion  when  high  up  involves  the  triceps,  the  brachialis  anticus,  and  the 
supinator  longus,  as  well  as  the  extensors  of  the  wrist  and  fingers.  Naturally, 
in  lesions  just  above  the  elbow  the  arm  muscles  and  the  supinator  longus  are 
bpared.  The  most  characteristic  feature  of  the  paralysis  is  the  wrist-drop  and 
the  inability  to  extend  the  first  phalanges  of  the  fingers  and  thumb.  In  the 
pressure  palsies  the  supinators  are  usually  involved  and  the  movements  of 
supination  can  not  be  accomplished.  The  sensations  may  be  impaired,  or  there 
may  be  marked  tingling,  but  the  loss  of  sensation  is  rarely  so  pronounced  as 
that  of  motion. 

The  affection  is  readily  recognized,  but  it  is  sometimes  difficult  to  say  upon 
what  it  depends.  The  sleep  and  pressure  palsies  are,  as  a  rule,  unilateral  and 
involve  the  supinator  longus.  The  paralysis  from  lead  is  bilateral  and  the 
supinators  are  unaffected.  Bilateral  wrist-drop  is  a  very  common  symptom 
in  many  forms  of  multiple  neuritis,  particularly  the  alcoholic;  but  the  mode 
of  onset  and  the  involvement  of  the  legs  and  arms  are  features  which  make  the 
diagnosis  easy.  The  duration  and  course  of  the  musculo-spiral  paralyses  are 
very  variable.  The  pressure  palsies  may  disappear  in  a  few  days.  Recovery 
is  the  rule,  even  when  the  affection  lasts  for  many  weeks.  The  electrical  exam- 
ination is  of  importance  in  the  prognosis,  and  the  rules  laid  down  under 
paralysis  of  the  facial  nerve  hold  good  here. 

The  treatment  is  that  of  neuritis. 

(d)  ULNAR  NERVE. — The  motor  branches  supply  the  ulnar  half  of  the 
deep  flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the  interossei,  the 
adductor  and  the  inner  head  of  the  short  flexor  of  the  thumb,  and  the  ulnar 
flexor  of  the  wrist.    The  sensory  branches  supply  the  ulnar  side  of  the  hand — 
two  and  a  half  fingers  on  the  back,  and  one  and  a  half  fingers  on  the  front. 
Paralysis  may  result  from  pressure,  usually  at  the  elbow  joint,  although  the 
nerve  is  here  protected.    Possibly  the  neuritis  in  the  ulnar  nerve  in  some  cases 
of  acute  illness  may  be  due  to  this  cause.    Gowers  mentions  the  case  of  a  lady 
•who  twice  had  ulnar  neuritis  after  confinement.     Owing  to  paralysis  of  the 
ulnar  flexor  of  the  wrist,  the  hand  moves  toward  the  radial  side;  adduction 
of  the  thumb  is  impossible;  the  first  phalanges  can  not  be  flexed,  and  the 
others  can  not  be  extended.     In  long  standing  cases  the  first  phalanges  are 
overextended  and  the  others  strongly  flexed,  producing  the  claw-hand ;  but  this 
is  not  so  marked  as  in  the  progressive  muscular  atrophy.    The  loss  of  sensa- 
tion corresponds  to  the  sensory  distribution  just  mentioned. 

(e)  MEDIAN  NERVE. — This  supplies  the  flexors  of  the  fingers  except  the 


10GO  DISEASES    OF   THE   NERVOUS    SYSTEM 

ulnar  half  of  the  deep  flexors,  the  abductor  and  the  flexors  of  the  thumb,  the 
two  radial  lumbricales,  the  pronators,  and  the  radial  flexor  of  the  wrist.  The 
sensory  fibres  supply  the  radial  side  of  the  palm  and  the  front  of  the  thumb, 
the  first  two  fingers  and  half  the  third  finger,  and  the  dorsal  surfaces  of  the 
same  three  fingers. 

This  nerve  is  seldom  involved  alone.  Paralysis  results  from  injury  and 
occasionally  from  neuritis.  The  signs  are  inability  to  pronate  the  forearm 
beyond  the  mid-position.  The  wrist  can  be  flexed  only  toward  the  ulnar  side; 
the  thumb  can  not  be  opposed  to  the  tips  of  fingers.  The  second  phalanges 
can  not  be  flexed  on  the  first;  the  distal  phalanges  of  the  first  and  second 
fingers  can  not  be  flexed ;  but  in  the  third  and  fourth  fingers  this  action  can 
be  performed  by  the  ulnar  half  of  the  flexor  profundus.  The  loss  of  sensation 
is  in  the  region  corresponding  to  the  sensory  distribution  already  mentioned. 
The  wasting  of  the  thumb  muscles,  which  is  usually  marked  in  this  paralysis, 
gives  to  it  a  characteristic  appearance. 

LUMBAR  AND  SACEAL  PLEXUSES 

Lumbar  Plexus. — The  lumbar  plexus  is  sometimes  involved  in  growths  of 
the  lymph  glands,  in  psoas  abscess,  and  in  disease  of  the  bones  of  the  vertebrae. 
When  paralyzed  the  obturator  nerve  is  occasionally  injured  during  parturition. 
When  paralyzed  the  power  is  lost  over  the  abductors  of  the  thigh  and  one  leg 
can  not  be  crossed  over  the  other.  Outward  rotation  is  also  disturbed.  The 
anterior  crural  nerve  is  sometimes  involved  in  wounds  or  in  dislocation  of 
the  hip-joint,  less  commonly  during  parturition,  and  sometimes  by  disease 
of  the  bones  and  in  psoas  abscess.  The  special  symptoms  of  affection  of  this 
nerve  are  paralysis  of  the  extensors  of  the  knee  with  wasting  of  the  muscles, 
anesthesia  of  the  antero-lateral  parts  of  the  thigh  and  of  the  inner  side  of 
the  leg  to  the  big  toe.  This  nerve  is  sometimes  involved  early  in  growths 
about  the  spine,  and  there  may  be  pain  in  its  area  of  distribution.  Loss  of 
the  power  of  abducting  the  thigh  results  from  paralysis  of  the  gluteal  nerve, 
which  is  distributed  to  the  gluteus  medius  and  minimus  muscles. 

External  Cutaneous  Nerve. — A  peculiar  form  of  sensory  disturbance,  con- 
fined to  the  territory  of  this  nerve,  was  first  described  by  Bernhardt  in  1895, 
and  a  few  months  later  by  Roth,  who  gave  it  the  name  of  meralgia  parcesthet- 
ica.  The  disease  is  probably  due  to  a  neuritis  which  seems  to  originate  in  that 
part  of  the  nerve  where  it  passes  under  Poupart's  ligament,  just  internal  to 
the  anterior  superior  iliac  spine.  The  nerve  is  usually  tender  on  pressure  at 
this  point.  The  disease  is  more  common  in  men.  Musser  and  Sailer  in  1900 
collected  99  cases,  of  which  75  were  in  men.  A  large  number  of  the  cases  are 
attributable  to  direct  traumatism  or  to  simple  pressure  on  the  nerve  by  the 
aponeurotic  canal  through  which  it  passes.  Pregnancy  is  among  the  more 
common  causes  in  women.  The  sensory  disturbances  consist  of  various  forms 
of  paraesthesia  located  over  the  outer  side  of  the  thigh,  oftentimes  with  some 
actual  diminution  in  the  acuity  of  sense  perception.  The  symptoms  in  vary- 
ing intensity  may  persist  for  years,  and  the  discomfort  in  some  cases  be  so 
great,  and  so  much  exaggerated  even  by  the  mere  touch  of  the  clothing,  that 
patients  may  be  greatly  incapacitated  thereby.  Excision  of  the  nerve  as  it 
passes  under  Poupart's  ligament  has  given  good  results. 


DISEASES    OF   THE    SPINAL   NERVES  1061 

Sacral  Plexus. — The  sacral  plexus  is  frequently  involved  in  tumors  and 
inflammations  within  the  pelvis  and  may  be  injured  during  parturition. 
Neuritis  is  common.,  usually  an  extension  from  the  sciatic  nerve. 

Goldthwaite  calls  attention  to  the  fact  that  the  lumbo-sacral  articulation 
varies  very  greatly  in  its  stability,  and  actual  displacement  of  the  bones  may 
result  with  separation  of  the  posterior  portion  of  the  intervertebral  disc.  The 
cauda  equina,  or  the  nerve  roots,  may  be  compressed.  With  displacement  on 
one  side  the  spine  is  rotated  and  the  articular  process  of  the  fifth  is  drawn 
into  the  spinal  canal,  with  such  narrowing  that  paraplegia  may  result,  and  he 
reports  a  remarkable  case  in  which  the  paralysis  came  on  during  the  applica- 
tion of  a  plaster  jacket.  Weakness  of  the  joints  or  the  partial  displacements 
may  cause  irritation  of  the  nerves  inside  and  outside  the  canal  with  resulting 
bilateral  sciatica. 

Of  the  branches,  the  sciatic  nerve,  when  injured  at  or  near  the  notch, 
causes  paralysis  of  the  flexors  of  the  legs  and  the  muscles  below  the  knee,  but 
injury  below  the  middle  of  the  thigh  involves  only  the  latter  muscles.  There 
is  also  anesthesia  of  the  outer  half  of  the  leg,  the  sole,  and  the  greater  portion 
of  the  dorsum  of  the  foot.  Wasting  of  the  muscles  frequently  follows,  and 
there  may  be  trophic  disturbances.  In  paralysis  of  one  sciatic  the  leg  is  fixed 
at  the  knee  by  the  action  of  the  quadriceps  extensor  and  the  patient  is  able  to 
walk. 

Paralysis  of  the  small  sciatic  nerve  is  rarely  seen.  The  gluteus  maximus 
is  involved  and  there  may  be  difficulty  in  rising  from  a  seat.  There  is  a  strip 
of  anaesthesia  along  the  back  of  the  middle  third  of  the  thigh. 

External  Popliteal  Nerve. — Paralysis  involves  the  peronsei,  the  long  ex- 
tensor of  the  toes,  tibialis  anticus,  and  the  extensor  brevis  digitorum.  The 
ankle  can  not  be  flexed,  resulting  in  a  condition  known  as  foot-drop,  and  as 
the  toes  can  not  be  raised  the  whole  leg  must  be  lifted,  producing  the  charac- 
teristic steppage  gait  seen  in  so  many  forms  of  peripheral  neuritis.  In  long- 
standing cases  the  foot  is  permanently  extended  and  there  is  wasting  of  the 
anterior  tibial  and  peroneal  muscles.  The  loss  of  sensation  is  in  the  outer 
half  of  the  front  of  the  leg  and  on  the  dorsum  of  the  foot. 

Internal  Popliteal  Nerve. — When  paralyzed,  plantar  flexion  of  the  foot  and 
flexion  of  the  toes  are  impossible.  The  foot  can  not  be  adducted,  nor  can  the 
patient  rise  on  tiptoe.  In  long  standing  cases  talipes  calcaneus  follows  and 
the  toes  assume  a  claw-like  position  from  secondary  contracture,  due  to  over- 
extension  of  the  proximal  and  flexion  of  the  second  and  third  phalanges. 

SCIATICA 

This  is,  as  a  rule,  a  neuritis  either  of  the  sciatic  nerve  or  of  its  cords  of 
origin.  It  may  in  some  instances  be  a  functional  neurosis  or  neuralgia. 

It  occurs  most  commonly  in  adult  males.  A  history  of  rheumatism  or  of 
gout  is  present  in  many  cases.  Exposure  to  cold,  particularly  after  heavy 
muscular  exertion,  or  a  severe  wetting  are  not  uncommon  causes.  Within  the 
pelvis  the  nerves  may  be  compressed  by  large  ovarian  or  uterine  tumors,  by 
lymphadenomata,  by  the  fetal  head  during  labor;  occasionally  lesions  of  the 
hip-joint  induce  a  secondary  sciatica.  More  commonly,  however,  the  condition 
is  due  to  chronic  arthritis  of  the  spinal  column.  The  condition  of  the  nerve 


1062  DISEASES    OP   THE   NERVOUS    SYSTEM 

has  been  examined  in  a  few  cases,  and  it  has  often  been  seen  in  the  operation 
of  stretching.  It  is,  as  a  rule,  swollen,  reddened,  and  in  a  condition  of  inter- 
stitial neuritis.  The  affection  may  be  most  intense  at  the  sciatic  notch  or  in 
the  nerve  about  the  middle  of  the  thigh. 

Symptoms, — Of  the  symptoms,  pain  is  the  most  constant  and  troublesome. 
The  onset  may  be  severe,  with  slight  pyrexia,  but,  as  a  rule,  it  is  gradual,  and 
for  a  time  there  is  only  slight  pain  in  the  back  of  the  thigh,  particularly  in 
certain  positions  or  after  exertion.  Soon  the  pain  becomes  more  intense  and, 
instead  of  being  limited  to  the  upper  portion  of  the  nerve,  extends  down  the 
thigh,  reaching  the  foot  and  radiating  over  the  entire  distribution  of  the 
nerve.  The  patient  can  often  point  out  the  most  sensitive  spots,  usually  at  the 
notch  or  in  the  middle  of  the  thigh;  and  on  pressure  these  are  exquisitely 
painful.  The  pain  is  described  as  gnawing  or  burning,  and  is  usually  con- 
stant, but  in  some  instances  is  paroxysmal,  and  often  worse  at  night.  On 
walking  it  may  be  very  great;  the  knee  is  bent  and  the  patient  treads  on  the 
toes,  so  as  to  relieve  the  tension  on  the  nerve.  In  protracted  cases  there  may 
be  much  wasting  of  the  muscles,  but  the  reaction  of  degeneration  can  seldom 
be  obtained.  In  these  chronic  cases  cramp  may  occur  and  fibrillar  contrac- 
tions. Herpes  may  develop,  but  this  is  unusual.  In  rare  instances  the  neu- 
ritis ascends  and  involves  the  spinal  cord. 

Duration  and  Course. — The  duration  and  course  are  extremely  variable. 
As  a  rule,  it  is  an  obstinate  affection,  lasting  for  months,  or  even,  with  slight 
remissions,  for  years.  Relapses  are  not  uncommon,  and  the  disease  may  be 
relieved  in  one  nerve  only  to  appear  in  the  other.  In  the  severer  forms  the 
patient  is  bedridden,  and  such  cases  prove  among  the  most  distressing  and 
trying  which  the  physician  is  called  upon  to  treat. 

Diagnosis. — In  the  diagnosis  it  is  important,  in  the  first  place,  to  de- 
termine whether  the  disease  is  primary,  or  secondary  to  some  affection  of  the 
pelvis  or  of  the  spinal  cord.  A  careful  rectal  examination  should  be  made, 
and,  in  women,  pelvic  tumor  should  be  excluded.  Lumbago  may  be  con- 
founded with  it.  Affections  of  the  hip-joint  are  easily  distinguished  by  the 
absence  of  tenderness  in  the  course  of  the  nerve  and  the  sense  of  pain  on 
movement  of  the  hip-joint  or  on  pressure  in  the  region  of  the  trochanter. 
There  are  instances  of  sacro-iliac  disease  in  which  the  patient  complains  of 
pain  in  the  upper  part  of  the  thigh,  which  may  sometimes  radiate ;  but  -care- 
ful examination  will  readily  distinguish  between  the  affections.  Pressure  on 
the  nerve  trunks  of  the  cauda  equina,  as  a  rule,  causes  bilateral  pain  and  dis- 
turbances of  sensation,  and,  as  double  sciatica  is  rare,  these  circumstances 
always  suggest  lesion  of  the  nerve  roots.  Between  the  severe  lightning  pains 
of  tabes  and  sciatica  the  differences  are  usually  well  defined.  It  is  not  to  be 
forgotten  that  in  a  certain  number  of  cases  of  so-called  rheumatic  sciatica  the 
condition  is  a  myositis,  or,  as  Gowers  calls  it,  a  fibrositis.  There  is  no  ten- 
derness along  the  course  of  the  sciatic  nerve,  but  there  is  pain  in  the  gluteal 
region,  with  disability  and  Lasegue's  sign,  i.  e.,  inability  to  extend  the  leg 
completely  when  the  thigh  is  flexed  on  the  abdomen. 

Treatment. — The  spinal  column  should  be  carefully  and  systematically  ex- 
amined, for  numerous  cases  have  been  relieved  by  orthopaedic  procedures.  The 
pelvic  organs  should  also  be  investigated.  Constitutional  conditions,  such  as 
rheumatism  and  gout,  should  receive  appropriate  treatment.  In  a  few  cases 


PARALYSIS    AGITANS  1063 

with  pronounced  rheumatic  history,  which  come  on  acutely  with  fever,  the 
salicylates  seem  to  do  good.  In  other  instances  they  are  quite  useless.  If 
there  is  a  suspicion  of  syphilis,  the  iodide  of  potassium  should  be  employed, 
and  in  gouty  cases  salines. 

Rest  in  bed  with  fixation  of  the  limb  by  means  of  a  long  splint  is  a  most 
valuable  method  of  treatment  in  many  cases,  one  upon  which  Weir  Mitchell 
has  specially  insisted.  I  have  known  it  to  relieve,  and  in  some  instances  to 
cure,  obstinate  and  protracted  cases  which  had  resisted  all  other  treatment. 
Hydrotherapy  is  sometimes  satisfactory,  particularly  the  warm  baths  or  the 
mud  baths.  Many  cases  are  relieved  by  a  prolonged  residence  at  one  of  the 
thermal  springs.  Antipyrin,  antifebrin,  and  quinine  are  of  doubtful  benefit. 

Local  applications  are  more  beneficial.  The  hot  iron  or  the  thermo-cautery 
or  blisters  relieve  the  pain  temporarily.  Deep  injections  into  the  nerves  give 
great  relief  and  may  be  necessary  for  the  pain.  It  is  best  to  use  cocaine  at 
first,  in  doses  of  from  an  eighth  to  a  quarter  of  a  grain  (0.008  to  0.016  gm.). 
If  the  pain  is  unbearable  morphia  may  be  used,  but  it  is  a  dangerous  remedy 
in  sciatica  and  should  be  withheld  as  long  as  possible.  The  disease  is  so  pro- 
tracted, so  liable  to  relapse,  and  the  patient's  morale  so  undermined  by  the 
constant  worry  and  the  sleepless  nights,  that  the  danger  of  contracting  the 
morphia  habit  is  very  great.  On  no  consideration  should  the  patient  be  per- 
mitted to  use  the  hypodermic  needle  himself.  It  is  remarkable  how  promptly, 
in  some  cases,  the  injection  of  distilled  water  into  the  nerve  will  relieve  the 
pain.  Acupuncture  may  also  be  tried;  the  needles  should  be  thrust  deeply  into 
the  most  painful  spot  for  a  distance  of  about  2  inches,  and  left  for  from  fif- 
teen to  twenty  minutes.  The  injection  of  chloroform  into  the  nerve  has  also 
been  recommended. 

Electricity  is  an  uncertain  remedy.  Sometimes  it  gives  prompt  relief;  in 
other  cases  it  may  be  used  for  weeks  without  the  slightest  benefit.  It  is  most 
serviceable  in  the  chronic  cases  in  which  there  is  wasting  of  the  legs,  and 
should  be  combined  with  massage.  The  galvanic  current  should  be  used;  a 
flat  electrode  should  be  placed  over  the  sciatic  notch,  and  a  smaller  one  used 
along  the  course  of  the  nerve  and  its  branches.  In  very  obstinate  cases  nerve- 
stretching  may  be  employed.  It  is  sometimes  successful;  but  in  other  in- 
stances the  condition  recurs  and  is  as  bad  as  ever. 


G.    GENERAL  AND  FUNCTIONAL  DISEASES 
I.    PARALYSIS   AGITANS 

(Parkinson's  Disease;  Shaking  Palsy) 

Definition. — A  chronic  affection  of  the  nervous  system,  characterized  by 
muscular  weakness,  tremors,  and  rigidity. 

Etiology. — Men  are  more  frequently  affected  than  women.  It  rarely 
occurs  under  forty,  but  instances  have  been  reported  in  which  the  disease  began 
about  the  twentieth  year.  It  is  by  no  means  an  uncommon  affection.  Direct 
heredity  is  rare,  but  the  patients  often  belong  to  families  in  which  there  are 
other  nervous  affections.  Among  exciting  causes  may  be  mentioned  exposure 


1064  DISEASES    OF    THE    NERVOUS    SYSTEM 

to  cold  and  wet,  and  business  worries  and  anxieties.  In  some  instances  the 
disease  has  followed  directly  upon  severe  mental  shock  or  trauma.  Cases  have 
been  described  after  the  specific  fevers.  Malaria  is  believed  by  some  to  be 
an  important  factor,  but  of  this  there  is  no  satisfactory  evidence. 

Morbid  Anatomy. — Xo  constant  lesions  have  been  found.  The  similarity 
between  certain  of  the  features  of  Parkinson's  disease  and  those  of  old  age 
suggests  that  the  affection  may  depend  upon  a  premature  senility  of  certain 
regions  of  the  brain.  Our  organs  do  not  age  uniformly,  but  in  some,  owing 
to  hereditary  disposition,  the  process  may  be  more  rapid  than  in  others. 
"Parkinson's  disease  has  no  characteristic  lesions,  but,  on  the  other  hand,  it  is 
not  a  neurosis.  It  has  for  anatomical  basis  the  lesions  of  cerebro-spinal 
senility,  which  only  differ  from  those  of  true  senility  in  their  early  onset  and 
greater  intensity"  (Dubief).  The  important  changes  are  doubtless  in  the  cere- 
bral cortex.  No  special  changes  have  been  found  in  the  organs  of  internal 
secretion. 

Symptoms. — The  disease  begins  gradually,  usually  in  one  or  other  hand, 
and  the  tremor  may  be  either  constant  or  intermittent.  With  this  may  be  asso- 
ciated weakness  or  stiffness.  At  first  these  symptoms  may  be  present  only 
after  exertion.  Although  the  onset  is  slow  and  gradual  in  nearly  all  cases, 
there  are  instances  in  which  it  sets  in  abruptly  after  fright  or  trauma.  When 
well  established  the  disease  is  very  characteristic,  and  the  diagnosis  can  be 
made  at  a  glance.  The  four  prominent  symptoms  are  tremor,  weakness, 
rigidity,  and  the  attitude. 

TREMOR. — This  may  be  in  the  four  extremities  or  confined  to  hands  or 
feet ;  the  head  is  not  so  commonly  affected.  The  tremor  is  usually  marked  in 
the  hands,  and  the  thumb  and  forefinger  display  the  motion  made  in  the  act 
of  rolling  a  pill.  At  the  wrist  there  are  movements  of  pronation  and  supina- 
tion,  and,  though  less  marked,  of  flexion  and  extension.  The  upper-arm  mus- 
cles are  rarely  involved.  In  the  legs  the  movement  is  most  evident  at  the 
ankle-joint,  and  less  in  the  toes  than  in  the  fingers.  Shaking  of  the  head  is 
less  frequent,  but  does  occur,  and  is  usually  vertical,  not  rotatory.  The  rate 
of  oscillation  is  about  five  per  second.  Any  emotion  exaggerates  the  move- 
ment. The  attempt  at  a  voluntary  movement  may  check  the  tremor 
(the  patient  may  be  able  to  thread  a  needle),  but  it  returns  with  in- 
creased intensity.  The  tremors  cease,  as  a  rule,  during  sleep,  but  per- 
sist when  the  muscles  are  not  in  use.  The  writing  of  the  patient  is  tremulous 
and  zigzag. 

WEAKNESS. — Loss  of  power  is  present  in  all  cases,  and  may  occur  even  be- 
fore the  tremor,  but  is  not  very  striking,  as  tested  by  the  dynamometer,  until 
the  late  stages.  The  weakness  is  greatest  where  the  tremor  is  most  developed. 
The  movements,  too,  are  remarkably  slow.  There  is  rarely  complete  loss  of 
power. 

RIGIDITY  may  early  be  expressed  in  a  slowness  and  stiffness  in  the  volun- 
tary movements,  which  are  performed  with  some  effort  and  difficulty,  and  all 
the  actions  of  the  patient  are  deliberate.  This  rigidity  is  in  all  the  muscles, 
and  leads  ultimately  to  the  characteristic  attitude. 

ATTITUDE  AND  GAIT. — The  head  is  bent  forward,  the  back  is  bowed,  and 
the  arms  are  held  away  from  the  body  and  are  somewhat  flexed  at  the  elbow- 
joints.  The  face  is  expressionless,  and  the  movements  of  the  lips  are  slow. 


PARALYSIS    AGITANS  1065 

The  eyebrows  are  elevated,  and  the  whole  expression  is  immobile  or  mask-like, 
the  so-called  Parkinson's  mask.  The  voice,  as  pointed  out  by  Buzzard,  is  apt 
to  be  shrill  and  piping,  and  there  is  often  a  hesitancy  in  beginning  a  sen- 
tence; then  the  words  are  tittered  with  rapidity,  as  if  thn  patient  was  in  a 
hurry.  This  is  sometimes  in  striking  contrast  to  the  scanning  speech  of 
insular  sclerosis.  The  fingers  are  flexed  and  in  the  position  assumed  when 
the  hand  is  at  rest ;  in  the  late  stages  they  can  not  be  extended.  Occasionally 
there  is  overextension  of  the  terminal  phalanges.  The  hand  is  usually  turned 
toward  the  ulnar  side  and  the  attitude  somewhat  resembles  that  of  advanced 
cases  of  rheumatoid  arthritis.  In  the  late  stages  there  are  contractures  at  the 
elbows,  knees,  and  ankles.  The  movements  of  the  patient  are  characterized 
by  great  deliberation.  He  rises  from  the  chair  slowly  in  the  stooping  atti- 
tude, with  the  head  projecting  forward.  In  attempting  to  walk  the  steps  are 
short  and  hurried,  and,  as  Trousseau  remarks,  he  appears  to  be  running  after 
his  centre  of  gravity.  This  is  termed  festination  or  propulsion,  in  contra- 
distinction to  a  peculiar  gait  observed  when  the  patient  is  pulled  backward, 
when  he  makes  a  number  of  steps  and  would  fall  over  if  not  prevented — retro- 
pulsion. 

The  EEFLEXES  are  normal  in  most  cases,  but  in  a  few  they  are  exaggerated. 

Of  SENSORY  disturbances  Charcot  has  noted  abnormal  alterations  in  the 
temperature  sense.  The  patient  may  complain  of  subjective  sensations  of  heat, 
either  general  or  local — a  phenomenon  which  may  be  present  on  one  side  only 
and  associated  with  an  actual  increase  of  the  surface  temperature,  as  much 
as  6°  F.  (Gowers).  In  other  instances,  patients  complain  of  cold.  Localized 
sweating  may  be  present.  The  skin,  especially  of  the  forehead,  may  be  thick- 
ened. The  mental  condition  rarely  shows  any  change. 

VARIATIONS  IN  THE  SYMPTOMS. — The  tremor  may  be  absent,  but  the  rigid- 
ity, weakness,  and  attitude  are  sufficient  to  make  the  diagnosis.  The  disease 
may  be  hemiplegic  in  character,  involving  only  one  side  or  even  one  limb. 
Usually  these  are  but  stages  of  the  disease. 

Diagnosis. — In  well  developed  cases  the  disease  is  recognized  at  a  glance. 
The  attitude,  gait,  stiffness,  and  mask-like  expression  are  points  of  as  much 
importance  as  the  oscillations,  and  usually  serve  to  separate  the  cases  from 
senile  and  other  forms  of  tremor.  Disseminated  sclerosis  develops  earlier,  and 
is  characterized  by  the  nystagmus,  and  the  scanning  speech,  and  does  not  pre- 
sent the  attitude  so  constant  in  paralysis  agitans.  Yet  Schultze  and  Sachs 
have  reported  cases  in  which  the  signs  of  multiple  sclerosis  have  been  asso- 
ciated with  those  of  paralysis.  The  hemiplegic  form  might  be  confounded 
with  post-hemiplegic  tremor,  but  the  history,  the  mode  of  onset,  and  the 
greatly  increased  reflexes  would  be  sufficient  to  distinguish  the  two.  The  Park- 
insonian  face  is  of  great  importance  in  the  diagnosis  of  the  obscure  and  anoma- 
lous forms. 

The  disease  is  incurable.  Periods  of  improvement  may  occur,  but  the 
tendency  is  for  the  affection  to  proceed  progressively  downward.  It  is  a  slow, 
degenerative  process  and  the  cases  last  for  years. 

Treatment.— There  is  no  method  which  can  be  recommended  as  satisfac- 
tory in  any  respect.  Arsenic,  opium,  hyoscine,  and  the  extract  of  the  para- 
thyroid gland  may  be  tried  and  sometimes  give  relief,  but  are  not  curative. 
The  friends  should  be  told  frankly  that  the  disease  is  incurable,  and  thai 
69 


1066  DISEASES    OF    THE    NEKVOUS    SYSTEM 

nothing  can  be  done  except  to  attend  to  the  physical  comforts  of  the  patient 
Regulated  and  systematized  exercises  should  be  carried  out. 

OTHER    FORMS    OF    TREMOR 

Simple  Tremor. — This  is  occasionally  found  in  persons  in  whom  it  is 
impossible  to  assign  any  cause.  It  may  be  transient  or  persist  for  an  indefi- 
nite time.  It  is  often  extremely  slight,  and  is  aggravated  by  all  causes  which 
lower  the  vitality. 

Hereditary  Tremor.  — C.  L.  Dana  has  reported  remarkable  cases  of  heredi- 
tary tremor.  It  occurred  in  all  the  members  of  one  family,  and  beginning 
in  infancy  continued  without  producing  any  serious  changes. 

Senile  Tremor. — With  advancing  age  tremulousness  during  muscular 
movements  is  extremely  common,  but  is  rarely  seen  under  seventy.  It  is 
always  a  fine  tremor,  which  begins  in  the  hands  and  often  extends  to  the 
muscles  of  the  neck,  causing  slight  movement  of  the  head. 

Toxic  tremor  is  seen  chiefly  as  an  effect  of  tobacco,  alcohol,  lead,  or 
mercury;  more  rarely  in  arsenical  or  opium  poisoning.  In  elderly  men  who 
smoke  much  it  may  be  entirely  due  to  the  tobacco.  One  of  the  commonest 
forms  of  this  is  the  alcoholic  tremor,  which  occurs  only  on  movement  and  has 
considerable  range.  Lead  tremor  is  considered  under  lead  poisoning,  of  which 
it  constitutes  a  very  important  symptom. 

Hysterical  tremor,  which  usually  occurs  under  circumstances  which  make 
the  diagnosis  easy,  will  be  considered  in  the  section  on  hysteria. 


II.  ACUTE  CHOREA 

(Sydenham's  Chorea;  St.  Vitus's  Dance) 

Definition. — A  disease  chiefly  affecting  children,  characterized  by  irregular, 
involuntary  contraction  of  the  muscles,  a  variable  amount  of  psychical  dis- 
turbance, and  a  remarkable  liability  to  acute  endocarditis. 

Etiology. — SEX. — Of  554  cases  which  I  analyzed  from  the  Philadelphia 
Infirmary  for  Diseases  of  the  Nervous  System,  71  per  cent,  were  in  females 
and  29  per  cent,  in  males.  Of  808  Johns  Hopkins  Hospital  cases,  71.2  per 
cent,  were  females  (Thayer  and  Thomas). 

AGE. — The  disease  is  most  common  between  the  ages  of  five  and  fifteen. 
Of  522  cases,  380  occurred  in  this  period;  84.5  per  cent,  in  Thayer  and 
Thomas'  series.  It  is  rare  among  the  negroes  and  native  races  of  America. 
Only  25  of  the  Johns  Hopkins  Hospital  cases  were  in  negroes.  The  cases  are 
most  numerous  when  the  mean  relative  humidity  is  excessive  and  the  baro- 
metric pressure  low  (Lewis). 

RHEUMATISM. — A  casual  relationship  between  rheumatism  and  chorea  has 
been  claimed  by  many  since  the  time  of  Bright.  The  English  and  French 
writers  maintain  the  closeness  of  this  connection;  on  the  other  hand,  German 
authors,  as  a  rule,  regard  the  connection  as  by  no  means  very  close.  Of  the 
554  cases,  in  15.5  per  cent,  there  was  a  history  of  rheumatism  in  the  family. 
In  88  cases,  15.8  per  cent.,  there  was  a  history  of  articular  swelling,  acute  or 


ACUTE    CHOREA  1067 

subacute.  In  33  cases  there  were  pains,  sometimes  described  as  rheumatic,  in 
various  parts,  but  not  associated  with  joint  trouble.  Adding  these  to  those 
with  manifest  articular  trouble,  the  percentage  is  raised  to  nearly  21.  It  is 
rather  remarkable  that  in  our  Baltimore  series  the  percentage  with  a  history 
of  rheumatism  was  the  same — 21.6. 

We  find  two  groups  of  cases  in  which  acute  arthritis  is  present  in  chorea. 
In  one,  the  arthritis  antedates  by  some  months  or  years  the  onset  of  the  chorea, 
and  does  not  recur  before  or  during  the  attack.  In  the  other  group,  the  chorea 
sets  in  with  or  follows  immediately  upon  the  acute  arthritis.  In  some  instances 
it  is  impossible  to  decide  whether  the  joint  symptoms  or  the  movements  have 
appeared  first.  It  is  difficult  to  differentiate  the  cases  of  irregular  pains  with- 
out definite  joint  affection.  It  is  probable  that  many  of  them  are  rheumatic, 
and  yet  I  think  it  would  be  a  mistake  to  regard  as  such  all  cases  in  children 
in  which  there  are  complaints  of  vague  pains  in  the  bones  or  muscles — so-called 
growing  pains.  It  should  never  be  forgotten,  however,  that  a  slight  articular 
swelling  may  be  the  sole  manifestation  of  rheumatic  fever  in  a  child — so  slight, 
indeed,  that  the  disease  may  be  entirely  overlooked. 

HEART-DISEASE. — Endocarditis  is  believed  by  some  writers  to  be  the  cause 
of  the  disease.  The  particles  of  fibrin  and  vegetations  from  the  valves  pass  as 
emboli  to  the  cerebral  vessels.  On  this  view,  which  we  shall  discuss  later, 
chorea  is  the  result  of  an  embolic  process  occurring  in  the  course  of  a  rheu- 
matic endocarditis. 

INFECTIOUS  DISEASES. — Scarlet  fever  with  arthritic  manifestations  may 
be  a  direct  antecedent.  Sturges  states  that  a  history  of  previous  whooping- 
cough  occurs  more  frequently  in  choreic  than  in  other  children,  but  I  find 
no  evidence  of  this  in  the  Infirmary  records.  With  the  exception  of  rheumatic 
fever,  there  is  no  intimate  relationship  between  chorea  and  the  acute  diseases 
incident  to  childhood.  It  may  be  noted  in  contrast  to  this  that  the  so-called 
canine  chorea  is.  a  common  sequel  of  distemper.  Chorea  has  been  known  to 
develop  in  the  course  of  an  acute  pyaemia,  and  to  follow  gonorrhoea  and  puer- 
peral fever. 

ANAEMIA  is  less  often  an  antecedent  than  a  sequence  of  chorea,  and  though 
cases  develop  in  children  who  are  anaemic  and  in  poor  health,  this  is  by  no 
means  the  rule.  Chorea  may  develop  in  chlorotic  girls  at  puberty. 

PREGNANCY. — A  choreic  patient  may  become  pregnant;  more  frequently 
the  disease  occurs  during  pregnancy;  sometimes  it  develops  post  partum. 
Buist,  of  Dundee,  has  tabulated  carefully  226  cases :  in  6  the  chorea  preceded 
the  pregnancy;  in  105  it  occurred  during  the  pregnancy;  in  31  in  recurrent 
pregnancies;  45  cases  terminated  fatally,  and  in  16  cases  the  chorea  developed 
post  partum.  The  alleged  frequency  in  illegitimate  primiparae  is  not  borne 
out  by  his  figures.  Beginning  in  the  first  three  months  were  108  cases,  in  the 
second  three  months  70  cases,  in  the  last  three  months  25  cases.  The  disease 
is  often  severe,  and  maniacal  symptoms  may  develop. 

A  tendency  to  the  disease  is  found  in  certain  families.  In  80  cases  there 
was  a  history  of  attacks  of  chorea  in  other  members.  In  one  instance  both 
mother  and  grandmother  had  been  affected.  High-strung,  excitable,  nervous 
children  are  especially  liable  to  the  disease.  Fright  is  considered  a  frequent 
cause,  but  in  a  large  majority  of  the  cases  no  close  connection  exists  between 
the  fright  and  the  onset  of  the  disease.  Occasionally  the  attack  sets  in  at 


1068  DISEASES    OF   THE   NERVOUS    SYSTEM 

once.  Mental  worry,  trouble,  a  sudden  grief,  or  a  scolding  may  apparently 
be  the  exciting  cause.  The  strain  of  education,  particularly  in  girls  during 
the  third  hemidecade,  is  a  most  important  factor  in  the  etiology  of  the  disease. 
Bright,  intelligent,  active  minded  girls  from  ten  to  fourteen,  ambitious  to  do 
well  at  school,  often  stimulated  in  their  efforts  by  teachers  and  parents,  form 
a  large  contingent  of  the  cases  of  chorea  in  hospital  and  private  practice. 
Sturges  has  called  special  attention  to  this  school-made  chorea  as  one  serious 
evil  in  our  modern  method  of  forced  education.  Imitation,  which  is  men- 
tioned as  an  exciting  cause,  is  extremely  rare,  and  does  not  appear  to  have 
influenced  the  onset  in  a  single  case  in  the  Infirmary  records. 

The  disease  may  rapidly  follow  an  injury  or  a  slight  •  surgical  operation. 
Reflex  irritation  was  believed  to  play  an  important  role  in  the  disease,  particu- 
larly the  presence  of  worms  or  genital  irritation;  but  I  have  met  with  no  in- 
stance in  which  the  disease  could  be  attributed  to  either  of  these  causes.  Local 
spasm,  particularly  of  the  face — the  habit  chorea  of  Mitchell — may  be  asso- 
ciated with  irritation  in  the  nostrils  and  adenoid  growths  in  the  vault  of  the 
pharynx,  as  pointed  out  by  Jacobi. 

It  has  been  claimed  by  Stevens  that  ocular  defects  lie  at  the  basis  of  many 
cases  of  chorea,  and  that  with  the  correction  of  these  the  irregular  movements 
disappear.  The  investigations  of  De  Schweinitz  show  that  ocular  defects  do 
not  occur  in  greater  proportion  in  choreic  than  in  other  children.  A  majority 
of  the  cases  in  which  operation  has  been  followed  by  relief  have  been  instances 
of  tic,  local  or  general. 

Morbid  Anatomy  and  Pathology. — No  constant  lesions  have  been  found 
in  the  nervous  system  in  acute  chorea.  Vascular  changes,  such  as  hyaline 
transformation,  exudation  of  leucocytes,  minute  haemorrhages,  and  thrombosis 
of  the  smaller  arteries,  have  been  described. 

Embolism  of  the  smaller  cerebral  vessels  has  been  found,  and  there  are 
on  record  7  cases  of  embolism  of  the  central  artery  of  the  retina  (H.  M. 
Thomas).  Based  on  the  presence  of  emboli,  Kirkes  and  others  have  supported 
what  is  known  as  the  embolic  theory  of  the  disease.  Endocarditis  is  by  far 
the  most  frequent  lesion  in  Sydenham's  chorea.  With  no  disease,  not  except- 
ing rheumatism,  is  it  so  constantly  associated.  I  collected  from  the  literature 
the  records  of  73  autopsies;  there  were  62  with  endocarditis.*  The  endo- 
carditis is  usually  of  the  simple  variety,  but  the  ulcerative  form  has  occasion- 
ally been  described. 

We  are  still  far  from  a  solution  of  all  the  problems  connected  with  chorea. 
Unfortunately,  the  word  has  been  used  to  cover  a  series  of  totally  diverse  dis- 
orders of  movement,  so  that  there  are  still  excellent  observers  who  hold  that 
chorea  is  only  a  symptom,  and  is  not  to  be  regarded  as  an  etiological  unit.  The 
chorea  of  childhood,  the  disease  which  Sydenham  described,  presents,  however, 
characteristics  so  unmistakable  that  it  must  be  regarded  as  a  definite,  substan- 
tive affection.  Some  regard  it  as  a  functional  brain  disorder  affecting  the 
nerve  centres  controlling  the  motor  apparatus,  an  instability  of  the  nerve  cells, 
brought  about,  one  supposes  by  hypersemia,  another  by  anasmia,  a  third  by 
psychical  influences,  a  fourth  by  irritation,  central  or  peripheral.  Of  the  actual 
nature  of  this  derangement  we  know  nothing,  nor,  indeed,  whether  the  changes 

*  Osier,  "Chorea  and  Choreif orm  Affections." 


ACUTE    CHOEEA  1069 

are  primary  and  the  result  of  a  faulty  action  of  the  cortical  cells  or  whether  the 
impulses  are  secondarily  disturbed  in  their  course  down  the  motor  path.  The 
predominance  of  the  disease  in  females,  and  its  onset  at  a  time  when  the  edu- 
cation of  the  brain  is  rapidly  developing,  are  etiological  facts  which  Sturges 
has  urged  in  favor  of  the  view  that  chorea  is  an  expression  of  functional  insta- 
bility of  the  nerve  centres. 

The  embolic  theory  originally  advanced  by  Kirkes  has  a  solid  basis  of 
fact,  but  it  is  not  comprehensive  enough,  as  all  of  the  cases  can  not  be 
brought  within  its  limits.  There  are  instances  without  endocarditis  and  with- 
out, so  far  as  can  be  ascertained,  plugging  of  cerebral  vessels;  and  there  are 
also  cases  with  extensive  endocarditis  in  which  the  histological  examination 
of  the  brain,  so  far  as  embolism  is  concerned,  was  negative.  In  favor  of 
the  embolic  view  is  the  experimental  production  in  animals  of  chorea  by 
Eosenthal,  and  later  by  Money,  by  injecting  fine  particles  into  the  carotids. 

Lately,  as  indeed  might  be  expected,  chorea  has  been  regarded  as  an  infec- 
tious disease.  Nothing  definite  has  yet  been  determined.  In  favor  of  this 
view  it  has  been  urged,  as  it  is  impossible  to  refer  the  chorea  to  endocarditis  or 
the  endocarditis  in  all  cases  to  rheumatism,  that  both  have  their  origin  in  a 
common  cause,  some  infectious  agent,  which  is  capable  also,  in  persons  predis- 
posed, of  exciting  articular  disease.  Cases  have  been  reported  in.  scarlet  fever 
with  arthritic  manifestations,  in  puerperal  fever,  and  rheumatism,  also  after 
gonorrhoea,  and  such  facts  are  suggestive  at  least  of  the  association  of  the 
disease  with  infective  processes.  Possibly,  as  has  been  suggested  by  some 
writers,  the  paralytic  condition  associated  with  chorea  may  be  analogous  to 
those  which  occur  in  typhoid  and  certain  of  the  infectious  diseases.  On  the 
other  hand,  there  are  conditions  extremely  difficult  to  harmonize  with  this 
view.  The  prominent  psychical  element  is  certainly  one  of  the  most  serious 
objections,  since  there  can  be  no  doubt  that  ordinary  chorea  may  rapidly  follow 
a  fright  or  a  sudden  emotion. 

Symptoms. — Three  groups  of  cases  may  be  recognized — the  mild,  severe, 
and  maniacal  chorea. 

Mild  Chorea. — In  this  the  affection  of  the  muscles  is  slight,  the  speech 
is  not  seriously  disturbed,  and  the  general  health  not  impaired.  Premoni- 
tory symptoms  are  shown  in  restlessness  and  inability  to  sit  still,  a  condition 
well  characterized  by  the  term  "fidgets."  There  are  emotional  disturbances, 
such  as  crying  spells,  or  sometimes  night  terrors.  There  may  be  pains  in  the 
limbs  and  headache.  Digestive  disturbances  and  anaemia  may  be  present.  A 
change  in  the  temperament  is  frequently  noticed,  and  a  docile,  quiet  child 
may  become  cross  and  irritable.  After  these  symptoms  have  persisted  for  a 
week  or  more  the  characteristic  involuntary  movements  begin,  and  are  often 
first  noticed  at  the  table,  when  the  child  spills  a  tumbler  of  water  or  upsets  a 
plate.  There  may  be  only  awkwardness  or  slight  incoordination  of  voluntary 
movements,  or  constant  irregular  clonic  spasms.  The  jerky,  irregular  char- 
acter of  the  movements  differentiates  them  from  almost  every  other  disorder 
of  motion.  In  the  mild  cases  only  one  hand,  or  the  hand  and  face,  are  affected, 
and  it  may  not  spread  to  the  other  side. 

In  the  second  grade,  the  severe  form,  the  movements  become  general  and 
the  patient  may  be  unable  to  get  about  or  to  feed  or  undress  herself,  owing 
to  the  constant,  irregular,  clonic  contractions  of  the  various  muscle  groups 


1070  DISEASES    OF    THE    NERVOUS    SYSTEM 

The  speech  is  also  affected,  and  for  days  the  child  may  not  be  able  to  talk. 
Often  with  the  onset  of  the  severer  symptoms  there  is  loss  of  power  on  one 
side  or  in  the  limb  most  affected. 

The  third  and  most  extreme  form,  the  so-called  maniacal  chorea,  or  chorea 
insaniens,  is  truly  a  terrible  disease,  and  may  develop  out  of  the  ordinary 
form.  These  cases  are  more  common  in  adult  women  and  may  develop  during 
pregnancy. 

Chorea  begins,  as  a  rule,  in  the  hands  and  arms,  then  involves  the  face,  and 
subsequently  the  legs.  The  movements  may  be  confined  to  one  side — hemi- 
chorea.  The  attack  begins  oftenest  on  the  right  side,  though  occasionally  it  is 
general  from  the  outset.  One  arm  and  the  opposite  leg  may  be  involved.  In 
nearly  one-fourth  of  the  cases  speech  is  affected ;  this  may  amount  only  to  an 
embarrassment  or  hesitancy,  but  in  other  instances  it  becomes  an  incoherent 
jumble.  In  very  severe  cases  the  child  will  make  no  attempt  to  speak.  The 
inability  is  in  articulation  rather  than  in  phonation.  Paroxysms  of  panting 
and  of  hard  expiration  may  occur,  or  odd  sounds  may  be  produced.  As  a  rule 
the  movements  cease  during  sleep. 

Paralysis. — A  prominent  symptom  is  muscular  weakness,  usually  no  more 
than  a  condition  of  paresis.  The  loss  of  power  is  slight,  but  the  weakness  may 
be  shown  by. an  enfeebled  grip  or  by  a  dragging  of  the  leg  or  limping.  In 
his  original  account  Sydenham  refers  to  the  "unsteady  movements  of  one  of 
the  legs,  which  the  patient  drags/'  There  may  be  extreme  paresis  with  but 
few  movements — the  paralytic  chorea  of  Todd.  Occasionally  a  local  paralysis 
or  weakness  remains  after  the  attack. 

Mutism  is.  an  interesting  feature;  for  weeks  the  child  may  not  say  a 
word.  It  is  more  common  in  severe  cases,  but  is  not  marked  by  special  choreic 
unrest  of  the  muscles  of  speech;  it  is  probably  a  motor  weakness.  Complete 
recovery  follows. 

It  is  doubtful  whether  choreic  spasms  extend  to  the  muscles  of  organic 
life.  The  rapid  action  and  disturbed  rhythm  of  the  heart  present  nothing 
peculiar  to  the  disease,  and  there  is  no  support  for  the  view  that  irregular  con- 
tractions occur  in  the  papillary  muscles. 

HEART  SYMPTOMS. — Neurotic. — As  so  many  of  the  subjects  of  chorea  are 
nervous  girls,  it  is  not  surprising  that  a  common  symptom  is  a  rapidly  acting 
heart.  Irregularity  is  not  so  special  a  feature  in  chorea  as  rapidity.  The 
patients  seldom  complain  of  pain  about  the  heart. 

Hcemic  Murmurs. — With  anaemia  and  debility,  not  uncommon  associates 
of  chorea  in  the  third  or  fourth  week,  we  find  a  corresponding  cardiac  condi- 
tion. The  impulse  is  diffuse,  perhaps  wavy  in  thin  children.  The  carotids 
throb  visibly,  and  in  the  recumbent  posture  there  may  be  pulsation  in  the  cer- 
vical veins.  On  auscultation  a  systolic  murmur  is  heard  at  the  base,  perhaps, 
too,  at  the  apex,  soft  and  blowing  in  quality. 

Endocarditis. — As  in  rheumatism,  so  in  chorea,  acute  valvulitis  rarely 
gives  evidence  of  its  presence  by  symptoms.  It  must  be  sought,  and  clinical 
experience  has  shown  that  it  is  usually  associated  with  murmurs  at  one  or 
other  of  the  cardiac  orifices. 

For  the  guidance  of  the  practitioner  these  statements  may  be  made : 

(a.)  In  thin,  nervous  children  a  systolic  murmur  of  soft  quality  is  ex- 
tremely common  at  the  base,  with  accentuation  of  the  second  sound,  par- 


ACUTE    CHOREA  1071 

ticularly  at  the  second  left  costal  cartilage,  and  is  probably  of  no  moment. 
(&)   A  systolic  murmur  of  maximum  intensity  at  the  apex,  and  heard 
also  along  the  left  sternal  margin,  is  not  uncommon  in  anaemic,  enfeebled 
states,  and  does  not  necessarily  indicate  either  endocarditis  or  insufficiency. 

(c)  A  murmur  of  maximum  intensity  at  the  apex,  with  rough  quality,  and 
transmitted  to  the  axilla  or  angle  of  the  scapula,  indicates  an  organic  lesion  of 
the  mitral  valve,  and  is  usually  associated  with  enlargement  of  the  heart. 

(d)  When  in  doubt  it  is  much  safer  to  trust  to  the  evidence  of  eye  and 
hand  than  to  that  of  the  ear.     If  the  apex  beat  is  in  the  normal  position, 
and  the  area  of  dulness  not  increased  vertically  or  to  the  right  of  the  sternum, 
there  is  probably  no  serious  valvular  disease. 

(e)  The  endocarditis  of  chorea  is  almost  invariably  of  the  simple  or 
warty  form,  and  in  itself  is  not  dangerous;  but  it  is  apt  to  lead  to  those 
sclerotic  changes  in  the  valve  which  produce  incompetency.     Of  140  patients 
examined  more  than  two  years  after  the  attack,  I  found  the  heart  normal  in 
51 ;  in  17  there  was  functional  disturbance,  and  72  presented  signs  of  organic 
heart-disease. 

(/)  Pericarditis  is  an  occasional  complication  of  chorea,  usually  in  cases 
with  well-marked  rheumatism. 

In  an  analysis  of  the  cases  at  the  Johns  Hopkins  Hospital,  Thayer  found 
evidence  of  involvement  of  the  heart  in  25  per  cent,  of  the  out-patients  and 
in  more  than  50  per  cent,  of  the  cases  in  the  wards.  Cardiac  involvement  was 
more  common  in  the  cases  with  a  history  of  rheumatism,  and  was  much  more 
frequent  in  the  relapses. 

SENSORY  DISTURBANCES. — Pain  in  the  affected  limbs  is  not  common. 
Occasionally  there  is  soreness  on  pressure.  There  are  cases,  usually  of  hemi- 
chorea,  in  which  pain  in  the  limbs  is  a  marked  symptom.  Weir  Mitchell  has 
spoken  of  these  as  painful  choreas.  Tender  points  along  the  lines  of  emergence 
of  the  spinal  nerves  or  along  the  course  of  the  nerves  of  the  limbs  are  rare. 

PSYCHICAL  DISTURBANCES  are  common,  though  in  a  majority  of  the  cases 
slight  in  degree.  Irritability  of  temper,  marked  wilfulness,  and  emotional 
outbreaks  may  indicate  a  complete  change  in  the  character  of  the  child.  There 
is  deficiency  in  the  powers  of  concentration,  the  memory  is  enfeebled,  and  the 
aptitude  for  study  is  lost.  Rarely  there  is  progressive  impairment  of  the 
intellect  with  termination  in  actual  dementia.  Acute  melancholia  has  been 
described.  Hallucinations  of  sight  and  hearing  may  occur.  Patients  may 
behave  in  an  odd  and  strange  manner  and  do  all  sorts  of  meaningless  acts. 
By  far  the  most  serious  manifestation  of  Ihis  character  is  the  maniacal  de- 
lirium, occasionally  associated  with  the  very  severe  cases — chorea  insaniens. 
Usually  the  motor  disturbance  in  these  cases  is  aggravated,  but  it  has  been 
overlooked  and  patients  have  been  sent  to  an  asylum. 

The  psychical  element  in  chorea  is  apt  to  be  neglected  by  the  practitioner. 
It  is  always  a  good  plan  to  tell  the  parents  that  it  is  not  the  muscles  alone 
of  the  child  which  are  affected,  but  that  the  general  irritability  and  change 
of  disposition,  so  often  found,  really  form  part  of  the  disease. 

The  condition  of  the  REFLEXES  in  chorea  is  usually  normal.  Trophic 
lesions  rarely  occur  in  chorea  unless,  as  some  writers  have  done,  we  regard 
the  joint  troubles  as  arthropathies  occurring  in  the  course  of  a  cerebro-spinal 
disease. 


1072  DISEASES    OF    THE    NERVOUS    SYSTEM 

FEVER,  usually  slight,  was  present  in  all  but  one  of  110  cases  treated  in 
my  wards  (Thayer).  H.  A.  Hare  states  that  in  monochorea  the  tempera- 
ture on  the  affected  side  may  be  elevated;  but  this  is  not  an  invariable  rule. 
Endocarditis  may  occur  with  little  if  any  rise  in  temperature;  but,  on  the 
other  hand,  with  an  acute  arthritis,  severe  endocarditis  or  pericarditis,  and  in 
the  cases  of  maniacal  chorea,  the  fever  may  range  from  102°  to  104°. 

CUTANEOUS  AFFECTIONS. — The  pigmentation,  which  is  not  uncommon,  is 
due  to  the  arsenic.  Herpes  zoster  occasionally  occurs.  Certain  skin  eruptions, 
usually  regarded  as  rheumatic  in  character,  are  not  uncommon.  Erythema 
nodosum  has  been  described  and  I  have  seen  several  cases  with  a  purpuric 
urticaria.  There  may,  indeed,  be  the  more  aggravated  condition  of  rheumatic 
purpura,  known  as  Schonlein's  peliosis  rlieumaiica.  Subcutaneous  fibrous 
nodules,  which  have  been  noted  by  English  observers  in  many  cases  of  chorea, 
associated  with  rheumatism,  are  extremely  rare  in  the  United  States. 

Duration  and  Termination. — From  eight  to  ten  weeks  is  the  average  dura- 
tion of  an  attack  of  moderate  severity.  Chronic  chorea  rarely  follows  the 
minor  disease  which  we  have  been  considering.  The  cases  described  under 
this  designation  in  children  are  usually  instances  of  cerebral  sclerosis  or  Fried- 
reich's  ataxia;  but  occasionally  an  attack  which  has  come  on  in  the  ordinary 
way  persists  for  months  or  years,  and  recovery  ultimately  takes  place.  A 
slight  grade  of  chorea,  particularly  noticeable  under  excitement,  may  persist 
for  months  in  nervous  children. 

The  tendency  of  chorea  to  recur  has  been  noticed  by  all  writers  since 
Sydenham  first  made  the  observation.  Of  410  cases  analyzed  for  this  purpose, 
240  had  one  attack,  110  had  two  attacks,  35  three  attacks,  10  four  attacks,  12 
five  attacks,  and  3  six  attacks.  The  recurrence  is  apt  to  be  vernal. 

Eecovery  is  the  rule  in  children.  The  statistics  of  out-patient  depart- 
ments are  not  favorable  for  determining  the  mortality.  A  reliable  estimate 
is  that  of  the  Collective  Investigation  Committee  of  the  British  Medical  Asso- 
ciation, in  which  9  deaths  were  reported  among  439  cases,  about  2  per  cent. 

The  paralysis  rarely  persists.  Mental  dulness  may  be  present  for  a  time, 
but  usually  passes  away ;  permanent  impairment  of  the  mind  is  an  exceptional 
sequence. 

Diagnosis. — There  are  few  diseases  which  present  more  characteristic  fea- 
tures, and  in  a  majority  of  instances  the  nature  of  the  trouble  is  recognized  at 
a  glance ;  but  there  are  several  affections  in  children  which  may  simulate  and 
be  mistaken  for  it. 

(a)  Multiple  and  diffuse  cerebral  sclerosis.  The  cases  are  often  mistaken 
for  ordinary  chorea,  and  have  been  described  in  the  literature  as  chorea 
spastica.  There  are  doubtless  chronic  changes  in  the  cortex.  As  a  rule,  the 
movements  are  readily  distinguishable  from  those  of  true  chorea,  but  the  simu- 
lation is  sometimes  very  close ;  the  onset  in  infancy,  the  impaired  intelligence, 
increased  reflexes  and  in  some  instances  rigidity^  and  the  chronic  course  of  the 
disease  separate  them  sharply  from  true  chorea. 

(ft)  Friedreich's  ataxia.  Cases  of  this  well-characterized  disease  were  for- 
merly classed  as  chorea.  The  slow,  irregular,  incoordinate  movements,  the 
scoliosis,  the  scanning  speech,  the  early  talipes,  the  nystagmus,  and  the  fam- 
ily character  of  the  disease  are  points  which  should  render  the  diagnosis  easy. 

(c)  In  rare  cases  the  paralytic  form  of  chorea  may  be  mistaken  for  polio- 


ACUTE    CHOREA  1073 

myelitis  or,  when  both  legs  are  affected,  for  paraplegia  of  spinal  origin;  but 
this  can  be  the  case  only  when  the  choreic  movements  are  very  slight. 

(d)  Hysteria  may  simulate  chorea  minor  most  closely,  and  unless  there 
are  other  manifestations  it  may  be  impossible  to  make  a  diagnosis.     Most 
commonly.,  however,   the  movements   in  the  so-called  hysterical  chorea   are 
rhythmic  and  differ  entirely  from  those  of  ordinary  chorea. 

(e)  As  mentioned  above,  the  mental  symptoms  in  maniacal  chorea  may 
mask  the  true  nature  of  the  disease  and  patients  have  even  been  sent  to  the 
asylum. 

Treatment. — Abnormally  bright,  active  minded  children  belonging  to  fam- 
ilies with  pronounced  neurotic  taint  should  be  carefully  watched  from  the  ages 
of  eight  to  fifteen  and  not  allowed  to  overtax  their  mental  powers.  So  fre- 
quently in  children  of  this  class  does  the  attack  of  chorea  date  from  the  worry 
and  stress  incident  to  school  examinations  that  the  competition  for  prizes  or 
places  should  be  emphatically  forbidden. 

The  treatment  of  the  attack  consists  largely  in  attention  to  hygienic  meas- 
ures, with  which  alone,  in  time,  a  majority  of  the  cases  recover.  Parents 
should  be  told  to  scan  gently  the  faults  and  waywardness  of  choreic  children. 
The  psychical  element,  strongly  developed  in  so  many  cases,  is  best  treated 
by  quiet  and  seclusion.  The  child  should  be  confined  to  bed  in  the  recumbent 
posture,  and  mental  as  well  as  bodily  quiet  enjoined.  In  private  practice  this 
is  often  impossible,  but  with  well-to-do  patients  the  disease  is  always  serious 
enough  to  demand  the  assistance  of  a  skilled  nurse.  Toys  and  dolls  should 
not  be  allowed  at  first,  for  the  child  should  be  kept  amused  without  excitement. 
The  rest  allays  the  hyper-excitability  and  reduces  to  a  minimum  the  possibility 
of  damage  to  the  valve  segments  should  endocarditis  exist.  Time  and  again 
have  I  seen  very  severe  cases  which  had  resisted  treatment  for  weeks  outside 
a  hospital  become  quite  and  the  movements  subside  after  two  or  three  days  of 
absolute  rest  in  bed. 

The  child  should  be  kept  apart  from  other  children  and,  if  possible,  from 
other  members  of  the  family,  and  should  see  only  those  persons  directly  con- 
cerned with  the  nursing  of  the  case.  In  the  latter  period  of  the  disease  daily 
rubbings  may  be  resorted  to  with  great  benefit. 

The  medical  treatment  of  the  disease  is  unsatisfactory ;  with  the  exception 
of  arsenic,  no  remedy  seems  to  have  any  influence  in  controlling  the  progress 
of  the  affection.  Without  any  specific  action,  it  certainly  does  good  in  many 
cases,  probably  by  improving  the  general  nutrition.  It  is  conveniently  given 
in  the  form  of  Fowler's  solution,  and  the  good  effects  are  rarely  seen  until 
maximum  doses  are  taken.  It  may  be  given  as  Martin  originally  advised 
(1813) ;  he  began  "with  five  drops  and  increased  one  drop  every  day,  until 
it  might  begin  to  disagree  with  the  stomach  or  bowels."  When  the  dose  of 
15  minims  is  reached,  it  may  be  continued  for  a  week,  and  then  again  in- 
creased, if  necessary,  every  day  or  two,  until  physiological  effects  are  manifest. 
On  the  occurrence  of  these  the  drug  should  be  stopped  for  three  or  four  days. 
The  practice  of  resuming  the  administration  with  smaller  doses  is  rarely  neces- 
sary, as  tolerance  is  usually  established  and  we  can  begin  with  the  dose  which 
the  child  was  taking  when  the  symptoms  of  saturation  occurred.  I  have  fre- 
quently given  as  much  as  25  minims  three  times  a  day.  Usually  the  signs  of 
saturation  are  trivial  but  plain,  but  in  very  rare  instances  more  serious  symp- 


1074 

toms  develop.  A  fatal  arsenical  neuritis  followed  in  the  case  of  a  child,  aged 
eight,  who  took  seven  drops  of  Fowler's  solution  three  times  a  day  for  ten 
days,  then  stopped  for  a  week,  and  then  took  seven  drops  three  times  a  day  for 
fourteen  days  (Gary  Gamble). 

Of  other  medicines  sedatives  are  useful  in  the  severe  attacks.  Chloral  is 
the  most  useful  and  may  be  begun  in  doses  of  five  grains  (0.3  gm.),  gradually 
increased  if  necessary.  Sodium  bromide  in  the  same  dosage  may  be  added. 
Belladonna  has  been  found  useful  in  some  cases. 

For  its  tonic  effect  electricity  is  sometimes  useful;  but  it  is  not  necessary 
as  a  routine  treatment.  The  question  of  gymnastics  is  an  important  one. 
Early  in  the  disease,  when  the  movements  are  active,  they  are  not  advisable; 
but  during  convalescence  carefully  graduated  exercises  are  undoubtedly  bene- 
ficial. It  is  not  well,  however,  to  send  a  choreic  child  to  a  school  gymnasium, 
as  the  stimulus  of  the  other  children  and  the  excitement  of  the  romping, 
violent  play  are  very  prejudicial. 

Other  points  in  treatment  may  be  mentioned.  Food  should  be  simple 
and  some  children  do  best  on  a  milk  diet,  the  amount  being  rapidly  increased. 
It  is  important  to  regulate  the  bowels  and  to  attend  carefully  to  the  digestive 
functions.  For  the  anaemia  so  often  present  preparations  of  iron  are  indicated. 

In  the  severe  cases  with  incessant  movements,  sleeplessness,  dry  tongue, 
and  delirium,  the  important  indication  is  to  procure  rest,  for  which  purpose 
chloral  may  be  freely  given,  and,  if  necessary,  morphia.  Chloroform  inhala- 
tions may  be  necessary  to  control  the  intensity  of  the  paroxysms,  but  the  high 
rate  of  mortality  in  this  class  of  cases  illustrates  how  often  our  best  endeavors 
are  fruitless.  The  wet  pack  is  sometimes  very  soothing  and  should  be  tried. 
As  these  patients  are  apt  to  sink  rapidly  into  a  low  typhoid  state  with  heart 
weakness,  a  supporting  treatment  is  required  from  the  outset. 

Cases  are  found  now  and  then  which  drag  on  from  month  to  month 
without  getting  either  better  or  worse  and  resist  all  modes  of  treatment. 
In  such  cases  a  combination  of  suggestion  and  passive  movements,  followed 
by  voluntary  movements  under  control,  and  later  simple  exercises,  may  be 
useful.  Change  of  air  and  scene  is  sometimes  followed  by  rapid  improvement, 
and  in  these  cases  the  treatment  by  rest  and  seclusion  should  always  be  given 
a  full  trial. 

In  all  cases  care  should  be  taken  to  examine  the  nostrils,  and  glaring  ocular 
defects  should  be  properly  corrected  either  by  glasses  or,  if  necessary,  by 
operation. 

After  the  child  has  recovered  from  the  attack,  the  parents  should  be  warned 
that  return  of  the  disease  is  by  no  means  infrequent,  and  is  particularly  liable 
to  follow  overwork  at  school  or  debilitating  influences  of  any  kind.  These 
relapses  are  apt  to  occur  in  the  spring.  Sydenham  advised  purging  in  order 
to  prevent  the  vernal  recurrence  of  the  disease. 


III.     OTHER  AFFECTIONS  DESCRIBED   AS   CHOREA 

Chorea  Major:  Pandemic  Chorea. — The  common  name,  St.  Vitus's  dance, 
applied  to  chorea  has  come  to  us  from  the  middle  ages,  when  under  the  influ- 
ence of  religious  fervor  there  were  epidemics  characterized  by  great  excitement, 


OTHER    AFFECTIONS    DESCRIBED   AS    CHOREA         1075 

gesticulations,  and  dancing.  For  the  relief  of  these  symptoms,  when  exces- 
sive, pilgrimages  were  made,  and,  in  the  Rhenish  provinces,  particularly  to 
the  Chapel  of  St.  Vitus  in  Zebern.  Epidemics  of  this  sort  occurred  also  during 
the  nineteenth  century,  and  descriptions  of  them  among  the  early  settlers  in 
Kentucky  have  been  given  by  Robertson  and  Yandell.  It  was  unfortunate 
that  Sydenham  applied  the  term  chorea  to  an  affection  in  children  totally 
distinct  from  this  chorea  major,  which  is  in  reality  an  hysterical  manifesta- 
tion under  the  influence  of  religious  excitement. 

Habit  Spasm  (Habit  Chorea);  Convulsive  Tic  (of  the  French). — Two 
groups  of  cases  may  be  recognized  under  the  designation  of  habit  spasm — 
one  in  which  there  are  simply  localized  spasmodic  movements,  and  the  other 
in  which,  in  addition  to  this,  there  are  explosive  utterances  and  psychical 
symptoms,  a  condition  to  which  French  writers  have  given  the  name  tic 
convuhif. 

(a)  HABIT  SPASM. — This  is  found  chiefly  in  childhood,  most  frequently  in 
girls  from  seven  to  fourteen  years  of  age  (Mitchell).  In  its  simplest  form 
there  is  a  sudden,  quick  contraction  of  certain  of  the  facial  muscles,  such  as 
rapid  winking  or  drawing  of  the  mouth  to  one  side,  or  the  neck  muscles  are 
involved  and  there  are  unilateral  movements  of  the  head.  The  head  is  given 
a  sudden,  quick  shake,  and  at  the  same  time  the  eyes  wink.  A  not  infrequent 
form  is  the  shrugging  of  one  shoulder.  The  grimace  or  movement  is  repeated 
at  irregular  intervals,  and  is  much  aggravated  by  emotion.  A  short  inspira- 
tory  sniff  is  not  an  uncommon  symptom.  The  cases  are  found  most  frequently 
in  children  who  are  "out  of  sorts,"  or  who  have  been  growing  rapidly,  or  who 
have  inherited  a  tendency  to  neurotic  disorders.  Allied  to  or  associated  with 
this  are  some  of  the  curious  tricks  of  children.  A  boy  at  my  clinic  was  in  the 
habit  every  few  moments  of  putting  the  middle  finger  into  the  mouth,  biting 
it,  and  at  the  same  time  pressing  his  nose  with  the  forefinger.  Hartley  Cole- 
ridge is  said  to  have  had  a  somewhat  similar  trick,  only  he  bit  his  arm.  In 
all  these  cases  the  habits  of  the  child  should  be  examined  carefully,  the  nose 
and  vault  of  the  pharynx  thoroughly  inspected,  and  the  eyes  accurately  tested. 
As  a  rule  the  condition  is  transient,  and  after  persisting  for  a  few  months 
or  longer  gradually  disappears.  Occasionally  a  local  spasm  persists — twitching 
of  the  eyelids,  or  the  facial  grimace. 

(6)  IMPULSIVE  Tic  (GILLES  DE  LA  TOURETTE'S  DISEASE). — This  remark- 
able affection,  often  mistaken  for  chorea,  more  frequently  for  habit  spasm,  is 
really  a  psychosis  allied  to  hysteria,  though  in  certain  of  its  aspects  it  has 
the  features  of  monomania.  The  disease  begins,  as  a  rule,  in  young  children, 
occurring  as  early  as  the  sixth  year,  though  it  may  develop  after  puberty. 
There  is  usually  a  markedly  neurotic  family  history.  The  special  features  of 
the  complaint  are : 

(1)  Involuntary  muscular  movements,   usually   affecting  the   facial   or 
brachial  muscles,  but  in  aggravated  cases  all  the  muscles  of  the  body  may 
be  involved  and  the  movements  may  be  extremely  irregular  and  violent. 

(2)  Explosive  utterances,  which  may  resemble  a  bark  or  an  inarticulate 
cry.     A  word  heard  may  be  mimicked  at  once  and  repeated  over  and  over 
again,  usually  with  the  involuntary  movements.     To  this  the  term  echolalia 
has  been  applied.     A  much  more  distressing  disturbance  in  these  cases  is 
coprolalia,  or  the  use  of  bad  language.      A  child  of  eight  or  ten  may  shock  its 


1076  DISEASES    OF   THE    NERVOUS    SYSTEM 

mother  and  friends  by  constantly  using  the  word  damn  when  making  the 
involuntary  movements,  or  by  uttering  all  sorts  of  obscene  words.  Occasion- 
ally actions  are  mimicked — echoJcinesis. 

(3)  Associated  with  some  of  these  cases  are  curious  mental  disturbances; 
the  patient  becomes  the  subject  of  a  form  of  obsession  or  a  fixed  idea.  In 
other  cases  the  fixed  idea  takes  the  form  of  the  impulse  to  touch  objects,  or 
it  is  a  fixed  idea  about  words — onomatomania — or  the  patient  may  feel 
compelled  to  count  a  number  of  times  before  doing  certain  actions — arithmo- 
mania. 

The  disease  is  well  marked  and  readily  distinguished  from  ordinary  chorea. 
The  movements  have  a  larger  range  and  are  explosive  in  character.  Tourette 
regards  the  coprolalia  as  the  most  distinctive  feature  of  the  disease.  The 
prognosis  is  doubtful.  I  have,  however,  known  recovery  to  follow. 

Saltatory  Spasm  (Latah;  Myriachit;  Jumpers). — Bamberger  has  described 
a  disease  in  which  when  the  patient  attempted  to  stand  there  were  strong 
contractions  in  the  leg  muscles,  which  caused  a  jumping  or  springing  motion. 
This  occurs  only  when  the  patient  attempts  to  stand.  The  affection  has 
occurred  in  both  men  and  women,  more  frequently  in  the  former,  and  the 
subjects  have  usually  shown  marked  neurotic  tendencies.  In  many  cases 
the  condition  has  been  transitory;  in  others  it  has  persisted  for  years.  Be- 
markable  affections  similar  to  this  in  certain  points  occur  as  a  sort  of  epi- 
demic neurosis.  One  of  the  most  striking  of  these  occurs  among  the  "jump- 
ing Frenchmen"  of  Maine  and  Canada.  As  described  by  Beard  and  Thorn- 
ton, the  subjects  are  liable  on  any  sudden  emotion  to  jump  violently  and  utter 
a  loud  cry  or  sound,  and  will  obey  any  command  or  imitate  any  action  without 
regard  to  its  nature.  The  condition  of  echolalia  is  present  in  a  marked  degree. 
The  "jumping"  prevails  in  certain  families. 

A  very  similar  disease  prevails  in  parts  of  Eussia  and  in  Java  and  Borneo, 
where  it  'is  known  by  the  names  of  myriachit  and  latah,  the  chief  feature  of 
which  is  mimicry  by  the  patient  of  everything  he  sees  or  hears. 

Chronic  Chorea  (Huntington's  Chorea}. — This  is  an  affection  character- 
ized by  irregular  movements,  disturbance  of  speech,  and  gradual  dementia.  It 
is  frequently  hereditary.  Irving  W.  Lyon  described  it  in  1863  as  chronic 
hereditary  chorea  and  traced  the  disease  through  five  generations.  Hunting- 
ton,  of  Pomeroy,  Ohio,  at  the  time  .a  practitioner  on  Long  Island,  gave,  in 
1872,  in  three  brief  paragraphs  the  salient  points  in  connection  with  the  dis- 
ease— namely,  the  hereditary  nature,  the  association  with  psychical  troubles, 
and  the  late  onset — between  the  thirtieth  and  fortieth  years.  The  disease  is 
not  uncommon  in  the  United  States.  Under  the  term  chronic  chorea  may  be 
grouped  the  hereditary  form  and  the  cases  which  come  on  without  family  dis- 
position, either  at  middle  life  or,  more  commonly,  in  the  aged — senile  chorea. 
It  is  doubtful  whether  the  cases  in  children  with  chronic  choreiform  move- 
ments, often  with  mental  weakness  and  spastic  condition  of  the  legs,  should 
go  into  this  category. 

The  hereditary  character  of  the  disease  is  very  striking ;  it  has  been  traced 
through  four  or  five  generations.  Huntington's  father  and  grandfather,  also 
physicians,  had  treated  the  disease  in  the  family  which  he  described.  Osborn, 
of  East  Hampton,  tells  me  that  the  disease  still  continues  to  recur  in  certain 
families  described  by  Huntington,  as  it  has  done,  so  it  is  said,  for  fully  two 


INFANTILE    CONVULSIONS  1077 

centuries.  An  identical  affection  occurs  without  any  hereditary  disposition. 
The  age  of  onset  is  late,  rarely  before  the  thirtieth  or  the  thirty-fifth  year. 

The  symptoms  are  very  characteristic.  The  irregular  movements  are  usu- 
ally first  seen  in  the  hands,  and  the  patient  has  slight  difficulty  in  performing 
delicate  manipulations  or  in  writing.  When  well  established  the  movements 
are  disorderly,  irregular,  incoordinate  rather  than  choreic,  and  have  not  the 
sharp,  brusque  motion  of  Sydenham's  chorea.  In  the  face  there  are  slow, 
involuntary  grimaces.  In  a  well-developed  case  the  gait  is  irregular,  swaying, 
and  somewhat  like  that  of  a  drunken  man.  The  speech  is  slow  and  difficult 
the  syllables  are  badly  pronounced  and  indistinct,  but  not  definitely  staccato. 
The  mental  impairment  leads  finally  to  dementia.  The  anatomical  condition 
is  a  chronic  diffuse  cortical  encephalitis  not  unlike  that  in  general  paralysis. 

Rhythmic  or  Hysterical  Chorea. — This  is  readily  recognized  by  the  rhyth- 
mical character  of  the  movements.  It  may  affect  the  muscles  of  the  abdomen, 
producing  the  salaam  convulsion,  or  involve  the  sterno-mastoid,  producing  a 
rhythmical  movement  of  the  head,  or  the  psoas,  or  any  group  of  muscles.  In 
its  orderly  rhythm  it  resembles  the  canine  chorea. 


IV.    INFANTILE  CONVULSIONS 

(Eclampsia) 

Convulsive  seizures  similar  to  those  of  epilepsy  are  not  infrequent  in  chil- 
dren and  in  adults.  The  fit  may  indeed  be  identical  with  epilepsy,  from  which 
the  condition  differs  in  that  when  the  cause  is  removed  there  is  no  tendency 
for  the  fits  to  recur.  Occasionally,  however,  the  convulsions  in  children  con- 
tinue and  develop  into  true  epilepsy. 

Etiology. — A  convulsion  in  a  child  may  be  due  to  many  causes,  all  of  which 
lead  to  an  unstable  condition  of  the  nerve  centres,  permitting  sudden,  exces- 
sive, and  temporary  nervous  discharges.  The  following  are  the  most  impor- 
tant of  them: 

(1)  Debility,  resulting  usually  from  gastro-intestinal  disturbance.     Con- 
vulsions frequently  supervene  toward  the  close  of  an  attack  of  entero-colitis 
and  recur,  sometimes  proving  fatal.    The  death-rate  in  children  from  eclamp- 
sia rises  steadily  with  that  of  gastro-intestinal  disorders  (Morris  J.  Lewis). 

(2)  Peripheral  Irritation. — Dentition  alone  is  rarely  a  cause  of  convul- 
sions, but  is  often  one  of  several  factors  in  a  feeble,  unhealthy  infant.    The 
greatest  mortality  from  convulsions  is  during  the  first  six  months,  before  the 
teeth  have  really  cut  through  the  gums.    Other  irritative  causes  are  the  over- 
loading of  the  stomach  with  indigestible  food.     It  has  been  suggested  that 
some  of  these  cases  are  toxic,  owing  to  the  absorption  of  poisonous  ptomaines. 
Worms,  to  which  convulsions  are  so  frequently  attributed,  probably  have  little 
influence.    Among  other  sources  possible  are  phimosis  and  otitis. 

(3)  iticTcets.— The  observation  of  Sir  William  Jenner  upon  the  associa- 
tion of  rickets  and  convulsions  has  been  amply  confirmed.     The  spasms  may 
be  laryngeal,  the  so-called  child-crowing,  which,  though  convulsive  in  nature, 
can  scarcely  be  reckoned  under  eclampsia.    The  influence  of  this  condition  is 
more  apparent  in  Europe  than  in  the  United  States,  although  rickets  is  a  com- 


1078  DISEASES    OF    THE    NERVOUS    SYSTEM 

mon  disease,  particularly  among  the  colored  people.  Spasms,  local  or  gen- 
eral, in  rickets  are  probably  associated  with  the  condition  of  debility  and  mal- 
nutrition and  with  cranio-tabes. 

(4)  Fever. — In  young  children  the  onset  of  the  infectious  diseases  is  fre- 
quently with  convulsions,  which  often  take  the  place  of  a  chill  in  the  adult. 
It  is  not  known  upon  what  they  depend.     Scarlet  fever,  measles,  and  pneu- 
monia are  most  often  preceded  by  convulsions. 

(5)  Congestion  of  the  Brain. — That  extreme  engorgement  of  the  blood- 
vessels may  produce  convulsions  is  shown  by  their  occasional  occurrence  in 
severe  whooping-cough,  but  their  rarity  in  this  disease  really  indicates  how 
small  a  part  mechanical  congestion  plays  in  the  production  of  fits. 

(6)  Severe  convulsions  usher  in  or  accompany  many  of  the  serious  dis- 
eases of  the  nervous  system  in  children.     In  more  than  50  per  cent,  of  the 
cases  of  infantile  hemiplegia  the  affection  follows  severe  convulsions.     They 
less  frequently  precede  a  spinal  paralysis.     They  occur  with  meningitis,  tuber- 
culous or  simple,  and  with  tumors  and  other  lesions  of  the  brain. 

And,  lastly,  convulsions  may  occur  immediately  after  birth  and  persist 
for  weeks  or  months.  In  such  instances  there  has  probably  been  meningeal 
hemorrhage  or  serious  injury  to  the  cortex. 

The  most  important  question  is  the  relation  of  convulsions  in  children 
to  true  epilepsy.  In  Gowers'  figures  of  1,450  cases  of  epilepsy,  the  attacks 
began  in  180  during  the  first  three  years  of  life.  Of  460  cases  of  epilepsy 
in  children  which  I  have  analyzed,  in  187  the  fits  began  within  the  first  three 
years.  Of  the  total  list  the  greatest  number,  74,  was  in  the  first  year.  In 
nearly  all  these  instances  there  was  no  interruption  in  the  convulsions.  That 
convulsions  in  early  infancy  are  necessarily  followed  by  epilepsy  in  after  life 
is  certainly  a  mistake. 

Symptoms. — The  attack  may  come  on  suddenly  without  any  warning;  more 
commonly  it  is  preceded  by  a  stage  of  restlessness,  accompanied  by  twitching 
and  perhaps  grinding  of  the  teeth.  It  is  rarely  so  complete  in  its  stages  as 
true  epilepsy.  The  spasm  begins  usually  in  the  hands,  most  commonly  in  the 
right  hand.  The  eyes  are  fixed  and  staring  or  are  rolled  up.  The  body 
becomes  stiff  and  breathing  is  suspended  for  a  moment  or  two  by  tonic  spasm 
of  the  respiratory  muscles,  in  consequence  of  which  the  face  becomes  con- 
gested. Clonic  convulsions  follow,  the  eyes  are  rolled  about,  the  hands  and 
arms  twitch,  or  are  fixed  and  extended  in  rhythmical  movements,  the  face 
is  contorted,  and  the  head  is  retracted.  The  attack  gradually  subsides  and 
the  child  sleeps  or  passes  into  a  state  of  stupor.  Following  indigestion  the 
attack  may  be  single,  but  in  rickets  and  intestinal  disorders  it  is  apt  to  be 
repeated.  Sometimes  the  attacks  follow  each  other  with  great  rapidity,  so  that 
the  child  never  rouses  but  dies  in  a  deep  coma.  If  the  convulsion  has  been 
limited  chiefly  to  one  side  there  may  be  slight  paresis  after  recovery,  or  in 
instances  in  which  the  convulsions  usher  in  infantile  hemiplegia,  when  the 
child  arouses,  one  side  is  completely  paralyzed.  During  the  fit  the  tempera- 
ture is  often  raised.  Death  rarely  occurs  from  the  convulsion  itself,  except 
in  debilitated  children  or  when  the  attacks  recur  with  great  frequency.  In  the 
so-called  hydrocephaloid  state  in  connection  with  protracted  diarrhoea  con- 
vulsions may  close  the  scene. 

Diagnosis.- — Coming  on  when  the  subject  is  in  full  health,  the  attack  is 


EPILEPSY  1079 

probably  due  either  to  an  overloaded  stomach,  to  some  peripheral  irritation,  or 
occasionally  to  trauma.  Setting  in  with  high  fever  and  vomiting,  it  may 
indicate  the  onset  of  an  exanthem,  or  occasionally  be  the  primary  symptom  of 
encephalitis,  or  whatever  the  condition  is  which  causes  infantile  hemiplegia. 
When  the  attack  is  associated  with  debility  and  with  rickets  the  diagnosis  is 
easily  made.  The  carpopedal  spasms  and  pseudo-paralytic  rigidity  which  are 
often  associated  with  rickets,  laryngismus  stridulus,  and  the  hydrocephalbid 
state  are  usually  confined  to  the  hands  and  arms  and  are  intermittent  and 
usually  tonic.  The  convulsions  associated  with  tumor  or  those  which  follow 
infantile  hemiplegia  are  usually  at  first  Jacksonian  in  character.  After  the 
second  year  convulsive  seizures  which  come  on  irregularly  without  apparent 
cause  and  recur  while  the  child  is  apparently  in  good  health,  are  likely  to 
prove  true  epilepsy. 

Prognosis. — Convulsions  play  an  important  part  in  infantile  mortality. 
In  Morris  J.  Lewis's  table  of  deaths  in  children  under  ten,  8.5  per  cent,  were 
ascribed  to  convulsions.  In  chronic  diarrhoea  convulsions  are  usually  of  ill 
omen.  Those  ushering  in  fevers  are  rarely  serious,  and  the  same  may  be  said 
of  the  fits  associated  with  indigestion  and  peripheral  irritation. 

Treatment. — Every  source  of  irritation  should  be  removed.  If  associated 
with  indigestible  food,  a  prompt  emetic  should  be  given,  followed  by  an  enema. 
The  teeth  should  be  examined,  and  if  the  gum  is  swollen,  hot,  and  tense,  it 
may  be  lanced ;  but  never  if  it  looks  normal.  When  seen  at  first,  if  the  parox- 
ysm is  severe,  no  time  should  be  lost  by  giving  a  hot  bath,  but  chloroform 
should  be  given  at  once,  and  repeated  if  necessary.  A  child  is  so  readily  put 
under  chloroform  and  with  such  a  small  quantity  that  this  procedure  is  quite 
harmless  and  saves  much  valuable  time.  The  practice  is  almost  universal  of 
putting  the  child  into  a  warm  bath,  and  if  there  is  a  fever  the  head  may  be 
douched  with  cold  water.  The  temperature  of  the  bath  should  not  be  above 
95°  or  96°.  The  very  hot  bath  is  not  suitable,  particularly  if  the  fits  are  due 
to  indigestion.  After  the  attack  an  ice-cap  may  be  placed  upon  the  head.  If 
there  is  much  irritability,  particularly  in  rickets  and  in  severe  diarrhoea,  small 
doses  of  opium  will  be  found  efficacious.  When  the  convulsions  recur  after 
the  child  comes  from  under  the  influence  of  chloroform  it  is  best  to  place  it 
rapidly  under  the  influence  of  opium,  which  may  be  given  as  morphia  hypo- 
dermically,  in  doses  of  from  one-twenty-fifth  to  one-thirtieth  of  a  grain 
(0.0026  to  0.0022  gm.)  for  a  child  of  one  year.  Other  remedies  recommended 
are  chloral  by  enema,  in  5  grain  (0.3  gm.)  doses,  and  nitrite  of  amyl.  After 
the  attack  has  passed  the  bromides  are  useful,  of  which  5  to  8  grains  (0.3  to 
0.5  gm.)  may  be  given  in  a  day  to  a  child  a  year  old.  Recurring  convulsions, 
particularly  if  they  come  on  without  special  cause,  should  receive  the  most 
thorough  and  careful  treatment  with  bromides.  When  associated  with  rickets 
the  treatment  should  be  directed  to  improving  the  general  condition. 


V.    EPILEPSY 

Definition. — An  affection  of  the  nervous  system  characterized  by  attacks 
of  unconsciousness,  with  or  without  convulsions. 

The  transient  loss  of  consciousness  without  convulsive  seizures  is  known 


1080  DISEASES    OF    THE    NERVOUS    SYSTEM 

as  petit  mal;  the  loss  of  consciousness  with  general  convulsive  seizures  is  known 
as  grand  mal.  Localized  convulsions,  occurring  usually  without  loss  of  con- 
sciousness, are  known  as  epileptiform,  or  more  frequently  as  Jacksonian  or 
cortical  epilepsy. 

Etiology. — AGE. — In  a  large  proportion  of  all  cases  the  disease  begins  be- 
fore puberty.  Of  the  1,450  cases  observed  by  Gowers,  in  422  the  disease  began 
before  the  tenth  year,  and  three-fourths  of  the  cases  began  before  the  twen- 
tieth year.  Of  460  cases  of  epilepsy  in  children  which  I  have  analyzed  the 
age  of  onset  in  427  was  as  follows:  First  year,  74;  second  year,  62;  third 
year,  51;  fourth  year,  24;  fifth  year,  17;  sixth  year,  18;  seventh  year,  19; 
eighth  year,  23;  ninth  year,  17;  tenth  year,  27;  eleventh  year,  17;  twelfth  year, 
18;  thirteenth  year,  15;  fourteenth  year,  21;  fifteenth  year,  34.  Arranged 
in  hemidecades  the  figures  are  as  follows:  From  the  first  to  the  fifth  year, 
229;  from  the  fifth  to  the  tenth  year,  104;  from  the  tenth  to  the  fifteenth  year, 
95.  These  figures  illustrate  in  a  striking  manner  the  early  onset  of  the  disease 
in  a  large  proportion  of  the  cases.  It  is  well  always  to  be  suspicious  of  epilepsy 
beginning  in  adult  life,  for  in  a  majority  of  such  cases  the  convulsions  are 
due  to  a  local  lesion. 

SEX. — No  special  influence  appears  to  be  discoverable  in  this  relation, 
certainly  not  in  children.  Of  433  cases  in  my  tables,  232  were  males  and 
203  were  females,  showing  a  slight  predominance  of  the  male  sex.  After 
puberty  unquestionably,  if  a  large  number  of  cases  are  taken,  the  males  are 
in  excess. 

HEREDITY. — Much  stress  has  been  laid  upon  this  by  many  authors  as  an 
important  predisposing  cause,  and  the  statistics  collected  give  from  9  to  over 
40  per  cent.  Gowers  gives  35  per  cent,  for  his  cases,  which  have  special  value 
apart  from  other  statistics  embracing  large  numbers  of  epileptics  in  that  they 
were  collected  by  him  in  his  own  practice.  In  other  figures  it  appears  to  play 
a  minor  role.  In  my  list  there  were  only  31  cases  in  which  there  was  a 
history  of  marked  neurotic  taint,  and  only  3  in  which  the  mother  herself  had 
been  epileptic.  In  the  Elwyn  cases,  as  might  be  expected,  the  percentage 
is  larger.  Of  the  126  there  was  in  32  a  family  history  of  nervous  derange- 
ment of  some  sort,  either  paralysis,  epilepsy,  marked  hysteria,  or  insanity. 
Spratling  found  16  per  cent,  among  2,523  cases. 

While,  then,  it  may  be  said  that  direct  inheritance  is  comparatively  un- 
common, yet  the  children  of  neurotic  families  in  which  neuralgia,  insanity, 
and  hysteria  prevail  are  more  liable  to  fall  victims  to  the  disease. 

Chronic  alcoholism  in  the  parents  is  regarded  by  many  as  a  potent  pre- 
disposing factor  in  the  production  of  epilepsy.  Echeverria  has  analyzed  572 
cases  bearing  upon  this  point  and  divided  them  into  three  classes,  of  which 
257  cases  could  be  traced  directly  to  alcohol  as  a  cause;  126  cases  in  which 
there  were  associated  conditions,  such  as  syphilis  and  traumatism;  189  cases 
in  which  the  alcoholism  was  probably  the  result  of  the  epilepsy.  Figures 
equally  strong  are  given  by  Martin,  who  in  150  insane  epileptics  found  83 
with  a  marked  history  of  parental  intemperance.  Spratling  found  15  per  cent, 
with  marked  alcoholic  history  in  the  parents. 

Syphilis. — This  in  the  parents  is  probably  less  a  predisposing  than  an 
actual  cause  of  epilepsy,  which  is  the  direct  outcome  of  local  cerebral  mani- 
festations. There  is  no  reason  for  recognizing  a  special  form  of  syphilitic 


EPILEPSY  1081 

epilepsy.  On  the  other  hand,  convulsive  seizures  due  to  acquired  syphilitic 
disease  of  the  brain  are  very  common. 

Alcohol. — Severe  epileptic  convulsions  may  occur  in  steady  drinkers. 

Of  exciting  causes  fright  is  believed  to  be  important,  but  is  less  so,  1 
think,  than  is  usually  stated.  Trauma  is  present  in  a  certain  number  of 
instances.  An  important  group  depends  upon  a  local  disease  of  the  brain 
existing  from  childhood,  as  seen  in  the  post-hemiplegic  epilepsy.  Occasion- 
ally cases  follow  the  infectious  fevers.  Masturbation  has  been  stated  to  be  a 
special  cause,  but  its  influence  is  probably  overrated.  A  large  group  of  con- 
vulsive seizures  allied  to  epilepsy  are  due  to  some  toxic  agent,  as  in  lead  poi- 
soning and  in  urasmia. 

REFLEX  CAUSES. — Eye  strain,  dentition,  and  worms,  the  irritation  of  a 
cicatrix,  some  local  affection,  such  as  adherent  prepuce,  or  a  foreign  body  in 
the  ear  or  the  nose,  are  given  as  causes.  In  some  of  these  cases  the  fits  cease 
after  the  removal  of  the  cause,  so  that  there  can  be  no  question  of  the  associa- 
tion between  the  two.  In  others  the  attacks  persist.  Genuine  cases  of  reflex 
epilepsy  are,  I  believe,  rare.  A  remarkable  instance  of  it  occurred  at  the 
Philadelphia  Infirmary  for  Diseases  of  the  Nervous  System  in  the  case  of 
a  man  with  a  testis  in  the  inguinal  canal,  pressure  upon  which  would  cause 
a  typical  fit.  Eemoval  of  the  organ  was  followed  by  cure. 

Cardio-vascular  epilepsy  is  usually  a  manifestation  of  advanced  arterio- 
sclerosis, and  is  associated  with  slow  pulse  (see  Stokes- Adams  Disease).  There 
may  be  palpitation  and  uneasy  sensations  about  the  heart  prior  to  the  attack. 
The  passage  of  a  gall-stone  or  the  removal  of  pleuritic  fluid  may  induce  a  fit. 
Indigestion  and  gastric  troubles  are  extremely  common  in  epilepsy,  and  in 
many  instances  the  eating  of  indigestible  articles  seems,  to  precipitate  an 
attack.  And  lastly,  epileptic  seizures  may  occur  in  old  people  without  obvious 
cause. 

Symptoms.  —  (a)  GRAND  MAL. — Preceding  the  fits  there  is  usually  a  local- 
ized sensation,  known  as  an  aura,  in  some  part  of  the  body.  This  may  be 
somatic,  in  which  the  feeling  comes  from  some  particular  region  in  the  periph- 
ery, as  from  the  finger  or  hand,  or  is  a  sensation  felt  in  the  stomach  or  about 
the  heart.  The  peripheral  sensations  preceding  the  fit  are  of  great  value, 
particularly  those  in  which  the  aura  always  occurs  in  a  definite  region,  as  in 
one  finger  or  toe.  It  is  the  equivalent  of  the  signal  symptom  in  a  fit  from 
a  brain  tumor.  The  varieties  of  these  sensations  are  numerous.  The  epigas- 
tric sensations  are  most  common.  In  these  the  patient  complains  of  an  uneasy 
sensation  in  the  epigastrium  or  distress  in  the  intestines,  or  the  sensation  may 
not  be  unlike  that  of  heartburn  and  may  be  associated  with  palpitation 
These  groups  are  sometimes  known  as  pneumogastric  aura?  or  warnings. 

Of  psychical  aurse  one  of  the  most  common,  as  described  by  Hughlings 
Jackson,  is  the  vague,  dreamy  state,  a  sensation  of  strangeness  or  sometimes 
of  terror.  The  auras  may  be  associated  with  special  senses;  of  these  the  most 
common  are  the  visual,  consisting  of  flashes  of  light  or  sensations  of  color; 
less  commonly,  distinct  objects  are  seen.  The  auditory  aurae  consist  of  noises 
in  the  ear,  odd  sounds,  musical  tones,  or  occasionally  voices.  Olfactory  and 
gustatory  auras,  unpleasant  tastes  and  odors,  are  rare. 

Occasionally  the  fit  may  be  preceded  not  by  an  aura,  but  by  certain  move- 
ments ;  the  patient  may  turn  round  rapidly  or  run  with  great  speed  for  a  few 
70 


1082  DISEASES    OF   THE   NERVOUS    SYSTEM 

minutes,  the  so-called  epilepsia  procursiva.  In  one  of  the  Elwyn  cases  the  lad 
stood  on  his  toes  and  twirled  with  extraordinary  rapidity,  so  that  his  features 
were  scarcely  recognizable.  It  is  stated  that  the  pulse  sometimes  stops  just 
before  the  fit.  The  studies  of  Gibson  and  Good  show  that  no  alteration  in  the 
pulse  occurred  up  to  the  point  of  clonic  convulsions,  and  there  was  no  lower- 
ing of  the  general  blood  pressure  suggesting  anaemia  of  the  brain.  At  the  onset 
of  the  attack  the  patient  may  give  a  loud  scream  or  yell,  the  so-called  epileptic 
cry.  The  patient  drops  as  if  shot,  making  no  effort  to  guard  the  fall.  In 
consequence  of  this  epileptics  frequently  injure  themselves,  cutting  the  face 
<or  head  or  burning  themselves.  In  the  attack,  as  described  by  Hippocrates, 
"the  patient  loses  his  speech  and  chokes,  and  foam  issues  from  the  mouth, 
the  teeth  are  fixed,  the  hands  are  contracted,  the  eyes  distorted,  he  becomes 
insensible,  and  in  some  cases  the  bowels  are  affected.  And  these  symptoms 
occur  sometimes  on  the  left  side,  sometimes  on  the  right,  and  sometimes  on 
both/'  The  fit  may  be  described  in  three  stages: 

(1)  Tonic  Spasm. — The  head  is  drawn  back  or  to  the  right,  and  the  jaws  are 
fixed.     The  hands  are  clinched  and  the  legs  extended.     This  tonic  contrac- 
tion affects  the  muscles  of  the  chest,  so  that  respiration  is  impeded  and  the 
initial  pallor  of  the  face  changes  to  a  dusky  or  livid  hue.     The  muscles  of 
the  two  sides  are  unequally  affected,  so  that  the  head  and  neck  are  rotated 
or  the  spine  is  twisted.    The  arms  are  usually  flexed  at  the  elbows,  the  hand 
at  the  wrist,  and  the  fingers  are  tightly  clinched  in  the  palm.    This  stage  lasts 
only  a  few  seconds,  and  then  the  clonic  stage  begins. 

(2)  Clonic  Stage. — The  muscular  contractions  become   intermittent;   at 
first  tremulous  or  vibratory,  they  gradually  become  more  rapid  and  the  limbs 
are  jerked  and  tossed  about  violently.    The  muscles  of  the  face  are  in  constant 
clonic  spasm,  the  eyes  roll,  the  eyelids  are  opened  and  closed  convulsively. 
The  movements  of  the  muscles  of  the  jaw  are  very  forcible  and  strong,  and 
it  is  at  this  time  that  the  tongue  is  apt  to  be  caught  between  the  teeth  and 
lacerated.     The  cyanosis,  marked  at  the  end  of  the  tonic  stage,  gradually 
lessens.    A  frothy  saliva,  which  may  be  blood  stained,  escapes  from  the  mouth. 
The  faces  and  urine  may  be  discharged  involuntarily.     The  duration  of  this 
stage  is  variable.    It  rarely  lasts  more  than  one  or  two  minutes.    The  contrac- 
tions become  less  violent  and  the  patient  gradually  sinks  into  the  condition 
of  coma. 

(3)  Coma. — The  breathing  is  noisy  or  even  stertorous,  the  face  congested, 
but  no  longer  intensely  cyanotic.    The  limbs  are  relaxed  and  the  unconscious- 
ness is  profound.     After  a  variable  time  the  patient  can  be  aroused,  but  if 
left  alone  he  sleeps  for  some  hours  and  then  awakes,  complaining  only  of 
slight  headache  or  mental  confusion.    If  the  attack  has  been  severe,  petechial 
haemorrhages  may  be  scattered  over  the  neck  and  chest.     In  the  case  of  a 
young  man  in  good  health  in  a  severe  convulsion  both  sub-conjunctival  spaces 
were  entirely  filled  with  blood,  and  free  blood  oozed  from  them    (Walter 
James).    Haemoptysis  is  a  rare  sequel. 

(4)  Status  Epilepticus. — This  is  the  climax  of  the  disease,  in  which  attacks 
occur  in  rapid  succession,  and  the  patient  does  not  recover  consciousness.    The 
pulse,  respirati&n,  and  temperature  rise  in  the  attack.     It  is  a  serious  condi- 
tion, and  often  proves  fatal. 

After  the  attack  the  reflexes  are  sometimes  absent;  more  frequently  they 


EPILEPSY  1083 

are  increased  and  the  ankle  clonus  can  usually  be  obtained.  The  state  of  the 
urine  is  variable,  particularly  as  regards  the  solids.  The  quantity  is  usually 
increased  after  the  attack,  and  albumin  is  not  infrequently  present. 

(5)  Post-epileptic  symptoms  are  of  great  importance.    The  patient  may  be 
in  a  trance-like  condition,  in  which  he  performs  actions  of  which  subsequently 
he  has  no  recollection.     More  serious  are  the  attacks  of  mania,  in  which  the 
patient  is  often  dangerous  and  sometimes  homicidal.     It  is  held  by  good 
authorities  that  an  outbreak  of  mania  may  be  substituted  for  the  fit.     And, 
lastly,  the  mental  condition  of  an  epileptic  patient  is  often  seriously  impaired, 
and  profound  defects  are  common. 

(6)  Paralysis,  which  rarely  follows  the  epileptic  fit,  is  usually  hemiplegic 
and  transient.     Slight  disturbances  of  speech  also  may  occur;  in  some  in- 
stances, forms  of  sensory  aphasia. 

The  attacks  may  occur  at  night,  and  a  person  may  be  epileptic  for  years 
without  knowing  it.  As  Trousseau  truly  remarks,  when  a  person  tells  us  that 
in  the  night  he  has  incontinence  of  urine  and  awakes  in  the  morning  with 
headache  and  mental  confusion,  and  complains  of  difficulty  in  speech  owing 
to  the  fact  that  he  has  bitten  his  tongue,  if  also  there  are  purpuric  spots  on  the 
skin  of  the  face  and  neck,  the  probability  is  very  strong  indeed  that  he  is 
subject  to  nocturnal  epilepsy. 

(6)  PETIT  MAL. — This  is  epilepsy  without  the  convulsions.  The  attack 
consists  of  transient  unconsciousness,  which  may  come  on  at  any  time,  accom- 
panied or  unaccompanied  by  a  feeling  of  faintness  and  vertigo.  Suddenly, 
for  example,  at  the  dinner  table,  the  subject  stops  talking  and  eating,  the  eyes 
become  fixed,  and  the  face  slightly  pale.  Anything  which  may  have  been  in 
the  hand  is  usually  dropped.  In  a  moment  or  two  consciousness  is  regained 
and  the  patient  resumes  conversation  as  if  nothing  had  happened.  In  other 
instances  there  is  slight  incoherency  or  the  patient  performs  some  almost 
automatic  action.  He  may  begin  to  undress  himself  and  on  returning  to 
consciousness  find  that  he  has  partially  disrobed.  He  may  rub  his  beard  or 
face,  or  may  spit  about  in  a  careless  way.  In  other  attacks  the  patient  may 
fall  without  convulsive  seizures.  A  definite  aura  is  rare.  Though  transient, 
unconsciousness  and  giddiness  are  the  most  constant  manifestations  of  petit 
mal;  there  are  many  other  equivalent  manifestations,  such  as  sudden  jerkings 
in  the  limbs,  sudden  tremor,  or  a  sudden  visual  sensation.  Gowers  mentions 
no  less  than  seventeen  different  manifestations  of  petit  mal.  Occasionally 
there  are  cases  in  which  the  patient  has  a  sensation  of  losing  his  breath  and 
may  even  get  red  in  the  face. 

After  the  attack  the  patient  may  be  dazed  for  a  few  seconds  and  perform 
pertain  automatic  actions,  which  may  seem  to  be  volitional.  As  mentioned, 
undressing  is  a  common  action,  but  all  sorts  of  odd  actions  may  be  performed, 
some  of  which  are  awkward  or  even  serious.  One  of  my  patients  after  an 
attack  was  in  the  habit  of  tearing  anything  he  could  lay  hands  on,  particu- 
larly books.  Violent  actions  have  been  committed  and  assaults  made,  fre- 
quently giving  rise  to  questions  which  come  before  the  courts.  This  condi- 
tion has  been  termed  masked  epilepsy,  or  epilepsia  larvata. 

In  a  majority  of  the  cases  of  petit  mal  convulsions  finally  occur,  at  first 
slight,  but  ultimately  the  grand  mal  becomes  well  developed,  and  the  attacks 
may  then  alternate. 


1084  DISEASES    OF    THE    NERVOUS    SYSTEM 

(c)  JACKSONIAN  EPILEPSY. — This  is  also  known  as  cortical,  symptomatic, 
or  partial  epilepsy.  It  is  distinguished  from  the  ordinary  epilepsy  by  the 
important  fact  that  consciousness  is  retained  or  is  lost  late.  The  attacks  are 
usually  the  result  of  irritative  lesions  in  the  motor  zone,  though  there  are 
probably  also  sensory  equivalents  of  this  motor  form.  In  a  typical  attack  the 
spasm  begins  in  a  limited  muscle  group  of  the  face,  arm,  or  leg.  The  zygo- 
matic  muscles,  for  instance,  or  the  thumb  may  twitch,  or  the  toes  may  first 
be  moved.  Prior  to  the  twitching  the  patient  may  feel  a  sensation  of  numb- 
ness or  tingling  in  the  part  affected.  The  spasm  extends  and  may  involve  the 
muscles  of  one  limb  only  or  of  the  face.  The  patient  is  conscious  throughout 
and  watches,  often  with  interest,  the  march  of  the  spasm. 

The  onset  may  be  slow,  and,  as  in  a  case  which  I  have  reported,  there  may 
be  time  for  the  patient  to  place  a  pillow  on  the  floor,  so  as  to  be  as  comfortable 
as  possible  during  the  attack.  The  spasms  may  be  localized  for  years,  but 
there  is  a  great  risk  that  the  partial  epilepsy  may  become  general.  The 
condition  is  due,  as  a  rule,  to  an  irritative  lesion  in  the  motor  zone.  Thus  of 
107  cases  analyzed  by  Eoland,  there  were  48  of  tumor,  21  instances  of  inflam- 
matory softening,  14  instances  of  acute  and  chronic  meningitis,  and  8  cases 
of  trauma.  The  remaining  instances  were  due  to  haemorrhage  or  abscess,  or 
were  associated  with  sclerosis  cerebri.  Two  other  conditions  may  be  mentioned, 
which  may  cause  typical  Jacksonian  epilepsy — namely,  uraemia  and  progres- 
sive paralysis  of  the  insane.  A  considerable  number  of  the  cases  of  Jack- 
sonian epilepsy  are  found  in  children  following  hemiplegia,  the  so-called  post- 
hemiplegic  epilepsy.  The  convulsions  usually  begin  on  the  affected  side,  either 
in  the  arm  or  leg,  and  the  fit  may  be  unilateral  and  without  loss  of  conscious- 
ness. Ultimately  they  become  more  severe  and  general. 

Diagnosis. — In  major  epilepsy  the  suddenness  of  the  attack,  the  abrupt  loss 
of  consciousness,  the  order  of  the  tonic  and  clonic  spasm,  and  the  relaxation 
of  the  sphincters  at  the  height  of  the  attack  are  distinctive  features.  The 
convulsive  seizures  due  to  uraemia  are  epileptic  in  character  and  usually  read- 
ily recognized  by  the  existence  of  greatly  increased  tension  and  the  condition 
of  the  urine.  Practically  in  young  adults  hysteria  causes  the  greatest  difficulty, 
and  may  closely  simulate  true  epilepsy.  The  table  on  page  1085,  from  Gowers' 
work,  draws  clearly  the  chief  differences  between  them. 

Recurring  epileptic  seizures  in  a  person  over  thirty  who  has  not  had  pre- 
vious attacks  is  always  suggestive  of  organic  disease.  According  to  H.  C. 
Wood,  whose  opinion  is  supported  by  that  of  Fournier,  in  9  cases  out  of  10 
the  condition  is  due  to  syphilis. 

Petit  mal  must  be  distinguished  from  attacks  of  syncope,  and  the  vertigo 
of  Meniere's  disease,  of  a  cardiac  lesion,  and  of  indigestion.  In  these  cases 
there  is  no  actual  loss  of  consciousness,  which  forms  a  characteristic  though 
not  an  invariable  feature  of  petit  mal. 

Jacksonian  epilepsy  has  features  so  distinctive  and  peculiar  that  it  is  at 
once  recognized.  It  is,  however,  by  no  means  easy  always  to  determine  upon 
what  the  spasm  depends.  Irritation  in  the  motor  centres  may  be  due  to  a 
great  variety  of  causes,  among  which  tumors  and  localized  meningo-encepha- 
litis  are  the  most  frequent ;  but  it  must  not  be  forgotten  that  in  uraemia  local- 
ized epilepsy  may  occur.  The  most  typical  Jacksonian  spasms  also  are  not 
infrequent  in  general  paresis  of  the  insane. 


EPILEPSY 


1085 


Apparent  cause. 
Warning 


Onset 

Scream 

Convulsion.. 


Biting . 


Micturition . 
Defecation . 

Talking 

Duration .  . 


Restraint  necessary. 
Termination. . . 


EPILEPTIC 


none. 

any,  but  especially  unilateral 
or  epigastric  aura. 

always  sudden. 

at  onset. 

rigidity  followed  by  "jerk- 
ing," rarely  rigidity  alone. 

tongue. 

frequent. 

occasional. 

never. 

a  few  minutes. 

to  prevent  accident, 
spontaneous. 


HYSTEROID 


emotion. 

palpitation,  malaise,  choking,  bi- 
lateral foot  aura. 

often  gradual. 

during  course. 

rigidity  or  "struggling,"  throwing 
about  of  limbs  or  head,  arching 
of  back. 

lips,  hands,  or  other  people  and 
things. 

never. 

never. 

frequent. 

more  than  ten  minutes,  often 
much  longer. 

to  control  violence. 

spontaneous  or  induced  (water, 
etc.). 


Prognosis. — This  may  be  given  to-day  in  the  words  of  Hippocrates :  "The 
prognosis  in  epilepsy  is  unfavorable  when  the  disease  is  congenital,  and  when 
it  endures  to  manhood,  and  when  it  occurs  in  a  grown  person  without  any 
previous  cause.  .  .  .  The  cure  may  be  attempted  in  young  persons,  but 
not  in  old."  W.  A.  Turner  concludes  that  of  cases  beginning  under  ten  years 
few  are  arrested,  whereas  of  those  beginning  at  puberty  the  opposite  is  true. 
Cases  beginning  between  the  twentieth  and  thirty-fifth  years  give  few  arrests. 
After  thirty-five  the  outlook  is  good. 

Death  during  the  fit  rarely  occurs,  but  it  may  happen  if  the  patient  falls 
into  the  water  or  if  the  fit  comes  on  while  he  is  eating.  Occasionally  the  fits 
seem  to  stop  spontaneously.  This  is  particularly  the  case  in  the  epilepsy  in 
children  which  has  followed  the  convulsions  of  teething  or  of  the  fevers.  Fre- 
quency of  the  attacks  and  marked  mental  disturbance  are  unfavorable  indi- 
cations. Hereditary  predisposition  is  apparently  of  no  moment  in  the  prog- 
nosis. The  outlook  is  better  in  males  than  in  females.  The  post-hemiplegic 
epilepsy  is  rarely  arrested.  Of  the  cases  coming  on  in  adults,  those  due  to 
syphilis  and  to  local  affections  of  the  brain  allow  a  more  favorable  prognosis. 

Treatment. — GENERAL. — In  the  case  of  children  the  parents  should  be 
made  to  understand  from  the  outset  that  epilepsy  in  the  great  majority  of 
cases  is  an  incurable  affection,  so  that  the  disease  may  interfere  as  little  as 
possible  with  the  education  of  the  child.  The  subjects  need  firm  but  kind 
treatment.  Indulgence  and  yielding  to  caprices  and  whims  are  followed  by 
weakening  of  the  moral  control,  which  is  so  necessary  in  these  cases.  The 
disease  does  not  incapacitate  a  person  for  all  occupation.  It  is  much  better 
for  epileptics  to  have  some  definite  pursuit.  There  are  many  instances  in' 
which  they  have  been  persons  of  extraordinary  mental  and  bodily  vigor,  as, 
for  example,  Julius  Caesar  and  Napoleon.  One  of  the  most  distressing  fea- 
tures in  epilepsy  is  the  gradual  mental  impairment  which  follows  in  a  certain 
number  of  cases.  If  such  patients  become  extremely  irritable  or  show  signs  of 
violence  they  should  be  placed  under  supervision  in  an  asylum.  Marriage 
should  be  forbidden  to  epileptics.  During  the  attack  a  cork  or  bit  of  rubber 


1086  DISEASES    OP   THE   NERVOUS    SYSTEM 

should  be  placed  between  the  teeth  and  the  clothes  should  be  loosened.  The 
patient  should  be  in  the  recumbent  posture.  As  the  attack  usually  passes  off 
with  rapidity,  no  special  treatment  is  necessary,  but  in  cases  in  which  the 
convulsion  is  prolonged  a  few  whiffs  of  chloroform  or  nitrite  of  amyl  or  a 
hypodermic  of  a  quarter  of  a  grain  of  morphia  may  be  given. 

DIETETIC. — The  old  authors  laid  great  stress  upon  regimen  in  epilepsy. 
The  important  point  is  to  give  the  patient  a  light  diet  at  fixed  hours,  and 
on  no  account  to  permit  overloading  of  the  stomach.  Meat  should  not  be 
given  more  than  once  a  day.  There  are  cases  in  which  animal  food  seems 
injurious.  A  strict  vegetable  diet  has  been  warmly  recommended.  The  pa- 
tient should  not  go  to  sleep  until  the  completion  of  gastric  digestion, 

MEDICINAL. — The  bromides  are  the  only  remedies  which  have  a  special 
influence  upon  the  disease.  Either  the  sodium  or  potassium  salt  may  be  given. 
Sodium  bromide  is  probably  less  irritating  and  is  better  borne  for  a  long 
period.  It  may  be  given  in  milk,  in  which  it  is  scarcely  tasted.  In  all  in- 
stances the  dilution  should  be  considerable.  In  adults  it  is  well  taken  in  soda 
water  or  in  some  mineral  water.  The  dose  for  an  adult  should  be  from  half 
a  drachm  to  a  drachm  and  a  half  (2  to  6  gm.)  daily.  As  Seguin  recommends, 
it  is  often  best  to  give  but  a  single  dose  daily,  about  four  to  six  hours  before 
the  attacks  are  most  likely  to  occur.  For  instance,  in  the  case  of  nocturnal 
epilepsy  a  drachm  should  be  given  an  hour  or  two  after  the  evening  meal. 
If  the  attack  occurs  early  in  the  morning,  the  patient  should  take  a  full  dose 
when  he  awakes.  When  given  three  times  a  day  it  is  less  disturbing  after 
meals.  Each  case  should  be  carefully  studied  to  determine  how  much  bro- 
mide should  be  used.  The  individual  susceptibility  varies  and  some  patients 
require  more  than  others.  Fortunately,  children  take  the  drug  well  and 
stand  proportionately  larger  doses  than  adults.  Saturation  is  indicated  by 
certain  unpleasant  effects,  particularly  drowsiness,  mental  torpor,  and  gastric 
and  cardiac  distress.  Loss  of  palate  reflex  is  one  of  the  earliest  indications 
that  the  system  is  under  the  influence  of  the  bromides,  and  is  a  condition  which 
should  be  attained.  A  very  unpleasant  feature  is  the  development  of  acne, 
which,  however,  is  no  indication  of  bromism.  Seguin  states  that  the  tendency 
to  this  is  much  diminished  by  giving  the  drug  largely  diluted  in  alkaline 
waters  and  administering  from  time  to  time  full  doses  of  arsenic.  To  be 
effectual  the  treatment  should  be  continued  for  a  prolonged  period  and  the 
cases  should  be  incessantly  watched  in  order  to  prevent  bromism.  The  medi- 
cine should  be  continued  for  at  least  two  years  after  the  cessation  of  the  fits ; 
indeed,  Seguin  recommends  that  the  reduction  of  the  bromides  should  not 
be  begun  until  the  patient  has  been  three  years  without  any  manifestations. 
Written  directions  should  be  given  to  the  mother  or  to  the  friends  of  the 
patient,  and  he  should  not  himself  be  held  responsible  for  the  administration 
of  the  medicine.  A  book  should  be  provided  in  which  the  daily  number  of 
attacks  and  the  amount  of  medicine  taken  should  be  noted.  The  addition  of 
belladonna  to  the  bromide  is  warmly  recommended  by  Black,  of  Glasgow.  In 
very  obstinate  cases  Flechsig  uses  opium,  5  or  6  grains  (0.35  gm.),  in  three 
doses  daily;  then  at  the  end  of  six  weeks  opium  is  stopped  and  the  bromides 
in  large  amounts,  75  to  100  grains  (4  to  6  gm.)  daily,  are  used  for  two 
months. 

Among  other  remedies  which  have  been  recommended  as  controlling  epi- 


MIGRAINE  1087 

lepsy  are  chloral,  cannabis  indica,  zinc,  nitre-glycerin,  and  borax.  Xitro- 
glycerin  is  sometimes  advantageous  in  petit  mod,  but  is  not  of  much  service  in 
the  major  form.  To  be  beneficial  it  must  be  given  in  full  doses,  from  2  to  5 
drops  of  the  1  per  cent,  solution,  and  increased  until  the  physiological  effects 
are  produced.  Calcium  lactate  in  20  grain  (1.3  gm.)  doses  daily  has  been 
highly  recommended.  Counter-irritation  is  rarely  advisable.  When  the  aura 
is  very  definite  and  constant  in  its  onset,  as  from  the  hand  or  from  the  toe, 
a  blister  about  the  part  or  a  ligature  tightly  applied  may  stop  the  oncoming  fit. 
In  children,  care  should  be  taken  that  there  is  no  source  of  peripheral  irrita- 
tion. In  boys,  adherent  prepuce  may  occasionally  be  the  cause.  The  irrita- 
tion of  teething,  the  presence  of  worms,  and  foreign  bodies  in  the  ears  or  nose 
have  been  associated  with  epileptic  seizures. 

The  subjects  of  a  chronic  and,  in  most  cases,  a  hopelessly  incurable  dis- 
ease, epileptic  patients  form  no  small  portion  of  the  unfortunate  victims  of 
charlatans  and  quacks,  who  prescribe  to-day,  as  in  the  time  of  the  father  of 
medicine,  "purifications  and  spells  and  other  illiberal  practices  of  like  kind." 

SURGICAL. — In  Jacksonian  epilepsy  the  propriety  of  surgical  interference 
is  universally  granted.  It  is  questionable,  however,  whether  in  the  epilepsy 
following  hemiplegia,  considering  the  anatomical  condition,  it  is  likely  to  be 
of  any  benefit.  In  idiopathic  epilepsy,  when  the  fit  starts  in  a  certain  region 
— the  thumb,  for  instance — and  the  signal  symptom  is  invariable,  the  centre 
controlling  this  part  may  be  removed.  Operation  in  the  traumatic  epilepsy,  in 
which  the  fit  follows  fracture,  is  much  more  hopeful. 

The  operation,  per  se,  appears  in  some  cases  to  have  a  curative  effect. 
Thus  of  50  cases  of  trephining  for  epilepsy  in  which  nothing  abnormal  was 
found  to  account  for  the  symptoms,  25  were  reported  as  cured  and  18  as 
improved.  The  operations  have  not  been  always  on  the  skull,  and  White  has 
collected  an  interesting  series  in  which  various  surgical  procedures  have  been 
resorted  to,  often  with  curative  effect,  such  as  ligation  of  the  carotid  artery, 
castration,  tracheotomy,  excision  of  the  superior  cervical  ganglia,  incision  of 
the  scalp,  circumcision,  etc. 

VI.    MIGRAINE 

(Hemicrania;  SicTc  Headache) 

Definition. — A  paroxysmal  affection  characterized  by  severe  headache,  usu- 
ally unilateral,  and  often  associated  with  disorders  of  vision. 

Etiology. — Heredity  plays  an  important  role  in  90  per  cent,  of  cases 
according  to  Mobius.  Women  and  members  of  neurotic  families  are  most 
frequently  attacked.  Many  distinguished  men  have  been  its  victims,  and 
the  astronomer  Airy  gave  a  classical  account  of  his  case.  The  nature  of  the 
disease  is  unknown,  and  many  views  have  been  entertained : 

(a)  That  it  is  a  toxaemia  from  disorder  of  the  intestinal  digestion,  from 
disturbed  uric  acid  output,  or  from  some  self-manufactured  poison. 

(&)  That  it  is  a  vasomotor  affection  with  spasm  of  the  arteries,  in  favor 
of  which  are  the  facts  that  in  the  attack  the  temporal  arteries  on  the  affected 
side  may  be  felt  to  be  small,  the  retinal  arteries  may  sometimes  be  seen  in 
spasm,  and  sclerosis  of  the  arteries  on  the  same  side  is  found  in  a  certain 


1088  DISEASES    OF    THE    NERVOUS    SYSTEM 

number  of  cases  of  hemicrania.  A  still  more  striking  confirmation  is  the 
temporary  paralysis  which  may  be  associated  with  an  attack  of  monoplegic 
or  hemiplegic  character.  Mitchell  Clarke  has  reported  a  history  of  recurring 
motor  paralysis  in  eleven  members  in  three  generations  of  the  same  family. 
The  characteristic  visual  phenomena  preceded  the  unilateral  headache,  espe- 
cially the  hemiopia.  In  most  of  the  attacks  the  hemiplegia  was  on  the  right 
side.  It  lasted  from  a  few  hours  to  a  day  and  disappeared  completely,,  leaving 
no  damage.  It  is  difficult  to  explain  such  cases  except  on  the  view  of  a  tran- 
sient spasm  of  the  arteries. 

(c)  Others  regard  the  affection  as  of  reflex  origin  arising  from  a  refractive 
error  in  the  eyes,  or  from  troubles  in  the  nose  or  sexual  organs. 

(d)  The  disease  has  been  attributed  to  transient  plugging  of  the  foramen 
of  Monro  with  increased  pressure  in  the  ventricles  (Spitzner). 

The  majority  of  cases  begin  early  in  life,  and  Sinclair  refers  to  a  case  in  a 
child  of  two  years.  Many  circumstances  bring  on  the  attack:  a  powerful  emo- 
tion of  any  sort,  mental  or  bodily  fatigue,  digestive  disturbances,  or  the  eat- 
ing of  some  particular  article  of  food.  The  paroxysmal  character  is  one  of 
the  most  striking  features  of  the  attacks  which  may  occur  on  the  same  day 
every  week,  every  fortnight,  or  every  month.  Headaches  of  the  migraine 
type  may  occur  for  years  in  connection  with  chronic  nephritis,  and  it  is  well 
to  remember  that  attacks  may  occur  in  connection  with  tumors  and  other 
lesions  of  the  base  of  the  brain. 

Symptoms. — Premonitory  signs  are  present  in  many  cases,  and  the  patient 
can  tell  when  an  attack  is  coming  on.  Eemarkable  prodromata  have  been 
described,  particularly  in  connection  with  vision.  Apparitions  may  appear — 
visions  of  animals,  such  as  mice,  dogs,  etc.  Transient  hemianopia  or  scotoma 
may  be  present.  In  other  instances  there  is  spasmodic  action  of  the  pupil  on 
the  affected  side,  which  dilates  and  contracts  alternately,  the  condition  known 
as  hippus.  Frequently  the  disturbance  of  vision  is  only  a  blurring,  or  there 
are  balls  of  light,  or  zigzag  lines,  or  the  so-called  fortification  spectra  (teichop- 
sia),  which  may  be  illuminated  with  gorgeous  colors.  Disturbances  of  the 
other  senses  are  rare.  Numbness  of  the  tongue  and  face  and  occasionally  of 
the  hand  may  occur  with  tingling.  More  rarely  there  are  cramps  or  spasms 
in  the  muscles  of  the  affected  side.  Transient  aphasia  has  also  been  noted, 
which  may  be  intermittent.  Some  patients  show  marked  psychical  disturb- 
ance, either  excitement  or,  more  commonly,  mental  confusion  or  great  depres- 
sion. Dizziness  occurs  in  some  cases.  The  headache  follows  a  short  time 
after  the  prodromal  symptoms  have  appeared.  It  is  cumulative  and  expansile 
in  character,  beginning  as  a  localized  small  spot,  which  is  generally  constant 
either  on  the  temple  or  forehead  or  in  the  eyeball.  It  is  usually  described  as 
of  a  penetrating,  sharp,  boring  character.  The  pain  gradually  spreads  and 
involves  the  entire  side  of  the  head,  sometimes  the  neck,  and  may  pass  into  the 
arm.  In  some  cases  both  sides  are  affected.  Nausea  and  vomiting  are  com- 
mon symptoms.  If  the  attack  comes  on  when  the  stomach  is  full  vomiting 
usually  gives  relief.  Vasomotor  symptoms  may  be  present.  The  face,  for 
instance,  may  be  pale,  and  there  may  be  a  marked  difference  between  the  two 
sides.  Subsequently  the  face  and  ear  on  the  affected  side  may  become  a  burn- 
ing red  from  the  vaso-dilator  influences.  The  pulse  may  be  slow.  The  tem- 
poral artery  on  the  affected  side  may  be  firm  and  hard,  and  in  a  condition  of 


NEURALGIA  1089 

arterio-sclerosis — a  fact  which  has  been  confirmed  anatomically  by  Thoma. 
Few  affections  are  more  prostrating  than  migraine,  and  during  the  paroxysm 
^the  patient  may  scarcely  be  able  to  raise  the  head  from  the  pillow.  The  slight- 
est noise  or  light  aggravates  the  condition. 

The  duration  of  the  entire  attack  is  variable.  The  severer  forms  usually 
incapacitate  the  patient  for  at  least  three  days.  In  other  instances  the  entire 
attack  is  over  in  a  day.  The  disease  recurs  for  years,  and  in  cases  with  a 
marked  hereditary  tendency  may  persist  throughout  life.  In  women  the 
attacks  often  cease  after  the  climacteric,  and  in  men  after  the  age  of  fifty. 
Two  of  the  greatest  sufferers  I  have  known,  who  had  recurring  attacks  every 
few  weeks  from  early  boyhood,  now  have  complete  freedom. 

Treatment. — The  patient  is  usually  aware  of  the  causes  which  precipitate 
an  attack.  Avoidance  of  excitement,  regularity  in  the  meals,  and  moderation 
in  diet  are  important  rules.  I  have  known  cases  greatly  benefited  by  a  strict 
vegetable  diet.  The  treatment  should  be  directed  toward  the  removal  of  the 
conditions  upon  which  the  attacks  depend.  In  children  much  may  be  done 
by  watchfulness  and  care  on  the  part  of  the  mother  in  regulating  the  bowels 
and  watching  the  diet  of  the  child.  Errors  of  refraction  should  be  adjusted. 
On  no  account  should  such  children  be  allowed  to  compete  in  school  for  prizes. 
A  prolonged  course  of  bromides  sometimes  proves  successful.  If  anaemia  is 
present,  iron  and  arsenic  should  be  given.  When  the  arterial  tension  is  in- 
creased a  course  of  nitroglycerin  may  be  tried.  Not  too  much,  however,  should 
be  expected  of  the  preventive  treatment  of  migraine.  In  a  very  large  propor- 
tion of  the  cases  the  headaches  recur  in  spite  of  all  we  (including  the  refrac- 
tionists)  can  do.  Herter  advised,  so  soon  as  the  patient  has  any  intimation  of 
the  attack,  to  wash  out  the  stomach  with  water  at  105°,  and  to  give  a  brisk 
saline  cathartic.  Irrigation  of  the  colon  with  hot  saline  solution  is  sometimes 
of  value  if  done  at  the  onset.  Alkaline  water  should  be  taken  freely  by  mouth. 
During  the  paroxysm  the  patient  should  be  kept  in  bed  and  absolutely  quiet. 
If  the  patient  feels  faint  and  nauseated  a  small  cup  of  hot,  strong  coffee  or  20 
drops  of  chloroform  give  relief.  Cannabis  indica  is  probably  the  most  satis- 
factory remedy.  Seguin  recommends  a  prolonged  course  of  the  drug.  Anti- 
pyrin,  antifebrin,  and  phenacetin  have  been  much  used  of  late.  When  given 
early,  at  the  very  outset  of  the  paroxysm,  they  are  sometimes  effective.  Small, 
repeated  doses  are  more  satisfactory.  Of  other  remedies,  caffeine,  in  5-grain 
doses  of  the  citrate,  nux  vomica,  and  ergot  have  been  recommended.  Elec- 
tricity does  not  appear  to  be  of  much  service. 

Ophthalmoplegic  Migraine. — This  term  was  applied  by  Charcot  to  a  special 
form  in  which  there  is  weakness  or  paralysis  of  one  or  more  eye  muscles,  with 
or  after  a  migraine  attack.  The  oculo-motor  nerve  is  usually  involved. 
Ptosis,  loss  of  certain  movements,  and  double  vision  are  the  common  features, 
which  may  persist  for  some  days.  Local  causes,  especially  syphilis,  should  be 
excluded  before  the  diagnosis  is  established.  The  treatment  is  the  same  as 
for  migraine. 

VH.    NEURALGIA 

Definition.— A  painful  affection  of  the  nerves,  due  either  to  functional 
disturbance  of  their  central  or  peripheral  extremities  or  to  neuritis  in  their 
course. 


1090  DISEASES    OF    THE    NERVOUS    SYSTEM 

Etiology. — Members  of  neuropathic  families  are  most  subject  to  the  disease. 
It  affects  women  more  than  men.  Children  are  rarely  attacked.  Of  all  causes 
debility  is  the  most  frequent.  It  is  often  the  first  indication  of  an  enfeebled 
nervous  system.  The  various  forms  of  anaemia  are  frequently  associated  with 
neuralgia.  It  may  be  a  prominent  feature  at  the  onset  of  certain  acute  dis- 
eases, particularly  typhoid  fever.  Malaria  has  been  thought  to  be  a  potent 
cause,  but  it  has  not  been  shown  that  neuralgia  is  more  frequent  in  malarial 
districts,  and  the  error  has  probably  arisen  from  regarding  periodicity  as  a 
special  manifestation  of  paludism.  It  occasionally  occurs  in  malarial  cachexia. 
Exposure  to  cold  is  a  cause  in  very  susceptible  persons.  Reflex  irritation, 
particularly  from  carious  teeth,  and  disease  of  the  antrum  and  frontal  sinuses 
are  common  causes  of  neuralgia  of  the  fifth  nerve.  The  disease  occurs  some- 
times in  gout,  lead  poisoning,  and  diabetes.  Persistent  neuralgia  may  be  a 
feature  of  latent  Bright's  disease. 

Symptoms. — Before  the  onset  of  the  pain  there  may  be  uneasy  sensations, 
sometimes  tingling  in  the  part  which  will  be  affected.  The  pain  is  localized 
to  a  certain  group  or  division  of  nerves,  usually  affecting  one  side.  The  pain 
is  not  constant,  but  paroxysmal,  and  is  described  as  stabbing,  burning,  or 
darting  in  character.  The  skin  may  be  exquisitely  tender  in  the  affected 
region,  particularly  over  certain  points  along  the  course  of  the  nerve,  the 
so-called  tender  points.  Movements,  as  a  rule,  are  painful.  Trophic  and 
vaso-motor  changes  may  accompany  the  paroxysm;  the  skin  may  be  cool,  and 
subsequently  hot  and  burning;  occasionally  local  oedema  or  erythema  occurs. 
More  remarkable  still  are  the  changes  in  the  hair,  which  may  become  blanched 
(canities),  or  even  fall  out.  Fortunately,  such  alterations  are  rare.  Twitch- 
ings  of  the  muscles,  or  even  spasms,  may  be  present  during  the  paroxysm. 
After  lasting  a  variable  time — from  a  few  minutes  to  many  hours — the  attack 
subsides.  Recurrence  may  be  at  definite  intervals — every  day  at  the  same  hour, 
or  at  intervals  of  two,,  three,  or  even  seven  days.  Occasionally  the  paroxysms 
develop  only  at  the  catamenia.  This  periodicity  is  quite  as  marked  in  non- 
malarial  as  in  malarial  regions. 

CLINICAL  VAEIETIES,  DEPENDING  ON  THE  NEEVE  BOOTS  AFFECTED 

Trigeminal  Neuralgia;  Tic  Douloureux. — A  distinction  must  be  drawn 
between  the  minor  and  major  neuralgias  of  the  fifth  cranial  nerve.  The  former 
may  merely  be  symptomatic  of  the  involvement  of  one  or  another  of  its  periph- 
eral branches  in  some  disease  process — the  pressure  of  a  tumor,  carious  teeth, 
or  a  neuritis  due  to  the  proximity  of  suppurative  processes  in  the  bony  sinuses, 
etc.  There  may  be  referred  neuralgic  pains  in  this  area  from  morbid  processes 
within  the  cranium,  or  from  visceral  disease  elsewhere.  A  painful  neuralgia 
may  follow  an  attack  of  zoster  in  any  division  of  the  fifth  nerve. 

The  typical  tic  douloureux,  epileptiform  neuralgia,  or  ''neuralgia  quinti 
major"  as  it  has  been  called,  is  probably  a  primary  affection  of  the  Gasserian 
ganglion.  The  disease  starts  in  middle  life,  without  obvious  cause,  as  a  sim- 
ple neuralgia  in  one  of  the  trigeminal  branches,  and  from  a  particular  spot 
the  pain  radiates  through  the  course  of  one  of  the  nerves,  most  often  the  upper 
branch.  The  pain  is  of  sudden  onset,  violent  and  paroxysmal  in  character. 
There  are  periods  of  remission,  which  at  first  may  extend  over  several  months, 


NEURALGIA  1091 

and  in  which  the  paroxysms  do  not  occur,  but  these  intervals  of  release  shorten 
after  each  successive  attack.  The  attacks  themselves  are  of  ever  increasing 
severity  and  longer  duration.  The  pain  finally  invades  the  territory  of  ad- 
joining nerves  and  ultimately,  after  years,  may  extend  over  the  entire  trige- 
minal  distribution.  Though  by  sympathy  there  may  be  pain  outside  of  the 
fifth  nerve  area,  particularly  in  the  occipital  region,  in  true  tic  douloureux 
the  pain  remains  limited  to  the  distribution  of  one  trigeminal  nerve,  and 
probably  never  becomes  bilateral.  In  advanced  cases  the  paroxysms  follow 
one  another  rapidly  and  without  assignable  cause,  and  in  the  intervals  the 
patient  may  never  be  quite  free  from  pain.  They  are  inaugurated  by  almost 
any  form  of  external  stimulus,  by  a  draught  of  air,  by  movement  of  the  facial 
muscles  or  of  the  tongue  in  speaking,  by  touching  the  skin,  particularly  over 
those  points  from  which  the  pain  seems  to  take  its  origin,  by  the  act  of  swal- 
lowing, especially  when  the  pain  involves  the  mucous  membrane  field  of  dis- 
tribution of  the  nerve.  It  is  not  a  self-limited  disease.  In  some  instances 
the  neuralgia  reaches  such  a  frightful  intensity  that  it  renders  the  patient's 
life  insupportable.  In  former  years  suicide  was  not  an  uncommon  conse- 
quence. 

Cervico-occipital  neuralgia  involves  the  posterior  branches  of  the  first 
four  cervical  nerves,  particularly  the  inferior  occipital,  at  the  emergence  of 
which  there  is  a  painful  point  about  half-way  between  the  mastoid  process  and 
the  first  cervical  vertebra.  It  may  be  caused  by  cold,  and  these  nerves  are 
often  affected  in  cervical  caries.  Surgical  measures  may  be  required  if  the  pain 
is  severe.  Krause  has  devised  an  operation  for  division  and  evulsion  of  the 
affected  nerves. 

Cervico-brachial  neuralgia  involves  the  sensory  nerves  of  the  brachial 
plexus,  particularly  in  the  cubital  division.  When  the  circumflex  nerve  is  in- 
volved the  pain  is  in  the  deltoid.  The  pain  is  most  commonly  about  the 
shoulder  and  down  the  course  of  the  ulnar  nerve.  There  is  usually  a  marked 
tender  point  upon  this  nerve  at  the  elbow.  This  form  rarely  follows  cold, 
but  more  frequently  results  from  rheumatic  affections  of  the  joints,  and 
trauma. 

Neuralgia  of  the  phrenic  nerve  is  rare.  It  is  sometimes  found  in  pleurisy 
and  in  pericarditis.  The  pain  is  chiefly  at  the  lower  part  of  the  thorax  on  a 
line  with  the  insertion  of  the  diaphragm,  and  here  may  be  painful  points  on 
deep  pressure.  Full  inspiration  is  painful,  and  there  is  great  sensitiveness  on 
coughing  or  in  the  performance  of  any  movement  by  which  the  diaphragm  is 
suddenly  depressed. 

Intercostal  Neuralgia. — Next  to  the  tic  douloureux  this  is  the  most  im- 
portant form.  It  is  most  frequent  in  women  and  very  common  in  hysteria. 
Post-zoster  neuralgias  are  common  in  this  situation.  The  possibility  of  spinal 
disease,  of  tumor,  caries,  or  aneurism  must  always  be  borne  in  mind. 

Lumbar  Neuralgia. — The  affected  nerves  are  the  posterior  fibres  of  the 
lumbar  plexus,  particularly  the  ilio-scrotal  branch.  The  pain  is  in  the  region 
of  the  iliac  crest,  along  the  inguinal  canal,  in  the  spermatic  cord,  and  in  the 
scrotum  or  labium  majus.  The  affection  known  as  irritable  testis,  probably  a 
neuralgia  of  this  nerve,  may  be  very  severe  and  accompanied  by  syncopal 
sensations. 

Coccydynia.—  This  is  regarded  as  a  neuralgia  of  the  coccygeal  plexus. 


1092  DISEASES    OF    THE    NEKVOUS    SYSTEM 

It  is  most  common  in  women,  and  is  aggravated  by  the  sitting  posture.  It 
is  very  intractable,,  and  may  necessitate  the  removal  of  the  coccyx,  an  operation, 
however,  which  is  not  always  successful.  Neuralgias  of  the  nerves  of  the  leg 
have  already  been  considered. 

Neuralgias  of  the  Nerves  of  the  Feet.  — Many  of  these  cases  accompany 
varying  degrees  of  flat-foot.  The  condition  is  brought  about  by  weakness  or 
fatigue  of  the  muscles  supporting  the  arches  of  the  foot,  which  consequently 
settle  until  the  strain  of  the  superimposed  body-weight  falls  upon  the  liga- 
mentous  and  aponeurotic  attachments  between  the  metatarsal  and  tarsal  bones. 
Eest,  massage,  exercises,  and  orthopedic  measures  are  indicated. 

PAINFUL  HEEL. — Both  in  women  and  men  there  may  be  about  the  heel 
severe  pains  which  interfere  seriously  with  walking — the  pododynia  of  S.  D. 
Gross.  There  may  be  little  or  no  swelling,  no  discoloration,  and  no  affection 
of  the  joints.  Some  cases  follow  a  gonococcus  infection  and  are  due  to  a  bony 
spur. 

PLANTAR  NEURALGIA. — This  is  often  associated  with  a  definite  neuritis, 
such  as  follows  typhoid  fever,  and  has  been  seen  in  an  aggravated  form  in 
caisson  disease  (Hughes).  The  pain  may  be  limited  to  the  tips  of  the  toes 
or  to  the  ball  of  the  great  toe.  Numbness,  tingling,  and  hyperaesthesia  or 
sweating  may  occur  with  it.  In  typhoid  fever  it  is  not  uncommon  for  patients 
to  complain  of  great  sensitiveness  in  the  toes. 

METATARSALGIA. — Thomas  G.  Morton's  "painful  affection  of  the  fourth 
metatarso-phalangeal  articulation"  is  a  peculiar  and  very  trying  disorder,  seen 
most  frequently  in  women,  and  usually  in  one  foot.  Morton  regards  it  as  due 
to  a  pinching  of  the  metatarsal  nerve.  The  condition  usually  requires  oper- 
ation. The  red,  painful  neuralgia — erythromelalgia — is  described  under  the 
vaso-motor  and  trophic  disturbances. 

Visceral  Neuralgias. — The  more  important  of  these  have  already  been 
referred  to  in  connection  with  the  cardiac  and  the  gastric  neuroses.  They  are 
most  frequent  in  women,  and  are  constant  accompaniments  of  neurasthenia 
and  hysteria.  The  pains  are  most  common  in  the  pelvic  region,  particularly 
about  the  ovaries.  Nephralgia  is  of  great  interest,  for,  as  has  already  been 
mentioned,  the  symptoms  may  closely  simulate  those  of  stone. 

TREATMENT   OP   NEURALGIA 

In  general,  causes  of  reflex  irritation  should  be  carefully  removed.  The 
neuralgia,  as  a  rule,  recurs  unless  the  general  health  improves;  so  that  tonic 
and  hygienic  measures  of  all  sorts  should  be  employed.  Often  a  change  of  air 
or  surroundings  will  relieve  a  severe  neuralgia.  I  have  known  obstinate  cases 
to  be  cured  by  a  prolonged  residence  in  the  mountains,  with  an  out-of-door  life 
and  plenty  of  exercise.  A  strict  vegetable  diet  will  sometimes  relieve  the 
neuralgia  or  headache  of  a  gouty  person.  Of  general  remedies,  iron  is  often 
a  specific  in  the  cases  associated  with  chlorosis  and  anasmia.  Arsenic,  too,  is 
very  beneficial  in  these  forms,  and  should  be  given  in  ascending  doses.  The 
value  of  quinine  has  been  much  overrated.  It  probably  has  no  more  influence 
than  any  other  bitter  tonic,  except  in  the  rare  instances  in  which  the  neuralgia 
is  definitely  associated  with  malarial  poisoning.  Strychnine,  cod-liver  oil,  and 
phosphorus  are  also  advantageous.  Of  remedies  for  the  pain,,  antipyrin,  anti- 


PROFESSIONAL    SPASMS;    OCCUPATION    NEUEOSES    1093 

febrin,  and  phenacetin  should  first  be  tried,  for  they  are  sometimes  of  service. 
Morphia  should  be  given  with  great  caution,  and  only  after  other  remedies 
have  been  tried  in  vain.  On  no  consideration  should  the  patient  be  allowed 
to  use  the  hypodermic  syringe.  Gelsemium  is  highly  recommended.  Of  nerve 
stimulants,  valerian  and  ether,  which  often  act  well  together,  may  be  given. 
Alcohol  is  a  valuable  though  dangerous  remedy,  and  should  not  be  ordered 
for  women.  In  the  minor  form  of  trigeminal  neuralgia  nitroglycerin  in  large 
doses  may  be  tried.  Dana  has  seen  good  results  follow  rest  with  large  doses 
of  strychnia  given  hypodermically.  Aconitin  in  doses  of  one  two-hundredth 
of  a  grain  (0.00032  gm.)  may  be  tried. 

Of  local  applications,  the  thermo-cautery  is  invaluable,  particularly  in 
ZOHK  and  the  more  chronic  forms  of  neuralgia.  Acupuncture  may  be  used. 
Chloroform  liniment,  camphor  and  chloral,  menthol,  the  oleates  of  morphia, 
atropia,  and  belladonna  used  with  lanolin  may  be  tried.  Freezing  over  the 
tender  point  with  ether  spray  is  sometimes  successful.  The  continuous  cur- 
rent may  be  used.  The  sponges  should  be  warm,  and  the  positive  pole  should 
be  placed  near  the  seat  of  the  pain.  The  strength  of  the  current  should  be 
such  as  to  cause  a  slight  tingling  or  burning,  but  not  pain. 

For  the  trigeminal  neuralgia  cutting  of  the  nerves  and  removal  of  the 
Gasserian  ganglion  are  practised.  Alcohol  injections  into  the  nerve  trunks 
have  been  extensively  used,  and  in  some  hands  with  excellent  results.  The 
nerve  fibres  are  destroyed  with  total  loss  of  the  function  of  the  nerve  until 
regeneration  occurs.  "VYilfred  Harris  has  destroyed  the  Gasserian  ganglion  by 
injecting  alcohol  into  it  through  the  foramen  ovale.  One  of  his  patients 
treated  in  this  way  thirteen  months  before  has  remained  perfectly  well,  and 
the  fifth  nerve  area  is  completely  anaesthetic.  Removal  of  the  ganglion  is  very 
satisfactory  in  skilled  hands.  Gushing  has  operated  on  130  cases  with  two 
deaths,  both  cases  early  in  the  series. 


VIII.     PROFESSIONAL   SPASMS;    OCCUPATION  NEUROSES 

The  continuous  and  excessive  use  of  the  muscles  in  performing  a  certain 
movement  may  be  followed  by  an  irregular,  involuntary  spasm  or  cramp,  which 
may  completely  check  the  performance  of  the  action.  The  condition  is  found 
most  frequently  in  writers,  hence  the  term  writer's  cramp  or  scrivener's  palsy ; 
but  it  is  also  common  in  piano  and  violin  players  and  in  telegraph  operators. 
The  spasms  occur  in  many  other  persons,  such  as  milkmaids,  weavers,  and 
cigarette-rollers. 

The  most  common  form  is  writer's  cramp,  which  is  much  more  frequent 
in  men  than  in  women.  Of  75  cases  of  impaired  writing  power  reported  by 
Poore,  all  of  the  instances  of  undoubted  writer's  cramp  were  in  men.  Morris 
J.  Lewis  states  that  in  the  United  States,  in  the  telegrapher's  cramp,  women, 
who  are  employed  a  great  deal  in  telegraphy,  are  much  less  frequently  affected 
(only  4  out  of  43  cases).  An  investigation  by  H.  Theodore  Thompson  and  J. 
Sinclair  into  telegraphist  cramp  in  England  shows  that  the  disease  is  rare, 
only  13  cases  among  between  7,000  and  8,000  employees.  Persons  of  a 
nervous  temperament  are  more  liable  to  the  disease.  Occasionally  it  follows 
slight  injury. 


1094  DISEASES    OF   THE   NERVOUS    SYSTEM 

Gowers  states  that  in  a  majority  of  the  cases  a  faulty  method  of  writing 
has  been  employed,  using  either  the  little  finger  or  the  wrist  as  the  fixed  point. 
Persons  who  write  with  the  middle  of  the  forearm  or  the  elbow  as  the  fixed 
point  are  rarely  affected. 

No  anatomical  changes  have  been  found.  The  most  reasonable  explanation 
of  the  disease  is  that  it  results  from  a  deranged  action  of  the  nerve  centres 
presiding  over  the  muscular  movements  involved  in  the  act  of  writing,  a  con- 
dition which  has  been  termed  irritable  weakness.  "The  education  of  centres 
which  may  be  widely  separated  from  each  other  for  the  performance  of  any 
delicate  movement  is  mainly  accomplished  by  lessening  the  lines  of  resistance 
between  them,  so  that  the  movement,  which  was  at  first  produced  by  a  con- 
siderable mental  effort,  is  at  last  executed  almost  unconsciously.  If,  there- 
fore, through  prolonged  excitation,  this  lessened  resistance  be  carried  too  far, 
there  is  an  increased  and  irregular  discharge  of  nerve  energy,  which  gives  rise 
to  spasm  and  disordered  movement.  According  to  this  view,  the  muscular 
weakness  is  explained  by  an  impairment  of  nutrition  accompanying  that  of 
function,  and  the  diminished  faradic  excitability  by  the  nutritional  disturbance 
descending  the  motor  nerves"  (Gay). 

Symptoms. — These  may  be  described  under  five  heads  (Lewis). 

(a)  CRAMP  OR  SPASM. — This  is  often  an  early  symptom  and  most  com- 
monly affects  the  forefinger  and  thumb;  or  there  may  be  a  combined  move- 
ment of  flexion  and  adduction  of  the  thumb,  so  that  the  pen  may  be  twisted 
from  the  grasp  and  thrown  to  some  distance.  Weir  Mitchell  has  described 
a  lock-spasm,  in  which  the  fingers  become  so  firmly  contracted  upon  the  pen 
that  it  can  not  be  removed. 

(&)  PARESIS  AND  PARALYSIS. — This  may  occur  with  the  spasm  or  alone. 
The  patient  feels  a  sense  of  weakness  and  debility  in  the  muscles  of  the 
hand  and  arm  and  holds  the  pen  feebly.  Yet  in  these  circumstances  the 
grasp  of  the  hand  may  be  strong  and  there  may  be  no  paralysis  for  ordinary 
acts. 

(c)  TREMOR. — This  is  most  commonly  seen  in  the  forefinger  and  may  be 
a  premonitory  symptom  of  atrophy.     It  is  not  an  important  symptom,  and  is 
rarely  sufficient  to  produce  disability. 

(d)  PAIN. — Abnormal  sensations,  particularly  a  tired  feeling  in  the  mus- 
cles, are  very  constantly  present.    Actual  pain  is  rare,  but  there  may  be  irregu- 
lar shooting  pains  in  the  arm.    Numbness  or  soreness  may  exist.    If,  as  some- 
times happens,  a  subacute  neuritis  develops,  there  may  be  pain  over  the  nerves 
and  numbness  or  tingling  in  the  fingers. 

(e)  VASO-MOTOR  DISTURBANCES. — These  may  occur  in  severe  cases.    There 
may  be  hyperaesthesia.     Occasionally  the  skin  becomes  glossy,  or  there  is  a 
condition  of  local  asphyxia  resembling  chilblains.    In  attempting  to  write,  the 
hand  and  arm  may  become  flushed  and  hot  and  the  veins  increased  in  size. 
Early  in  the  disease  the  electrical  reactions  are  normal,  but  in  advanced  cases 
there  may  be  diminution  of  faradic  and  sometimes  increase  in  the  galvanic 
irritability. 

Diagnosis. — A  well  marked  case  of  writer's  cramp  or  palsy  could  scarcely 
be  mistaken  for  any  other  affection.  Care  must  be  taken  to  exclude  the  exist- 
ence of  any  cerebro-spinal  disease,  such  as  progressive  muscular  atrophy  or 
hemiplegia.  The  physician  is  sometimes  consulted  by  nervous  persons  who 


HYSTERIA  1095 

fancy  they  are  becoming  subject  to  the  disease  and  complain  of  stiffness  or 
weakness  without  displaying  any  characteristic  features. 

Prognosis. — The  course  of  the  disease  is  usually  chronic.  If  taken  in 
time  and  if  the  hand  is  allowed  perfect  rest,  the  condition  may  improve  rapidly, 
but  too  often  there  is  a  strong  tendency  to  recurrence.  The  patient  may  learn 
to  write  with  the  left  hand,  but  this  also  may  after  a  time  be  attacked. 

Treatment. — Various  prophylactic  measures  have  been  advised.  As  men- 
tioned, it  is  important  that  a  proper  method  of  writing  be  adopted.  Gowers 
suggests  that  if  all  persons  wrote  from  the  shoulder  writer's  cramp  would 
practically  not  occur.  Various  devices  have  been  invented  for  relieving  the 
fatigue,  but  none  of  them  are  very  satisfactory.  The  use  of  the  type-writer 
has  diminished  very  much  the  frequency  of  scrivener's  palsy.  Rest  is  essential. 
No  measures  are  of  value  without  this.  Massage  and  manipulation,  when 
combined  with  systematic  gymnastics,  give  the  best  results.  The  patient 
should  systematically  practise  the  opposite  movements  to  those  concerned  in 
the  cramp.  This  muscle  training  often  gives  good  results.  Poore  recommends 
the  galvanic  current  applied  to  the  muscles,  which  are  at  the  same  time  rhyth- 
mically exercised.  In  very  obstinate  cases  the  condition  remains  incurable. 
I  saw  a  few  years  ago  a  distinguished  gynaecologist  who  had  had  writer's 
cramp  twenty  years  before,  and  who  had  tried  all  sorts  of  treatment,  including 
Wolff's  method,  without  any  avail.  He  still  has  it  in  aggravated  form, 
but  he  can  do  all  the  finer  manipulations  of  operative  work  without  any 
difficulty. 

The  nutrition  of  the  patients  is  apt  to  be  much  impaired,  and  cod-liver  oil, 
strychnia,  and  other  tonics  will  be  found  advantageous.  Local  applications  are 
of  little  benefit.  Tenotomy  and  nerve  stretching  have  been  abandoned. 


IX.    HYSTERIA 

Definition. — A  disorder,  chiefly  of  young  women,  in  which  emotional 
states  control  the  body,  leading  to  perversion  of  mental,  sensory,  motor  and 
secretory  functions. 

Etiology. — Many  and  diverse  views  have  prevailed  since  the  Greeks  as- 
cribed the  disease  to  the  vague  desires  and  wanderings  of  the  womb,  after 
which  they  named  it. 

Charcot  and  his  followers  regarded  hysteria  as  a  psychosis,  in  which  mor- 
bid states  are  induced  by  ideas.  The  capability  of  responding  to  suggestion 
is  the  test  of  its  existence.  It  is  a  disturbance  in  the  sphere  of  personality,  in 
which  the  emotions  have  an  exaggerated  influence  on  the  sensory,  motor  and 
secretory  functions. 

Babinski,  in  a  modification  of  this  view,  holds  that  hysteria  is  a  mental 
condition  with  certain  primary  phenomena  and  certain  secondary  accidental 
symptoms.  The  essence  of  the  primary  features  is  that  they  may  be  produced 
by  suggestion,  and  they  may  be  made  to  disappear  by  persuasion  (pithiatism). 
The  primary  symptoms  include  such  features  as  hemi-anassthesia,  paralysis, 
contractures,  etc. ;  secondary  features,  as  for  example  muscular  atrophy,  are 
directly  dependent  upon  the  primary  and  cannot  themselves  be  induced  by 
suggestion. 


1096  DISEASES    OF    THE    NEKVOUS    SYSTEM 

In  the  Breuer-Freud  theory,  now  the  vogue,  we  return  to  the  days  of 
Aretaeus,  who  originated  (?)  the  views  of  sexual  hysteria  and  believed  the 
womb,  "like  an  animal  within  an  animal"  and  altogether  erratic,  caused  all 
sorts  of  trouble  in  its  wanderings.  Freud's  view  is  thus  analyzed  by  Jelliffe 
in  his  article  in  my  "System  of  Medicine,"  Vol.  VII.,  page  817:  "There  de- 
velop usually  on  a  constitutional  basis,  in  the  period  before  puberty,  definite 
sexual  activities  which  are  mostly  of  a  perverse  nature.  These  activities  do 
not,  as  a  rule,  lead  to  a  definite  neurosis  up  to  the  time  of  puberty,  which  in 
the  psychic  sphere  appears  much  earlier  than  in  the  body,  but  sexual  phantasy 
maintains  a  perverse  constellated  direction  by  reason  of  the  infantile  sexual 
activities.  On  constitutional  (affect)  grounds  the  increased  fantasy  of  the 
hysteric  leads  to  the  formation  of  complexes  which  are  not  taken  up  by  the 
personality  and  by  reason  of  shame  or  disgust  remain  buried.  There,  there- 
fore, results  a  conflict  between  the  characteristic  normal  libido  and  the  sexual 
repressions  of  these  buried  infantile  perversions.  These  conflicts  give  rise  to 
the  hysterical  symptoms.  It  is  in  his  contributions  to  the  sexual  theory  that 
Freud  develops  his  later  thoughts  of  the  sexual  origin  of  the  hysterical  reac- 
tion. By  sexual  it  is  important  to  remember  that  Freud  is  not  speaking  of 
sensual. 

"The  significance  of  Freud's  theory  is-  the  tracing  of  every  case  to  sexual 
traumata  during  early  childhood.  Sexual  experiences  differ,  however,  from, 
ordinary  experiences — the  latter  have  a  tendency  to  fade  out,  while  the  idea 
of  the  former  grows  with  increasing  sexual  maturity.  There  results  a  dis- 
proportionate capacity  for  increased  reaction  which  takes  place  in  the  sub- 
conscious. This  is  the  cause  of  the  mischief. 

"There  must  be,  however,  a  connecting  link  between  the  infantile  sexual 
traumata  and  the  later  manifestations.  This  connection  Freud  finds  in  the 
so-called  ^hysterical  fancies/  These  are  the  day-dreams  of  erotic  coloring, 
wish-gratifications,  originating  in  privation  and  longing.  These  fancies  hark 
back  to  the  original  traumatic  moment,  and,  either  originating  in  the  sub- 
conscious or  shortly  becoming  conscious,  are  transformed  into  hysterical  symp- 
toms. They  constitute  a  defence  of  the  ego  against  the  revival,  as  reminis- 
cences, of  the  repressed  traumatic  experiences  of  childhood"  (White). 

The  affection  is  most  common  in  women,  and  usually  appears  first  about 
the  time  of  puberty,  but  the  manifestations  may  continue  until  the  menopause, 
or  even  until  old  age.  Men,  however,  are  by  no  means  exempt,  and  hysteria 
in  the  male  is  not  rare.  It  occurs  in  all  races,  but  is  much  more  prevalent, 
particularly  in  its  severer  forms,  in  members  of  the  Latin  race.  In  England 
and  the  United  States  the  milder  grades  are  common,  but  the  graver  forms 
are  rare  in  comparison  with  the  frequency  with  which  they  are  seen  in  France. 

Children  under  twelve  years  of  age  are  not  very  often  affected,  but  the 
disease  may  be  well  marked  as  early  as  the  fifth  or  sixth  year.  One  of  the 
saddest  chapters  in  the  history,  of  human  deception,  that  of  the  Salem  witches, 
might  be  headed  hysteria  in  children,  since  the  tragedy  resulted  directly  from 
the  hysterical  pranks  of  girls  under  twelve  years  of  age. 

Of  predisposing  causes,  two  are  important — heredity  and  education.  The 
former  acts  by  endowing  the  child  with  a  mobile,  abnormally  sensitive  nervous 
organization.  We  see  cases  most  frequently  in  families  with  marked  neuro- 
pathic tendencies,  the  members  of  which  have  suffered  from  neuroses  of  vari- 


HYSTEEIA  1097 

cms  sorts.  Education  at  home  too  often  fails  to  inculcate  habits  of  self  control. 
A  child  grows  to  girlhood  with  an  entirely  erroneous  idea  of  her  relations  to 
others,  and  accustomed  to  have  every  whim  gratified  and  abundant  sympathy 
lavished  on  every  woe,  however  trifling;  she  reaches  womanhood  with  a  moral 
organization  unfitted  to  withstand  the  cares  and  worries  of  every-day  life.  At 
school,  between  the  ages  of  twelve  and  fifteen,  the  most  important  period  in 
her  life,  when  the  vital  energies  are  absorbed  in  the  rapid  development  of  the 
body,  she  is  often  cramming  for  examinations  and  cooped  in  close  school  rooms 
for  six  or  eight  hours  daily.  The  result  too  frequently  is  an  active,  bright 
mind  in  an  enfeebled  body,  ill  adapted  to  subserve  the  functions  for  which  it 
was  framed,  easily  disordered,  and  prone  to  react  abnormally  to  the  ordinary 
stimuli  of  life.  Among  the  more  direct  influences  are  emotions  of  various 
kinds,  fright  occasionally,  more  frequently  love  affairs,  grief,  and  domestic 
worries.  Physical  causes  less  often  bring  on  hysterical  outbreaks,  but  they 
may  follow  directly  upon  an  injury  or  develop  during  the  convalescence  from 
an  acute  illness  or  be  associated  with  disease  of  the  generative  organs. 

Symptoms. — A  useful  division  is  into  the  convulsive  and  non-convulsive 
varieties. 

CONVULSIVE  HYSTEEIA. — (a)  Minor  Forms. — The  attack,  commonly  fol- 
lowing emotional  disturbance,  sets  in  suddenly  or  may  be  preceded  by  symp- 
toms, called  by  the  laity  "hysterical,"  such  as  laughing  and  crying  alternately, 
or  a  sensation  of  constriction  in  the  neck,  or  of  a  ball  rising  in  the  throat — 
the  globus  hystericus.  Sometimes,  preceding  the  convulsive  movements,  there 
may  be  painful  sensations  arising  from  the  pelvic,  abdominal,  or  thoracic 
regions.  From  the  description  these  sensations  resemble  aura?.  They  become 
more  intense  with  the  rising  sensation  of  choking  in  the  neck  and  difficulty  in 
getting  breath,  and  the  patient  falls  into  a  more  or  less  violent  convulsion. 
The  fall  is  not  sudden,  as  in  epilepsy,  but  the  subject  goes  down,  as  a  rule, 
easily,  often  picking  a  soft  spot,  like  a  sofa  or  an  easy-chair,  and  in  the  move- 
ments apparently  exercises  care  to  do  herself  no  injury.  Yet  at  the  same  time 
she  appears  to  be  quite  unconscious.  The  movements  are  clonic  and  disorderly, 
while  the  head  and  arms  are  thrown  about  in  an  irregular  manner.  The  par- 
oxysm after  a  few  minutes  slowly  subsides,  then  the  patient  becomes  emo- 
tional, and  gradually  regains  consciousness.  When  questioned  the  patient  may 
confess  to  having  some  knowledge  of  the  events  which  have  taken  place,  but, 
as  a  rule,  has  no  accurate  recollection.  During  the  attack  the  abdomen  may  be 
much  distended  with  flatus,  and  subsequently  a  large  amount  of  clear  urine 
may  be  passed.  These  attacks  vary  greatly  in  character.  There  may  be 
scarcely  any  movements  of  the  limbs,  but  after  a  nerve  storm  the  patient  sinks 
into  a  torpid,  semi-unconscious  condition,  from  which  she  is  roused  with 
great  difficulty.  In  some  cases  from  this  state  the  patient  passes  into  a  condi- 
tion of  catalepsy. 

(&)  Major  Forms;  Hystero-epilepsy—  Typical  instances  passing  through 
the  various  phases  are  very  rare  in  the  United  States  and  in  England.  The 
attack  is  initiated  by  certain  prodromata,  chiefly  minor  hysterical  manifesta- 
tions, either  foolish  or  unseemly  behavior,  excitement,  sometimes  dyspeptic 
symptoms  with  tympanites,  or  frequent  micturition.  Areas  of  hyperasthesia 
may  at  this  time  be  marked,  the  so-called  hysterogenic  spots  so  elaborately  de- 
scribed by  Eichet.  These  are  usually  symmetrical  and  situated  over  the  upper 
71 


1098  DISEASES    OF    THE    NERVOUS    SYSTEM 

dorsal  vertebra,  and  in  front  in  a  series  of  symmetrically  placed  spots  on  the 
chest  and  abdomen,  the  most  marked  being  those  in  the  inguinal  regions  over 
the  ovaries.  Painful  sensations  or  a  feeling  of  oppression  and  a  globus  rising 
in  the  throat  may  be  complained  of  prior  to  the  onset  of  the  convulsion,  which, 
according  to  French  writers,  has  four  distinct  stages:  (1)  Epileptoid  condition, 
which  closely  simulates  a  true  epileptic  attack  with  tonic  spasm  (often  leading 
to  opisthotonos),  grinding  of  the  teeth,  congestion  of  the  face,  followed  by 
clonic  convulsions,  gradual  relaxation,  and  coma.  (2)  Succeeding  this  is  the 
period  which  Charcot  has  termed  clownism,  in  which  there  is  an  emotional 
display  and  a  remarkable  series  of  contortions  or  of  cataleptic  poses.  (3)  Then 
in  typical  cases  there  is  a  stage  in  which  the  patient  assumes  certain  attitudes 
expressive  of  the  various  passions — ecstasy,  fear,  beatitude,  or  erotism.  (4) 
Finally  consciousness  returns  and  the  patient  enters  upon  a  stage  in  which 
she  may  display  very  varied  symptoms,  chiefly  manifestations  of  a  delirium 
with  the  most  extraordinary  hallucinations.  Visions  are  seen,  voices  heard^ 
and  conversations  held  with  imaginary  persons.  In  this  stage  patients  will 
relate  with  the  utmost  solemnity  imaginary  events,  and  make  extraordinary 
and  serious  charges  against  individuals.  This  sometimes  gives  a  grave  aspect 
to  these  seizures,  for  not  only  will  the  patient  at  this  stage  make  and  believe 
the  statements,  but  when  recovery  is  complete  the  hallucination  sometimes  per- 
sists. After  an  attack  a  patient  may  remain  for  days  in  a  state  of  lethargy 
or  trance. 

NON-CONVULSIVE  FORMS. — So  complex  and  varied  is  the  clinical  picture 
of  hysteria  that  various  manifestations  are  best  considered  according  to  the 
systems  which  are  involved. 

(a)  Disorders  of  Motion. —  (1)  Paralysis. — These  may  be  hemiplegic,  para- 
plegic, or  monoplegic.  Hysterical  diplegia  is  extremely  rare.  The  paralysis 
either  sets  in  abruptly  or  gradually,  and  may  take  weeks  to  attain  its  full 
development.  There  is  no  type  or  form  of  organic  paralysis  which  may  not 
be  simulated  in  hysteria.  Sensation  is  either  lessened  or  lost  on  the  affected 
side.  The  hysterical  paraplegia  is  more  common  than  hemiplegia.  The  loss 
of  power  is  not  absolute ;  the  legs  can  usually  be  moved,  but  do  not  support  the 
patient.  The  reflexes  may  be  increased,  though  the  knee-jerk  is  often  normal. 
A  spurious  ankle  clonus  may  sometimes  be  present.  The  feet  are  usually  ex- 
tended and  turned  inward  in  the  equino-varus  position.  The  muscles  do  not 
waste  and  the  electrical  reactions  are  normal.  Other  manifestations,  such  as 
paralysis  of  the  bladder  or  aphonia,  are  usually  associated  with  the  hysterical 
paraplegia.  Hysterical  monoplegias  may  be  facial,  crural,  or  brachial.  A  con- 
dition of  ataxia  sometimes  occurs  with  paresis.  The  incoordination  may  be  a 
marked  feature,  and  there  are  usually  sensory  manifestations. 

(2)  Contractures  and  Spasms. — The  hysterical  contractures  may  attack 
almost  any  group  of  voluntary  muscles  and  be  of  the  hemiplegic,  paraplegic, 
or  monoplegic  type.  They  may  come  on  suddenly  or  slowly,  persist  for  months 
or  years,  and  disappear  rapidly.  The  contracture  is  most  commonly  seen  in 
the  arm,  which  is  flexed  at  the  elbow  and  wrist,  while  the  fingers  tightly  grasp 
the  thumb  in  the  palm  of  the  hand;  more  rarely  the  terminal  phalanges  are 
hyperextended  as  in  athetosis.  It  may  occur  in  one  or  in  both  legs,  more  com- 
monly in  one.  The  ankle  clonus  is  present;  the  foot  is  inverted  and  the  toes 
are  strongly  flexed.  These  cases  may  be  mistaken  for  lateral  sclerosis  and  the 


HYSTERIA  1099 

difficulty  in  diagnosis  may  really  be  very  great.  The  spastic  gait  is  very 
typical,  and  with  the  exaggerated  knee-jerk  and  ankle  clonus  the  picture  may 
be  characteristic.  Other  forms  of  contracture  may  be  in  the  muscles  of  the 
hip,  shoulder,  or  neck ;  more  rarely  in  those  of  the  jaws — hysterical  trismus — 
or  in  the  tongue.  Remarkable  indeed  are  the  local  contractures  in  the  dia- 
phragm and  abdominal  muscles,  producing  a  phantom  tumor,  in  which  just 
below  and  in  the  neighborhood  of  the  umbilicus  is  a  firm,  apparently  solid 
growth.  According  to  Gowers,  this  is  produced  by  relaxation  of  the  recti  and 
a  spasmodic  contraction  of  the  diaphragm,  together  with  inflation  of  the  in- 
testines with  gas  and  an  arching  forward  of  the  vertebral  column.  They  are 
apt  to  occur  in  middle-aged  women  about  the  menopause,  and  are  frequently 
associated  with  the  symptoms  of  spurious  pregnancy — pseudo-cyesis.  The 
resemblance  to  a  tumor  may  be  striking,  and  I  have  known  skilful  diagnos- 
ticians to  be  deceived.  The  only  safeguard  is  to  be  found  in  complete  anaes- 
thesia, when  the  tumor  entirely  disappears.  Mitchell  has  reported  an  instance 
of  a  phantom  tumor  in  the  left  pectoral  region  just  above  the  breast,  which 
was  tender,  hard,  and  dense. 

Rhythmic  Hysterical  Spasm. — The  movements  may  be  of  the  arm,  either 
flexion  and  extension,  or,  more  rarely,  pronation  and  supination.  Clonic  con- 
tractions of  the  sterno-cleido-mastoid  or  of  the  muscles  of  the  jaws  or  of  the 
rotatory  muscles  of  the  head  may  produce  rhythmic  movements  of  these  parts. 
The  spasm  may  be  in  one  or  both  psoas  muscles,  lifting  the  leg  in  a  rhythmic 
manner  eight  or  ten  times  in  a  minute.  In  other  instances  the  muscles  of  the 
trunk  are  affected,  and  every  few  moments  there  is  a  bowing  movement — 
salaam  convulsions — or  the  muscles  of  the  back  may  contract,  causing  strong 
arching  of  the  vertebral  column  and  retraction  of  the  head. 

Tremor  may  be  a  purely  hysterical  manifestation,  occurring  either  alone 
or  with  paralysis  and  contracture.  It  most  commonly  involves  the  hands  and 
arms;  more  rarely  the  head  and  legs.  The  movements  are  small  and  quick. 
In  the  type  described  by  Rendu  the  tremor  may  or  may  not  persist  during 
repose,  but  it  is  increased  or  provoked  by  volitional  movements.  Volitional 
or  intentional  tremor  may  exist,  simulating  closely  the  movements  of  insular 
sclerosis.  Buzzard  states  that  many  instances  of  this  disease  in  young  girls 
are  mistaken  for  hysteria. 

(b)  Disorders  of  Sensation. — Anaesthesia  is  most  common,  and  usually  con- 
fined to  one  half  of  the  body.  It  may  not  be  noticed  by  the  patient.  Usually 
it  is  accurately  limited  by  the  middle  line  and  involves  the  mucous  surfaces  and 
deeper  parts.  The  conjunctiva,  however,  is  often  spared.  There  may  be  hemi- 
anopia.  This  symptom  may  come  on  slowly  or  follow  a  convulsive  attack. 
Sometimes  the  various  sensations  are  dissociated  and  the  anesthesia  may  be 
only  to  pain  and  to  touch.  The  skin  of  the  affected  side  is  usually  pale  and 
cool,  and  a  pin-prick  may  not  be  followed  by  blood.  With  the  loss  of  feeling 
there  may  be  loss  of  muscular  power.  Curious  trophic  changes  may  be  present, 
as  in  an  interesting  case  of  Weir  Mitchell's,  in  which  there  was  unilateral 
swelling  of  the  hemiplegic  side. 

By  metallotherapy,  the  application  of  certain  metals,  the  anaesthesia  or 
analgesia  can  be  transferred  to  the  other  side  of  the  body.  It  has  been  shown, 
however,  that  this  phenomenon  may  be  caused  by  the  electro-magnet  and  by 
wood  and  various  other  agents,  and  is  an  effect  of  suggestion. 


1100  DISEASES    OF    THE    NERVOUS    SYSTEM 

Hypercesthesia. — Increased  sensitiveness  and  pains  occur  in  various  parts 
of  the  body.  One  of  the  most  frequent  complaints  is  of  pain  in  the  head, 
usually  over  the  sagittal  suture,  less  frequently  in  the  occiput.  This  is  de- 
scribed as  agonizing,  and  is  compared  to  the  driving  of  a  nail  into  the  part; 
hence  the  name  clavus  hystericus.  Neuralgias  are  common.  Hyperaesthetic 
areas,  the  hysterogenic  points,  exist  on  the  skin  of  the  thorax  and  abdomen, 
pressure  upon  which  may  cause  minor  manifestations  or  even  a  convulsive 
attack.  Increased  sensitiveness  exists  in  the  ovarian  region,  but  is  not  pecu- 
liar to  hysteria.  Pain  in  the  back  is  an  almost  constant  complaint  of  hysterical 
patients.  The  sensitiveness  may  be  limited  to  certain  spinous  processes,  or  it 
may  be  diffuse.  In  hysterical  women  the  pains  in  the  abdomen  may  simulate 
those  of  gastralgia  and  of  gastric  ulcer,  or  the  condition  may  be  almost  identi- 
cal with  that  of  peritonitis;  more  rarely  the  abdominal  pains  closely  resemble 
those  of  appendix  disease. 

Special  Senses. — Disturbances  of  taste  and  smell  are  not  uncommon  and 
may  cause  a  good  deal  of  distress.  Of  ocular  symptoms,  retinal  hyperaasthesia 
is  the  most  common,  and  the  patients  always  prefer  to  be  in  a  darkened  room. 
Retraction  of  the  field  of  vision  is  common  and  usually  follows  a  convulsive 
seizure.  It  may  persist  for  years.  The  color  perception  may  be  normal  even 
with  complete  anaesthesia.  Hysterical  deafness  may  be  complete  and  may 
alternate  or  come  on  at  the  same  time  with  hysterical  blindness.  Hysterical 
amaurosis  may  occur  in  children.  One  must  carefully  distinguish  between 
functional  loss  of  power  and  simulation. 

(c)  Visceral  Manifestations. — Respiratory  Apparatus. — Of  disturbances  in 
the  respiratory  rhythm,  the  most  frequent,  perhaps,  is  an  exaggeration  of  the 
deeper  breath,  which  is  taken  normally  every  fifth  or  sixth  inspiration,  or 
there  may  be  a  "catching"  breathing,  such  as  is  seen  when  cold  water  is 
poured  over  a  person.  In  hysterical  dyspnoea  there  is  no  special  distress  and 
the  pulse  is  normal.  In  what  is  known  as  the  syndrome  of  Briquet  there  are 
shortness  of  breath,  suppression  of  the  voice,  and  paralysis  of  the  diaphragm. 
The  anhelation  is  extreme.  In  rare  instances  there  is  bradypncea.  Among 
laryngeal  manifestations  aphonia  is  frequent  and  may  persist  for  months  or 
even  years  without  other  special  symptoms  of  the  disease.  Spasm  of  the 
muscles  may  occur  with  violent  inspiratory  efforts  and  great  distress,  and 
may  even  lead  to  cyanosis.  Hiccough,  or  sounds  resembling  it,  may  be  present 
for  weeks  or  months  at  a  time.  Among  the  most  remarkable  of  the  respiratory 
manifestations  are  the  hysterical  cries.  These  may  mimic  the  sounds  produced 
by  animals,  such  as  barking,  mewing,  or  grunting,  and  in  France  epidemics 
of  them  have  been  repeatedly  observed.  Extraordinary  cries  may  be  produced, 
either  inspiratory  or  expiratory.  Attacks  of  gaping,  yawning,  and  sneezing 
may  also  occur. 

The  hysterical  cough  is  a  frequent  symptom,  particularly  in  young  girls. 
It  may  occur  in  paroxysms,  but  is  often  a  dry,  persistent,  croaking  cough, 
extremely  monotonous  and  unpleasant  to  hear.  Sir  Andrew  Clark  has  called 
attention  to  a  loud,  barking  cough  (cynobex  hebetica)  occurring  about  the 
time  of  puberty,  chiefly  in  boys  belonging  to  neurotic  families.  The  attacks, 
which  last  about  a  minute,  recur  frequently. 

A  peculiar  form  of  hysterical  haemoptysis  may  be  very  deceptive  and  lead 
to  the  diagnosis  of  pulmonary  disorders.  The  sputum  is  a  pale-red  fluid,  not 


HYSTERIA  HOI 

so  bright  in  color  as  in  ordinary  haemoptysis,  and  on  settling  presents  a  red- 
dish-brown sediment.  It  contains  particles  of  food,  pavement  epithelium,,  red 
corpuscles,  and  micrococci,  but  no  cylindrical  or  ciliated  epithelium.  It 
probably  comes  from  the  mouth  or  pharynx. 

Digestive  System. — Disturbed  or  depraved  appetite,  dyspepsia,  and  gastric 
pains  are  common  in  hysterical  patients.  The  patient  may  have  difficulty  in 
swallowing  the  food,  apparently  from  spasm  of  the  gullet.  There  are  instances 
in  which  the  food  seems  to  be  expelled  before  it  reaches  the  stomach.  In  other 
cases  there  is  incessant  gagging.  In  the  hysterical  vomiting  the  food  is  regur- 
gitated without  much  effort  and  without  nausea.  This  feature  may  persist  for 
years  without  great  disturbance  of  nutrition.  The  most  striking  and  remark- 
able digestive  disturbance  in  hysteria  is  the  anorexia  nervosa  described  by  Sir 
William  Gull.  "To  call  it  loss  of  appetite — anorexia — but  feebly  character- 
izes the  symptom.  It  is  rather  an  annihilation  of  appetite,  so  complete  that 
it  seems  in  some  cases  impossible  ever  to  eat  again.  Out  of  it  grows  an 
antagonism  to  food  which  results  at  last  and  in  its  worst  forms  in  spasm  on 
the  approach  of  food,  and  this  in  turn  gives  rise  to  some  of  those  remarkable 
cases  of  survival  for  long  periods  without  food"  (Mitchell).  There  are  three 
special  features  in  anorexia  nervosa :  First,  and  most  important,  a  psychical 
state,  usually  depressant,  occasionally  excited  and  restless.  It  is  not  always 
hysterical.  Secondly,  stomach  symptoms,  loss  of  appetite,  regurgitation,  vom- 
iting, and  the  whole  series  of  phenomena  associated  with  nervous  dyspepsia. 
Thirdly,  emaciation,  which  reaches  a  grade  seen  only  in  cancer  and  dysentery. 
The  patient  finally  takes  to  bed,  and  in  extreme  cases  lies  upon  one  side  with 
the  thighs  and  legs  flexed,  and  contractures  may  occur.  Food  is  either  not 
taken  at  all  or  only  upon  urgent  compulsion.  The  skin  becomes  wasted,  dry, 
and  covered  with  bran-like  scales.  No  food  may  be  taken  for  several  weeks  at 
a  time,  and  attempts  to  feed  may  be  followed  by  severe  spasms.  Although  the 
condition  looks  so  alarming,  these  cases,  when  removed  from  their  home  sur- 
roundings and  treated  by  Weir  Mitchell's  method,  sometimes  recover  in  a 
remarkable  way.  It  may  take  many  months  before  any  improvement  is  noted. 
Death,  however,  may  follow  with  extreme  emaciation.  In  a  fatal  case  under 
my  care  the  girl  weighed  only  49  pounds.  No  lesions  were  found  post  mortem. 

Hysterical  tympanites  is  a  common  feature,  caused  usually  by  tonic  con- 
traction of  the  diaphragm  and  retraction  of  the  other  abdominal  muscles.  It 
may  be  associated  with  the  condition  of  peristaltic  unrest  (Kussmaul).  Fre- 
quent discharges  of  fasces  may  be  due  to  disturbance  in  either  the  small  or 
large  bowel.  An  obstinate  form  of  diarrhoea  is  found  in  some  hysterical 
patients,  which  proves  very  intractable  and  is  associated  especially  with  the 
taking  of  food.  It  seems  an  aggravated  form  of  the  looseness  of  bowels  to 
which  so  many  nervous  people  are  subject  on  emotion  or  of  the  tendency  which 
some  have  to  diarrhoea  immediately  after  eating.  An  entirely  different  form 
is  that  produced  by  what  Mitchell  calls  the  irritable  rectum,  in  which  scybala 
are  passed  frequently  during  the  day,  sometimes  with  great  violence.  Con- 
stipation is  more  frequent,  however,  and  may  be  due  to  a  loss  of  power  in  the 
muscles  of  the  bowel,  or  in  the  abdominal  muscles.  In  extreme  cases  the 
bowels  may  not  be  moved  for  two  or  three  weeks,  leading  to  great  accumula- 
tion of  fasces.  Other  disturbances  are  ano-spasm  or  intense  pain  in  the  rectum 
apart  from  any  fissure.  Hysterical  ileus  and  faecal  vomiting  are  among  the 


1102  DISEASES    OF    THE    NERVOUS    SYSTEM 

most  remarkable  of  hysterical  phenomena.  Following  a  shock  there  are  con* 
stipation,  tympanites,  vomiting,  sometimes  hsematemesis.  The  constipation 
grows  worse,  everything  taken  by  the  mouth  is  rejected,  the  vomitus  becomes 
faecal  in  character,  even  scybala  are  brought  up,  and  suppositories  and  enemata 
are  vomited.  The  symptoms  may  continue  for  weeks  and  then  gradually  sub- 
side. Laparotomy — even  thrice  in  one  patient — has  shown  a  perfectly  normal- 
looking  condition  of  the  bowels  (Parkes  Weber). 

Cardio-vascular. — Rapid  action  of  the  heart  on  the  slightest  emotion,  with 
or  without  the  subjective  sensation  of  palpitation,  is  often  a  source  of  great 
distress.  A  slow  pulse  is  less  frequent.  Pains  about  the  heart  may  simulate 
angina.  Flushes  in  various  parts  are  among  the  most  common  symptoms. 
Sweating  may  occur,  or  the  seborrhcea  nigricans,  causing  a  darkening  of  the 
skin  of  the  eyelids. 

Among  the  more  remarkable  vaso-motor  phenomena  are  the  so-called  stig- 
mata or  haemorrhages  in  the  skin,  such  as  were  present  in  the  celebrated  case 
of  Louise  Lateau.  In  many  cases  these  are  undoubtedly  fraudulent,  but  if, 
as  appears  credible,  such  bleeding  may  exist  in  the  hypnotic  trance,  there  seems 
no  reason  to  doubt  its  occurrence  in  the  trance  of  prolonged  religious  ecstasy. 

(d)  Joint  Affections. — To  Sir  Benjamin  Brodie  and  Sir  James  Paget  we 
owe  the  recognition  of  these  extraordinary  manifestations  of  hysteria.     Per- 
haps no  single  affection  has  brought  more  discredit  upon  the  profession,  for 
the  cases  are  very  refractory,  and  finally  fall  into  the  hands  of  a  charlatan  or 
faith-healer,  under  whose  touch  the  disease  may  disappear  at  once.     Usually 
it  affects  the  knee  or  the  hip,  and  may  follow  a  trifling  injury.     The  joint  is 
usually  fixed,  sensitive,  and  swollen.    The  surface  may  be  cool,  but  sometimes 
the  local  temperature  is  increased.     To  the  touch  it  is  very  sensitive  and 
movement  causes  great  pain.    In  protracted  cases  the  muscles  about  the  joint 
are  somewhat  wasted,  and  in  consequence  it  looks  larger.    The  pains  are  often 
nocturnal,  at  which  time  the  local  temperature  may  be  much  increased.    While, 
as  a  rule,  neuromimetic  joints  yield  to  proper  management,  there  are  inter- 
esting instances  in  the  literature  in  which  organic  change  has  succeeded  the 
functional  disturbance. 

Intermittent  hydrarthrosis  may  be  a  manifestation  of  hysteria,  occurring 
in  the  knee  or  other  joints,  sometimes  with  transient  paresis. 

(e)  Mental  Symptoms. — Mental  perversions  of  all  kinds  are  common  in 
hysterical  patients  and  not  much  dependence  can  be  placed  on  statements 
either  about  themselves  or  about  others.    A  morbid  craving  for  sympathy  may 
lead  to  the  commission  of  all  sorts  of  bizarre  and  foolish  acts. 

Hallucinations  and  delirium  may  alternate  with  emotional  outbursts  of  an 
aggravated  character.  There  is  an  interesting  condition  which  may  be  spoken 
of  as  the  status  hystericus.  For  weeks  or  months  they  may  be  confined  to  bed, 
entirely  oblivious  to  their  surroundings,  with  a  dilirium  which  may  simulate 
that  of  delirium  tremens,  particularly  in  being  associated  with  loathsome  and 
unpleasant  animals.  The  nutrition  may  be  maintained,  but  there  is  always  a 
very  heavy,  foul  breath.  With  seclusion  and  care  recovery  usually  takes  place 
within  three  or  four  months.  At  the  onset  of  these  attacks  and  during  con- 
valescence the  patients  must  be  incessantly  watched,  as  a  suicidal  tendency 
is  by  no  means  uncommon. 

Of  hysterical  manifestations  in  the  higher  centres  that  of  trance  is  the 


HYSTERIA  1103 

most  remarkable.  This  may  develop  spontaneously  without  any  convulsive 
seizure,  but  more  frequently  it  follows  hysteroid  attacks.  Catalepsy  may  be 
present,  a  condition  in  which  the  limbs  are  plastic  and  remain  in  any  position 
in  which  they  are  placed. 

_  (/)  The  Metabolism  in  Hysteria. — In  the  ordinary  forms  of  hysteria  the 
urine  does  not  show  quantitative  or  qualitative  changes,  but  in  the  severer 
types,  characterized  by  convulsions,  etc.,  there  are  important '  modifications ; 
reduction  in  the  urates  and  phosphates ;  the  ratio  of  the  earthy  to  the  alkaline 
phosphates,  normally  1 :3,  is  1 :2,  or  even  1 :1.  The  urine  is  also  reduced  in 
amount. 

(g)  Self  inflicted  wounds,  more  particularly  burns,  are  sometimes  met 
with  in  hysterical  patients.  I  saw  at  the  Hotel  Dieu,  Paris,  the  remarkable 
condition  described  by  Dieulafoy  under  the  term  Pathomimia,  in  which  a 
young  woman  supposed  to  be  the  subject  of  a  severe  trophic  disorder  sub- 
mitted to  the  amputation  of  the  left  arm  before  the  confession  was  obtained 
that  the  lesions  were  self-inflicted !  It  is  to  be  borne  in  mind  that  in  Japan 
and  other  Eastern  countries  spontaneous  tears  occur  in  the  soft  parts,  usually 
of  the  legs — the  so-called  Kamitachi  disease,  believed  to  be  due  to  variations 
in  atmospheric  conditions,  particularly  during  thunderstorms. 

(li)  Hysterical  Fever. — In  hysteria  the  temperature,  as  a  rule,  is  normal. 
The  cases  with  fever  may  be  grouped  as  follows:  (1)  Instances  in  which  the 
fever  is  the  sole  manifestation.  These  are  rare,  but  I  have  seen  cases  in  which 
the  chronic  course,  the  retention  of  the  nutrition,  and  the  entirely  negative 
condition  of  the  organs  left  no  other  diagnosis  possible.  In  one  case  the 
patient  had  for  four  or  five  years  an  afternoon  rise  of  temperature,  reaching 
usually  to  102°  or  103°.  She  was  well  nourished  and  presented  no  pro- 
nounced hysterical  symptoms,  beyond  a  form  of  interrupted  sighing  respira- 
tion so  often  seen  in  hysteria.  There  was  a  marked  neurotic  history  on  one 
side  of  the  family. 

(2)  Cases  of  hysterical  fever  with  spurious  local  manifestations.     These 
are  very  troublesome  and  deceptive  cases.    The  patient  may  be  suddenly  taken 
ill  with  pain  in  various  regions  and  elevation  of  temperature.    The  case  may 
simulate  meningitis.     There  may  be  pain  in  the  head,  vomiting,  contracted 
pupils,  and  retraction  of  the  neck — symptoms  which  may  persist  for  weeks — 
and  some  anomalous  manifestation  during  convalescence  may  alone  indicate 
to  the  physician  that  he  has  had  to  deal  with  a  case  of  hysteria,  and  has  not, 
as  he  perhaps  flattered  himself,  cured  a  case  of  meningitis.     Mary  Putnam 
Jacobi,  in  an  article  on  hysterical  fever,  mentions  a  case  in  the  service  of 
Cornil  which  was  admitted  with  dyspnoea,  slight  cyanosis,  and  a  temperature 
of  39°  C.    The  condition  proved  to  be  hysterical.    There  is  also  an  hysterical 
pseudo-phthisis  with  pain  in  the  chest,  slight  fever,  and  the  expectoration  of  a 
blood-stained  mucus.    The  cases  of  hysterical  peritonitis  may  also  show  fever. 

(3)  Hysterical  Hyperpyrexia. — It  is  a  suggestive  fact  that  the  cases  of 
paradoxical  temperatures  reported  of  late  years,  in  which  the  thermometer  has 
registered  112°  to  120°  or  more,  have  been  in  women.    Fraud  has  been  prac- 
tised in  nearly  all  these  cases. 

Diagnosis. — Inquiry  into  the  occurrence  of  previous  manifestations  and 
the  mental  conditions  may  give  important  information.  These  questions,  as 
a  rule,  should  not  be  asked  the  mother,  who  of  all  others  is  least  likely  to  give 


1104  DISEASES    OF   THE   NERVOUS    SYSTEM 

satisfactory  information  about  the  patient's  condition.  The  occurrence  of  the 
globus  hystericus,  of  emotional  attacks,  of  weeping  and  crying  is  always 
suggestive.  The  points  of  difference  between  the  convulsive  attacks  and  true 
epilepsy  were  referred  to  in  their  description,  and,  as  a  rule,  little  difficulty  is 
experienced  in  distinguishing  between  the  two  conditions.  The  hysterical 
paralyses  are  very  variable  and  apt  to  be  associated  with  anaesthesia.  The 
contractures  may  at  times  be  very  deceptive,  but  the  occurrence  of  areas  of 
anaesthesia,  of  retraction  of  the  visual  field,  and  the  development  of  minor 
hysterical  manifestations  give  valuable  indications.  The  contractures  disap- 
pear under  full  anaesthesia.  Special  care  must  be  taken  not  to  confound  the 
spastic  paraplegia  of  hysteria  with  lateral  sclerosis. 

The  visceral  manifestations  are  usually  recognized  without  much  difficulty. 
The  practitioner  has  constantly  to  bear  in  mind  the  strong  tendency  in  hys- 
terical patients  to  practice  deception. 

Treatment. — The  prophylaxis  in  hysteria  may  be  gathered  from  the  re- 
marks on  the  relation  of  education  to  the  disease.  The  successful  treatment 
of  hysteria  demands  qualities  possessed  by  few  physicians.  The  first  element 
is  a  due  appreciation  of  the  nature  of  the  disease  on  the  part  of  the  physician 
and  friends.  It  is  pitiable  to  think  of  the  misery  which  has  been  inflicted  on 
these  unhappy  victims  by  the  harsh  and  unjust  treatment  which  has  resulted 
from  false  views  of  the  nature  of  the  trouble;  on  the  other  hand,  worry  and 
ill  health,  often  the  wrecking  of  mind,  body,  and  estate,  are  entailed  upon 
the  near  relatives  in  the  nursing  of  a  protracted  case  of  hysteria.  The  minor 
manifestations,  attacks  of  the  vapors,  the  crying  and  weeping  spells,  are  not 
of  much  moment  and  rarely  require  treatment.  The  physical  condition  should 
be  carefully  looked  into  and  the  mode  of  life  regulated  so  as  to  insure  system 
and  order  in  everything.  A  congenial  occupation  offers  the  best  remedy  for 
many  of  these  manifestations.  Any  functional  disturbance  should  be  attended 
to  and  a  course  of  tonics  prescribed.  Special  attention  should  be  paid  to  the 
action  of  the  bowels. 

PSYCHOTHERAPY,  in  which  the  important  features  are  hypnosis,  sugges- 
tion, and  reeducation. 

Hypnosis. — The  majority  of  hysterical  patients  can  be  hypnotized,  but  the 
general  opinion  now  of  those  who  know  most  on  the  subject  is  that  by  hyp- 
nosis alone  hysteria  is  rarely  cured.  Sometimes  a  brilliant  miracle  is  wrought 
in  the  case  of  hysterical  paraplegia  or  hemiplegia,  but  as  a  routine  treatment 
it  has  fallen  into  disfavor  even  in  France. 

Suggestion. — 'Babinski  defines  suggestion  as  "the  action  by  which  one  en- 
deavors to  make  another  accept  or  realize  an  idea  which  is  manifestly  un- 
reasonable." On  the  other  hand,  persuasion  is  applied  when  the  ideas  are 
reasonable,  or  at  least  are  not  in  opposition  to  good  sense.  Most  writers,  how- 
ever, use  the  word  "suggestion"  as  meaning  the  introduction  of  mental  associa- 
tions and  modifications  of  the  patient's  mental  state  leading  to  betterment.  In 
proper  hands  it  is  a  most  powerful  instrument,  particularly  when  the  patient 
has  faith  in  the  person  who  makes  it.  After  a  careful  and  sympathetic  ex- 
amination and  testing  the  electrical  reactions  of  the  muscles  of  a  paralyzed 
limb  the  suggestion  to  the  hysteric,  "Now  I  think  you  will  be  able  to  move  it" 
may  be  all-sufficient.  A  strong,  imperative  command  may  sometimes  have  the 
same  effect. 


HYSTERIA  1105 

Reeducation. — In  both  hysteria  and  neurasthenia  this  should  be  the  aim  of 
all  reasonable  practice,  but  we  must  remember  it  is  not  always  feasible :  some 
of  our  patients  would  have  to  be  rebuilt  from  the  blastoderm.  With  patience 
and  method  much  may  be  done,  and  the  special  merit  of  Weir  Mitchell's  work 
and  of  his  system  (which  is  not  simply  a  rest  cure,  as  many  suppose)  is  that 
it  is  an  elaborate  plan  of  reeducation.  The  essentials  are  that  the  patient 
should  be  isolated  from  his  friends  and  under  the  charge  of  an  intelligent 
nurse.  The  physical  condition  is  carefully  studied  and  a  rigid  daily  regime 
carried  out :  A  milk  diet  of  three  to  four  quarts  daily,  rising  to  five  or  six, 
varying  the  food  as  the  patient  improves,  and  as  the  weight  increases.  This 
may  be  followed  by  a  rapid  gain  in  weight  and  the  disappearance  of  all  the 
unpleasant  abdominal  symptoms.  Massage,  hydrotherapy,  and  electricity  are 
brought  in  as  adjuncts,  but  very  much  depends  upon  the  tact,  patience,  and, 
above  all,  the  personality  of  the  physician;  the  man  counts  more  than  the 
method.  The  mental  condition  has  to  be  carefully  studied  and  the  patient's 
attitude  toward  life  influenced  by  specially  selected  literature,  careful  con- 
versation, and  the  suggestion  of  topics  for  thought. 

THE  ANALYTICAL  OR  CATHARTIC  METHOD. — Introduced  by  Breuer  and 
extended  by  Freud,  it  is  in  reality  the  old  method  of  the  confessional,  in  which 
the  sinner  poured  out  his  soul  in  the  sympathetic  ear  of  the  priest.  It  is  a 
difficult  procedure,  not  for  all  to  attempt,  exhausting  alike  to  patient  and 
doctor,  and,  when  thoroughly  carried  out,  time  consuming.  In  the  hands  of 
those  who  have  practised  it,  very  good  results  have  been  obtained,  particularly 
in  young  and  carefully  selected  cases.  The  following  statement  of  the 
method  I  take  from  Jelliffe  ("System  of  Medicine,"  Vol.  VII,  page  866)  : 

"His  (Freud's)  general  procedure  is  to  place  the  patient  in  a  recumbent 
position,  the  physician  sitting  behind  the  patient's  head  at  the  end  of  the 
lounge.  The  physician  thus  remains  practically  out  of  sight  of  the  patient, 
who  is  then  asked  to  give  a  detailed  account  of  his  troubles,  and  to  say  every- 
thing that  comes  to  the  mind  irrespective  of  its  seeming  logic  or  sense,  and 
apart  from  disturbing,  mortifying,  or  unnice  suggestions.  In  all  such  his- 
tories gaps  are  inevitable.  These  the  patient  is  urged  to  fill  in  by  thinking 
closely  of  the  attendant  circumstances,  speaking  aloud  all  of  the  flitting 
thoughts  that  pass  during  this  search  ('free  association').  All  the  thoughts 
are  requested  to  be  uttered,  notwithstanding  their  disagreeable  nature.  The 
patient  must  exercise  no  critique  and  remain  passive.  It  will  be  found  that 
the  disagreeable  thoughts  are  pushed  back  with  the  greatest  resistance.  This 
is  made  all  the  more  striking  since  the  hysterical- reaction,  i.  e.,  the  symptom, 
is  the  symbolic  expression  of  the  realization  of  a  repressed  wish  and  gives  the 
patient  some  gratification.  A  great  effort  is  made  to  retain  the  symptom, 
especially  as  its  origin  is  not  really  perceived,  and  since  it  represents,  in 
symbol,  the  individual's  former  conscious  strivings.  In  psycho-analysis  one 
attempts  to  overcome  all  of  these  resistances,  and  by  a  series  of  judicious  and 
tactful  probings  reconduct  into  the  patient's  consciousness  the  hidden  thoughts 
which  underlie  these  symptoms.  Every  symptom  has  some  meaning ;  behind  it 
there  lies  some  associated  mechanism,  the  origin  of  which  the  patient  uncon- 
sciously or  partly  consciously  represses.  In  the  psycho-neurotic  symbol  may 
be  read  the  cryptic  expression  of  the  original  thought  driven  back  and  hidden. 

"To  slowly  analyze  and  pick  apart  the  mechanism  is  the  object  of  the  ana- 


1106  DISEASES    OF    THE    NERVOUS    SYSTEM 

lytical  method.  One  needs  not  only  special  tact  for  such  excursions  into  the 
subtleties  of  the  mental  life  of  some  individuals,  but  also  a  developed  method 
of  interpretation.  Every  act,  every  symbolic  expression  or  action,  lapse  in 
speech,  mannerism,  needs  to  be  carefully  noted  and  its  bearing  coordinated. 
Freud  lays  particular  emphasis  on  the  analysis  of  dreams,  since  he  believes 
that  in  the  dream  the  subconscious,  or  the  'repressed  conscious'  is  more  apt  to 
reveal  itself.  Hence  a  careful  reading  of  Freud's  'Significance  of  Dreams'  is 
of  the  greatest  value  in  this  study,  also  his  'Psychopathology  of  Every-day 
Life.'  In  his  work  on  dreams  he  has  developed  to  the  full  the  chief  directions 
along  which  his  mind  has  traveled  in  the  psychoanalytical  method. 

"It  is  of  the  utmost  importance  to  trace  back  into  the  earliest  years  the 
striking  emotional  influences  that  have  come  into  experience,  as,  for  Freud, 
the  hysterical  reaction  consists  in  a  perverted  type  of  reaction  to  these  ex- 
periences. As  is  known,  the  blurring,  or  loss  of  an  emotional  influence — an 
affect,  in  short — is  due  to  a  number  of  factors.  In  normal  life  forgetting  is 
the  commonest  type  of  a  corrective  adaptation,  and  forgetting  is  carried  out 
"with  special  ease  if  the  emotional  stress  has  not  been  excessive.  Forgetting, 
however,  is  only  a  secondary  phenomenon,  and  usually  is  more  successful  if 
the  immediate  reaction  has  been  an  adequate  one.  Such  immediate  reactions 
express  themselves  as  tears,  as  anger,  as  impulsive  acts,  etc.,  and  in  such 
reactions  the  effect  is  discharged.  In  every-day  life  one  calls  it  giving  vent  to 
one's  feelings.  If,  however,  the  reaction  is  suppressed,  the  effect  becomes 
united  to  the  memory  of  the  experience,  and  an  emotional  complex,  or,  to  use 
a  rather  broad  simile,  a  psychic  boil,  results,  which  must  heal  by  absorption, 
by  discharge,  or  by  other  means.  Freud  uses  the  term  ab-react  (abreagieren) 
to  signify  the  adequate  reaction,  or  discharge  of  such  effects  or  their  resulting 
complexes.  Talking  the  whole  thing  over,  giving  vent  to  one's  secrets  and 
confessions  are  well-known  abreactions. 

"In  hysteria  certain  of  these  complexes  remain  prominent ;  they  are  neither 
reacted  too  promptly,  nor  is  their  unpleasant  feeling  tone  diminished  by  the 
blurring  process  of  forgetting,  although  it  is  characteristic  of  the  Freud  point 
of  view  that  the  actual  experience  which  gives  rise  to  them  becomes  forgotten 
and  the  cause  of  the  affect  disturbance  which  becomes  later  converted,  it  may 
be  into  physical  signs,  remains  apparently  unknown  to  the  patient.  It  must 
be  dug  out  by  psycho-analysis,  and  when  once  discovered  catharsis  takes  place 
and  the  patient  becomes  cured." 

HYDROTHERAPY  is  of  great  value,  especially  wet  packs,  salt  baths,  and 
various  douches.  General  tonics,  such  as  arsenic  and  iron,  may  be  helpful, 
especially  if  the  patients  are  nervous  and  anaemic.  Sedatives  are  rarely  indi- 
cated. Occasionally  bromides  may  be  necessary,  but  for  the  relief  of  sleepless- 
ness all  possible  measures  should  be  resorted  to  before  the  employment  of 
drugs.  The  wet  pack  given  hot  or  cold  at  night  will  usually  suffice. 

X.    NEURASTHENIA 

(Psychasthenia) 

Definition. — A  condition  of  weakness  or  exhaustion  of  the  nervous  system, 
giving  rise  to  various  forms  of  mental  and  bodily  inefficiency. 


NEURASTHENIA  1107 

The  term,  an  old  one,  but  first  popularized  by  Beard,  covers  an  ill-defined, 
motley  group  of  symptoms,  wbich  may  be  either  general  and  the  expression 
of  derangement  of  the  entire  system,  or  local,  limited  to  certain  organs ;  hence, 
the  terms  cerebral,  spinal,  cardiac,  and  gastric  neurasthenia. 

Etiology. — The  causes  may  be  grouped  as  hereditary  and  acquired. 

(a)  HEREDITARY. — We  do  not  all  start  in  life  with  the  same  amount  of 
nerve  capital.  Parents  who  have  led  irrational  lives,  indulging  in  excesses  of 
various  kinds,  or  who  have  been  the  subjects  of  nervous  complaints  or  of  men- 
tal trouble,  may  transmit  to  their  children  an  organization  which  is  defective 
in  what,  for  want  of  a  better  term,  we  must  call  "nerve  force."  Such  indi- 
viduals start  handicapped  with  a  neuropathic  predisposition,  and  furnish  a 
considerable  proportion  of  our  neurasthenic  patients.  As  van  Gieson  sonor- 
ously puts  it,  "the  potential  energies  of  the  higher  constellations  of  their 
association  centres  have  been  squandered  by  their  ancestors."  So  long  as 
these  individuals  are  content  to  transact  a  moderate  business  with  their  life 
capital,  all  may  go  well,  but  there  is  no  reserve,  and  in  the  exigencies  of  mod- 
ern life  these  small  capitalists  go  under  and  come  to  us  as  bankrupts. 

(&)  ACQUIRED. — The  functions,  though  perverted  most  readily  *in  persons 
who  have  inherited  a  feeble  organization,  may  also  be  damaged  in  persons  with 
no  neuropathic  predisposition  by  exercise  which  is  excessive  in  proportion  to 
the  strength — i.  e.,  by  strain.  The  cares  and  anxieties  attendant  upon  the 
gaining  of  a  livelihood  may  be  borne  without  distress,  but  in  many  persons  the 
strain  becomes  excessive  and  is  first  manifested  as  worry.  The  individual  loses 
the  distinction  between  essentials  and  non-essentials,  trifles  cause  annoyance, 
and  the  entire  organism  reacts  with  unnecessary  readiness  to  slight  stimuli, 
and  is  in  a  state  which  the  older  writers  called  irritable  weakness.  If  such 
a  condition  be  taken  early  and  the  patient  given  rest,  the  balance  is  quickly 
restored.  In  this  group  may  be  placed  a  large  proportion  of  the  neurasthenia 
which  we  see  among  business  men,  teachers,  and  journalists.  Neurasthenia 
may  follow  the  infectious  diseases,  particularly  influenza,  typhoid  fever,  and 
syphilis.  The  abuse  of  certain  drugs,  alcohol,  tobacco,  morphine  may  lead  to 
a  high  grade  of  neurasthenia,  though  the  drug  habit  is  more  often  a  result 
rather  than  a  cause  of  the  neurasthenia. 

(c)  SEXUAL  CAUSES. — Undoubtedly  the  part  played  in  the  production  of 
hysteria  and  allied  neuroses  by  sexual  factors  is  of  the  first  importance.  As 
already  stated,  Freud  regards  sexual  trauma  as  the  basis  of  hysteria,  and  he 
also  regards  neurasthenia  as  largely  a  product  of  disturbance  in  the  sexual 
sphere.  For  him  and  his  school  the  sexual  impulses  furnish  the  basis  of  the 
psychoneuroses.  Repressed  as  they  have  to  be  in  so  many  in  our  modern 
civilization,  without  normal  outlet,  the  thought  formations,  retained  in  the 
unconscious  state,  express  themselves  by  means  of  somatic  phenomena— the 
objective  features  of  hysteria  and  neurasthenia.  Cherchez  la  femme  is  a  safe 
rule  in  investigating  a  neurotic  case.  Freud  may  have  ridden  his  hobby  too 
hard,  particularly  in  the  insistence  upon  the  importance  of  infantile  sexuality, 
but  in  recognizing  the  role  of  the  younger  Aphrodite  in  the  lives  of  men  and 
women  he  has  but  followed  the  great  master,  Plato,  who  saw,  while  he  de- 
plored, the  havoc  wrought  by  her  universal  dominance. 

The  traumatic  forms,  especially  those  following  upon  railway  accidents, 
will  be  separately  considered. 


1108  DISEASES    OF    THE    NEBVOUS    SYSTEM 

Symptoms. — These  are  extremely  varied,  and  may  be  general  or  localized; 
more  often  a  combination  of  both.  The  appearance  of  the  patient  is  sug- 
gestive, sometimes  characteristic,  but  difficult  to  describe.  Important  informa- 
tion can  be  gained  by  the  physician  if  he  observes  the  patient  closely  as  he 
enters  the  room — the  way  he  is  clothed,  the  manner  in  which  he  holds  his  body, 
his  facial  expression,  and  the  humor  which  he  is  in.  Loss  of  weight  and  slight 
ana?mia  may  be  present.  The  physical  debility  may  reach  a  high  grade  and 
the  patient  may  be  confined  to  bed.  Mentally  the  patients  are  usually  low- 
spirited  and  despondent;  women  are  frequently  emotional. 

The  local  symptoms  may  dominate  the  situation,  and  there  have  accord- 
ingly been  described  a  whole  series  of  types  of  the  disease — cerebral,  spinal, 
cardio-vascular,  gastric,  and  sexual.  In  all  forms  there  is  a  striking  lack  of 
accordance  between  the  symptoms  of  which  the  patient  complains  and  the 
objective  changes  discoverable  by  the  physician.  In  nearly  every  clinical  type 
of  the  disease  the  predominant  symptoms  are  referable  to  pathological  sensa- 
tions and  the  psychic  effects  of  these.  Imperfect  sleep  is  also  complained  of 
by  a  majority  of  patients,  or,  if  not  complained  of,  is  found  to  exist  on  inquiry. 

In'  the  cerebral  or  psychic  form  the  symptoms  are  chiefly  connected  with 
an  inability  to  perform  the  ordinary  mental  work.  Thus,  a  row  of  figures 
can  not  be  correctly  added,  the  dictation  or  the  writing  of  a  few  letters  is  a 
source  of  the  greatest  worry,  the  transaction  of  petty  details  in  business  is  a 
painful  effort,  and  there  is  loss  of  power  of  fixed  attention.  With  this  condi- 
tion there  may  be  no  headache,  the  appetite  may  be  good,  and  the  patient 
may  sleep  well.  As  a  rule,  however,  there  are  sensations  of  fulness  and  weight 
or  flushes,  if  not  actual  headache.  Sleeplessness  is  a  frequent  concomitant  of 
the  cerebral  form,  and  may  be  the  first  manifestation.  Some  of  these  patients 
are  good-tempered  and  cheerful,  but  a  majority  are  moody,  irritable,  and 
depressed. 

Hyperassthesia.,  especially  to  sensations  of  pain,  is  one  of  the  main  charac- 
teristics of  almost  all  neurasthenic  individuals.  The  sensations  are  nearly 
always  referred  to  some  special  region  of  the  body — the  skin,  eye  muscles,  the 
joints,  the  blood-vessels,  or  the  viscera.  It  is  frequently  possible  to  localize 
a  number  of  points  painful  to  pressure  (Valleix's  points).  In  some  patients 
there  is  marked  vertigo,  occasionally  even  resembling  that  of  Meniere's 
disease. 

If  such  pathological  sensations  continue  for  a  long  time  the  mood  and 
character  of  the  patient  gradually  alter.  The  so-called  "irritable  humor" 
develops.  Many  obnoxiously  egoistic  individuals  met  with  in  daily  life  are  in 
reality  examples  of  psychic  neurasthenia.  Everything  is  complained  of.  The 
patient  demands  the  greatest  consideration  for  his  condition;  he  feels  that  he 
has  been  deeply  insulted  if  his  desires  are  not  always  immediately  granted. 
He  may  at  the  same  time  have  but  little  consideration  for  others.  Indeed,  in 
the  severer  forms  of  the  disease  he  may  show  a  malicious  pleasure  in  attempt- 
ing to  make  people  who  seem  happier  than  himself  uncomfortable.  Such 
patients  complain  frequently  that  they  are  "misunderstood"  by  their  fellows. 

In  many  cases  the  so-called  "anxiety  conditions"  gradually  come  on;  one 
scarcely  ever  sees  a  case  of  advanced  neurasthenia  without  the  existence  of 
some  form  of  "anxiety."  In  the  simpler  forms  of  anxiety  (nosophobic)  there 
may  be  only  a  fear  of  impending  insanity  or  of  approaching  death  or  of  apo- 


NEURASTHENIA  1109 

plexy.  More  frequently  the  anxious  feeling  is  localized  somewhere  in  the  body 
—in  the  pra?cordial  region,  in  the  head,  in  the  abdomen,  in  the  thorax,  or  more 
rarely  in  the  extremities. 

In  some  cases  the  anxiety  becomes  intense  and  the  patients  are  restless,  and 
declare  that  they  do  not  know  what  to  do  with  themselves.  They  may  throw 
themselves  upon  a  bed,  crying  and  complaining,  and  making  convulsive  move- 
ments with  the  hands  and  feet.  Suicidal  tendencies  are  not  uncommon  in 
such  cases,  and  the  patients  may  in  desperation  actually  take  their  own  lives. 

Involuntary  mental  activity  may  be  very  troublesome;  the  patient  com- 
plains that  when  he  is  overtired  thoughts  which  he  cannot  stop  or  control 
run  through  his  head  with  lightning-like  rapidity.  In  other  cases  there  is 
marked  absence  of  ideas,  the  individual's  mind  being  so  filled  up  owing  to 
the  overexcitability  of  latent  memory  pictures  that  he  is  unable  to  form  the 
proper  associations  for  ideas  called  up  by  external  stimuli.  Sometimes  a 
patient  complains  that  a  definite  word,  a  name,  a  number,  a  melody,  or  a  song 
keeps  running  in  his  head  in  spite  of  all  he  can  do  to  abolish  it. 

In  the  severer  cases  the  so-called  "phobias"  are  common.  The  most  fre- 
quent form  perhaps  is  agoraphobia,  in  which  patients  the  moment  they  come 
into  an  open  space  are  oppressed  by  an  exaggerated  feeling  of  anxiety.  They 
seem  "frightened  to  death,"  and  commence  to  tremble  all  over ;  they  complain 
of  compression  of  the  thorax  and  palpitation  of  the  heart.  They  may  break 
into  profuse  perspiration  and  assert  that  they  feel  as  though  chained  to  the 
ground  or  that  they  can  not  move  a  step.  It  is  remarkable  that  in  some  such 
cases  the  open  space  can  be  crossed  if  the  individual  be  accompanied  by  some 
one,  even  by  a  child,  or  if  he  carry  a  stick  or  an  umbrella !  Other  people  are 
afraid  to  be  left  alone  (monophobia),  especially  in  a  closed  compartment 
(claustrophobia). 

The  fear  of  people  and  of  society  is  known  as  anthropophobia.  A  whole 
series  of  other  phobias  have  been  described — batophobia,  or  the  fear  that  high 
things  will  fall;  pathophobia,  or  fear  of  disease;  siderodromophobia,  or  fear 
of  a  railway  journey;  siderophobia  or  astrophobia,  fear  of  thunder  and  light- 
ning. Occasionally  we  meet  with  individuals  who  are  afraid  of  everything  and 
every  one — victims  of  the  so-called  pantophobia. 

The  special  senses  may  be  disturbed,  particularly  vision.  An  aching  or 
weariness  of  the  eyeballs  after  reading  a  few  minutes  or  flashes  of  light  are 
common  symptoms.  The  "irritable  eye,"  the  so-called  nervous  or  neurasthenic 
asthenopia,  is  familiar  to  every  family  physician. 

There  may  be  acoustic  disturbances — hyperalgesia  and  even  true  hyper- 
acusia. 

One  of  the  most  common  of  all  the  symptoms  of  neurasthenia  is  the  pres- 
sure in  the  head  complained  of  by  these  patients.  This  symptom,  variously  de- 
scribed, may  be  diffuse,  but  is  more  frequently  referred  to  some  one  region — 
frontal,  temporal,  parietal,  or  occipital. 

When  the  spinal  symptoms  predominate — spinal  irritation  or  spinal  neuras- 
thenia— in  addition  to  many  of  the  features  just  mentioned,  the  patients  com- 
plain of  weariness  on  the  least  exertion,  of  weakness,  pain  in  the  back,  inter- 
costal neuralgiform  pains,  and  of  aching  pains  in  the  legs.  There  may  be 
spots  of  local  tenderness  on  the  spine.  The  rachialgia  may  be  spontaneous, 
or  may  be  noticed  only  on  pressure  or  movement.  Occasionally  there  may  be 


1110 

disturbances  of  sensation,  particularly  a  feeling  of  numbness  and  tingling,  and 
the  reflexes  may  be  increased.  Visceral  neuralgias,  especially  in  connection 
with  the  genital  organs,  are  frequently  met  with.  The  aching  pain  in  the 
back  or  in  the  back  of  the  neck  is  the  most  constant  complaint  in  these  cases. 
In  women  it  is  often  impossible  to  say  whether  this  condition  is  one  of  neuras- 
thenia or  hysteria.  It  is  in  these  cases  that  the  disturbances  of  muscular 
activity  are  most  pronounced,  and  in  the  French  writings  amyosthenia  particu- 
larly plays  an  important  role.  The  symptoms  may  be  irritative  or  paretic,  or 
a  combination  of  both.  Disturbances  of  coordination  are  not  uncommon  in 
the  severer  forms.  These  are  particularly  prone  to  involve  the  associated 
movements  of  the  eye  muscles,  leading  to  asthenopic  lack  of  accommodation. 
Drooping  of  one  eyelid  is  very  common,  probably  owing  to  insufficient  inner- 
vation  on  the  part  of  the  sympathetic  rather  than  to  paresis  of  the  oculo- 
motor nerve.  Occasionally  Eomberg's  symptom  may  be  present,  and  the  pa- 
tient, or  even  his  physician,  may  fear  a  beginning  tabes.  More  rarely  there 
is  disturbance  of  such  finely  coordinated  acts  as  writing  and  articulation,  not 
unlike  those  seen  at  the  onset  of  general  paresis.  Such  symptoms  are  always 
alarming,  and  the  greatest  care  must  be  taken  in  establishing  a  diagnosis. 
That  they  may  be  the  symptoms  of  pure  neurasthenia,  however,  can  no  longer 
be  doubted. 

The  reflexes  in  neurasthenia  are  usually  increased,  the  deep  reflexes  espe- 
cially never  being  absent.  The  condition  of  the  superficial  reflexes  is  less  con- 
stant, though  these,  too,  are  usually  increased.  The  pupils  are  often  dilated, 
and  the  reflexes  are  usually  normal.  There  may  be  inequality  of  the  pupils 
in  neurasthenia.  Errors  in  refraction  are  common,  the  correction  of  which 
may  give  great  relief. 

In  another  type  of  cases  the  muscular  weakness  is  extreme,  and  may  go  on 
even  to  complete  motor  helplessness.  Very  thorough  examination  is  necessary 
before  deciding  as  to  the  nature  of  the  affection,  since  in  some  instances  serious 
mistakes  have  been  made.  Here  belong  the  atremia  of  Neftel,  the  akinesia 
algera  of  Mb'bius,  and  the  neurasthenic  form  of  astasia  abasia  described  by 
Binswanger. 

In  other  cases  the  cardio-vascular  symptoms  are  the  most  distressing,  and 
may  occur  with  only  slight  disturbance  of  the  cerebro-spinal  functions,  though 
the  conditions  are  nearly  always  combined.  Palpitation  of  the  heart,  irregular 
and  very  rapid  action  (neurasthenic  tachycardia),  and  pains  and  oppressive 
feelings  in  the  cardiac  region  are  the  most  common  symptoms.  The  slightest 
excitement  may  be  followed  by  increased  action  of  the  heart,  sometimes  asso- 
ciated with  sensations  of  dizziness  and  anxiety,  and  the  patients  frequently 
have  the  idea  that  they  suffer  from  serious  disease  of  this  organ.  Attacks  of 
pseudo-angina  may  occur. 

Vaso-motor  disturbances  constitute  a  special  feature  of  many  cases.  Flushes 
of  heat,  especially  in  the  head,  and  transient  hyperaemia  of  .the  skin  may  be 
very  distressing  symptoms.  Profuse  sweating  may  occur,  either  local  or  gen- 
eral, and  sometimes  nocturnal.  The  pulse  may  show  interesting  features, 
owing  to  the  extreme  relaxation  of  the  peripheral  arterioles.  The  arterial 
throbbing  may  be  everywhere  visible,  almost  as  much  as  in  aortic  insufficiency. 
The  pulse,  too,  may  under  these  circumstances  have  a  somewhat  water-hammer 
quality.  The  capillary  pulse  may  be  seen  in  the  nails,  on  the  lips,  or  on  the 


NEURASTHENIA  1111 

margins  of  a  line  drawn  upon  the  forehead,  and  I  have  on  several  occasions 
seen  pulsation  in  the  veins  of  the  back  of  the  hand.  A  characteristic  symptom 
in  some  cases  is  the  throbbing  aorta.  This  "preternatural  pulsation  in  the 
epigastrium/'  as  Allan  Burns  calls  it,  may  be  extremely  forcible  and  suggest 
the  existence  of  abdominal  aneurism.  The  subjective  sensations  associated 
with  it  may  be  very  unpleasant,  particularly  when  the  stomach  is  empty. 

In  women  especially,  and  sometimes  in  men,  the  peripheral  blood-vessels 
are  contracted,  the  extremities  are  cold,  the  nose  is  red  or  blue,  and  the  face 
has  a  pinched  expression.  These  patients  feel  much  more  comfortable  when 
the  cutaneous  vessels  are  distended,  and  resort  to  various  means  to  favor  this 
(wearing  of  heavy  clothing,  use  of  diffusible  stimulants). 

The  general  features  of  g astro-intestinal  neurasthenia  have  been  dealt  with 
under  the  section  of  nervous  dyspepsia.  The  connection  of  these  cases  with 
dilatation  of  the  stomach,  floating  kidney,  and  the  condition  which  Glenard 
calls  enteroptosis  has  already  been  mentioned. 

Sexual  neurasthenia  is  a  condition  in  which  there  is  an  irritable  weakness 
of  the  sexual  organs  manifested  by  nocturnal  emissions,  unusual  depression 
after  intercourse,  and  often  by  a  distressing  dread  of  impotence.  The  mental 
condition  of  these  patients  is  most  pitiable,  and  they  fall  an  easy  prey  to 
quacks  and  charlatans  of  all  kinds.  In  males  these  symptoms  are  frequently 
due  to  diseased  conditions  in  the  deep  urethra,  especially  of  the  verumontanum, 
and  prostate. 

Spermatorrhoea  is  the  bugbear  of  the  majority.  They  complain  of  con- 
tinued losses,  usually  without  accompanying  pleasurable  sensations.  After 
defecation  or  micturition  there  may  be  seminal  discharges.  Microscopic  ex- 
amination sometimes  reveals  the  presence  of  spermatozoa.  Actual  nervous 
impotence  is  not  uncommon.  The  "painful  testicle"  is  a  well-known  neuras- 
thenic phenomenon.  In  the  severer  cases,  especially  those  bearing  the  stig- 
mata of  degeneration,  there  may  be  evidence  of  sexual  perversion. 

In  females  it  is  common  to  find  a  tender  ovary,  and  painful  or  irregular 
menstruation. 

In  all  forms  of  neurasthenia  the  condition  of  the  urine  is  important. 
Many  cases  are  complicated  with  the  symptoms  of  the  condition  known  as 
lithasmia,  and  so  marked  may  this  be  that  some  have  indeed  made  a  special 
form  of  lithaemic  neurasthenia.  Polyuria  may  be  present,  but  is  more  com- 
mon in  hysteria.  With  disturbed  digestion  the  urates  and  oxalates  may  be 
in  excess. 

Diagnosis. — Psychasthenia. — Under  this  term  Janet  would  separate  from 
neurasthenia  the  cases  characterized  by  mental,  emotional,  and  physical  dis- 
turbances, imperative  ideas,  phobias  of  all  sorts,  doubts,  enfeebled  will,  uncon- 
trollable movements,  and  many  of  the  borderland  features  of  the  insanity  of 
young  persons.  It  is  really  an  inherited  psychoneurosis,  while  neurasthenia 
is  usually  acquired.  Obsessions  of  all  sorts  characterize  the  condition  and 
there  may  be  a  feeling  of  unreality  and  even  of  loss  of  personality.  How  com- 
plicated the  condition  may  be  is  shown  from  the  following  varieties  distin- 
guished by  Janet:  (1)  The  doubter,  in  whom  obsessive  ideas  are  not  very 
precise,  more  of  the  nature  of  a  general  indication  rather  than  a  specific  idea, 
such  as  a  craze  for  research,  for  explanation,  for  computing.  (2)  The  scru- 
pulous, whose  obsessions  are  of  a  moral  nature.  Their  manias  are  of  literal- 


1112  DISEASES   OP   THE   NERVOUS    SYSTEM 

ness  of  statement,  of  exact  truth,  of  conjuration,  of  reparation,  of  symbols, 
etc.  (3)  The  criminal,  whose  obsessive  ideas  are  of  homicide,  theft,  and  other 
overt  acts.  The  impulsive  idea  is  stronger  in  this  than  in  the  other  varieties. 
(4)  The  inebriates,  dipsomaniac,  morphinomaniac,  etc.,  in  whom  the  impulse 
seems  to  be  least  resistible.  (5)  The  genesically  perverted.  (6)  Delirious 
psychasthenia,  a  condition  in  which  a  delirious  state  of  mind  occurs,  connected 
with  the  obsession. 

The  anxiety  conditions  and  various  phobias,  as  well  as  the  different  varie- 
ties of  tic  and  the  occupation  neuroses  when  they  accompany  neurasthenia, 
are  regarded  as  complications  dependent  in  the  majority  of  instances  upon 
faulty  heredity. 

Neurasthenia  is  a  disease  above  all  others  which  has  to  be  diagnosed  from 
the  subjective  statements  of  the  patient,  and  from  an  observation  of  his  general 
behavior  rather  than  from  the  physical  examination.  The  physical  examina- 
tion is  of  the  highest  importance  in  excluding  other  diseases  likely  to  be  con- 
founded with  it.  That  somatic  changes  occur  and  that  physical  signs  are  often 
to  be  made  out  is  very  true,  but  there  is  nothing  typical  or  pathognomonic  in 
these  objective  changes. 

The  hypochondriac  differs  from  the  neurasthenic  in  the  excessive  psychic 
distortion  of  the  pathological  sensations  to  which  he  is  subject.  He  is  the 
victim  of  actual  delusions  regarding  his  condition. 

The  confusion  of  neurasthenia  with  hysteria  is  still  more  frequent;  in 
women  especially  a  diagnosis  of  hysteria  is  often  made  when  in  reality  the 
condition  is  one  of  neurasthenia.  In  the  absence  of  hysterical  paroxysms,  of 
crises,  and  of  those  marked  emotional  and  intellectual  characteristics  of  the 
hysterical  individual  the  diagnosis  of  hysteria  should  not  be  made.  Of  course, 
in  many  of  the  cases  of  hysteria  definite  hysterical  stigmata  (hysterical  paraly- 
ses, convulsions,  contractures,  anesthesias,  alterations  in  the  visual  field,  etc.) 
are  present,  and  the  diagnosis  is  not  difficult. 

Epilepsy  is  not  likely  to  be  confounded  with  neurasthenia  if  there  be 
definite  epileptic  attacks,  but  the  cases  of  petit  mal  may  be  puzzling. 

The  onset  of  exophthalmic  goitre  may  be  mistaken  for  neurasthenia,  espe- 
cially if  there  be  no  exophthalmos  at  the  beginning.  The  emotional  disturb- 
ances and  the  irritability  of  the  heart  may  mislead  the  physician.  In  pro- 
nounced cases  of  nervous  prostration  the  differential  diagnosis  from  the  various 
psychoses  may  be  extremely  difficult. 

The  two  forms  of  organic  disease  of  the  nervous  system  with  which  neuras- 
thenia is  most  likely  to  be  confounded  are  tabes  and  general  paresis.  The 
symptoms  of  the  spinal  form  of  neurasthenia  may  resemble  those  of  the  former 
disease,  while  the  symptoms  of  the  psychic  or  cerebral  form  of  neurasthenia 
may  be  very  similar  to  those  of  general  paresis.  The  diagnosis,  as  a  rule, 
presents  no  difficulty  if  the  physician  be  careful  to  make  a  thorough  routine 
examination.  It  is  only  the  superficial  study  of  a  case  that  is  likely  to  lead 
one  astray.  In  tabes  especially  a  consideration  of  the  sensory  disturbances,  of 
the  deep  reflexes,  and  of  the  pupillary  findings  will  always  establish  the  pres- 
ence or  absence  of  the  disease.  In  general  paresis  there  is  sometimes  more 
difficulty.  The  onset  of  general  paresis  is  often  characterized  by  the  appear- 
ance of  symptoms  quite  like  those  of  ordinary  neurasthenia,  and  the  family 
physician  may  entirely  overlook  the  grave  nature  of  the  malady.  The  mis- 


NEURASTHENIA  1113 

take  in  the  other  direction  is,  however,  perhaps  just  as  common.  A  physician 
who  once  or  twice  has  seen  a  case  of  general  paresis  arise  out  of  what  appeared 
to  be  one  of  pronounced  neurasthenia  is  too  prone  afterward  to  suspect  every 
neurasthenic  to  be  developing  the  malign  affection.  The  most  marked  symp- 
toms, however,  of  psychic  exhaustion  do  not  justify  a  diagnosis  of  general 
paresis  even  when  the  history  is  suspicious,  unless  along  with  it  there  is  a 
definite  paresis  of  the  pupils,  of  the  facial  muscles,  or  of  the  muscles  of  articu- 
lation. A  history  of  syphilis  or  of  chronic  alcoholism  or  morphinism  asso- 
ciated with  severe  psychic  exhaustion  should,  of  course,  put  one  always  on  his 
guard,  and  the  physician  should  be  sharply  on  the  lookout  for  the  appearance 
of  intellectual  defects,  paraphasia,  facial  paresis,  and  sluggishness  of  the  pupils. 

Treatment. — PROPHYLAXIS. — Many  patients  come  under  our  care  a  gen' 
eration  too  late  for  satisfactory  treatment,  and  it  may  be  impossible  to  restore 
the  exhausted  capital.  The  greatest  care  should  be  taken  in  the  rearing  of 
children  of  neuropathic  predisposition.  From  a  very  early  age  they  should 
be  submitted  to  a  process  of  "psychic  hardening,"  every  effort  being  made  to 
strengthen  the  bodily  and  mental  condition.  Even  in  infancy  the  child  should 
not  be  pampered.  Later  on  the  greatest  care  should  be  exercised  with  regard 
to  food,  sleep,  and  school  work.  Complaints  of  children  should  not  be  too 
seriously  considered. 

Much  depends  upon  the  example  set  by  the  parents.  A  restless,  emotional, 
constantly  complaining  mother  will  rack  the  nervous  system  of  a  delicate  child. 
In  some  instances,  for  the  welfare  of  a  developing  boy  or  girl,  the  physician 
may  find  it  necessary  to  advise  its  removal  from  home. 

Neurotic  children  are  especially  liable  during  development  to  fits  of  temper 
and  of  emotional  disturbance.  These  should  not  be  too  lightly  considered. 
Above  all,  violent  chastisement  in  such  cases  is  to  be  avoided,  and  loss  of 
temper  on  the  part  of  the  parent  or  teacher  is  particularly  pernicious  for  the 
nervous  system  of  the  child.  Where  possible,  in  such  instances,  the  best  trea't- 
ment  is  to  put  the  obstreperous  child  immediately  to  bed,  and  if  the  excite- 
ment and  temper  continue  a  warm  bath  followed  by  a  cool  douche  may  be 
effective.  If  he  be  put  to  bed  after  the  bath  sleep  soon  follows. 

Special  attention  is  necessary  at  puberty  in  both  boys  and  girls.  If  there 
be  at  this  period  any  marked  tendency  to  emotional  disturbance  or  to  intellec- 
tual weakness  the  child  should  be  removed  from  school  and  every  care  taken 
tc  avoid  unfavorable  influences. 

PERSONAL  HYGIENE. — Throughout  life  individuals  of  neuropathic  predis- 
position should  obey  scrupulously  certain  hygienic  and  prophylactic  rules.  In- 
tellectual work  especially  should  be  judiciously  limited  and  should  dternate 
frequently  with  periods  of  repose.  Excitement  of  all  kinds  should  of  course 
be  avoided,  and  such  individuals  will  do  well  to  be  abstemious  in  the  use  of 
tobacco,  tea,  coffee,  and  alcohol,  if,  indeed,  they  be  permitted  to  use  these 
substances  at  all.  The  habit,  happily  becoming  very  common,  of  taking  at 
least  once  a  year  a  prolonged  holiday  away  from  the  ordinary  environment, 
in  the  woods,  in  the  mountains,  or  at  the  seashore,  should  be  urgently  en- 
joined upon  every  neuropathic  individual.  In  many  instances  it  is  found  to 
be  the  greatest  relief  and  rest  if  the  patient  can  take  his  holiday  away  from 
his  relatives. 

During  ordinary  life  nervous  people  should,  during  some  portion  of  each 
72 


1114  DISEASES    OP   THE   NERVOUS    SYSTEM 

day,  pay  rational  attention  to  the  body.  Cold  baths,  swimming,  exercises  in 
the  gymnasium,  gardening,  golf,  lawn  tennis,  cricket,  hunting,  shooting,  row- 
ing, sailing,  and  bicycling  are  of  value  in  maintaining  the  general  nutrition. 
Such  exercises  are,  of  course,  to  be  recommended  only  to  individuals  physically 
equal  to  them.  If  neurasthenia  be  once  well  established  the  greatest  care  must 
be  observed  in  the  ordering  of  exercise.  Many  nervous  girls  have  been  com- 
pletely broken  down  by  following  injudicious  advice  with  regard  to  long  walks. 

TREATMENT  OF  THE  CONDITION. — The  treatment  of  neurasthenia  when 
once  established  presents  a  varied  problem  to  the  thoughtful  physician.  Every 
case  must  be  handled  upon  its  own  merits,  no  two,  as  a  rule,  requiring  exactly 
the  same  methods.  In  general  it  will  be  the  aim  of  the  medical  adviser  to 
remove  the  patient  as  far  as  possible  from  the^  influences  which  have  led  to 
his  downfall,  and  to  restore  to  normal  the  nervous  mechanisms  which  have 
been  weakened  by  injurious  influences.  The  general  character  of  the  indi- 
vidual, his  physical  and  social  status,  must  of  course  be  considered  and  the 
therapeutic  measures  carefully  adjusted  to  these. 

The  diagnosis  having  been  settled,  the  physician  may  assure  the  patient 
that  with  prolonged  treatment,  during  which  his  cooperation  with  the  physi- 
cian is  absolutely  essential,  he  may  expect  to  get  well.  He  must  be  told  that 
much  depends  upon  himself  and  that  he  must  make  a  vigorous  effort  to  over- 
come certain  of  his  tendencies,  and  that  all  his  strength  of  will  will  be  needed 
to  further  the  progress  of  the  cure.  In  the  case  of  business  or  professional 
men,  in  whom  the  condition  develops  as  a  result  of  overwork  or  overstudy,  it 
may  be  sufficient  to  enjoin  absolute  rest  with  change  of  scene  and  diet.  A  trip 
abroad,  with  a  residence  for  a  month  or  two  in  Switzerland,  or,  if  there  are 
symptoms  of  nervous  dyspepsia,  a  residence  at  one  of  the  Spas  will  usually 
prove  sufficient.  The  excitement  of  the  large  cities  abroad  should  be  avoided. 
The  longer  the  disease  has  lasted  and  the  more  intense  the  symptoms  have 
been,  the  longer  the  time  necessary  for  the  restoration  of  health.  In  cases  of 
any  severity  the  patient  must  be  told  that  at  least  six  months'  complete  ab- 
sence from  business,  under  strict  medical  guidance,  will  be  necessary.  Shorter 
periods  may  of  course  be  of  benefit,  which,  however,  as  a  rule,  will  be  only 
temporary. 

It  will  often  be  found  advisable  to  make  out  a  daily  programme,  which 
shall  occupy  almost  the  whole  time  of  the  patient.  At  first  he  need  know 
nothing  about  this,  the  case  being  given  over  entirely  to  the  nurse.  As  im- 
provement advances,  moderate  physical  and  intellectual  exercises,  alternating 
frequently  with  rest  and  the  administration  of  food,  may  be  undertaken.  Some 
one  hour  of  the  day  may  be  left  free  for  reading,  correspondence,  conversa- 
tion, and  games.  In  some  instances  the  writing  of  letters  is  particularly 
harmful  to  the  patient  and  must  be  prohibited  or  limited.  Cultured  indi- 
viduals may  find  benefit  from  attention  to  drawing,  painting,  modelling,  trans- 
lating from  a  foreign  language,  the  making  of  abstracts,  etc.,  for  short  periods 
in  the  day. 

In  not  a  few  cases,  including  a  large  proportion  of  neurasthenic  women, 
a  systematic  Weir  Mitchell  treatment  rigidly  carried  out  should  be  tried.  The 
patient  must  be  isolated  from  his  friends,  and  any  regulations  undertaken  must 
be  strictly  adhered  to,  the  consent  of  the  patient  and  his  family  having  first 
been  gained.  The  treatment  of  the  gastric  and  intestinal  symptoms  so  im- 


NEUKASTHEKEA  1115 

portant  in  this  condition  has  already  been  considered.    For  the  irregular  pains, 
particularly  in  the  back  and  neck,  the  therm o-cautery  is  invaluable. 

Hydrotherapy  is  indicated  in  nearly  every  case  if  it  can  be  properly  applied. 
Much  can  be  done  at  home  or  in  an  ordinary  hospital,  but  for  systematic 
hydrotherapeutic  treatment  residence  in  a  suitable  sanitarium  is  necessary. 
I  have  found  the  wet  pack  of  especial  value.  Particularly  at  night,  in  cases  of 
sleeplessness,  it  is  perhaps  the  best  remedy  against  insomnia  we  have.  Salt 
baths  are  more  helpful  to  some  patients.  The  various  forms  of  douches,  par- 
tial packs,  foot  baths,  etc.,  may  be  valuable  in  individual  cases.  Electro- 
therapy is  of  some  value,  though  only  in  combination  with  psychic  treatment 
and  hydrotherapy. 

Special  care  should  be  given  to  the  recognition  of  local  disease  and 
proper  measures  instituted.  Attention  to  the  eyes  is  important.  Infection 
of  the  naso-pharynx,  sinus  disease,  visceroptosis,  or  anaemia  should  be  cor- 
rected. In  women  the  pelvjc  organs  and  in  men  the  deep  urethra  and  pros- 
tate may  require  treatment. 

Treatment  by  drugs  should  be  avoided  as  much  as  possible.  They  are 
of  benefit  chiefly  in  the  combating  of  single  symptoms.  Alcohol,  morphia, 
chloral,  or  cocaine  should  never  be  given.  General  tonics  may  be  helpful, 
especially  if  the  individual  be  anaemic.  Arsenic  and  more  often  iron  are  then 
indicated.  For  the  severer  pains  and  nervous  attacks  some  sedative  may 
occasionally  be  necessary,  especially  at  the  beginning  of  the  treatment.  The 
bromides  may  here  be  given  with  advantage.  An  occasional  dose  of 
phenacetin  or  aspirin  may  be  required,  but  the  less  of  these  substances  we 
can  get  along  with  the  better.  For  the  relief  of  sleeplessness  all  possible 
measures  should  be  resorted  to  before  the  employment  of  drugs.  The  wet  pack 
will  usually  suffice.  If  absolutely  necessary  to  give  a  drug,  sulphonal,  trional, 
or  amylene  hydrate  may  be  employed. 

In  cases  in  which  the  anxiety  conditions  are  disturbing  the  cautious  use 
of  opium  in  pill  form  may  be  necessary,  since,  as  in  the  psychoses,  opium  here 
will  sometimes  yield  permanent  relief.  A  prolonged  treatment  with  opium  is, 
however,  never  necessary  in  neurasthenia. 

PSYCHOTHERAPY. — Hypnotism  is  rarely  indicated.  Carefully  practiced 
suggestion  is  most  helpful  and  the  psycho-analytic  method  of  Freud,  as  de- 
scribed under  Hysteria,  may  be  tried. 

The  use  of  religious  ideas  and  practices  may  be  most  helpful,  and  this  has 
come  into  vogue  in  various  forms,  as  Christian  Science,  Emmanualism,  Mental 
Healing,  etc.  It  is  an  old  story.  In  all  ages,  and  in  all  lands,  the  prayer  of 
faith,  to  use  the  words  of  St.  James,  has  healed  the  sick ;  and  we  must  remem- 
ber that  amid  the  ^Esculapian  cult,  the  most  elaborate  and  beautiful  system  of 
faith  healing  the  world  has  seen,  scientific  medicine  took  its  rise.  As  a  pro- 
fession, consciously  or  unconsciously,  more  often  the  latter,  faith  has  been  one 
of  our  most  valuable  assets,  and  Galen  expressed  a  great  truth  when  he  said, 
"He  cures  most  successfully  in  whom  the  people  have  the  greatest  confidence." 
It  is  in  these  cases  of  neurasthenia  and  psychasthenia,  the  weak  brothers  and 
the  weak  sisters,  that  the  personal  character  of  the  physician  comes  into  play, 
and  once  let  him  gain  the  confidence  of  the  patient,  he  can  work  just  the  same 
sort  of  miracles  as  Our  Lady  of  Lourdes  or  Ste.  Anne  de  Beaupre.  Three 
elements  are  necessary :  first,  a  strong  personality  in  whom  the  individual  has 


1116  DISEASES    OF    THE    NERVOUS    SYSTEM 

faith — Christ,  Buddha,  yEsculapius  (in  the  days  of  Greece),  one  of  the  saints, 
or,  what  has  served  the  turn  of  common  humanity  very  well,  a  physician. 
Secondly,  certain  accessories — a  shrine,  a  sanctuary,  the  services  of  a  temple, 
or  for  us  a  hospital  or  its  equivalent,  with  a  skillful  nurse.  Thirdly,  sugges- 
tion, either  of  the  "only  believe,"  "feel  it,"  "will  it"  attitude  of  mind,  which 
is  the  essence  of  every  cult  and  creed,  or  of  the  active  belief  in  the  assurance  of 
the  physician  that  the  precious  boon  of  health  is  within  reach. 


XI.     THE    TRAUMATIC    NEUROSES 

(Railway  Brain  and  Railway  Spine;  Traumatic  Hysteria  ) 

Definition. — A  morbid  condition  following  shock  which  presents  the  symp- 
toms of  neurasthenia  or  hysteria  or  of  both.  The  condition  is  known  as  "rail- 
way brain"  and  "railway  spine." 

Erichsen  regarded  the  condition  as  the  result  of  inflammation  of  the  men- 
inges  and  cord,  and  gave  it  the  name  railway  spine.  Walton  and  J.  J.  Put- 
nam, of  Boston,  were  the  first  to  recognize  the  hysterical  nature  of  many  of 
the  cases,  and  to  Westphal's  pupils  we  owe  the  name  traumatic  neurosis. 

Etiology. — The  condition  follows  an  accident,  often  in  a  railway  train,  in 
which  injury  has  been  sustained,  or  succeeds  a  shock  or  concussion,  from  which 
the  patient  may  apparently  not  have  suffered  in  his  body.  A  man  may  appear 
perfectly  well  for  several  days,  or  even  a  week  or  more,  and  then  develop  the 
symptoms  of  the  neurosis.  Bodily  shock  or  concussion  is  not  necessary.  The 
affection  may  follow  a  profound  mental  impression;  thus,  an  engine-driver 
ran  over  a  child,  and  received  thereby  a  very  severe  shock,  subsequent  to  which 
the  most  pronounced  symptoms  of  neurasthenia  developed.  Severe  mental 
strain  combined  with  bodily  exposure  may  cause  it,  as  in  a  case  of  a  naval 
officer  who  was  wrecked  in  a  violent  storm  and  exposed  for  more  than  a  day 
in  the  rigging  before  he  was  rescued.  A  slight  blow,  a  fall  from  a  carriage 
or  on  the  stairs  may  suffice. 

Symptoms.- — The  cases  may  be  divided  into  three  groups:  simple  neuras- 
thenia, cases  with  marked  hysterical  manifestations,  and  cases  with  severe 
symptoms  indicating  or  simulating  organic  disease. 

(a)  SIMPLE  TRAUMATIC  NEURASTHENIA. — The  first  symptoms  usually  de- 
velop a  few  weeks  after  the  accident,  which  may  or  may  not  have  been  asso- 
ciated with  an  actual  trauma.  The  patient  complains  of  headache  and  tired 
feelings.  He  is  sleepless  and  finds  himself  unable  to  concentrate  his  attention 
properly  upon  his  work.  A  condition  of  nervous  irritability  develops,  which 
may  have  a  host  of  trivial  manifestations,  and  the  entire  mental  attitude  of 
the  person  may  for  a  time  be  changed.  He  dwells  constantly  upon  his  condi- 
tion, gets  very  despondent  and  low-spirited,  and  in  extreme  cases  melancholia 
may  develop.  He  may  complain  of  numbness  and  tingling  in  the  extremities, 
and  in  some  cases  of  much  pain  in  the  back.  The  bodily  functions  may  be 
well  performed,  though  such  patients  usually  have,  for  a  time  at  least,  dis- 
turbed digestion  and  loss  in  weight.  The  physical  examination  may  be  entirely 
negative.  The  reflexes  are  slightly  increased,  as  in  ordinary  neurasthenia. 
The  pupils  may  be  unequal;  the  cardio-vascular  changes  already  described  in 


THE    TEAUMATIC    NEUROSES  1117 

neurasthenia  may  be  present  in  a  marked  degree.  According  as  the  symptoms 
are  more  spinal  'or  more  cerebral,  the  condition  is  known  as  railway  brain  or 
railway  spine. 

(2)  CASES  WITH  MARKED  HYSTERICAL  FEATURES. — Following  an  injury 
of  any  sort,  neurasthenic  symptoms,  like  those  described  above,  may  develop, 
and  in  addition  symptoms  regarded  as  characteristic  of  hysteria.     The  emo- 
tional element  is  prominent,  and  there  is  but  slight  control  over  the  feelings. 
The  patients  have  headache,  backache,  and  vertigo.     A  violent  tremor  may  be 
present,  and,  indeed,  constitutes  the  most  striking  feature  of  the  case.    In  the 
case  of  an  engineer  who  developed  subsequent  to  an  accident  a  series  of  nervous 
phenomenon  the  most  marked  feature  was  an  excessive  tremor  of  the  entire 
body,  which  was  specially  manifest  during  emotional  excitement.     The  most 
pronounced  hysterical  symptoms  are  the  sensory  disturbances.    As  first  noted 
by  Putnam  and  Walton,  hemianaBsthesia  may  occur  as  a  consequence  of  trau- 
matism.     This  is  a  common  symptom  in  France,  but  rare  in  England  and  in 
the  United  States.    Achromatopsia  may  exist  on  the  anaesthetic  side.     A  sec- 
ond, more  common,  manifestation  is  limitation  of  the  field  of  vision,  similar 
to  that  which  occurs  in  hysteria. 

(3)  CASES  IN  WHICH  THE  SYMPTOMS  SUGGEST  ORGANIC  DISEASE  OF  THE 
BRAIN  AND  CORD. — As  a  result  of  spinal  concussion,  without  fracture  or  ex- 
ternal injury,  there  may  subsequently  develop  symptoms  suggestive  of  organic 
disease,  which  may  come  on  rapidly  or  at  a  late  date.    In  a  case  reported  by 
Leyden  the  symptoms  following  the  concussion  were  at  first  slight  and  the 
patient  was  regarded  as  a  simulator,  but  finally  the  condition  became  aggra- 
vated and  death  resulted.    The  post  mortem  showed  a  chronic  pachymeningitis, 
which  had  doubtless  resulted  from  the  accident.     The  cases  in  this  group 
about  which  there  is  so  much  discussion  are  those  which  display  marked  sen- 
sory and  motor  changes.     Following  an  accident  in  which  the  patient  has  not 
received  external  injury  a  condition  of  excitement  may  develop  within  a  week 
or  ten  days ;  he  complains  of  headache  and  backache,  and  on  examination  sen- 
sory disturbances  are  found,  either  hemianaesthesia  or  areas  on  the  skin  in 
which  the  sensation  is  much  benumbed ;  or  painful  and  tactile  impressions  may 
be  distinctly  felt  in  certain  regions,  and  the  temperature  sense  is  absent.     The 
distribution  may  be  bilateral  and  symmetrical  in  limited  regions  or  hemiplegic 
in  type.     Limitation  of  the  field  of  vision  is  usually  marked  in  these  cases, 
and  there  may  be  disturbance  of  the  senses  of  taste  and  smell.     The  super- 
ficial reflexes  may  be  diminished;  usually  the  deep  reflexes  are  exaggerated. 
The  pupils  may  be  unequal ;  the  motor  disturbances  are  variable.    The  French 
writers  describe  cases  of  monoplegia  with  or  without  contracture,  symptoms 
upon  which  Charcot  lays  great  stress  as  a  manifestation  of  profound  hysteria. 
The  combination  of  sensory  disturbances — anaesthesia  or  hyperaesthesia — with 
paralysis,  particularly  if  monoplegic,  and  the  occurrence  of  contractures  with- 
out atrophy  and  with  normal  electrical  reactions,  may  be  regarded  as  dis- 
tinctive of  hysteria. 

In  rare  cases  following  trauma  and  succeeding  to  symptoms  which  may 
have  been  regarded  as  neurasthenic  or  hysterical  there  are  organic  changes 
which  may  prove  fatal.  That  this  sequence  occurs  is  demonstrated  clearly 
by  recent  post  mortem  examinations.  The  features  upon  which  the  greatest 
reliance  can  be  placed  as  indicating  organic  change  are  optic  atrophy,  bladder 


1118  DISEASES    OF    THE    NERVOUS    SYSTEM 

symptoms,  particularly  in  combination  with  tremor,  paresis,  and  exaggerated 
reflexes. 

The  anatomical  changes  in  this  condition  have  not  heen  very  definite. 
When  death  follows  spinal  concussion  within  a  few  days  there  may  be  no 
apparent  lesion,  but  in  some  instances  the  brain  or  cord  has  shown  puncti- 
form  haemorrhages.  Edes  has  reported  4  cases  in  which  a  gradual  degenera- 
tion in  the  pyramidal  tracts  followed  concussion  or  injury  of  the  spine ;  but  in 
all  these  cases  there  was  marked  tremor  and  the  spinal  symptoms  developed 
early,  or  followed  immediately  upon  the  accident. 

Diagnosis. — A  condition  of  fright  and  excitement  following  an  accident 
may  persist  for  days  or  even  weeks,  and  then  gradually  pass  away.  The  symp- 
toms of  neurasthenia  or  of  hysteria  which  subsequently  develop  present  nothing 
peculiar  and  are  identical  with  those  which  occur  under  other  circumstances. 
Care  must  be  taken  to  recognize  simulation,  and,  as  in  these  cases  the  condition 
is  largely  subjective,  this  is  sometimes  extremely  difficult.  In  a  careful  exam- 
ination a  simulator  will  often  reveal  himself  by  exaggeration  of  certain  symp- 
toms, particularly  sensitiveness  of  the  spine,  and  by  increasing  voluntarily  the 
reflexes.  Maunkopff  suggests  as  a  good  test  to  take  the  pulse  rate  before,  dur- 
ing, and  after  pressure  upon  an  area  said  to  be  painful.  If  the  rate  is  quick- 
ened, it  is  held  to  be  proof  that  the  pain  is  real.  This  is  not,  however,  always 
the  case.  It  may  require  a*careful  study  of  the  case  to  determine  whether  the 
individual  is  honestly  suffering  from  the  symptoms  of  which  he  complains. 
A  still  more  important  question  is,  Has  the  patient  organic  disease?  The 
symptoms  given  under  the  first  two  groups  of  cases  may  exist  in  a  marked 
degree  and  may  persist  for  several  years  without  the  slightest  evidence  of 
organic  change.  Hemiansesthesia,  limitation  of  the  field  of  vision,  monople- 
gia  with  contracture,  may  all  be  present  as  hysterical  manifestations,  fiom 
which  recovery  may  be  complete.  In  our  present  knowledge  the  diagnosis  of 
an  organic  lesion  should  be  limited  to  those  cases  in  which  optic  atrophy, 
bladder  troubles,  and  signs  of  sclerosis  of  the  cord  are  well  marked — indica- 
tions either  of  degeneration  of  the  lateral  columns  or  of  multiple  sclerosis. 
Examination  by  the  X-rays  is  an  important  aid  and  has  showed  in  some  cases 
definite  injury  to  the  spine. 

Prognosis. — A  majority  of  patients  with  traumatic  hysteria  recover.  In 
railway  cases,  so  long  as  litigation  is  pending  and  the  patient  is  in  the  hands 
of  lawyers,  the  symptoms  usually  persist.  Settlement  is  often  the  starting- 
point  of  a  speedy  and  perfect  recovery.  On  the  other  hand,  there  are  a  few 
cases  in  which  the  symptoms  persist  even  after  the  litigation  has  been  closed; 
the  patient  goes  from  bad  to  worse  and  psychoses  develop,  such  as 
melancholia,  dementia,  or  occasionally  progressive  paresis.  And,  lastly,  in 
extremely  rare  cases  organic  lesions  may  occur  as  a  sequence  of  the  traumatic 
neurosis. 

The  function  of  the  physician  acting  as  medical  expert  in  these  cases  con- 
sists in  determining  (a)  the  existence  of  actual  disease,  and  (&)  its  character, 
whether  simple  neurasthenia,  severe  hysteria,  or  an  organic  lesion.  The  out- 
look for  ultimate  recovery  is  good  except  in  cases  which  present  the  more 
serious  symptoms  above  mentioned.  Nevertheless  it  must  be  borne  in  mind 
that  traumatic  hysteria  is  one  of  the  most  intractable  affections  which  we  are 
called  upon  to  treat.  In  the  treatment  of  the  traumatic  neuroses  the  practi- 


OTHER    FORMS    OF    FUNCTIONAL    PARALYSIS          1119 

tioner  may  be  guided  by  the  principles  laid  down  in  the  preceding  chapter,  in 
which  the  treatment  of  neurasthenia  in  general  has  been  described. 


XII.  OTHER  FORMS  OF  FUNCTIONAL  PARALYSIS 

Periodical  Paralysis. — The  periodical  paralysis  of  the  ocular  muscles, 
which  may  recur  for  years,  has  already  been  referred  to.  A  periodical  paraly- 
sis involving  the  general  muscles,  also  a  "family"  affection,  may  return  with 
great  regularity.  Goldflam  described  twelve  cases  in  one  family,  the  heredity 
being  through  the  mother.  In  the  United  States  E.  W.  Taylor  described  eleven 
cases  in  one  family  in  five  generations.  Holtzapple,  of  York,  Pa.,  reports  16 
cases  in  one  family.  Six  of  the  number  died  in  an  attack. 

The  clinical  picture  is  similar  in  all  recorded  cases.  The  paralysis  involves, 
as  a  rule,  the  arms  and  legs,  but  may  be  general  below  the  neck.  It  comes  on 
in  healthy  persons  without  apparent  cause,  and  often  during  sleep.  At  first 
there  may  be  weakness  of  the  limbs,  a  feeling  of  weariness  and  sleepiness,  but 
rarely  sensory  symptoms.  The  paralysis,  beginning  in  the  legs,  to  which  it 
may  be  confined,  is  usually  complete  within  the  first  twenty  four  hours.  The 
neck  muscles  are  sometimes  involved,  and  occasionally  those  of  the  tongue  and 
pharynx.  The  cerebral  nerves  and  the  special  senses  are,  as  a  rule,  unaffected. 
The  temperature  is  normal  or  subnormal  and  the  pulse  slow.  The  deep  re- 
flexes are  diminished,  sometimes  abolished,  and  the  skin  reflexes  may  be 
enfeebled.  A  most  remarkable  feature  is  the  extraordinary  reduction  or  com- 
plete abolition  of  the  faradic  excitability  of  both  muscles  and  nerves. 

Improvement  begins  within  a  few  hours  or  a  day  or  two,  the  paralysis 
disappearing  completely  and  the  patient  becoming  perfectly  well.  The  attacks 
usually  recur  at  intervals  of  one  to  two  weeks,  but  they  may  return  daily. 
They  generally  cease  after  the  fiftieth  year.  There  may  be  signs  of  acute 
dilatation  of  the  heart  during  the  attack.  In  the  three  cases  reported  by 
J.  K.  Mitchell,  Flexner,  and  Edsall  a  diminished  kreatinin  excretion  for 
several  days  before  and  at  the  beginning  of  a  seizure  was  repeatedly  found. 
There  was  a  rise  to  normal  after  the  attacks.  Potassium  citrate  in  full  doses 
either  shortened  -or  aborted  the  paralyses. 

Astasia;  Abasia. — These  terms,  indicating  respectively  inability  to  stand 
and  inability  to  walk,  have  been  applied  by  Charcot  and  Blocq  to  diseased  con- 
ditions characterized  by  loss  of  the  power  of  standing  or  of  walking,  with 
retention  of  muscular  power,  coordination,  and  sensation.  Blocq's  definition 
is  as  follows:  "A  morbid  state  in  which  the  impossibility  of  standing  erect 
and  walking  normally  is  in  contrast  with  the  integrity  of  sensation,  of  muscu- 
lar strength,  and  of  the  coordination  of  the  other  movements  of  the  lower 
extremities."  The  condition  forms  a  symptom  group,  not  a  morbid  entity, 
and  is  probably  a  functional  neurosis.  Knapp  analyzed  50  cases,  of  which 
half  were  in  women.  In  21  cases  hysteria  was  present;  in  3,  chorea;  in  2, 
epilepsy;  and  in  4,  intention  psychoses.  As  a  rule,  the  patients,  though  able 
to  move  the  feet  and  legs  perfectly  when  in  bed,  are  either  unable,  to  walk 
properly  or  can  not  stand  at  all.  The  disturbances  have  been  very  varied,  and 
different  forms  have  been  recognized.  The  commonest,  according  to  Knapp's 
analysis  of  the  recorded  cases,  is  the  paralytic,  in  which  the  legs  give  out  as 


1120  DISEASES    OF    THE    NERVOUS    SYSTEM 

the  patient  attempts  to  walk  and  "bend  under  him  as  if  made  of  cotton." 
"There  is  no  rigidity,  no  spasm,  no  incob'rdination.  In  bed,  sitting,  or  even! 
while  suspended,  the  muscular  strength  is  found  to  be  good."  Other  cases  are 
associated  with  spasm  or  ataxia;  thus  there  may  be  movements  which  stiffen 
the  legs  and  give  to  the  gait  a  somewhat  spastic  character.  In  other  instances 
there  are  sudden  flexions  of  the  legs,  or  even  of  the  arms,  or  a  saltatory, 
spring-like  spasm.  In  a  majority  of  the  cases  it  is  a  manifestation  of  a  neuro- 
sis allied  to  hysteria. 

The  cases,  as  a  rule,  recover,  particularly  in  young  persons.    Relapses  are 
not  uncommon.    The  rest  treatment  and  static  electricity  should  be  employed. 


H.    VASO-MOTOE   AND    TROPHIC    DISORDERS 
I.     RAYNAUD'S  DISEASE 

Definition. — A  vascular  change,  without  organic  disease  of  the  vessels, 
chiefly  seen  in  the  extremities,  but  occurring  also  in  the  internal  parts,  in 
which  a  persistent  ischsemia  or  a  passive  hyperaemia  leads  to  disturbance  of 
function  or  to  loss  of  vitality  with  necrosis. 

Etiology. — It  is  a  comparatively  rare  disease.  There  were  only  19  cases 
in  about  20,000  medical  patients  admitted  to  the  Johns  Hopkins  Hospital. 
Women  are  more  frequently  attacked  than  men — 62.5  to  37.5  per  cent,  in 
Monro's  series. 

Sixty  per  cent,  of  the  cases  occurred  in  the  second  and  third  decades,  but 
no  age  is  exempt.  A  case  has  been  reported  in  a  six-months-old  child  and  in 
a  woman  of  77  years. 

Several  members  of  a  family  may  be  affected.  Neurotic  and  hysterical 
patients  are  more  prone  to  the  disease.  Damp  and  cold  weather,  as  in  Great 
Britain,  appears  to  favor  its  occurrence.  Severe  chilblain  leading  to  super- 
ficial necrosis  represents  a  type  of  the  malady.  In  the  infectious  diseases  areas 
of  multiple  necrosis  occur,  but,  as  a  rule,  the  distribution  is  very  different,  and 
such  cases  should  not  be  included  under  Raynaud's  disease,  nor  should  the 
local  gangrene  associated  with  arteritis. 

Pathology. — According  to  the  definition,  cases  are  excluded  in  which 
organic  disease  of  the  vessels  is  present.  In  advanced  cases  sclerosis  of  the 
blood-vessels  has  been  found;  and  neuritis  has  been  described,  but  neither 
is  an  essential  factor.  Changes  in  the  spinal  cord  have  been  reported,  but  in  a 
majority  of  all  cases  the  examination  has  been  negative.  The  local  syncope  is 
an  expression  of  a  widespread  constrictor  influence  causing  spasm  of  the 
arteries  and  arterioles,  so  that  not  a  drop  of  blood  enters  a  part.  This  may 
be  followed  in  an  hour  or  two,  or  less,  by  active  hyperasmia ;  the  arteries  and 
arterioles  dilate  widely  and  the  dead-white  finger  becomes  a  bright  pink. 
While  hypersemia  may  follow  the  ischemia  directly,  more  commonly  there  is 
an  intervening  period  of  asphyxia  in  which  the  finger  becomes  blue.  In 
frost-bite, -active  hyperaemia,  cyanosis,  and  local  syncope  is  the  order.  In  Ray- 
naud's disease  the  order  is  usually  syncope,  asphyxia,  and  hyperasmia.  In 
frost-bite  it  seems  clear  that  the  asphyxia  is  due  to  a  backward  flow  from  the 
veins,  to  which  the  local  syncope  yields  as  the  part  thaws,  before  the  arteries 


RAYNAUD'S    DISEASE 

passing  to  the  part  can  be  felt  to  pulsate.  The  asphyxia  of  Eaynaud's  dis- 
ease may  be  due  to  the  same  cause ;  contraction  of  the  veins  has  been  seen  by 
Barlow  and  by  Weiss,  but  that  was  when  the  asphyxia  already  existed.  The 
first  thing  must  be  the  relaxation  of  the  spasm  of  the  venules  and  veins  to 
permit  of  the  blood  entering  the  empty  capillaries.  In  moderate  grades  of 
asphyxia  some  little  blood  trickles  through  the  sluice  gates,  but  in  the  deep 
purple  skin  of  a  typical  example  of  Eaynaud's  disease  the  circulation  has 
ceased  and  death  of  the  part  is  imminent.  The  necrosis  is  a  simple  matter,  as 
simple  as  if  a  string  is  tied  tightly  about  the  finger-tip. 

The  disease  is  the  result  of  some  as  yet  unknown  instability  of  the  vaso- 
motor  centres. 

Symptoms.  — There  are  various  grades  of  the  disease,  of  which  mild,  moder- 
ate, and  severe  types  may  be  recognized.  In  the  mild  forms  the  disease  never 
gets  beyond  the  stage  of  such  vascular  disturbance  as  is  frequently  seen  in 
chilblains.  The  hands  alone  may  be  affected — more  often  the  hands  and  feet. 
In  the  winter,  on  the  slightest  exposure,  there  is  aero-cyanosis,  which  gives 
place  in  the  warmth  to  active  hypersemia,  sometimes  with  swelling,  throbbing, 
and  aching.  The  so-called  "beefsteak"  hand  is  often  a  great  annoyance  to 
women.  It  is  a  vaso-motor  disturbance  representing  a  potential  case  of  Ray- 
naud's  disease.  In  these  mild  attacks  I  have  seen  one  finger  white  and  the 
adjacent  ones  red  and  blue. 

The  condition  may  persist  for  yoars  and  never  pass  on  to  necrosiE.  In  a 
case  of  moderate  severity  a  woman,  aged  say  twenty  or  twenty  five,  after  a 
period  of  worry  or  ill  health,  has  pains  in  the  fingers,  or  a  numbness  or 
tingling;  then  she  notices  that  they  are  white  and  cold,  and  in  an  hour  or  so 
they  become  red  and  hot.  Within  a  day  or  two  a  change  occurs;  they  remain 
permanently  blue  perhaps  as  far  as  the  second  joint  or  to  the  knuckles.  There 
is  pain,  sometimes  severe  enough  to  require  morphia.  The  cyanosis  persists 
and  the  tip  of  one  finger  or  the  terminal  joint  of  another  gets  darker  and  a 
few  blebs  form.  The  other  fingers  show  signs  of  restored  circulation,  but 
necrosis  has  occurred  in  the  pad  of  one  finger  and  perhaps  the  terminal  inch 
of  another.  The  necrotic  parts  gradually  separate,  and  the  patient  may  never 
have  another  attack,  or  in  a  year  or  two  there  is  a  recurrence. 

The  severer  form  is  a  terrible  malady,  and  may  affect  fingers  and  toes  at 
once  and  with  them  sometimes  the  tip  of  the  nose  and  the  ears.  The  pain 
is  of  great  severity.  Both  feet  may  be  swollen  to  the  ankle  with  the  toes 
black.  It  may  look  as  if  both  feet  would  become  gangrenous,  but  as  a  rule 
the  process  subsides,  and  in  a  case  even  of  great  severity  only  the  tips  of  the 
toes  are  lost.  A  severe  attack  of  this  sort  may  last  three  or  four  months,  when 
the  patient  recovers  with  the  loss  of  two  or  three  fingers  or  toes,  a  snip  off 
the  edge  of  both  ears  and  a  scar  on  the  tip  of  the  nose.  Attacks  of  this  severity 
may  occur  year  by  year,  and  there  are  terrible  instances  in  which  the  patients 
have  lost  both  hands  and  feet. 

Of  the  parts  affected  Monro  states  that  in  43  per  cent,  of  the  cases  one  or 
both  of  the  upper  extremities  is  involved.  Parts  other  than  the  extremities 
may  be  attacked,  as  the  chin,  lips,  nates,  and  eyelids. 

Complications. — Temporary  amblyopia  due  to  spasm  of  the  retinal  vessels, 
transient  aphasia,  and  transient  hemiplegia  have  been  met  with.  In  a  case 
which  I  have  reported  there  were  three  attacks  of  aphasia  with  hemiplegia  from 


1122  DISEASES    OF    THE    NERVOUS    SYSTEM 

which  complete  recovery  took  place.  Associated  with  these  were  the  features 
of  Raynaud's  disease.  The  patient  died  in  a  severe  attack  with  pain  in  the 
right  hand,  gangrene  to  the  elbow,  and  coma.  Epilepsy  has  been  reported  in 
a  great  number  of  cases,  and  in  one  case  in  my  clinic,  reported  by  Thomas, 
the  attacks  only  occurred  in  the  winter  when  he  had  Raynaud's  disease. 

Albuminuria  may  occur  during  the  attacks.  Haemoglobinuria  has  been 
present  in  a  number  of  cases,  and  was  well  studied  by  the  well-known  surgeon, 
Druitt,  in  his  own  case.  It  is  of  the  same  nature  as  the  paroxysmal  hasmo- 
globinuria  already  described. 

Scleroderma  of  the  fingers  may  follow  recurring  attacks.  Occasionally  true 
generalized  scleroderma  begins  with  the  features  of  Raynaud's  disease. 
Arthritis  has  been  present  in  certain  cases. 

Diagnosis. — There  is  rarely  any  difficulty  in  the  diagnosis.  One  condition 
closely  simulates  it,  namely,  local  gangrene  of  the  toes  associated  with  oblitera- 
tive  arteritis ;  but  this  occurs  most  frequently  in  older  persons,  in  diabetic  sub- 
jects, or  in  connection  with  well  marked  arterio-sclerosis.  As  a  rule,  the  pulse 
in  such  cases  is  not  to  be  felt  in  the  dorsal  artery.  Allied  to  this  form  is  a 
remarkable  affection  described  by  Buerger  among  the  Russian  Jews  in  New 
York — thrombotic  phlebo-arteritis  of  the  vessels  of  the  leg  with  local  gan- 
grene. In  the  early  stages  the  resemblance  to  Raynaud's  disease  is  very  close. 

In  the  acute  infections,  particularly  typhus  fever,  occasionally  in  epidemics 
of  typhoid  fever,  and  in  malaria,  areas  of  multiple  gangrene  occur.  The 
distribution  is  usually  different,  and  there  is  rarely  any  difficulty  in  distin- 
guishing this  form  from  Raynaud's  disease. 

Lastly,  there  are  cases  of  multiple  neurotic  skin  gangrene  met  with  in 
hysterical  and  nervous  patients,  in  the  majority  of  which  the  lesions  are  self- 
inflicted.  In  military  recruits  local  gangrene  of  the  big  toe  has  been  caused 
by  carbolic  acid,  and  it  seems  probable  that  all  of  those  so-called  trophic  and 
hysterical  lesions  are  simulated. 

Treatment. — In  many  cases  the  attacks  recur  for  years  uninfluenced  by 
treatment.  Mild  attacks  require  no  treatment.  In  the  severer  forms  of  local 
asphyxia,  if  in  the  feet,  the  patient  should  be  kept  in  bed  with  the  legs  ele- 
vated. The  toes  should  be  wrapped  in  cotton  wool.  The  pain  is  often  very 
intense  and  may  require  morphia.  Carefully  applied,  systematic  massage  of 
the  extremities  is  sometimes  of  benefit.  Galvanism  may  be  tried.  Barlow 
advises  immersing  the  affected  limb  in  salt  water  and  placing  one  electrode 
over  the  spine  and  the  other  in  the  water.  Nitroglycerin  has  been  warmly 
recommended  by  Gates.  Calcium  lactate  in  15  grain  (1  gm.)  doses,  three  or 
four  times  a  day,  is  sometimes  very  effectual.  It  often  relieves  chilblains. 
Gushing  has  introduced  a  plan  of  treatment  with  the  tourniquet  which  has 
proved  very  successful  in  several  cases  in  my  wards.  The  elastic  bandage, 
or,  better,  one  of  his  pneumatic  tourniquets,  is  applied  to  an  extremity  tight 
enough  to  shut  off  the  arterial  circulation  and  left  for  some  minutes.  On 
releasing  the  constriction  the  member  flushes  brightly,  owing  to  the  vaso- 
motor  relaxation.  The  application  in  cases  of  severe  spasm  may  have  to  be 
repeated  at  frequent  intervals  before  the  vascular  constriction  in  the  affected 
parts  will  be  overcome,  and  the  normal  temperature  and  color  return  in  them. 


ANGIO-NEUROTIC    (EDEMA  1123 

H.    ERYTHROMELALGIA 

(Red  Neuralgia) 

Definition. — "A  chronic  disease  in  which  a  part  or  parts — usually  one  or 
more  extremities — suffer  with  pain,  flushing,  and  local  fever,  made  far  worse 
if  the  parts  hang  down"  (Weir  Mitchell).  The  name  signifies  a  painful,  red 
extremity. 

Symptoms.— In  1872  (Phila.  Med.  Times,  November  23d),  in  a  lecture  on 
certain  painful  affections  of  the  feet,  Weir  Mitchell  described  the  case  of  a 
sailor,  aged  forty,  who  after  an  African  fever  began  to  have  "dull,  heavy  pains, 
at  first  in  the  left  and  soon  after  in  the  right  foot.  There  was  no  swelling  at 
first.  When  at  rest  he  was  comfortable  and  the  feet  were  not  painful.  After 
walking  the  feet  were  swollen.  They  scarcely  pitted  on  pressure,  but  were 
purple  with  congestion;  the  veins  were  everywhere  singularly  enlarged,  and 
the  arteries  were  throbbing  visibly.  The  whole  foot  was  said  to  be  aching  and 
burning,  but  above  the  ankle  there  was  neither  swelling,  pain,  nor  flushing." 
As  the  weather  grew  cool  he  got  relief.  Nothing  seemed  to  benefit  him.  This 
brief  summary  of  Mitchell's  first  case  gives  an  accurate  clinical  picture  of  the 
disease.  His  second  communication,  On  a  Rare  Vaso-Motor  Neurosis  of  the 
Extremities,  appeared  in  the  Am.  Jour,  of  the  Medical  Sciences  for  July,  1878, 
while  in  his  Clinical  Lessons  on  Nervous  Diseases,  1897,  will  be  found  addi- 
tional observations. 

The  disease  is  rare.  The  feet  are  much  more  often  affected  than  the  hands. 
The  pain  may  be  of  the  most  atrocious  character.  It  is  usually,  but  not  always, 
relieved  by  cool  weather ;  in  one  of  my  cases  the  winter  aggravates  the  trouble. 
In  a  few  cases  (Eisner,  Dehio,  Rolleston)  the  affection  has  been  complicated 
with  Raynaud's  disease. 

Mitchell  speaks  of  it  as  a  "painful  nerve-end  neuritis."  Dehio  suggests 
that  there  may  be  irritation  in  the  cells  of  the  ventral  horns  of  the  cord  at 
certain  levels.  Excision  of  the  nerves  passing  to  the  parts  has  been  followed 
by  relief.  In  one  of  Mitchell's  cases  gangrene  of  the  foot  followed  excision 
of  four  inches  of  the  musculo-cutaneous  nerve  and  stretching  of  the  posterior 
tibial.  Sclerosis  of  the  arteries  was  found.  Of  the  9  cases  in  which  the  local 
conditions  were  studied  anatomically,  the  only  constant  change  was  a  chronic 
endarteritis  (Batty  Shaw). 

m.    ANGIO-NEUROTIC  (EDEMA 

(Quinclce's  Disease} 

Definition. — An  affection  characterized  by  the  occurrence  of  local  cedema- 
tous  swellings,  more  or  less  limited  in  extent,  and  of  transient  duration. 
Severe  colic  is  sometimes  associated  with  the  outbreak.  There  is  a  marked 
hereditary  disposition  in  the  disease. 

Symptoms. — The  oedema  appears  suddenly  and  is  usually  circumscribed. 
It  may  appear  in  the  face;  the  eyelid  is  a  common  situation;  or  it  may 
involve  the  lips  or  cheek.  The  backs  of  the  hands,  the  legs,  or  the  throat  may 
be  attacked.  Usually  the  condition  is  transient,  associated  perhaps  with  slight 


1124  DISEASES    OF    THE    NERVOUS    SYSTEM 

gastro-intestinal  distress,  and  the  affection  is  of  little  moment.  There  may  be 
a  remarkable  periodicity  in  the  outbreak  of  the  cedema.  In  Matas'  case  this 
periodicity  was  very  striking ;  the  attack  came  on  every  day  at  eleven  or  twelve 
o'clock.  The  disease  may  be  hereditary  through  many  generations.  In  the 
family  whose  history  I  reported  five  generations  had  been  affected,  including 
twenty  two  members.  The  swellings  appear  in  various  parts;  only  rarely  are 
they  constant  in  one  locality.  The  hands,  face,  and  genitalia  are  the  parts 
most  frequently  affected.  Itching,  heat,  redness,  or  in  some  instances  urti- 
caria, may  precede  the  outbreak.  Sudden  cedema  of  the  larynx  may  prove 
fatal.  Two  members  of  the  family  just  referred  to  died  of  this  complication. 
In  one  member  of  this  family,  whom  I  saw  repeatedly  in  attacks,  the  swellings 
came  on  in  different  parts ;  for  example,  the  under  lip  would  be  swollen  to  such 
a  degree  that  the  mouth  could  not  be  opened.  The  hands  enlarge  suddenly, 
so  that  the  fingers  can  not  be  bent.  The  attacks  recur  every  three  or  four ' 
weeks.  Accompanying  them  are  usually  gastro-intestinal  attacks,  severe  colic, 
pain,  nausea,  and  sometimes  vomiting.  It  is  quite  possible  that  some  of  the 
cases  of  Leyden's  intermittent  vomiting  may  belong  to  this  group.  The  colic 
is  of  great  intensity  and  usually  requires  morphia.  Arthritis  apparently  does 
not  occur.  Periodic  attacks  of  cardialgia  have  also  been  met  with  during  the 
outbreak  of  the  oedema.  Haemoglobinuria  has  occurred  in  several  cases. 

The  disease  has  affinities  with  urticaria,  the  giant  form  of  which  is  prob- 
ably the  same  disease.  There  is  a  form  of  severe  purpura,  often  with  urti- 
carial  manifestations,  which  is  also  associated  with  marked  gastro-intestinal 
crises,  and  it  is  interesting  to  note  that  Schlesinger  has  reported  a  case  in 
which  a  combination  of  erythromelalgia,  Raynaud's  disease,  and  acute  cedema 
occurred.  Quincke  regards  the  condition  as  a  vaso-motor  neurosis,  under  the 
influence  of  which  the  permeability  of  the  vessels  is  suddenly  increased. 

The  treatment  is  very  unsatisfactory.  In  the  cases  associated  with  ansemia 
and  general  nervousness,  tonics,  particularly  large  doses  of  strychnia,  do  good. 
I  have  seen  great  improvement  follow  the  prolonged  use  of  nitroglycerin;  and 
calcium  lactate  may  be  tried,  in  doses  of  15  grains  (1  gm.)  thrice  daily. 

IV.    PERSISTENT   HEREDITARY    (EDEMA    OF    THE   LEGS 

(Milroy's  Disease] 

This  remarkable  condition,  first  described  by  Milroy  of  Omaha,  is  char- 
acterized by  persistent  cedema  of  the  legs,  without  any  traceable  cause,  or  any 
constitutional  features.  It  is  a  fairly  common  complaint,  affecting  males  and 
females  equally.  As  many  as  22  persons  in  Milroy's  series  were  affected 
among  97  in  six  generations;  in  Hope  and  French's  series  13  to  42  persons 
in  five  generations.  The  cedema  is  strictly  limited  to  the  lower  limbs  and 
varies  very  slightly.  In  some  instances  there  are  remarkable  acute  attacks, 
with  chill,  fever,  and  increase  of  swelling.  Except  mechanically  the  condition 
does  not  seriously  interfere  with  health. 

Here  may  be  mentioned  a  remarkable  familial  affection  described  by  Edge- 
worth  of  Bristol  (Lancet,  July  22,  1911),  of  a  general  subcutaneous  cedema. 
Of  six  infants  born  of  healthy  parents,  all  but  one  died  within  the  first  few 
months,  with  general  cedema,  following  upon  diarrhoea.  The  cases  differ 
essentially  from  those  of  cedema  neonatorum. 


SCLEBODEBMA  1125 


V.    FACIAL   HEMIATROPHY 

A  rare  affection  characterized  by  progressive  wasting  of  the  bones  and  soft 
tissues  of  one  side  of  the  face.  The  atrophy  starts  in  childhood,  but  in  a  few 
cases  has  not  come  on  until  adult  life.  Perhaps  after  a  trifling  injury  or  dis- 
ease the  process  begins,  either  diffusely  or  more  commonly  at  one  spot  on  the 
skin.  It  gradually  spreads,  involving  the  fat,  then  the  bones,  more  particu- 
larly the  upper  jaw,  and  last  and  least  the  muscles.  The  wasting  is  sharply 
limited  at  the  middle  line,  and  the  appearance  of  the  patient  is  very  remarka- 
ble, the  face  looking  as  if  made  up  of  two  halves  from  different  persons. 
There  is  usually  change  in  the  color  of  the  skin  and  the  hair  falls.  Owing  to 
the  wasting  of  the  alveolar  processes  the  teeth  become  loose  and  ultimately 
drop  out.  The  eye  on  the  affected  side  is  sunken,  owing  to  loss  of  orbital 
fat.  There  is  usually  hemiatrophy  of  the  tongue  on  the  same  side.  Disturb- 
ance of  sensation  and  muscle  twitching  may  precede  or  accompany  the  atrophy. 
In  a  majority  of  the  cases  the  atrophy  has  been  confined  to  one  side  of  the 
face,  but  there  are  instances  on  record  in  which  the  disease  was  bilateral,  and 
a  few  cases  in  which  there  were  areas  of  atrophy  on  the  back  and  on  the  arm 
of  the  same  side. 

Of  the  autopsies,  Mendel's  alone  is  satisfactory.  There  was  the  terminal 
stage  of  an  interstitial  neuritis  in  all  the  branches  of  the  trigeminus,  from 
its  origin  to  the  periphery,  most  marked  in  the  superior  maxillary  branch. 

The  disease  is  recognized  at  a  glance.  The  facial  asymmetry  associated 
with  congenital  wryneck  must  not  be  confounded  with  progressive  facial  hemi- 
atrophy. Other  conditions  to  be  distinguished  are :  Facial  atrophy  in  anterior 
polio-myelitis,  and  more  rarely  in  the  hemiplegia  of  infants  and  adults;  the 
atrophy  following  nuclear  lesions  and  sympathetic  nerve  paralysis;  acquired 
facial  hemihypertrophy,  such  as  in  the  case  recorded  by  D.  W.  Montgomery, 
which  may  by  contrast  give  to  the  other  side  an  atrophic  appearance;  and, 
lastly,  scleroderma  (a  closely  related  affection),  if  confined  to  one  side  of  the 
face.  The  precise  nature  of  the  disease  is  still  doubtful,  but  it  is  a  suggestive 
fact  that  in  many  of  the  cases  the  atrophy  has  followed  the  acute  infections. 
It  is  incurable. 

VI.    SCLERODERMA 

Definition. — A  condition  of  localized  or  diffuse  induration  of  the  skin. 

Varieties. — Two  forms  are  recognized:  the  circumscribed,  which  corre- 
sponds to  the  keloid  of  Addison,  and  to  morphcea;  and  the  diffuse,  in  which 
large  areas  are  involved. 

The  disease  affects  females  more  frequently  than  males.  The  cases  occur 
most  commonly  at  the  middle  period  of  life.  The  sclerema  neonatorum  is  a 
different  affection,  not  to  be  confounded  with  it.  The  disease  is  more  common 
in  the  United  States  than  statistics  indicate.  I  saw  20  cases  in  sixteen  years. 

In  the  circumscribed  form  there  are  patches,  ranging  from  a  few  centime- 
tres in  diameter  to  the  size  of  the  hand  or  larger,  in  which  the  skin  has  a 
waxy  or  dead-white  appearance,  and  to  the  touch  is  brawny,  hard,  and  in- 
elastic. Sometimes  there  is  a  preliminary  hypersemia  of  the  skin,  and  sub- 


1126  DISEASES    OF    THE    NERVOUS    SYSTEM 

sequently  there  are  changes  in  color,  either  areas  of  pigmentation  or  of  com- 
plete atrophy  of  the  pigment — leucoderma.  The  sensory  changes  are  rarely 
marked.  The  secretion  of  sweat  is  diminished  or  entirely  abolished.  The 
disease  is  more  common  in  women  than  in  men,  and  is  situated  most  fre- 
quently about  the  breasts  and  neck,  sometimes  in  the  course  of  the  nerves. 
The  patches  may  develop  with  great  rapidity,  and  may  persist  for  months  or 
years;  sometimes  they  disappear  in  a  few  weeks. 

The  diffuse  form,  though  less  common,  is  more  serious.  It  develops  first 
in  the  extremities  or  in  the  face,  and  the  patient  notices  that  the  skin  is  unusu- 
ally hard  and  firm,  or  that  there  is  a  sense  of  stiffness  or  tension  in  making 
accustomed  movements.  Gradually  a  diffuse,  brawny  induration  develops 
and  the  skin  becomes  firm  and  hard,  and  so  united  to  the  subcutaneous  tis- 
sues that  it  cannot  be  picked  up  or  pinched.  The  skin  may  look  natural, 
but  more  commonly  is  glossy,  drier  than  normal,  and  unusually  smooth.  With 
reference  to  the  localization,  in  Lewin  and  Heller's  statistics  in  66  observa- 
tions the  disease  was  universal;  in  203,  regions  of  the  trunk  were  affected; 
in  193,  parts  of  the  head  or  face;  in  287,  portions  of  one  or  other  of  the 
upper  extremities;  and  in  122,  portions  of  the  lower  extremities.  In  80  cases 
there  were  disturbances  of  sensation.  The  disease  may  gradually  extend  and 
involve  the  skin  of  an  entire  limb.  When  universal,  the  face  is  expression- 
less, the  lips  can  not  be  moved,  mastication  is  hindered,  and  it  may  become 
extremely  difficult  to  feed  the  patient.  The  hands  become  fixed  and  the  fin- 
gers immobile,  on  account  of  the  extreme  induration  of  the  skin  over  the 
joints.  Remarkable  vaso-motor  disturbances  are  common,  as  extreme  cyanosis 
of  the  hands  and  legs.  In  one  of  my  cases  tachycardia  was  present.  The 
disease  is  chronic,  lasting  for  months  or  years.  There  are  instances  on  record 
of  its  persistence  for  more  than  twenty  years.  Recovery  may  occur,  or  the 
disease  may  be  arrested.  One  of  my  patients,  with  extensive  involvement  of 
the  face,  ears,  and  hands,  improved  very  much.  The  patients  are  apt  to  suc- 
cumb to  pulmonary  complaints  or  to  nephritis.  Arthritic  troubles  have  been 
noticed  in  some  instances;  in  others,  endocarditis.  Raynaud's  disease  may 
be  associated  with  it.  I  have  seen  an  instance  of  the  diffuse  form  in  which 
the  primary  symptoms  were  those  of  local  asphyxia  of  the  fingers,  and  in 
which,  with  extensive  scleroderma  of  the  arms  and  hands  and  face,  there  were 
cyanosis  and  swelling  of  the  skin  of  the  feet  without  any  brawny  induration. 
The  pigmentation  of  the  skin  may  be  as  deep  as  in  Addison's  disease,  for 
which  cases  have  been  mistaken;  scleroderma  may  occur  as  a  complication  of 
exophthalmic  goitre. 

The  remarkable  dystrophy  known  as  sclerodactylie  belongs  to  this  disorder. 
There  are  symmetrical  involvements  of  the  fingers,  which  become  deformed, 
shortened,  and  atrophied;  the  skin  becomes  thickened,  of  a  waxy  color,  and 
is  sometimes  pigmented.  Multiple  calcareous  nodules,  not  unlike  tophi,  but 
not  uratic,  may  occur  about  the  fingers.  Bulls  and  ulcerations  have  been 
met  with  in  some  instances,  and  a  great  deformity  of  the  nails.  The  disease 
has  usually  followed  exposure,  and  the  patients  are  much  worse  during  the 
winter,  and  are  curiously  sensitive  to  cold.  There  may  be  changes  in  the 
skin  of  the  feet,  but  the  deformity  similar  to  that  which  occurs  in  the  hand 
has  not  been  noted.  Some  of  the  cases  present  in  addition  diffuse  scleroderma- 
tous  changes  of  the  skin  of  other  parts.  In  Lewin  and  Heller's  monograph 


AINHUM  1127 

there  are  35  cases  of  isolated  sclerodactylism,  and  106  cases  in  which  it  was 
combined  with  scleroderma. 

The  pathology  of  the  disease  is  unknown.  It  is  usually  regarded  as  a 
tropho-neurosis,  probably  dependent  upon  changes  in  the  arteries  of  the  skin 
leading  to  connective  tissue  overgrowth.  The  thyroid  has  been  found  atro- 
phied. 

Treatment. — The  patients  require  to  be  warmly  clad  and  to  be  guarded 
against  exposure,  as  they  are  particularly  sensitive  to  changes  in  the  weather. 
Warm  baths  followed  by  frictions  with  oil  should  be  systematically  used.  I 
have  tried  the  thyroid  feeding  thoroughly  in  the  diffuse  form.  In  one  case 
the  disease  appears  to  be  arrested;  the  patient  has  taken  the  extract  for  seven 
years.  In  a  second  case,  after  a  year  the  face  became  softer,  and  there  has 
been  permanent  improvement.  In  a  case  of  quite  extensive  localized  sclero- 
derma the  patches  became  softer  and  the  pigmentation  much  less  intense. 
Salol  in  15  grain  (1  gm.)  doses  three  times  a  day  is  stated  to  >have  been 
successful  in  several  cases. 

VII.    AINHUM 

Here  a  brief  reference  may  be  made  to  the  remarkable  trophic  lesion  de- 
scribed by  Da  Silva  Lima,  which  is  met  with  in  negroes  in  Brazil,  Africa, 
India,  and  occasionally  in  the  Southern  States.  It  is  confined  to  the  toes,  usu- 
ally the  little  toe,  and  begins  as  a  furrow  on  the  line  of  the  digito-plantar  fold. 
This  gradually  deepens,  the  end  of  the  toe  enlarges,  and,  usually  without 
inflammation  or  pain,  the  toe  falls  off.  The  process  may  last  some  years. 
Cases  have  been  reported  in  America  by  Hornaday,  Pittman,  F.  J.  Shepherd, 
and  Morrison. 


SECTION"    XII 

DISEASES   OF  THE   LOCOMOTOR  SYSTEM 

A.    DISEASES    OF    THE   MUSCLES 

• 

I.    MYOSITIS 

Definition.  — Inflammation  of  the  voluntary  muscles. 

A  primary  myositis  occurs  as  an  acute,  subacute,  or  chronic  affection.     It 
is  seen  in  two  chief  forms — the  suppurative  and  non-suppurative. 

I.  Suppurative   myositis,    known   also   as   infectious   myositi?,   is   espe- 
cially frequent  in  Japan,  where,  according  to  Miyake,  some  250  cases  have 
been  reported;  but  he  claims  that  some  of  these  examples  belong  to  other 
affections.     Miyake  personally   saw   33    cases   in  Japan  during  twenty   one 
months'  practice,  and  took  cultures  from  all  but  one  of  them.     In  2  cases  the 
results  were  negative,  but  in  27  a  pure  culture  of  the  staphylococcus  pyogenes 
aureus  was  obtained,  while  in  another  the  streptococcus  and  in  2  more  the 
albus  with  the  aureus  was  grown.    The  malady  may  involve  one  or  many  mus- 
cles, and  is  usually  sudden  in  its  onset.    There  are  also  high  fever  and  marked 
prostration.      Subsequently   abscesses   occur   in   the   indurated   muscles,   and 
pyagmia  may  ensue  if  the  implicated  muscles  are  not  thoroughly  evacuated. 

II.  Dermato-myositis. — An  acute  or  subacute  inflammation  of  the  mus- 
cles of  unknown  origin  associated  with  oedema  and  dermatitis.     Steiner  col- 
lected 28  cases  from  the  literature  and  reported  two  cases  from  my  clinic. 
The  muscle  inflammation  is  here  multiple,  and  is  associated  with  cedema  and 
a  dermatitis.    The  case  of  E.  Wagner  may  be  taken  as  a  typical  example.    A 
tuberculous  but  well-built  woman  entered  the  hospital,  complaining  of  stiff- 
ness in  the  shoulders  and  a  slight  cedema  of  the  back  of  the  hands  and  fore- 
arms.   There  was  para?sthesia,  the  arms  became  swollen,  the  skin  tense,  and  the 
muscles  felt   doughy.     Gradually  the  thighs  became  affected.      The  disease 
lasted  about  three  months.    The  post  mortem  showed  slight  pulmonary  tuber- 
culosis ;  all  the  muscles  except  the  glutei,  the  calf,  and  abdominal  muscles  were 
stiff  and  firm,  but  fragile,  and  there  were  serious  infiltration,  great  prolifera- 
tion of  the  interstitial  tissue,  and  fatty  degeneration.     In  the  case  reported 
by  Jacoby  the  muscles  were  firm,  hard,   and  tender,  and  there  was  slight 
cedema  of  the  skin.    The  cases  usually  last  from  one  to  three  months,  though 
there  are  instances  in  which  it  has  been  longer.     The  swelling  and  tenderness 
of  the  muscles,  the  cedema,  and  the  pain  naturally  suggest  trichinosis,  and, 
indeed,  Hepp  speaks  of  it  as  a  pseudo-trichinosis.     The  nature  of  the  disease 
is  unknown.     Of  the  28  cases  collected  by  Steiner  17  died.     The  anatomical 
changes  are  those  just  mentioned  as  found  in  E.  Wagner's  cases.       One  of 

1128 


MYALGIA  1129 

Senator's  cases  presented  marked  disorders  of  sensation  and  has  been  named 
neuro-myositis.  Wagner  suggests  that  some  of  these  cases  were  examples  of 
acute  progressive  muscular  atrophy.  The  differentiation  from  trichinosis  is 
possible  only  by  removing  a  portion  of  the  muscle.  It  has  not  yet  been  de- 
termined whether  the  eosinophilia  described  by  Brown  is  peculiar  to  the 
trichinosis  myositis. 

III.  Polymyositis  Haemorrhagica.— This  form  resembles  the  dermato- 
myositis  in  general  features,  but  differs  in  the  presence  of  haemorrhages  into 
and  between  the  muscles.  Of  the  ten  cases  analyzed  by  Thayer  four  recov- 
ered. Purpura  and  hemorrhages  from  the  mucous  membranes  may  occur. 


II     MYOSITIS    OSSIFICANS   PROGRESSIVA 

This  is  a  progressive  inflammatory  affection  of  the  locomotor  system  of 
unknown  origin,  characterized  by  the  gradual  formation  of  bony  masses  in 
the  fasciae,  muscles,  aponeuroses,  tendons,  ligaments,  and  bones,  with  resulting 
ankylosis  of  most  of  the  articulations  (Steiner).  About  100  cases  have  been 
reported.  The  process  begins  in  the  neck  or  back,  usually  with  swelling  of 
the  affected  muscles,  redness  of  the  skin,  and  slight  fever,  or  with  small 
nodules  in  the  muscles  which  appear  and  disappear.  After  subsiding  an 
induration  remains,  which  becomes  progressively  harder  as  the  transformation 
into  bone  takes  place.  The  disease  may  ultimately  involve  a  majority  of  the 
skeletal  muscles.  Nothing  is  known  of  the  etiology.  Malformation,  micro- 
dactylism  of  the  thumbs  and  big  toes,  is  present  in  75  per  cent,  of  the  cases. 


III.    MYALGIA 

(Fibrosiiis,  Myositis} 

Definition. — A  painful  affection  of  the  voluntary  muscles  and  of  the  fascia? 
and  periosteum  to  which  they  are  attached.  It  is  probable  that  in  many  cases 
the  fibrous  tissue  is  especially  affected — a  fibrositis.  It  is  by  no  means  cer- 
tain that  the  muscular  tissues  are  the  seat  of  the  disease.  Many  writers  claim 
that  in  some  cases  it  is  a  neuralgia  of  the  sensory  nerves  of  the  muscles.  The 
affection  has  received  various  names,  according  to  its  seat,  as  torticollis,  lum- 
bago, pleurodynia,  etc. 

Etiology. — The  attacks  follow  cold  and  exposure,  and  trauma  is  often  a 
factor.  It  is  most  commonly  met  with  in  men,  particularly  those  exposed  to 
cold  and  whose  occupations  are  laborious.  It  is  apt  to  follow  exposure  to  a 
draft  of  air,  as  from  an  open  window  in  a  railway  carriage.  A  sudden  chill- 
ing after  heavy  exertion  may  bring  on  an  attack  of  lumbago.  Persons  of  a 
gouty  habit  are  certainly  more  prone  to  this  affection,  and  one  attack  ren- 
ders an  individual  more  liable  to  another.  It  is  usually  acute,  but  may  be- 
come subacute  or  even  chronic,  the  last  being  more  common  in  later  life. 

Pathology.  — The  changes  are  usually  in  the  white  fibrous  tissue  and  are 
of  an  inflammatory  nature.  In  acute  cases  there  is  a  serous  exudation  in  the 
affected  parts  and  following  this  there  may  be  proliferation  of  the  fibrous 
73 


1130  DISEASES    OF    THE    LOCOMOTOR    SYSTEM 

tissue.  This  may  extend  between  the  muscle  fibres  and  cause  stiffness  and 
pain.  Disability  with  muscular  atrophy  may  result  from  this.  Nodules  some- 
times form  which  may  be  painful. 

Symptoms. — In  the  acute  forms  the  affection  is  entirely  local.  The  consti- 
tutional disturbance  is  slight,  and,  even  in  severe  cases,  there  may  be  no 
fever.  Pain  is  a  prominent  feature  and  may  be  constant  or  occur  only  when 
the  muscles  are  drawn  into  certain  positions.  It  may  be  a  dull  ache,  like  the 
pain  of  a  bruise,  or  sharp,  severe,  and  cramp-like.  It  is  often  sufficiently 
intense  to  cause  the  patient  to  cry  out.  Pressure  on  the  affected  part  usually 
gives  relief.  As  a  rule,  myalgia  is  a  transient  affection,  lasting  from  a  few 
hours  to  a  few  days,  although  occasionally  it  is  prolonged  for  several  weeks. 
It  is  very  apt  to  recur. 

Much  attention  has  been  given  of  late  to  a  form  of  myositis  occurring 
chiefly  in  the  muscles  of  the  head  and  neck,  causing  at  first  swelling  and 
puffiness,  later  indurations.  They  are  found  particularly  in  the  muscles  at 
the  back  of  the  neck,  but  they  are  occasionally  present  in  the  muscles  of  the 
abdomen  and  limbs.  They  may  appear  quite  suddenly,  sometimes  in  muscles 
that  are  over-worked,  but  in  other  instances  they  seem  to.  be  associated  with 
changes  in  the  weather.  The  affection  of  the  muscles  of  the  head  and  neck 
may  be  associated  with  headache,  the  so-called  indurative  headache.  Some 
of  the  cases  have  a  picture  very  similar  to  migraine.  In  the  abdominal  mus- 
cles these  limited  swellings  may  cause  pain  and  suggest  appendicitis. 

The  following  are  the  principal  varieties  of  myalgia : 

(1)  Lumbago,  one  of  the  most  common  and  painful  forms,  affects  the 
muscles  of  the  loins  and  their  tendinous  attachments.     Some  patients  are  sub- 
ject to  attacks  at  short  intervals.     It  occurs  chiefly  in  workingmen  and  often 
after  a  strain  in  lifting.    It  comes  on  suddenly,  and  in  very  severe  cases  com- 
pletely incapacitates  the  patient,  who  may  be  unable  to  turn  in  bed  or  to  rise 
from  the  sitting  posture.     There  may  be  difficulty  in  distinguishing  this  from 
arthritis  of  the  spine  or  sacro-iliac  joint  disease.     In  these  conditions  the 
symptoms  are  more  persistent.     The  restriction  of  motion  in  the  spine  is  an 
aid  in  recognizing  arthritis  and  the  special  features  of  sacro-iliac  joint  involve- 
ment should  be  looked  for.    The  X-ray  plates  are  a  great  aid. 

(2)  S,tiff  neck  or  torticollis  affects  the  muscles  of  the  antero-lateral  or 
back  region  of  the  neck.    It  is  very  common,  often  unilateral,  and  occurs  most 
frequently  in  the  young.     The  patient  holds  the  head  in  a  peculiar  manner 
turned  to  one  side,  and  rotates  the  whole  body  in  attempting  to  turn  it. 

(3)  Pleurodynia  involves  the  intercostal  muscles  on  one  side,  and  in  some 
instances  the  pectorals  and  serratus  magnus.    This  is,  perhaps,  the  most  pain- 
ful form  of  the  disease,  as  the  chest  can  not  be  at  rest.    It  is  more  common  on 
the  left  than  on  the  right  side.     A  deep  breath,  or  coughing,  causes  a  very 
intense  pain  on  pressure,  sometimes  over  a  very  limited  area.     It  may  be 
difficult  to  distinguish  from  intercostal  neuralgia,  in  which  affection,  however, 
the  pain  is  usually  more  circumscribed  and  paroxysmal,  and  there  are  tender 
points  along  the  course  of  the  nerves.     It  is  sometimes  mistaken  for  pleurisy, 
but  careful  physical  examination  readily  distinguishes  between  the  two  af- 
fections. 

(4)  Among  other  forms  which  may  be  mentioned  are  cephalodynia,  affect- 
ing the  muscles  of  the  head;  scapulodynia,  omodynia,  and  dorsodynia,  af- 


MYOTOtflA  1131 

fecting  the  muscles  about  the  shoulder  and  upper  part  of  the  hack.  Myalgia 
may  also  occur  in  the  abdominal  muscles  and  in  the  muscles  of  the  extremities. 
The  chronic  forms  are  distinguished  by  soreness  or  pain  associated  with  vary- 
ing degrees  of  disability.  There  may  be  marked  stiffness  of  the  muscles, 
which  are  sometimes  painful  on  pressure  and  may  show  definite  tender  areas 
of  induration. 

Treatment. — Eest  of  the  affected  muscles  is  of  the  first  importance,  and 
it  is  well  to  protect  them  from  cold  by  a  covering  of  flannel.  Strapping  of 
the  side  will  sometimes  completely  relieve  pleurodynia.  No  belief  is  more 
widespread  among  the  public  than  in  the  efficacy  of  porous  plasters  for  mus- 
cular pains  of  all  sorts,  particularly  those  about  the  trunk.  If  the  pain  is 
severe  and  agonizing,  a  hypodermic  of  morphia  gives  immediate  relief.  For 
lumbago  acupuncture  is,  in  acute  cases,  the  most  efficient  treatment.  Needles 
of  from  three  to  four  inches  in  length  (ordinary  bonnet-needles,  sterilized,  will 
do)  are  thrust  into  the  lumbar  muscles  at  the  seat  of  pain,  and  withdrawn 
after  five  or  ten  minutes.  In  many  instances  the  relief  is  immediate,  and  I 
can  corroborate  fully  the  statements  of  Einger,  who  taught  me  this  practice, 
as  to  its  extraordinary  and  prompt  efficacy  in  many  instances.  The  constant 
current  is  sometimes  very  beneficial.  In  many  forms  of  myalgia  the  thermo- 
cautery  gives  great  relief  and  in  obstinate  cases  blisters  may  be  tried.  Hot 
fomentations  are  soothing,  and  at  the  outset  a  Turkish  bath  may  cut  short 
the  attack.  The  bowels  should  be  freely  opened  and  large  amounts  of  water 
taken.  The  salicylates  are  usually  effectual;  sodium  salicylate  (gr.  x  to  xv, 
0.6  to  1  gm.),  aspirin  (gr.  x,  0.6  gm.),  or  salol  (gr.  v>0.3  gm.)  may  be  given. 
Some  patients  respond  well  to  colchicum  ( ify  xv,  1  c.  c.  of  the  wine) .  In 
chronic  cases  potassium  iodide  may  be  used,  and  both  guaiacum  and  sulphur 
have  been  strongly  recommended.  Persons  subject  to  this  affection  should  be 
warmly  clothed,  and  avoid,  if  possible,  exposure  to  cold  and  damp.  In  gouty 
persons  the  diet  should  be  restricted  and  the  alkaline  mineral  waters  taken 
freely.  Large  doses  of  nux  vomica  are  sometimes  beneficial.  Massage  some- 
times gives  relief ;  it  should  be  given  gently  at  first  and  more  vigorously  later, 


IV.    MYOTONIA 

(Tliomsen's  Disease) 

Definition. — An  affection  characterized  by  tonic  cramp  of  the  muscles  on 
attempting  voluntary  movements.  The  disease  received  its  name  from  the 
physician  who  first  described  it,  in  whose  family  it  existed  for  five  generations. 

While  the  disease  is  in  a  majority  of  cases  hereditary,  hence  the  name 
myotonia  congenita,  there  are  other  forms  of  spasm  very  similar  which  may 
be  acquired,  and  others  still  which  are  quite  transitory. 

Etiology. — All  the  typical  cases  have  occurred  in  family  groups;  a  few 
isolated  instances  have  been  described  in  which  similar  symptoms  have  been 
present.  Males  are  much  more  frequently  affected  than  females.  In  102 
recorded  cases,  91  were  males  and  only  11  females  (Hans  Koch).  The  disease 
is  rare  in  America  and  in  England;  it  seems  more  common  in  Germany  and 
in  Scandinavia, 


1132  DISEASES    OF   THE    LOCOMOTOR    SYSTEM 

Symptoms. — The  disease  comes  on  in  childhood.  It  is  noticed  that  on 
account  of  the  stiffness  the  children  are  not  able  to  take  part  in  ordinary 
games.  The  peculiarity  is  noticed  only  during  voluntary  movements.  The 
contraction  which  the  patient  wills  is  slowly  accomplished;  the  relaxation 
which  the  patient  wills  is  also  slow.  The  contraction  often  persists  for  a  little 
time  after  he  has  dropped  an  object  which  he  has  picked  up.  In  walking,  the 
start  is  difficult;  one  leg  is  put  forward  slowly,  it  halts  from  stiffness  for  a 
second  or  two,  and  then  after  a  few  steps  the  legs  become  limber  and  he  walks 
without  any  difficulty.  The  muscles  of  the  arms  and  legs  are  those  usually 
implicated ;  rarely  the  facial,  ocular,  or  laryngeal  muscles.  Emotion  and  cold 
aggravate  the  condition.  In  some  instances  there  is  mental  weakness.  The 
sensation  and  the  reflexes  are  normal.  G.  M.  Hammond  has  reported  three 
remarkable  cases  in  one  family,  in  which  the  disease  began  at  the  eighth  year 
and  was  confined  entirely  to  the  arms.  It  was  accompanied  with  some  slight 
mental  feebleness.  The  condition  of  the  muscles  is  interesting.  The  patients 
appear  and  are  muscular,  and  there  is  sometimes  a  definite  hypertrophy  of  the 
muscles.  The  force  is  scarcely  proportionate  to  the  size.  Erb  has  described 
a  characteristic  reaction  of  the  nerve  and  muscle  to  the  electrical  currents — 
the  so-called  myotonic  reaction,  the  chief  feature  of  which  is  that  normally  the 
contractions  caused  by  either  current  attain  their  maximum  slowly  and  relax 
slowly,  and  vermicular,  wave-like  contractions  pass  from  the  cathode  to  the 
anode. 

The  disease  is  incurable,  but  it  may  be  arrested  temporarily.  The  nature 
of  the  affection  is  unknown.  Dejerine  and  Sottas  have  found  hypertrophy  of 
the  primitive  fibres  with  multiplication  of  the  nuclei  of  all  the  muscles, 
including  the  diaphragm,  but  not  the  heart.  The  spinal  cord  and  the  nerves 
were  intact.  From  Jacoby's  latest  studies  it  is  doubtful  whether  these  changes 
in  the  muscles  are  in  any  way  characteristic  or  peculiar  to  the  disease.  J. 
Koch,  however,  has  found,  in  addition  to  the  muscle  hypertrophy,  degenera- 
tive and  regenerative  changes  present,  which  he  considers  sufficient  to  account 
for  the  myotonic  disorder.  Karpinsky  and  von  Bechterew,  from  careful 
urinary  examinations,  regard  the  affection  as  due  to  an  auto-intoxication  of 
the  muscle  tissue,  caused  by  some  faulty  metabolism.  No  treatment  for  the 
condition  is  known. 


V.    PARAMYOCLONUS  MULTIPLEX  • 

(Myoclonia) 

Definition. — An  affection,  described  by  Friedreich,  characterized  by  clonic 
contractions,  chiefly  of  the  muscles  of  the  extremities,  occurring  either  con- 
stantly or  in  paroxysms. 

The  cases  have  been  chiefly  in  males,  and  the  disease  has  followed  emo- 
tional disturbance,  fright,  or  straining.  The  contractions  are  usually  bilateral 
and  may  vary  from  fifty  to  one  hundred  and  fifty  in  the  minute.  Occasionally 
tonic  spasms  occur.  They  are  not  accompanied  by  any  sensory  disturbances. 
In  the  intervals  between  the  attacks  there  may  be  tremors  of  the  muscles.  In 
the  severe  spasms  the  movements  may  be  very  violent;  the  body  is  tossed 
about,  and  it  is  sometimes  difficult  to  keep  the  patient  in  bed.  Gucci  hat 


AMYOTONIA    CONGENITA  1133 

described  a  family  in  which  the  affection  has  occurred  in  three  generations. 
Weiss  has  also  noted  heredity  in  four  generations.  According  to  this 
author  the  essential  symptoms  are  continuous  or  paroxysmal  contractions, 
usually  symmetrical  and  rhythmical,  of  muscles  otherwise  normal,  which 
cease  during  sleep.  There  are  neither  psychical  nor  sensory  disturbances. 
The  condition  is  most  common  in  young  males,  and  is  unaffected  by  treat- 
ment. Eaymond  groups  this  disease  with  fibrillary  tremors,  electric  chorea 
(Dubini's  disease),  tic  non  douloureux  of  the  face,  and  the  convulsive  tic, 
under  the  name  of  myoclonies,  believing  that  it  is  only  one  link  in  a  chain  of 
pathological  manifestations  in  the  degenerate.  Dana,  in  1903,  divided  the 
myoclonias  into  five  groups.  In  the  first  he  placed  paramyoclonus  multiplex, 
and  considered  the  names  of  four  somewhat  similar  affections  as  synonyms 
of  the  same. 

VI.    MYASTHENIA   GRAVIS 

(Asthenic  Bulbar  Paralysis;  Erb-Goldflam's  Symptom-Complex) 

Definition. — A  disease  with  fatigue  symptoms  referable  to  the  muscular 
system,  due  to  failure  of  innervation  without  definite  changes  in  muscles  or 
nerves. 

Of  180  cases  collected  by  McCarthy,  83  were  males  and  96  females.  The 
disease  is  most  frequent  in  the  third  decade.  The  etiology  is  unknown. 

The  muscles  innervated  by  the  bulb  are  first  affected — those  of  the  eyes, 
the  face,  of  mastication,  and  of  the  neck.  After  effort  the  muscles  show 
fatigue,  and  if  persisted  in  they  fail  to  act  and  a  condition  of  paresis  or  com- 
plete paralysis  follows.  All  the  voluntary  muscles  may  become  involved. 
After  rest  the  power  is  recovered.  In  severe  cases  paralysis  may  persist.  The 
myasthenic  reaction  of  Jolly  is  the  rapid  exhaustion  of  the  muscles,  by  farad- 
ism,  not  by  galvanism.  There  are  marked  remissions  and  fluctuations  in  the 
severity  of  the  symptoms. 

Examination  of  the  nervous  system  has  revealed  no  abnormality.  Weigert 
found  a  thymus  tumor  with  metastatic  growths  in  the  muscles.  Hun, 
Bloomer,  and  Streeter  have  described  an  infiltration  of  the  muscles  and  of  the 
thymus  gland  with  lymphoid  cells  and  a  proliferation  of  the  glandular  ele- 
ments of  the  thymus. 

The  diagnosis  is  easy — from  the  ptosis,  the  facial  expression,  the  nasal 
speech,  the  rapid  fatigue  of  the  muscles,  the  myasthenic  reaction,  the  absence 
of  atrophy,  tremors,  etc.,  and  the  remarkable  variations  in  the  intensity  of 
the  symptoms.  Of  the  180  collected  cases  72  proved  fatal.  The  patient  may 
live  many  years;  recovery  may  take  place.  Rest,  strychnia  in  full  doses, 
massage,  and  alternate  courses  of  iodide  of  potassium  and  mercury  may  be 
tried. 

VH.    AMYOTONIA   CONGENITA 

(Oppenheim's  Disease) 

A  congenital  affection  characterized  by  general  or  local  hypotonus  of  the 
voluntary  muscles,  Oppenheim  called  the  disease  myatonia,  but  this  is  pho- 


1134  DISEASES    OF    THE    LOCOMOTOR    SYSTEM 

nctically  so  similar  to  myotonia  (Thomson's  disease)  that  the  name  amyoto- 
nia  of  English  writers  is  preferable. 

Collier  and  Wilson,  who  have  analyzed  the  recorded  cases,  give  the  follow- 
ing definition:  "A  condition  of  extreme  flaccidity  of  the  muscles,  associated 
with  an  entire  loss  of  the  deep  reflexes.,  most  marked  at  the  time  of  birth  and 
always  showing  a  tendency  to  slow  and  progressive  amelioration.  There  is 
great  weakness,  but  no  absolute  paralysis  of  any  of  the  muscles.  The  limbs 
are  most  affected;  the  face  is  almost  always  exempt.  The  muscles  are  small 
and  soft,  but  there  is  no  local  wasting.  Contractures  are  prone  to  occur  in  the 
course  of  time.  The  faradic  excitability  in  the  muscles  is  lowered  and  strong 
faradic  stimuli  are  borne  without  complaint.  No  other  symptoms  indicative 
of  lesions  of  the  nervous  system  occur." 

In  Spiller's  case  no  lesions  were  found,  but  in  an  autopsy  by  Baudouin 
the  cells  of  the  anterior  horns  were  found  to  be  small,  and  there  were  ex- 
tensive changes  in  the  muscle  fibres,  similar  to  those  in  the  myopathies. 


B.    DISEASES   OF    THE   JOINTS 
I.    ARTHRITIS  DEFORMANS 

Definition. — A  disease  of  the  joints  of  doubtful  etiology,  but  probably  the 
result  of  infection,  characterized  by  changes  in  the  synovial  membranes,  car- 
tilage, and  peri-articular  structures,  and  in  some  cases  by  atrophic  and  hyper- 
trophic  changes  in  the  bones.  A  tendency  to  a  chronic  course  is  the  rule. 

Long  believed  to  be  intimately  associated  with  gout  and  rheumatism 
(whence  the  names  rheumatic  gout  and  rheumatoid  arthritis),  this  relatipnship 
seems  disproved.  By  the  studies  of  the  Boston  orthopedic  surgeons  (Bradford, 
Goldthwaite,  and  Lovett)  and  of  Strangeways  and  his  pupils  at  Cambridge 
(England)  we  are  gradually  getting  a  more  accurate  knowledge  of  the  an- 
atomical and  clinical  forms  of  this  common  disease.  There  is  a  difference  of 
opinion  as  to  whether  there  are  two  distinct  diseases  or  varying  forms  of 
the  same  disease  included  under  this  heading.  Those  who  hold  the  former 
view  consider  that  in  one  disease  the  synovial  membranes  and  the  peri- 
articular  tissues  are  particularly  affected  (rheumatoid  arthritis)  and  in  the 
other  disease  the  cartilage  and  bone  (osteo-arthritis).  The  disease  occurs 
frequently  and  to  it  belong  many  of  the  cases  termed  "chronic  rheumatism." 

Etiology. — AGE. — A  majority  of  the  cases  are  between  the  ages  of  twenty 
and  fifty.  In  A.  E.  Garrod's  analysis  of  500  cases  there  were  only  25  under 

twenty  years  of  age.  In  40  per  cent,  of  the  series  of  500  cases  studied  by 
T.  McCrae,  the  onset  was  before  the  age  of  thirty  years.  In  the  group  with 
peri-articular  changes  predominating  the  age  of  onset  is  usually  lower  than 
in  the  group  with  special  cartilaginous  and  bony  changes. 

SEX. — Among  Garrod's  cases  there  were  411  in  women.  Practically  half 
of  the  series  of  McCrae  were  males.  The  incidence  as  to  sex  is  influenced  by 
the  inclusion  of  the  cases  of  spondylitis,  of  which  a  large  majority  is  in  males. 
In  women  a  close  association  with  the  menopause  has  been  noted. 

PREDISPOSITION. — In  216  in  Garrod's  series  there  was  a  family  history  of 
joint  trouble;  in  McCrae's  series  only  in  114  among  500.  Two  or  three  chil- 


ARTHRITIS   DEFOBMAXS  1135 

dren  in  a  family  may  be  affected.  In  America  the  incidence  in  the  negro  is 
relatively  much  less  than  in  the  white.  Occupation  and  the  station  in  life 
do  not  seem  to  have  any  special  influence. 

EXPOSURE  TO  COLD,  wet  and  damp,  errors  in  diet,  worry  and  care,  and 
local  injuries  are  all  spoken  of  as  possible  exciting  causes,  but  probably  play 
but  a  small  part. 

As  regards  the  views  of  the  etiology  of  arthritis  deformans,  the  one  that 
t  is  of  nervous  origin  is  only  of  historical  interest,  and  the  modern  opinion  is 
that  it  is  a  result  of  some  infectious  process,  certainly  in  the  majority  of 
cases. 

ARTHRITIS  DEFORMANS  AS  A  CHRONIC  INFECTION.— This  view  is  steadily 
gaining  ground  and  the  evidence  suggests  certain  varieties  of  streptococci  as 
the  causal  organism.  This  seems  more  probable  than  that  the  disease  is  due 
to  a  specific  organism.  The  arthritis  is  secondary  to  a  focus  of  infection 
somewhere.  The  possible  sources  are  many  but  infection  of  the  mouth  and 
throat  probably  takes  first  place.  Abscesses  about  the  teeth  should  always 
be  searched  for  (X-ray  study)  and  the  tonsils  carefully  examined.  Other 
sources  are :  infection  of  the  nose  or  sinuses,  pyorrhoea  alveolaris,  otitis  media, 
chronic  bronchitis,  infection  of  the  urinary  tract,  pelvic  disease  in  women, 
and  infection  of  the  prostate  and  seminal  vesicles  in  men.  The  possibility 
of  chronic  infection  from  the  intestinal  tract  must  be  considered  although  this 
is  difficult  to  prove. 

The  acute  onset,  with  fever  in  many  cases,  the  polyarthritis,  the  presence 
of  enlarged  glands,  the  frequent  enlargement  of  the  spleen,  the  occurrence  of 
pleurisy,  endocarditis,  and  pericarditis  in  some  cases  are  all  suggestive  of  an 
infection.  The  likeness  of  the  lesions  to  those  due  to  arthritis  from  a  specific 
cause,  such  as  the  gonococcus,  is  suggestive,  and  also  the  association  of  the 
arthritis  with  definite  foci  of  infection  in  some  cases.  Lastly,  a  consideration 
of  the  form  in  children  described  by  Still  lends  weight  to  this  view,  particu- 
larly in  the  widespread  enlargement  of  the  lymph  glands  and  the  swelling  of 
the  spleen. 

METABOLIC. — While  the  nutrition  suffers  in  many  cases  there  does  not 
seem  any  evidence  to  support  the  view  that  the  disease  is  primarily  due  to 
disturbance  of  metabolism.  Metabolic  changes  are  probably  secondary  just  as 
are  the  trophic  changes. 

Morbid  Anatomy. — The  usual  descriptions  are  of  the  late  stages  of  the 
disease  when  extensive  damage  has  occurred,  for  there  have  been  few  oppor- 
tunities to  study  the  early  changes,  although  more  frequent  operations  have 
extended  our  knowledge  of  them  and  radiographs  have  aided  much.  There  are 
three  main  forms  of  change:  (1)  Lesions  principally  in  the  synovial  mem- 
branes and  peri-articular  tissues  (the  so-called  rheumatoid  arthritis),  (2) 
with  atrophic  changes  in  the  cartilage  and  bones  predominating,  and  (3)  with 
hypertrophy  and  overgrowth  of  bone  (so-called  osteo-arthritis).  The  first 
and  second  are  seen  most  frequently  in  the  joints  of  the  extremities,  the  third 
in  the  spine.  Whether  these  are  distinct  diseases  or  different  manifestations 
of  the  same  disease  it  is  difficult  to  say.  In  many  cases  all  forms  of  change 
are  found,  which  speaks  against  the  view  that  there  are  two  distinct  diseases. 
The  changes  in  general  are:  (1)  Effusion,  which  is  not  constant  and  shows 
no  special  features.  (2)  Changes  in  the  synovial  membrane.  These  are  in- 


1136  DISEASES    OF   THE    LOCOMOTOK    SYSTEM 

flammatory  and  often  haemorrhagic  at  the  onset.  There  may  be  marked 
thickening  and  proliferation  of  the  synovial  fringes  with  the  formation  of 
villi — villous  arthritis.  (3)  The  capsule  and  surrounding  tissues  may  be 
infiltrated  and  much  swollen.  The  peri-articular  tissues  show  infiltration  and 
swelling,  and  the  enlargement  of  the  joint  is  more  often  due  to  swelling  about 
it  than  to  bony  changes.  (4)  Cartilage.  This  may  show  erosion,  ulceration, 
atrophy,  or  proliferation.  The  cartilage  may  disappear  entirely,  but  the 
changes  are  often  very  irregular  and  uneven  and  the  cartilage  may  be  replaced 
by  fibrous  tissue  or  by  bone,  the  latter  being  most  common  at  the  edge  of  the 
cartilage.  The  cartilages  may  be  soft  and  gradually  absorbed  or  thinned  (this 
often  begins  opposite  the  point  of  greatest  involvement  of  the  synovial  mem- 
brane). (5)  Bone.  This  may  show  atrophy  of  varying  grade.  If  the  cartilage 
is  completely  absorbed  the  surface  of  the  bone  often  becomes  hard  and  ebur- 
nated.  In  the  form  spoken  of  as  Jiypertropliic  there  is  new  bone  formation 
which  is  most  common  at  the  edge  of  the  articular  surfaces.  In  the  hip  joint 
this  may  form  an  irregular  ring  of  bone  about  the  joint  cavity.  The  common- 
est example  of  overgrowth  of  bone  is  seen  on  the  so-called  "Heberden's  nodes," 
which  are  bony  outgrowths  at  the  terminal  interphalangeal  joints.  There 
may  be  deposit  of  new  bone  in  the  ligaments,  particularly  in  the  spine.  Pro- 
liferation of  bone  usually  occurs  at  the  margins  of  the  joints  in  the  form  of 
irregular  nodules — the  osteophytes — which  may  lock  the  joints.  The  forma- 
tion of  bone  may  also  occur  in  ligaments,  especially  of  the  spine,  which  may 
be  converted  into  a  rigid  bony  column.  Bony  ankylosis  rarely  occurs  in  the 
peripheral  joints,  but  is  common  in  the  spine. 

There  may  be  extensive  secondary  changes.  Muscular  atrophy  is  common 
and  may  appear  with  great  rapidity.  Subluxation  may  occur,  especially  in 
the  knee  and  finger  joints.  The  hands  often  show  great  deformity,  particu- 
larly ulnar  deflection.  Contractures  may  follow  and  the  joints  become  fixed 
in  a  flexed  position.  Neuritis  and  trophic  disturbances  may  be  associated; 
the  neuritis  is  sometimes  due  to  direct  extension  of  the  inflammatory  process. 
Subcutaneous  fibroid  nodules  occasionally  occur. 

The  radiographs  show  the  changes  very  well.  Erosion  of  the  cartilage  is 
easily  seen.  In  the  type  with  predominant  peri-articular  changes  the  carti- 
lage and  bone  often  show  little  alteration.  The  occurrence  of  various  changes 
in  different  joints  or  even  in  the  same  joint  is  common  and  bony  change  may 
occur  with  marked  involvement  of  the  peri-articular  tissues. 

Symptoms. — The  onset  may  be  acute  or  gradual.  In  the  acute  form  a 
number  of  joints  may  be  involved,  there  may  be  high  fever  and  the  whole 
condition  be  suggestive  of  rheumatic  fever.  In  other  cases  the  onset  is  "acute 
in  one  joint  and  others  are  involved  a  few  days  later.  With  the  gradual 
onset  one  joint  is  attacked  and  others  follow.  Some  cases  are  between  and 
may  be  termed  subacute.  In  cases  with  an  acute  onset  the  attack  may  not 
persist  very  long;  with  the  chronic  onset  the  duration  is  usually  prolonged. 
The  acute  onset  occurs  more  frequently  in  the  form  in  which  changes  in  the 
soft  parts  predominate. 

ARTHRITIS. — In  the  acute  form  the  joints  are  swollen,  tender,  and  hot  to 
the  touch,  but  do  not  often  show  marked  redness.  There  may  be  effusion  in 
the  larger  joints.  Pain  is  a  marked  feature  and  is  increased  by  movement, 
the  patient  usually  taking  the  position  in  which  he  has  the  greatest  ease. 


ARTHRITIS    DEFORMANS  1137 

When  a  joint  is  once  attacked,  the  process  does  not  subside  quickly,  and  when 
the  arthritis  lessens  some  change  remains  in  the  joint  which,  however,  may  be 
very  slight.  The  joints  of  the  spine,  especially  in  the  cervical  region,  are 
often  involved  in  the  more  acute  forms,  and  in  these  there  is  rarely  any  per- 
manent change.  The  temporo-maxillary  joint  is  often  involved,  and  arthritis 
here  is  always  suggestive  of  this  disease.  The  hands,  when  involved,  show 
very  characteristic  changes.  The  knuckle  joints  are  red,  swollen,  tender,  and 
show  limitation  of  motion.  The  fingers  are  often  involved;  swelling  of  the 
interphalangeal  joints  is  common  with  a  resulting  thickening  which  gives  a 
fusiform  appearance  to  the  finger.  Partial  dislocation,  particularly  at  the 
terminal  joint,  is  common.  The  knee  joints  are  often  involved  with  pain, 
effusion,  limitation  of  motion,  and  later  villous  arthritis  or  subluxation. 
Thickening  of  the  capsule  usually  occurs  early. 

In  the  hypertrophic  (osteo-arthritis  form)  the  process  is  rarely  as  acute 
as  when  the  peri-articular  parts  are  particularly  involved  (rheumatoid  ar- 
thritis), but  is  usually  polyarticular.  The  terminal  finger  joints,  the  hip  joint, 
and  the  spine  are  especially  affected.  Pain  is  usually  a  marked  feature,  and 
the  local  features  are  not  so  marked.  The  process  is  more  likely  to  be 
chronic. 

HEBERDEN'S  XODES. — These  are  small  bony  outgrowths  ('little  hard 
knobs" — Heberden)  at  the  terminal  phalaugeal  joints,  which  develop  gradu- 
ally at  the  sides  of  the  distal  phalanges.  They  are  much  more  common  in 
women  than  in  men.  Heberden  says  "they  have  no  connection  with  gout, 
being  found  in  persons  who  have  never  had  it,"  yet  they  are  often  regarded 
as  indicating  gout.  In  the  early  stage  the  joints  may  be  swollen,  tender,  and 
slightly  red,  particularly  when  injured.  The  attacks  of  pain  and  swelling  may 
come  on  in  the  joints  at  long  intervals  or  follow  injury.  Sometimes  they  are 
the  first  manifestation  of  a  general  arthritis.  Their  distribution  is  not 
always  regular  and  they  are  often  largest  on  the  fingers  most  used.  They 
are  often  found  in  patients,  the  arthritis  in  whose  other  joints  is  of  the  other 
form.  The  condition  is  not  curable;  but  there  is  this  hopeful  feature — the 
subjects  whose  arthritis  begins  in  this  way  rarely  have  severe  involvement  of 
the  larger  joints.  They  have  been  regarded,  too,  as  an  indication  of  longevity. 

The  MON-ARTICULAR  FORM  affects  chiefly  old  persons',  and  is  seen  particu- 
larly in  the  hip  and  shoulder.  It  is  identical  with  the  general  disease  in  its 
anatomical  features.  The  muscles  show  wasting  early  and  in  the  hip  the  con- 
dition ultimately  becomes  that  described  as  morbus  coxce  senilis.  These  cases 
seem  not  infrequently  to  follow  an  injury.  They  differ  from  the  polyarticu- 
lar form  in  occurring  chiefly  in  men  and  at  a  later  period  of  life. 

THE  VERTEBRAL  FORM  (Spondylitis). — This  may  occur  alone  or  with 
involvement  of  the  peripheral  joints.  With  the  acute  polyarthritis  of  the 
peripheral  joints  the  spine  may  be  involved,  but  there  is  usually  no  permanent 
change.  With  the  hypertrophic  form  there  is  often  bony  proliferation  and 
some  spinal  rigidity  results  which  may  involve  the  whole  spine  or  only  a  part ; 
in  the  latter  case  the  lower  dorsal  and  lumbar  regions  suffer  most  frequently. 
The  condition  may  not  involve  more  than  a  few  vertebras.  The  features  are 
as  variable  as  in  the  peripheral  joints  and  there  may  be  repeated  acute  at- 
tacks or  a  steady  progressive  process.  In  the  general  spine  involvement  the 
ribs  may  be  fixed,  the  thorax  immobile,  and  the  breathing  abdominal.  There 


1138  JJISUASES    UF    THE    LOCOMUTOK    SYSTEM 

are  two  varieties  of  the  general  involvement  which  are  sometimes  regarded 
as  special  diseases.  In  one  (von  Bechterew)  the  spine  alone  is  involved, 
and  there  are  pronounced  nerve-root  symptoms — pain,  anaesthesia,  atrophy 
of  the  muscles,  and  ascending  degeneration  of  the  cord.  Von  Bechterew 
thinks  it  begins  as  a  meningitis,  leads  to  compression  of  the  nerve  roots,  loss 
of  function  of  the  spinal  muscles,  atrophy  of  the  intervertebral  disks,  and 
gradually  ankylosis  of  the  spine.  In  the  other — Striimpell-Marie  type — the 
hip  and  shoulder  joints  may  he  involved  (spondylose  rhizomelique),  and  the 
nervous  symptoms  are  less  prominent.  Both  appear  to  be  forms  of  arthritis 
deformans,  and  should  neither  be  regarded  nor  described  as  separate  diseases. 
Spondylitis  deformans  is  more  frequent  in  males  than  in  females,  and  trauma 
probably  plays  an  important  part  in  its  etiology.  Local  involvement  is  par- 
ticularly common  in  the  lumbar  region  and  may  cause  sciatica  and  a  great 
variety  of  referred  pains.  Pressure  on  the  nerve-roots  cause  great  pain, 
paraesthesia,  and  atrophy  of  the  muscles.  Movement  of  the  spine  is  usually 
restricted. 

ARTHRITIS  DEFORMANS  IN  CHILDREN. — Some  cases  resemble  closely  the 
disease  in  adults,  in  others  there  are  very  striking  differences.  A  very  inter- 
esting variety  has  been  differentiated  by  Still,  in  which  the  general  enlarge- 
ment of  the  joints  is  associated  with  swelling  of  the  lymph  glands  and  of  the 
spleen.  The  onset  is  almost  always  before  the  second  dentition,  and  girls  are 
more  frequently  affected  than  boys.  The  symptoms  complained  of  are  usu- 
ally slight  stiffness  in  one  or  two  joints;  gradually  others  become  involved. 
The  onset  may  be  acute  with  fever  or  even  with  chills.  The  enlargement  of 
the  joints  is  due  rather  to  a  general  thickening  of  the  soft  tissues  than  to  a 
bony  enlargement.  The  limitation  of  movement  may  be  extreme,  owing  to 
the  fixation  of  the  joints,  and  there  may  be  much  muscular  wasting.  The 
enlargement  of  the  lymph  glands  is  most  striking,  increases  with  fever,  and 
may  be  general;  even  the  epitrochlear  glands  may  be  as  large  as  hazel- 
nuts.  The  edge  of  the  spleen  can  usually  be  felt  below  the  costal  margin. 
Sweating  is  often  profuse  and  there  may  be  anaemia,  but  heart  complica- 
tions are  rare.  The  children  look  puny  and  generally  show  arrest  of  devel- 
opment. 

GENERAL  FEATURES. — Temperature. — In  the  acute  attacks  this  may  rise  to 
102°  or  103°  F.,  but  is  frequently  lower  and  often  persists  for  weeks  with 
a  maximum  about  100°  F.  The  pulse  is  usually  rapid  in  proportion  to  the 
fever,  the  most  frequent  range  being  from  90  to  110.  Cardiac  changes  are 
found  in  a  small  proportion  of  cases.  Glandular  enlargement  is  common  and 
may  be  general  or  especially  marked  in  the  glands  related  to  the  affected  joints. 
The  spleen  is  enlarged  in  some  cases,  the  frequency  being  greater  in  the 
younger  patients.  Subcutaneous  nodules  occur  in  a  few  cases  and  are  some? 
times  tender.  The  blood  often  shows  a  slight  anaemia,  which  is  not  as  marked 
as  might  be  expected  from  the  appearance  of  the  patients.  There  is  rarely 
much  increase  in  the  leucocytes  and  the  differential  count  shows  no  pecu- 
liarity. The  urine  does  not  show  any  change  of  moment.  The  skin  sometimes 
shows  irregular  areas  of  yellow  pigmentation,  especially  on  the  face  and  arms. 
It  may  have  a  glossy  appearance  over  the  affected  joints.  Profuse  sweating 
of  the  hands  and  feet  is  common.  The  reflexes  are  usually  increased  in  acute 
cases  and  a  return  to  normal  is  of  good  significance.  They  are  sometimes 


ARTHRITIS   DEFORMANS  1139 

absent.  Muscular  atrophy  is  common  and  sometimes  advances  very  rapidly. 
It  is  most  marked  in  the  hands.  Twitching  of  the  muscles  is  not  uncommon. 

In  some  patients  the  bony  atrophy  is  very  marked.  This  is  most  common 
in  females.  In  these  disorganization  of  the  joints  occurs  and  the  carti- 
lage rapidly  disappears.  These  cases  usually  progress  rapidly  downward. 
This  atrophy  is  to  be  distinguished  from  that  due  to  disuse. 

COURSE. — General  Progressive  Form. — This  occurs  in  two  varieties,  acute 
and  chronic.  The  acute  form  may  resemble,  at  its  outset,  ordinary  rheumatic 
fever.  There  is  involvement  of  many  joints;  swelling,  particularly  of  the 
synovial  sheaths  and  bursae,  but  not  often  redness;  there  is  moderate  fever 
which  is  often  persistent  and  may  be  from  99°  to  100°  F.  for  weeks.  The 
pulse  rate  is  usually  high  in  proportion  to  the  fever.  In  this  form  there  may 
be  repeated  acute  attacks,  perhaps  at  intervals  of  years,  or  there  may  be 
repeated  attacks  in  various  joints.  These  usually  leave  definite  changes, 
which  may  be  slight  at  first,  but  tend  to  increase  with  subsequent  attacks. 
Acute  cases  may  occur  at  the  menopause.  Some  cases  progress  very  rapidly; 
they  lose  weight  and  strength;  atrophy  and  arthritic  deformity  are  marked; 
and  they  suggest  a  progressive  septic  process  without  suppuration. 

The  chronic  form  is  the  most  common,  although  most  of  these  have  had  at 
some  time  an  acute  attack,  especially  at  the  onset.  The  first  symptoms  are 
pain  on  movement  and  slight  swelling,  which  may  be  in  the  joint  itself  or 
in  the  peri-articular  sheaths.  In  some  cases  the  effusion  is  marked,  in  others 
slight.  The  local  conditions  vary  greatly,  and  periods  of  improvement  alter- 
nate with  attacks  of  swelling,  redness,  and  pain.  At  first  only  one  or  two 
joints  are  affected;  gradually  other  articulations  are  involved,  and  in  extreme 
cases  every  joint  in  the  body  is  affected.  Pain  is  an  extremely  variable  symp- 
tom. Some  cases  proceed  to  the  most  extreme  deformity  without  severe  pain; 
in  others  the  suffering  is  very  great,  particularly  at  night  and  during  exacerba- 
tions of  the  disease.  There  are  cases  in  which  pain  of  an  agonizing  character 
is  an  almost  constant  symptom,  quite  apart  from  the  occurrence  of  acute  dis- 
turbances. Pain  has  an  important  influence  in  the  production  of  deformity,  as 
it  hinders  movement  and  the  joints  are  kept  in  the  position  of  greatest  ease. 

Gradually  the  shape  of  the  joints  is  greatly  altered,  partly  by  the  thick- 
ening of  the  capsule  and  surrounding  tissues,  perhaps  by  the  pressure  of  osteo- 
phytes,  and  often  by  the  muscular  contraction.  In  moving  the  affected  joint 
crepitus  may  be  felt.  Ultimately  the  joints  may  be  completely  immobile,  not 
by  a  true  bony  anchylosis,  although  it  may  be  by  the  osteophytes  which  form 
around  the  articular  surfaces  like  ringbone  in  the  horse,  but  more  often  from 
adhesions,  and  peri-articular  thickening.  There  is  often  an  acute  atrophy  of 
the  muscles  about  the  joints  and  atrophy  from  disuse  usually  supervenes,  so 
that  contractures  tend  to  flex  the  thigh  upon  the  abdomen  and  the  leg  upon 
the  thigh.  There  are  cases  with  rapid  muscular  wasting,  symmetrical  involve- 
ment of  the  joints,  increased  reflexes,,  and  trophic  changes,  which  strongly 
suggest  a  central  origin.  Numbness,  tingling,  pigmentation  or  glossiness  of 
the  skin,  and  onychia  may  be  present.  In  extreme  cases  the  patient  is  com- 
pletely helpless,  and  lies  with  the  legs  drawn  up,  the  arms  fixed,  and  all  the 
articulations  of  the  extremities  fixed.  Fortunately,  it  often  happens  in  these 
severe  general  cases  that  the  joints  of  the  hand  are  not  so  much  affected,  and 
the  patient  may  be  able  to  knit  or  write,  though  unable  to  walk  or  use  th# 


1140  DISEASES    OF   THE   LOCO-MOTOR    SYSTEM 

arms.  In  many  cases,  after  involving  two  or  three  joints,  the  disease  be* 
comes  arrested,  and  no  further  development  occurs.  A  majority  of  the  pa- 
tients finally  reach  a  quiescent  stage,  in  which  they  are  free  from  pain  and 
enjoy  excellent  health,  suffering  only  from  the  inconvenience  and  crippling 
necessarily  associated  with  the  disease.  Coincident  affections  are  not  un- 
common. In  the  active  stage  the  patients  often  suffer  from  dyspepsia,  which 
may  recur  at  intervals.  A  small  percentage  show  cardiac  lesions,  and  the 
pulse  rate  is  usually  higher  than  normal. 

Diagnosis. — The  cases  with  an  acute  onset  may  be  difficult  to  distinguish 
from  rheumatic  fever.  The  affected  joints  are  rarely  as  tender  as  in  rheu- 
matic fever,  and  the  smaller  joints  are  more  often  involved.  The  presence  of 
thickening  in  a  joint,  rapid  muscular  atrophy,  a  relatively  high  pulse  rate 
in  relation  to  the  fever  (in  the  absence  of  endocarditis),  and  the  absence  of 
marked  response  to  salicylate  medication  speak  against  rheumatic  fever.  The 
diagnosis  from  gonorrhoeal  arthritis  may  be  difficult,  but  in  this  the  small 
joints  are  nsually  not  attacked  so  often,  and  after  an  onset  with  polyarthritis 
the  majority  &f  the  affected  joints  usually  clear,  leaving  one  joint  particularly 
involved.  This  rarely  occurs  in  arthritis  deformans.  A  careful  search  for 
gonococci  is  a  great  aid  in  diagnosis.  In  the  chronic  stage  there  may  be 
oonsiderable  difficulty  in  distinguishing  this  disease  from  gout.  This  is  par- 
ticularly marked  in  either  disease  without  marked  joint  changes.  The  study 
of  the  radiographs  is  particularly  helpful  and  marked  peri-articular  changes 
speak  for  arthritis  deformans.  The  finding  of  tophi  or  the  estimation  of  the 
uric  acid  excretion  may  give  the  diagnosis  of  gout.  It  is  important  to  dis- 
tinguish sub-deltoid  bursitis  from  the  mon-articular  form  in  the  shoulder; 
the  radiographs  are  a  great  aid.  They  are  also  important  in  the  recognition 
of  disease  of  the  sacro-iliac  joint  and  tuberculosis  of  the  hip-joint.  Special 
importance  attaches  to  the  diagnosis  of  the  spinal  forms.  There  is  no  dif- 
ficulty in  the  case  of  general  involvement,  but  with  local  changes  in  the  lower 
spine  it  is  not  so  easy.  Pain  on  and  restriction  of  movement  are  important; 
the  patient  is  careful  to  limit  any  motion  of  the  spine.  Tuberculosis  of  the 
spine  rarely  offers  any  difficulty,  especially  with  skiagrams. 

Prognosis. — The  age,  general  circumstances,  character  of  the  patient,  the 
extent  of  damage  to  the  joints,  and  the  variety  of  change  are  all  important. 
The  outlook  is  not  as  dark  as  it  is  usually  described.  If  the  source  of  infec- 
tion can  be  found  and  properly  treated  the  prognosis  is  encouraging.  In  many 
patients  the  disease  runs  a  certain  course,  and,  if  they  can  be  brought  through 
it  with  a  minimum  of  damage,  the  ultimate  outlook  is  good.  In  the  form  with 
peri-articular  changes  predominating,  early  diagnosis,  treatment  of  the  point 
of  infection,  the  preservation  of  good  nutrition,  and  a  patient  who  is  willing  to 
fight  are  all  encouraging  factors.  The  outlook  in  the  cases  with  the  acute 
attacks  is  usually  better  than  in  those  with  a  more  chronic  progressive  course. 
Rapid  muscular  atrophy  is  of  grave  import.  Cases  in  women  beginning  about 
the  menopause  should  always  have  a  grave  prognosis.  Rapid  advancement  in 
the  joint  changes  is  serious.  In  the  form  in  children  the  outlook  is  not  good, 
but  some  recover  entirely.  The  group  with  marked  hypertrophic  changes 
(osteo-arthritis)  usually  do  well.  Heberden's  nodes  are  permanent,  but  in 
the  larger  joints  it  is  rare  for  the  condition  to  advance  to  absolute  crippling, 
although  there  may  be  considerable  interference  with  function.  Spondylitis 


ARTHRITIS    DEFORMANS  1141 

rarely  advances  to  complete  immobility  of  the  whole  spine.  The  outlook  is 
good  in  the  local  cases,  but  depends  somewhat  on  the  occupation  and  possi- 
bility of  further  trauma.  The  general  condition  of  the  patient  is  always  of 
importance  in  estimating  the  outlook  in  any  case.  In  those  with  marked 
nervous  features  the  prognosis  is  not  good. 

Treatment.— Much  depends  on  proper  management  and  the  pessimistic 
attitude  is  not  justified.  Certain  things  are  important:  early  diagnosis  so 
that  treatment  can  be  begun  early,  the  avoidance  of  harmful  measures,  careful 
attention  to  the  general  condition,  and  every  effort  to  limit  the  damage  to  the 
joints.  Too  much  stress  can  not  be  placed  on  the  need  of  early  diagnosis; 
the  disease  is  often  regarded  as  "rheumatic"  and  the  treatment  directed  to 
this  (especially  restriction  of  diet  and  the  giving  of  salicylates  for  long 
periods)  is  usually  harmful. 

SOURCE  OF  INFECTION. — This  should  be  carefully  searched  for  and,  if 
found,  properly  treated.  If  the  tonsils  are  diseased  they  should  be  removed. 
Antistreptococcus  serum  has  been  used,  and  in  some  cases  with  benefit. 

GENERAL  MEASURES. — The  patient  should  be  kept  out  of  doors  as  much 
as  possible  and  every  effort  made  to  improve  the  general  health.  The  diet 
should  be  the  most  nourishing  possible.  The  mistake  of  cutting  down  the 
proteins  is  often  made.  Regard  must  be  had  to  the  digestion,  and  it  is  more 
often  the  carbohydrates  which  should  be  reduced.  Water  should  be  freely 
given,  as  elimination  is  important.  The  bowels  should  be  kept  open,  and  for 
this  the  salines  are  useful.  It  is  important  to  see  that  the  patients  are  warmly 
clad  in  cold  weather  and  guarded  against  chilling.  Hydrotherapy  is  useful 
locally  in  the  form  of  compresses,  but  the  hot  bath  treatment,  so  often  given, 
more  frequently  does  harm  than  good,  particularly  in  acute  cases.  Baths, 
when  taken,  should  be  of  very  short  duration.  In  more  chronic  cases  bathing 
is  sometimes  of  value.  Massage  is  especially  useful  in  the  cases  with  synovial 
and  peri-articular  changes,  and  in  them  passive  motion  should  be  used  early. 
Climate  is  of  value  in  so  far  as  patient  is  able  to  be  out  of  doors  and  is  saved 
from  rapid  changes  of  temperature. 

MEDICINAL. — There  is  no  drug  which  essentially  influences  the  disease. 
The  salicylates  may  be  an  aid  in  relieving  pain,  but  should  not  be  given  for 
long  periods.  Iron,  arsenic,  and  iodine  are  often  useful.  The  iodide  of  iron 
in  half  drachm  (2  c.  c.)  doses  should  be  given  persistently  and  alternated  with 
Fowler's  solution  in  five  drop  doses.  Iodine  may  be  given  as  the  tincture  in 
doses  of  two  or  three  drops.  Potassium  iodide  is  sometimes  of  value  when 
given  for  a  long  period.  Thyroid  and  thymus  gland  extracts  given  persist- 
ently are  sometimes  beneficial.  For  the  pain  it  is  necessary  to  give  drugs, 
although  local  measures  should  be  used  as  much  as  possible.  There  are  many 
which  are  available.  Aspirin  (gr.  x,  0.6  gm.),  guaiacol  carbonate  (gr.  v, 
0.3  gm.),  antipyrin  (gr.  iii,  0.2  gm.),  and  sometimes  codeia  (gr.  yz)  are 
useful.  Morphia  should  not  be  given  on  account  of  the  danger  of  a  habit. 

LOCAL. — (a)  Use  of  the  joints  must  be  governed  by  the  condition.  When 
the  cartilage  and  bones  are  not  involved,  passive  motion  and  massage  are 
useful,  followed  later  by  active  motion.  The  patient  should  be  taught  simple 
exercises.  When  the  cartilages  and  bones  are  involved,  rest  is  usually  advisa- 
ble for  a  time.  Every  effort  should  be  made  to  avoid  contracture  and  dis- 
placement, and  in  this  the  use  of  splints  during  the  night  is  often  valuable. 


1142  DISEASES   OF  THE  LOCOMOTOR   SYSTEM 

Caution  should  be  exercised  in  advising  complete  fixation.  This  is  sometimes 
useful  for  short  periods  in  the  osteo-arthritic  form,  but  may  result  in  fixation 
in  the  other  form  and  is  usually  not  advisable  for  it.  (&)  Counter-irritation. 
This  is  usually  an  aid,  and  the  Paquclin  cautery,  blisters,  mustard,  and  iodine 
may  be  used.  It  is  usually  better  to  use  light  counter-irritation  frequently  than 
severe  at  longer  intervals,  (c)  IJyperosmia.  This  may  be  active,  and  baking 
js  a  favorite  method,  but  it  should  not  be  given  for  more  than  thirty  minutes 
at  a  time.  The  temperature  should  be  as  high  as  the  patient  can  stand.  Pas- 
sive hyperaemia  may  be  used  for  a  short  period  at  first,  and  later  for  many 
hours  at  a  time,  (d)  Hydrotherapy.  The  persistent  use  of  compresses  is 
often  of  value.  They  may  be  put  on  in  the  evening  and  left  on  all  night. 

SURGICAL  MEASURES. — These  are  useful  for  the  correction  of  deformities. 
In  the  case  of  villous  arthritis  operation  is  usually  indicated.  In  the  group 
with  marked  hypertrophy  of  bone  removal  of  the  outgrowths  may  be  helpful. 

SPECIAL  FORMS. — (a)  Heberden's  nodes.  Avoidance  of  irritation  and  in- 
jury is  important,  and  in  the  case  of  pain  the  use  of  compresses  is  helpful. 
(&)  Spondylitis.  During  the  acute  stages  rest  is  essential  and  should  be 
secured  by  a  plaster  jacket  or  simple  apparatus.  In  the  milder  forms  firm 
strapping  may  give  relief.  Trauma  should  be  especially  avoided,  (c)  Knee 
Joint.  In  many  cases  a  simple  elastic  support  is  useful  and  may  save  the 
joint  from  injury. 

VACCINES. — These  have  not  proved  of  great  value,  but  in  a  few  cases  the 
use  of  a  polyvalent  antistreptococcus  serum  has  been  of  benefit. 

Arthritis  Secondary  to  Acute  Infection. — While  the  majority  of  cases  of 
arthritis  are  secondary  to  some  form  of  infection,  it  is  important  to  recognize 
that  there  are  various  forms.  (1)  Those  with  a  definite  bacterial  cause,  such 
as  gonorrhoeal  or  tuberculous  arthritis.  These  usually  have  fairly  well  defined 
features.  (2)  Those  secondary  to  infections  of  doubtful  etiology,  such  as 
scarlet  fever  or  measles.  In  some  of  these  the  arthritis  is  due  to  a  secondary 
infection,  but  in  others  it  appears  to  be  due  to  the  specific  cause  of  the  dis- 
ease. (3)  Arthritis  secondary  to  definite  infections  in  which  there  is  no 
evidence  of  any  organism  in  the  joint.  These  are  comparatively  common  and 
are  difficult  to  designate.  For  example,  arthritis,  which  may  not  be  severe 
and  subsides  rapidly,  occurs  with  an  attack  of  tonsillitis  or  influenza.  It  has 
been  suggested  that  these  might  be  termed  "toxic"  or  "toxaemic"  arthritis. 
The  term  "infectious"  arthritis,  sometimes  applied,  is  not  a  satisfactory  one. 
The  cases  in  this  group  usually  clear  without  leaving  permanent  damage,  but 
it  is  possible  that  if  long  continued  they  may  result  in  the  changes  included 
under  the  heading  of  arthritis  deformans. 

"Chronic  Rheumatism." — This  term  deserves  mention  because  it  is  so 
commonly  used,  but  it  is  a  question  whether  its  retention  is  justified.  There 
is  no  uniformity  in  its  usage  and  it  is  applied  without  discrimination  to  all 
kinds  of  arthritis  and  frequently  to  conditions  which  have  nothing  to  do  with 
the  joints.  Painful  conditions  of  the  joints,  muscles,  fascia?,  bones,  and 
nerves  are  all  termed  "rheumatism."  There  is  no  disease  entity  to  which  the 
term  can  be  applied,  and  it  would  be  an  advantage  to  give  it  up  entirely. 


HYPERTROPHIC    PULMONARY   ARTHROPATHY         1143 

II.    INTERMITTENT    HYDRARTHROSIS 

The  condition  was  described  by  Perrin  in  1845,  and  there  are  about  70 
cases  on  record  (Garrod).  The  affection  is  characterized  by  a  remarkable 
periodic  swelling  of  one  or  several  of  the  joints  without  fever.  The  swelling 
may  take  place  with  great  rapidity,  and  there  may  even  be  a  sensation  of 
water  rushing  into  the  joint.  There  are  usually  pain  and  stiffness.  The 
periods  may  be  from  ten  to  twelve  days,  or  a  month  or  even  three  months. 
Many  of  the  cases  have  been  in  women  and  sometimes  with  marked  hysterical 
symptoms.  While  some  of  the  cases  are  secondary  and  only  represent  a 
phase  in  the  evolution  of  various  articular  lesions,  there  appears  to  be  a 
primary  form  characterized  by  a  periodic  swelling  and  nothing  else.  It  is 
sometimes  the  joint  equivalent  to  Quincke's  cedema  and  may  be  associated 
with  erythema,  with  angio-neurotic  cedema,  and  in  one  of  Garrod's  patients 
there  was  at  the  same  time  circumscribed  cedema  of  the  lips  and  eyelids. 
A  mother  and  daughter  have  been  affected.  The  prognosis  is  not  good;  the 
attacks  are  apt  to  recur  in  spite  of  all  forms  of  treatment. 

C.    DISEASES   OF   THE   BONES 
I.    HYPERTROPHIC    PULMONARY    ARTHROPATHY 

Definition. — A  symmetrical  enlargement  of  the  bones  of  the  hands  and 
feet,  and  of  the  distal  ends  of  the  long  bones,  occurring  in  association  with 
certain  chronic  diseases,  particularly  affections  of  the  lungs. 

Bamberger  in  1889  reported  a  condition  of  abnormal  thickening  of  the 
long  bones  in  bronchiectasis,  and  the  next  year  Marie  described  other  cases 
and  named  the  condition. 

Etiology.' — Clubbing  of  the  fingers,  or  the  Hippocratic  fingers,  represent 
a  minor  manifestation  of  this  condition.  Many  varieties  occur;  indeed,  there 
is  a  monograph  with  sketches  of  some  thirty  or  forty  forms.  It  is  met  with 
perhaps  most  constantly  in  congenital  disease  of  the  heart,  in  tuberculosis 
and  in  other  affections  of  the  lungs,  particularly  bronchiectasis,  in  congenital 
syphilis,  in  chronic  jaundice,  and  in  other  chronic  affections.  In  thoracic 
aneurism  it  may  involve  only  the  fingers  of  one  hand.  It  usually  comes  on 
very  slowly,  but  cases  have  been  described  of  an  acute  appearance  within  a 
week  or  a  fortnight.  It  may  disappear.  There  is  no  bony  alteration,  but  there 
is  a  fibrous  thickening  of  the  connective  tissues  with  turgescence  of  the  ves- 
sels. The  condition  is  by  no  means  easy  to  explain.  The  mechanical  effect 
of  congestion,  the  usual  feature,  explains  the  heart  and  lung  cases,  but  not 
those  of  congenital  syphilis  and  diseases  of  the  liver,  in  which  this  is  not 
present.  Others  have  attributed  it  to  a  toxin. 

Marie's  syndrome  is  met  with:  (1)  In  diseases  of  the  lungs  and  pleura. 
This  was  the  case  in  43  out  of  55  cases  collected  by  Thayer,  and  in  68  of 
Wynn's  100  cases.  Bronchiectasis  is  the  most  -common,  then  pulmonary 
tuberculosis  and  empyema. 

(2)  Other  affections,  such  as  chronic  diarrhoea,  chronic  jaundice,  nephri- 
tis, and  congenital  syphilis. 


1144  DISEASES    OF   THE   LOCOMOTOR    SYSTEM 

Marie  regards  the  process  as  resulting  from  the  absorption  of  toxins  caus- 
ing a  periostitis;  others  have  regarded  it  as  a  low  form  of  tuberculous  infec- 
tion. The  bones  most  frequently  involved  are  the  lower  ends  of  the  radius 
and  ulna  and  the  metacarpals,  more  rarely  the  lower  end  of  the  humerus,  and 
the  lower  ends  of  the  tibia  and  fibula. 

Symptoms. — The  affection  comes  on  gradually,  unnoticed  by  the  patient. 
In  other  cases  there  is  great  sensitiveness  of  the  ends  of  the  long  bones  and 
of  the  fingers  and  toes.  In  one  of  my  cases  this  was  present  in  an  extreme 
degree.  The  fully  developed  condition  is  easily  recognized.  The  hands  are 
large,  the  terminal  phalanges  swollen,  the  nails  large  and  much  curved. 
Similar  changes  occur  in  the  toes,  and  the  feet  look  large,  especially  the  toes 
and  the  malleoli.  The  bones  of  the  fore-arms  are  diffusely  thickened,  par- 
ticularly near  the  wrist,  and  the  tibia3  and  fibulae  are  greatly  enlarged.  Some- 
times in  advanced  cases  both  ankles  and  knee-joints  stand  out  prominently. 
The  hypertrophy  rarely  affects  the  other  long  bones,  though  occasionally  the 
extremities  of  the  humerus  and  femur  may  be  involved.  The  bones  of  the 
head  are  not  attacked.  Kyphosis  may  occur. 

Diagnosis. — There  is  rarely  any  difficulty,  as  the  picture  presented  by  the 
hands  and  feet  differs  from  that  in  acromegaly,  and  in  practically  all  cases 
it  is  a  secondary  condition. 

H.     OSTEITIS   DEFORMANS 

(Paget's  Disease) 

Definition. — A  chronic  affection  of  the  bones  characterized  by  enlargement 
of  the  head,  dorso-cervical  kyphosis,  enlargement  of  the  clavicles,  spreading 
of  the  base  of  the  thorax  and  an  outward  and  forward  bowing  of  the  legs. 

The  affection  was  described  first  by  Sir  James  Paget,  in  1877. 

Etiology. — In  the  generalized  form  it  is  a  rare  disease,  only  two  cases 
occurring  among  about  20,000  medical  cases  at  the  Johns  Hopkins  Hospital. 
I  have  seen  three  or  four  instances  in  private  practice.  The  etiology  of  the 
disease  is  unknown.  Mother  and  daughter  have  been  affected.  Some  have 
regarded  it  as  luetic,  others  as  due  to  the  arterio-sclerosis,  which  is  a  constant 
lesion.  It  may  possibly  be  due  to  perversion  of  some  internal  secretion. 

Pathology. — The  skull,  spine,  and  long  bones  are  chiefly  affected,  those 
of  the  face,  hands  and  feet  are  less  involved.  The  skull  may  be  as  much  as 
three  quarters  of  an  inch  in  thickness,  and  its  circumference  is  increased. 
In  one  of  Paget's  cases  it  measured  71  cm.  The  shafts  of  the  long  bones 
are  greatly  thickened  and  they  may  weigh  twice  as  much  as  a  healthy  bone 
of  the  same  length.  The  femur  is  bent,  the  convexity  forward ;  the  tibiae  may 
be  huge  and  very  much  bowed  anteriorly.  The  bones  of  the  upper  extremities 
are  less  often  involved,  the  spine  shows  a  marked  kyphosis,  sometimes  partial 
ankylosis ;  the  pelvis  is  broadened. 

The  process  is  a  rarefying  osteitis  which  gradually  involves  the  centre 
of  the  bones  with  the  formation  of  Howship's  lacunae,  Haversian  spaces, 
and  perforating  canals.  There  is  also  new  bone  formation,  both  subperiosteal 
and  myelogenous ;  the  latter  process  gradually  gains,  and  so  the  bones  thicken. 

Symptoms. — The  disease  begins,  as  a  rule,  in  the  sixth  decade,  sometimes 


OSTEOGB1TESI8   IMPEBFECTA  1145 

jrith  rheumatoid  pains,  but  more  frequently  the  patient  notices  first  that  the 
head  begins  to  enlarge,  so  that  he  has  to  bay  a  larger  hat.  Then  his  friends 
notice  that  he  is  growing  shorter,  and  that  the  legs  are  getting  more  and 
more  bowed. 

There  is  a  painful  variety  of  the  disease  with  great  soreness  of  the  arms 
and  legs,  which  may  be  much  worse  at  night.  Headache,  bronchitis,  pigmenta- 
tion of  the  skin,  have  been  noted.  The  reduction  in  stature  is  very  remarka- 
ble; one  of  my  patients  lost  13  inches  in  height. 

Diagnosis. — The  disease  is  readily  recognized.  The  face  differs  from 
acromegaly,  in  which  it  is  ovoid  or  egg-shaped  with  the  large  end  down,  while 
in  Paget's  disease  the  face  is  triangular  with  the  base  upward.  In  a  few 
cases  the  disease  may  be  limited  to  a  few  bonejs.  There  is  a  variety,  of  which 
I  have  seen  three  examples,  involving  the  tibise  and  fibulae  alone,  and  in  one  to 
a  slight  extent  the  femurs.  These  bones  gradually  enlarge,  are  bowed  ante- 
riorly and  laterally,  so  that  the  only  obvious  features  are  a  reduction  in  height 
with  bowing  of  the  legs. 

There  is  also  a  variety  which  is  sometimes  known  as  tumor-forming  ostei- 
tis deformans,  in  which  the  bones  are  much  deformed  with  multiple  hyper- 
ostosis  and  new  growths.  The  relation  of  this  to  Paget's  disease  is  doubtful. 


III.     LEONTIASIS    OSSEA 

In  a  remarkable  condition  known  as  leontiasis  ossea  there  is  hyperostosis 
of  the  bones  of  the  cranium,  and  sometimes  those  of  the  face.  The  description 
is  largely  based  upon  the  skulls  in  museums,  but  Allen  Starr  has  recently 
reported  an  instance  in  a  woman,  who  presented  a  slowly  progressing  increase 
in  the  size  of  the  head,  face,  and  neck,  the  hard  and  soft  tissues  both  being 
affected.  He  has  applied  to  the  condition  the  term  megalo-cephaly.  Putnam 
states  that  the  disease  begins  in  early  life,  often  as  a  result  of  injury.  There 
may  be  osteophytic  growths  from  the  outer  or  inner  tables,  which  in  the 
latter  situation  may  give  the  symptoms  of  tumor. 


IV.    OSTEOGENESIS   IMPERFECTA 

(Fragilitas  Ossium) 

This  is  a  systemic  disease  of  the  fetus  in  which  the  normal  osseous  devel- 
opment does  not  occur.  At  birth  there  is  marked  fragility  of  all  the  bones. 
There  may  have  been  intra-uterine  fractures  \vhich  have  united  and  show  large 
calluses.  The  extremities  are  often  bent  and  deformed.  The  main  features 
are  defective  development  of  the  cranium  and  fragility  of  all  the  bones.  It  was 
thought  that  death  always  occurred,  but  Nathan  has  shown  that  some  of  the 
patients  survive  and  that  the  bones  become  firmer  as  the  child  grows  older. 
Treatment  consists  in  using  every  protection  against  injury.  Fractures 
usually  unite  readily. 
74 


1146  DISEASES    OF   THE    LOCOMOTOR   SYSTEM 

V.  OSTEOPSATHYROSIS 

(Fragilitas  Ossium,  Lobsteiris  Disease) 

Definition. — A  rare  affection  characterized  by  abnormal  brittleness  of  the 
bones. 

In  the  aged  the  bones  get  thin  and  fragile,  and  the  same  happens  in  many 
chronic  wasting  diseases  and  in  the  insane.  In  osteopsathyrosis  the  general 
health  of  the  patient  is  excellent  and  the  fractures  follow  very  trifling  in- 
juries, as  a  slight  blow,  or  pull,  turning  over  in  bed,  or  in  the  simple  act 
of  chewing  the  patient  may  fracture  the  jaw.  It  is  more  common  in  the 
early  period  of  life,  and  many  of  the  cases  in  children  represent  the  condition 
just  spoken  of — osteogenesis  imperfecta — but  there  are  cases  in  which  it  has 
continued  until  old  age.  The  number  of  fractures  which  a  patient  may  have 
may  amount  to  one  hundred  or  more.  The  fractures  may  be  painless  and  heal 
readily;  there  are  rarely  any  complications,  and  in  a  case  reported  by  B. 
Sachs  the  condition  was  associated  with  general  muscular  atrophy  and  poly- 
uria. 

VI.  ACHONDROPLASIA 

(Chondrodystrophia  Fetalis) 

Definition. — A  dystrophy  of  the  epiphyseal  cartilages  due  to  connective 
tissue  invasion  from  the  periosteum,  in  consequence  of  which  the  epiphyses 
and  diphyses  are  prematurely  united  and  there  is  failure  of  the  normal  growth 
of  the  long  bones.  In  consequence  the  subjects  become  dwarfs  with  normal 
heads  and  trunks,  but  short,  stumpy  extremities. 

Description.' — Achondroplasic  dwarfs  are  easily  recognized.  They  are  well 
nourished  and  strong,  and  of  average  intelligence.  Their  height  varies  from 
3  to  4  feet;  the  head  and  trunk  are  of  about  normal  size,  but  the  extremities 
are  very  short,  the  fingers,  when  the  arms  are  at  the  sides,  reaching  little 
below  the  crest  of  the  ilium.  The  important  point  in  diagnosis  is  that  in 
the  shortness  of  the  limbs  it  is  the  proximal  segments  which  are  specially 
involved,  the  humerus  and  femur  being  even  shorter  than  the  ulna  and  tibia 
(rhizomelia).  The  limbs  are  considerably  bent,  but  this  is  more  an  exag- 
geration of  normal  curves  and  abnormalities  in  the  joints  than  pathological 
curves  as  in  rickets.  The  features  of  rickets  are  absent.  The  hand  is  short, 
and  has  a  trident  shape,  since  the  fingers,  which  are  of  almost  equal  length, 
often  diverge  somewhat.  The  root  of  the  nose  is  depressed,  the  back  flat,  and 
the  lumbar  lordosis  abnormally  deep,  owing  to  a  tilting  forward  of  the  sacrum. 
The  scapulas  are  short,  the  fibulae  longer  than  the  tibiae,  and  the  pelvis  is  con- 
tracted ;  hence,  the  number  of  these  cases  reported  by  obstetricians.  Heredity 
plays  little  part. 

Pathology. — Anatomically  it  is  a  dystrophy  of  the  epiphyseal  cartilages, 
the  cells  of  which  are  irregularly  scattered,  and  the  ground  substances  in- 
vaded by  connective  tissues  from  the  periosteum,  which  sends  in  bands  of 


OXYCEPHALY  1U7 

tissues  across  the  end  of  the  diaphysis.     The  development  of  the  bones  with 
a  membranous  matrix  seems  normal. 

Virchow  described  the  disease  as  fetal  cretinism,  others  as  fetal  rickets. 
Of  late  naturally  its  origin  has  been  associated  with  disturbance  of  the  pitui- 
tary function,  or  of  its  hormonic  relations.  On  the  other  hand,  Murk  Jansen 
of  Ley  den,  in  a  recent  monograph  (1912),  brings  forward  evidence  to  show 
that  it  results  from  a  disturbance  of  the  direct  and  indirect  amniotic  pres- 
sure, and  he  brings  it  into  relationship  with  a  number  of  other  fetal  mal- 
formations. He  states,  too,  that  the  anatomical  evidence  is  against  changes 
in  the  sella  turcica  in  the  disease.  But  it  is  an  argument  in  favor  of  some 
associated  disturbance  of  the  pituitary  gland  that  achondroplasics  often  show 
precocious  sexual  development. 


VII.     OXYCEPHALY 

Definition. — A  cranial  deformity  associated  with  exophthalmos  and  im- 
pairment of  vision. 

Description. — The  condition,  known  as  tower  or  steeplehead,  is  character- 
ized by  great  height  of  the  forehead,  sloping  to  a  pointed  vertex,  with  feebly 
marked  supraorbital  ridges,  and  the  hairy  scalp  may  be  raised  above  the  nor- 
mal level,  looking  as  if  perched  on  the  top  of  a  comb.  The  intelligence  is 
unimpaired.  The  condition  is  usually  present  at  birth,  though  in  some  in- 
stances it  develops  from  the  second  to  the  sixth  year.  As  this  curious  growth 
of  the  head  proceeds,  headache  may  be  present,  exophthalmos  develops,  and 
the  vision  becomes  impaired,  due  to  progressive  optic  atrophy.  Smell  is  often 
completely  lost.  The  deformity  appears  to  be  due  to  premature  synostosis 
of  certain  sutures,  notably  the  sagittal  and  coronal.  As  a  result  of  the  pre- 
mature union  of  these  two  sutures  the  growth  of  the  vault  of  the  skull  is 
restricted  in  both  its  antero-posterior  and  tranverse  diameters,  and  to  accom- 
modate the  increasing  bulk  of  the  brain  a  compensatory  increase  in  height 
takes  place.  Eventually  the  anterior  fontanelle  closes,  but  there  is  reason 
to  think  that  this  occurs  at  a  later  date  than  the  normal,  and  its  former  site 
is  marked  by  a  slight  protuberance  with  thinning  of  the  bone.  (Morley 
Fletcher,  Quarterly  Jour.  Med.,  IV,  1911.) 

The  optic  neuritis  and  atrophy  are  the  result  of  direct  pressure  exerted 
by  the  growing  brain  and  may  be  compared  to  that  of  cerebral  tumor.  As 
yet  we  do  not  know  the  cause  of  this  premature  synostosis.  The  condition  is 
one  for  which  a  decompression  operation  is  indicated. 


INDEX 


Abasia,  1119,  1120. 

Abdominal  scrofula,  177,  178. 

Abdominal  tuberculosis,  177,  178. 

Abducens  nerve.     (See  Sixth  nerve.) 

Abductors,  paralysis  of,  1050. 

Aberrant  thyroids,  871. 

Abortion  in  acute  yellow  atrophy,  560;  in 
relapsing  fever,  263;  in  small-pox,  323; 
in  syphilis,  277. 

Abortive  cerebro-spinal  fever,  112. 

A.bscess,  atheromatous,  843;  following  per- 
foration in  peptic  ulcer,  495 ;  hepatic,  in 
amcebiasis,  239,  240,  243;  in  acute  sup- 
purative  gastritis,  478;  in  appendicitis, 
534,  535;  in  cholera  Asiatica,  136;  in 
glanders,  233;  in  pyelitis,  714;  in  sup- 
purative  tonsillitis,  467;  in  typhus  fever, 
355;  in  yellow  fever,  360;  Jacksonian 
epilepsy  due  to,  1084;  metastatic,  51; 
of  brain,  Bacillus  coli  in,  48;  of  brain, 
bronchiectasis  and,  627;  of  brain,  defi- 
nition of,  1015-1018;  of  brain,  diagno- 
sis of,  1017;  of  brain,  etiology  of,  1015, 
1016;  of  brain,  following  putrid  bron- 
chitis, 624;  of  brain,  following  scarlet 
fever  339 ;  of  brain,  gangrene  of  the 
lung  and,  651;  of  brain,  in  influenza, 
118;  of  brain,  in  measles,  347;  of  brain, 
morbid  anatomy  of,  1016;  of  brain, 
symptoms  of,  1016,  1017;  of  brain,  treat- 
ment of,  1017,  1018;  of  broad  ligaments, 
peritonitis  due  to,  603;  of  kidney  (pyo- 
nephrosis),  712-715;  of  kidney,  pyuria 
and,  687;  of  liver,  complicating  amo3- 
biasis,  241 ;  of  liver,  diagnosis  of,  585, 
586;  of  liver,  etiology  of,  583-587;  of 
liver,  in  bacillary  dysentery,  128;  of 
liver,  in  typhoid  fever,  26;  of  liver,  lo- 
calized peritonitis  and,  604;  of  liver, 
morbid  anatomy  of,  583,  584;  of  liver, 
pysemic,  583;  of  liver,  symptoms  of,  584, 
585;  of  liver,  treatment  of,  586,  587; 
of  lung,  652,  653;  of  lung,  acute  plastic 
pleurisy  in,  654 ;  of  lung,  fibroid  changes 
due  to,  640;  of  lung,  hemoptysis  in, 
636;  of  lung  in  typhoid  fever,  13;  of 
lymph  glands,  672,  673;  of  mediastinum, 
675;  of  muscles,  in  suppurative  myositis, 
1128;  of  parotid  gland,  463;  of  spleen, 
885;  of  spleen,  case  of,  in  dysentery, 


128;  pancreatic,  595;  perinephric,  725, 
726;  perinephritic  and  pericaecal,  differ- 
entiation of,  from  appendicitis,  537; 
periurethral,  123 ;  periurethral,  in  bilhar- 
ziasis,  283;  prostatic,  septicopyasmia  fol- 
lowing, 52;  putrid  bronchitis  and,  624; 
retro-pharyngeal,  466;  retro-pharyngeal, 
in  glandular  fever,  386;  rupture  of, 
pyuria  and,  688;  subphrenic,  604,  605; 
tropical,  583,  584,  585. 

Abscesses,  embolic,  51;  miliary,  in  acute 
endocarditis,  800. 

Aeanthocephala,  310. 

Acardia,  832. 

Acarus  folliculorum,  310. 

Acarus  scabiei,  310,  311. 

Accessory  spasm,  1052-1054. 

Accessory  thyroids,  871. 

Acephalocysts.     (See  Hydatid  cysts.) 

Acetonuria,  433. 

Acholuric  icterus,  congenital,  558;  spleno- 
megaly with,  887. 

Achondroplasia,  definition  of,  1146;  de- 
scription of,  1146;  pathology  of,  1146, 
1147. 

Achromatopsia  in  traumatic  hysteria,  1117. 

Achylia  in.  pernicious  anaemia,  736. 

Achylia  gastrica  nervosa,  512. 

Acidosis  in  diabetes  mellitus,  433. 

Acne  due  to  bromides,  1086;  following 
small-pox,  322;  iu  constipation,  546; 
rosacea  in  alcoholism,  398. 

Acromegaly,  definition  of,  890;  etiology  of, 
890,  891;  glycosuria  in,  892;  symptoms 
of,  891,  892;  treatment  of,  892. 

Actinomycosis,  cerebral,  233;  cutaneous, 
233;  definition  of,  232;  diagnosis  of, 
234;  digestive,  232,  233;  etiology  of, 
232;  mode  of  infection  in,  232;  morbid 
anatomy  of,  232;  of  the  thyroid,  871; 
pulmonary,  233;  symptoms  of,  233; 
treatment  of,  234. 

Acupuncture  in  lumbago,  1131. 

Acute  bulbar  paralysis,  931. 

Acute  yellow  atrophy,  557 ;  albumosuria  in, 
686;  definition  of,  559;  diagnosis  of, 
560,  561;  etiology  of,  559;  fatty  liver 
and,  590;  hajmatemesis  in,  507;  morbid 
anatomy  of,  559,  560;  phosphaturia  and, 
691;  symptoms  of,  560;  treatment  of, 
561. 

Addison's     disease,     anaemia     resembling, 


1149 


1150 


INDEX 


739;  asthenia  in,  865;  "chromaffin  sys- 
tem" in,  863;  definition  of,  803;  diag- 
nosis of,  865,  866;  etiology  of,  863;  in- 
testinal catarrh  in,  517;  morbid  anat- 
omy of,  864;  pathology  of,  863,  864; 
pigmentation  of  the  skin  in,  865 ;  prog- 
nosis of,  866,  867;  symptoms  of,  864, 
865 ;  treatment  of,  867 ;  tuberculous  peri- 
tonitis confused  with,  181. 

Addison's  keloid,  1125. 

Addison  'a  pill,  281. 

Adductor  paralysis,  1050;  in  lead-palsy, 
405. 

Aclenie,  747. 

Adenitis,  acute,  in  children,  386;  cervical, 
176;  in  scarlet  fever,  339;  tuberculous, 
174,  175;  tuberculous,  cervical,  211;  tu- 
berculous, generalized,  175,  176;  tuber- 
culous, local,  176-178;  tracheo-bronchial, 
176. 

Adeno-carcinoma  of  the  stomach,  499. 

Adeno-Hpomatosis,  453. 

Adenoids,  468-471;  following  measles,  346; 
hypertrophic  emphysema,  following,  646; 
treatment  of,  471. 

Adenoma,  causing  intestinal  obstruction, 
541 ;  of  kidney,  722 :  of  pituitary  gland, 
891;  of  pituitary  gland,  malignant, 
1013;  of  thyroid,  871. 

Adherent  pericardium,  767-769;  chronic 
cardiac  insufficiency  due  to,  786;  mitral 
incompetency  and,  818. 

Adhesive  pylephlebitis,  562. 

Adiposis  dolorosa,  452;  453. 

Adiposity,  cerebral,  453. 

Adolescence,  albuminuria  of,  684,  685. 

Adrenal  therapy  in  Addison's  disease,  867. 

Adrenalitis,  haemorrhagic,  868. 

Adrenals,  glycosuria  and,  428;  hyperplasia 
of,  864,  867;  hypoplasia  of,  864,  867; 
in  Addison's  disease,  864;  tumors  of, 
868. 

^Erophagia,  510. 

JEstivo-autumnal  type  of  malarial  fever, 
248-253. 

Afebrile  typhoid  fever,  18,  33. 

Afferent  system,  diseases  of,  913-927. 

Ageusia,  1049. 

Agglutination  test  in  typhoid  fever,  36. 

Agnosia,  981. 

Agoraphobia,  1109. 

Agraphia,  979;  in  motor  aphasia,  981; 
in  visual  aphasia,  980. 

Ague,  248,  249. 

Ague  cake.     (See  Spleen,  enlargement  of.) 

Ainhum,  1127. 

Air-hunger  in  diabetes  mellitua,  433. 

Akinesia  algera,  1110. 

A-koria,  514. 


Alastrin  amas,  Brazilian,  316. 

Albinism,  in  leprosy  (see  Lepra  albo) ;  of 
the  lung,  647. 

Albuminuria,  684;  due  to  haemic  changes, 
685;  febrile,  685;  functional,  684;  in 
acute  Bright 's  disease,  698,  699;  in 
acute  yellow  atrophy,  560;  in  appendi- 
citis, 534;  in  arterio-sclerosis,  845;  in 
chronic  parenchymatous  nephritis,  703; 
in  diabetes,  434;  in  diphtheria,  67;  in 
erysipelas,  56;  in  erythraemia,  758;  in 
exophthalmic  goitre,  879;  in  gout,  420; 
in  mumps,  351;  in  purpura,  753;  in  pye- 
litis,  713;  in  Eaynaud's  disease,  1122; 
in  rheumatism,  375;  in  rubella,  349;  in 
scarlet  fever,  336,  337;  in  small-pox,  322; 
in  tonsillitis,  381;  in  trichiniasis,  299; 
in  typhoid  fever,  30;  in  yellow  fever, 
359;  life  insurance  and,  687;  of  adoles- 
cence, 684,  685;  prognosis  of,  686;  with 
definite  lesions  of  the  urinary  organs, 
686. 

Albuminuric  retinitis,  1029. 

Albumosuria,  686 ;  'in  acute  yellow  atrophy, 
560;  myelopathic,  686. 

Alcohol,  acute  gastritis  due  to,  477;  acute 
haemorrhagic  pancreatitis  and,  594;  aor- 
tic incompetency  due  to,  809;  cancer  of 
the  stomach  and,  498;  chronic  parenchy- 
matous nephritis  due  to,  702;  chronic 
gastritis  and,  479;  epilepsy  and,  1081; 
fatty  liver  and,  590;  in  arterio-sclerosis, 
843;  in  gout,  418;  in  septico-pysemia,  52. 

Alcohol  poisoning,  poliencephalitis  in,  1014; 
toxic  amaurosis  in,  1030. 

Alcoholic  cirrhosis  of  the  liver,  diagnosis 
of,  579;  differentiation  of  splenic  anae- 
mia from,  888;  etiology  of,  576,  577; 
morbid  anatomy  of,  577,  578 ;  prognosis 
of,  579,  580;  symptoms  of,  578,  579. 

Alcoholic  neuritis,  1023,  1024;  treatment 
of,  1026. 

Alcoholism,  acute,  396;  chronic,  396-398; 
chronic,  proliferative  peritonitis  and, 
606;  delirium  tremens  in,  398,  399;  diag- 
nosis of,  399;  differentiation  of  cerebral 
apoplexy  from,  997;  differentiation  of 
urasmie  coma  from,  696;  epilepsy  and, 
1080;  Korsakoff's  psychosis  in,  397; 
meningism  in,  951;  prognosis  of,  399; 
psychosis  polyneuritica  in,  397;  treat- 
ment of,  399,  400;  "wet  brain"  in, 
397. 

Aleppo  boil,  261. 

Alcxia,  subcortical,  980. 

Algid  form  of  pernicious  malaria,  253,  254. 

Alkaline  treatment  of  rheumatic  fever, 
379. 

Alkaptonuria,  454,  692. 


INDEX 


1151 


Allocheiria,  in  locomotor  ataxia,  917. 

Alopecia,  syphilitic,  267. 

Altitude,  erythraemia  and,  757;  in  climatic 
treatment  of  tuberculosis,  226. 

Amaurosis,  following  haemorrhage  in  peptic 
ulcer,  494;  hysterical,  1030,  1100;  in 
diabetes,  434;  toxic,  1030. 

Amaurotic  family  idiocy,  939. 

Amblyopia,  1030;  crossed,  due  to  lesion  of 
the  angular  gyrus,  1032,  1033;  in  Kay- 
naud's  disease,  1121. 

Ambulatory  form  of  erysipelas,  56;  of 
plague,  140;  of  typhoid  fever,  15,  33. 

Amenorrhcea  in  acromegaly,  892;  in  chlo- 
rosis, 733 ;  in  chronic  ulcerative  tubercu- 
losis, 191. 

Arnette's  blood  picture,  534. 

"Amnesia  verbalis,"  980. 

Amoeba  dysenteries,  238,  239. 

Amcebiasis,  complication  and  sequelae  of, 
241;  definition  of,  237;  diagnosis  of, 
241,  242;  distribution  of,  237,  238;  mor- 
bid anatomy  of,  239,  240;  organism  of, 
238,  239 ;  prognosis  of,  242 ;  symptoms 
of,  240,  241;  treatment  of,  242,  243; 
Trichocephalus  dispar  and,  309;  tropical 
abscess  following,  583. 

Amoebic  dysentery  (see  Amcebiasis) ;  acute, 
240,  241 ;  chronic,  241. 

Amoebic  hepatitis.     (See  Amoebiasis.) 

Amphistoma,  283. 

Amputation  neuromata,  1027. 

Amyloid  degeneration,  ascites  and,  610;  in 
chronic  interstitial  pneumonia,  641,  642; 
in  chronic  ulcerative  tuberculosis,  190; 
in  syphilis,  268;  of  heart,  275,  789;  of 
kidneys,  711,  712;  of  kidneys,  albuminu- 
ria  and,  686;  of  kidneys,  chronic  paren- 
chymatous  nephritis  and,  702;  of  liver, 
590,  591;  differentiation  of  cancer  from, 
589. 

Amyosthenia  in  neurasthenia,  1110. 

Amyotonia  congenita,  1133,  1134. 

Amyotrophic  lateral  sclerosis  (see  Progres- 
sive central  muscular  atrophy)  ;  differen- 
tiation of  haemorrhagic  pachymeningitis 
from,  948. 

Amyotrophic  paralysis  in  syringomyelia, 
965. 

Anaeidity,  nervous,  512. 

Anaemia,  acute  chorea  and,  1067;  acute 
secondary,  728,  729;  albuminuria  in, 
^  685;  aplastic,  735,  738;  ascitic  fluid  in, 
610;  bradycardia  in,  777;  causing  con- 
stipation, 545;  cerebral,  986;  chronic, 
epistaxis  in,  614;  chronic  gastritis  and, 
480;  chronic  secondary,  729,  730;  con- 
fusion of,  with  septico-pyaemia,  52;  dila- 
tation of  heart  in,  784;  fatty  liver  and, 


590;  following  haemorrhage  in  peptic  ul- 
cer, 494;  following  malaria,  252;  gastric 
ulcer  and,  491;  haematemesis  in,  507,  508; 
haemorrhagic  pachymeningitis  in,  947; 
idiopathic  or  pernicious,  733,  739;  in 
acquired  syphilis,  266 ;  in  acute  Bright  'a 
disease,  698,  701;  in  Addison's  disease, 
865;  in  aortic  incompetency,  811;  in 
arthritis  deformans,  1138;  in  cancer  of 
stomach,  500,  501,  504;  in  chronic 
Bright 's  disease,  710;  in  chronic  pareii- 
chymatous  nephritis,  704;  in  chronic 
pleuro-pulmonary  carcinoma,  653,  654; 
in  chronic  ulcerative  tuberculosis,  191; 
in  diagnosis  of  pulmonary  tuberculosis, 
206;  in  exophthalmic  goitre,  879;  in 
haemorrhage  from  the  stomach,  508;  in 
Hodgkin's  disease,  748,  749,  750;  in 
hook-worm  disease,  302,  303;  in  Indian 
kala-azar,  260;  in  infantile  scurvy,  450; 
in  lead  poisoning,  403;  in  leukaemia, 
743 ;  in  lymphoid  leukaemia,  745 ;  in  pep- 
tie  ulcer,  494,  495;  in  polyarteritis  acuta 
nodosa,  862;  in  pulmonary  tuberculosis, 
204;  in  purpura  hsemorrhagica,  753;  in 
rheumatic  fever,  374;  in  rickets,  445;  in 
septico-pysemia,  52;  in  simple  ulcerative 
colitis,  521;  in  sprue,  519;  in  syphilis  of 
liver,  274,  275;  in  whooping  cough,  121; 
infective  haemolytic,  oral  sepsis  and,  462 ; 
intestinal  catarrh  in,  517;  jaundice  and, 
558;  liver,  561;  local,  727,  728;  lym- 
phatica,  747;  mitral  stenosis  and,  821; 
muscular  incompetency  in,  817;  neural- 
gia and,  1090;  oedema  of  pharynx  in, 
464;  of  brain,  in  Stokes- Adams  disease, 
779;  of  miners,  bricklayers,  tunnel- work- 
ers, 300,  301;  of  spinal  cord,  956;  optic 
neuritis  in,  1030;  pernicious,  733;  per- 
nicious toxic  combined  sclerosis  in,  945; 
phosphaturia  in,  691;  primary  (or  essen- 
tial), 730-739;  primary,  differentiation 
of  cancer  of  stomach  from,  504;  primary 
combined,  sclerosis  and,  943,  944;  pyel- 
itis  and,  712;  retinitis  in,  1029;  splenic 
(see  Splenomegaly  with  anaemia)  ;  splen- 
ica  inf antum,  886 ;  systolic  brain  murmur 
in,  1046;  thrombosis  of  cerebral  sinuses 
and  veins  and,  1004;  Trichocephalus  dis- 
par and,  309;  typhoid  fever  and,  20. 

Anaemic  necrosis,  786. 

Anaesthesia,  death  from,  in  lymphatism, 
870;  general  dilatation  of  the  stomach 
following,  486;  dolorosa,  in  compression 
myelitis,  960;  due  to  affection  of  an- 
terior crural  nerve,  1060;  due  to  injury 
to  sciatic  nerve,  1061;  in  acute  cere- 
bro-spinal  leptomeningitis,  950;  in  beri- 
beri, 415;  in  cervical  rib  pressure,  1057; 


1152 


INDEX 


in  focal  lesions  of  spinal  cord,  955,  956; 
in  haematomyelia,  959;  in  hysteria,  1099; 
in  locomotor  ataxia,  917;  in  neuritis, 
1023;  in  paralysis  of  fifth  nerve,  1039; 
in  spinal  hrcmorrhagic  pachymeningitis, 
948;  in  spondylitis,  1138;  in  syringo- 
myelia,  965;  in  traumatic  neuroses, 
1117. 

Anaesthesia  paralysis,  1025 ;  pneumonia,  94, 
95. 

Anaesthetic  leprosy,  153,  154;  differentia- 
tion of  syringomyelia  from,  965. 

Analytical  method  of  treatment  in  hysteria, 
1105,  1106. 

Aiiaphylaxis,  72;  immunity  to  tuberculosis 
and,  161;  in  asthma  subjects,  629. 

Anarthria,  977,  978;  due  to  lesion  of  pons 
and  medulla  oblongata,  973;  due  to  tu- 
mor of  cerebellum,  976. 

Anasarca,  in  aortic  stenosis,  816;  in  cancer 
of  the  stomach,  501;  in  chronic  paren- 
chymatous  nephritis,  703;  in  diabetes, 
434 ;  in  Hodgkin  's  disease,  748 ;  in  mitral 
stenosis,  824;  in  myeloid  leukaemia,  743. 

Anastomosis,  nerve,  in  treatment  of  facial 
paralysis,  1044;  nerve,  in  treatment  of 
muscular  spasm  due  to  lesions  of  the 
facial  nerve,  1045. 

Aneurism,  aortic  insufficiency  due  to,  810; 
arterio-venous,  861 ;  causing  obstruction 
of  the  bile  ducts,  567;  causing  obstruct- 
ive jaundice,  555;  cerebral  embolism  due 
to,  998;  cerebral  thrombosis  due  to,  998; 
cervical  rib  pressure  and,  1057;  classifi- 
cation of,  847,  848 ;  compression  myelitis 
due  to,  960;  definition  of,  847;  differen- 
tiation of  mediastinal  tumors  from, 
674;  dilatation,  847;  dissecting,  850; 
dissecting,  healed,  851;  etiology  of,  848, 
849;  haematemesis  due  to  rupture  of, 
507;  haemopericardium  in,  769;  haemop- 
tysis due  to,  636;  history  of,  847;  in 
locomotor  ataxia,  918 ;  in  peptic  ulcer, 
492;  in  walls  of  tuberculous  cavities, 
190;  indurative  changes  in  lung  due  to, 
641 ;  lameness  due  to,  in  arterio-sclero- 
sis,  846;  locomotor  ataxia  and,  918; 
mesenteric  haemorrhage  and,  553;  mili- 
ary,  cerebral  haemorrhage  due  to,  988, 
989 ;  miliary,  haemorrhage  from  the  stom- 
ach in,  506;  morbid  anatomy  and  path- 
ology of,  849;  cesophageal  stricture  and, 
474;  of  abdominal  aorta,  859-861;  of 
aorta,  chronic  bronchitis  and,  622;  of 
aorta,  pericarditis  and,  760,  761 ;  of 
aorta  simulating  pneumo-thorax,  671; 
of  branches  of  the  circle  of  Willis, 
cerebral  haemorrhage  due  to,  989;  of 
the  cerebral  arteries,  etiology  of,  1003; 


of  cerebral  arteries,  morbid  anatomy 
of,  1003,  1004;  of  cerebral  arteries, 
symptoms  of,  1004;  of  heart,  829, 
830;  of  heart,  fibrous  myocarditis  and, 
7S7;  of  heart  in  arterio-sclerosis,  845; 
of  hepatic  artery,  563,  583,  861;  of  pul- 
monary artery,  861;  of  pulmonary  ar- 
tery in  chronic  interstitial  pneumonia, 
641;  of  renal  artery,  861;  of  splenic 
artery,  860,  861;  of  superior  mesen- 
teric artery,  861;  of  thoracic  aorta, 
857-859;  of  thoracic  aorta,  diagno- 
sis of,  856,  857;  of  thoracic  aorta, 
dilatation,  849,  850;  of  thoracic  aorta, 
dissecting,  850,  851;  of  thoracic  aorta, 
physical  signs  of,  852-854;  of  thoracic 
aorta,  prognosis  of,  857;  of  thoracic 
aorta,  sacculated,  851,  852;  of  thoracic 
aorta,  symptoms  of,  854-856;  pneumo- 
thorax  and,  854;  polyarteritis  acuta  no- 
dosa,  862;  pupil  symptoms  of,  855;  rup- 
ture of,  and  haemorrhage  into  the  spinal 
membranes,  958;  rupture  of,  causing 
meningeal  haemorrhage,  989;  rupture  of, 
differentiation  of  acute  peritonitis  from, 
603;  rupture  of  haemoptysis  due  to,  638, 
639 ;  spinal  pachymeningitis  due  to,  946 ; 
spontaneous,  847;  surgical  treatment  of, 
858;  syphilis  and,  275,  848;  thoracic, 
hypertrophic  pulmonary  arthropathy  in, 
1143 ;  traction,  849 ;  valvular,  799. 

Aneurismal  varix,  861. 

Angina,  in  acute  lymphoid  leukaemia,  745; 
abdominis,  839;  Ludovici,  466;  pseudo- 
diphtheritic,  complicating  small-pox,  322. 

Angina  pectoris,  836;  acute  vesicular  em- 
physema in,  650;  definition  of,  836; 
dilatation  of  heart  in,  783;  etiology  of, 
836,  837;  extra-pectoral  features  of,  838, 
839 ;  failure  of  the  left  ventricle  and, 
789;  history  of,  836;  initiative  features 
of,  837;  in  aneurism  of  the  sinuses  of 
Valsalva,  851;  in  aortic  incompetency, 
811;  in  arterio-sclerosis,  845;  in  dilata- 
tion aneurism  of  the  thoracic  aorta,  849, 
850;  major  form  of,  838;  minor  form  of, 
837;  morbid  anatomy  and  pathology  of, 
839,  840;  oedema  of  the  lungs  in,  635; 
prognosis  of,  840;  symptoms  of,  837- 
839;  theory  of,  840;  treatment  of,  840, 
841. 

Angina  simplex,  464. 

Angiocholitis,  chronic  catarrhal,  564;  sup- 
purative  and  ulcerative,  565. 

Angioma,  haematuria  due  to,  682 ;  of  brain, 
1010;  of  kidney,  722;  of  liver,  588. 

Angio-neurotic  hydrocephalus,   1018,   1019. 

Angio-neurotic  oedema,  definition  of,  1123; 
O3dema  of  the  glottis  ip,  616;  oedema  of 


INDEX 


1153 


the  lungs  in,   635;    symptoms  of,   1123, 
1124;  treatment  of,  1124. 

Angio-sclerosis,  844. 

Acgor  animi,  in  angina  pectoris,  838. 

Anguillula  aceti,  309. 

Anisocoria,  1036;    due  to  aneurism,  856. 

Ankylostoma,  anaemia  due  to,  729;  duode- 
nal, 301. 

Ankylostomiasis,  diagnosis  of,  303,  304; 
distribution  of,  301;  history  of,  300, 
301;  modes  of  infection  with,  302;  mor- 
bid anatomy  and  pathology  of,  302; 
parasites  of,  301,  302;  prophylaxis  of, 
304;  symptoms  of,  302,  303 ;.  treatment 
of,  304,  305. 

Anopheles,  in  transmission  of  malaria,  245, 
247;  protective  measures  against,  256, 
257. 

Anorexia  in  Addison  's  disease,  865 ;  in  can- 
cer of  the  stomach,  501;  in  pellagra, 
412;  in  pulmonary  tuberculosis,  204; 
nervosa,  514,  1101. 

Anosmia,  1028. 

Anterior  cerebral  artery,  symptoms  of 
blocking  of,  1001. 

Anterior  crural  nerve,  affections  of,  1060. 

Anterior  polio-myelitis,  acute,  analogy  of 
herpes  zoster  with,  926;  chronic,  940. 

Anthracaemia,   150. 

Anthracosis  of  the  liver,  576;  of  the  lungs, 
642,  643;  tuberculosis  and,  644. 

Anthrax,  definition  of,  148;  bacillus  of, 
148,  800;  bacillus  of,  causing  gastritis, 
479;  etiology  of,  148,  149;  prophylaxis 
of,  150;  symptoms  of,  149,  150;  treat- 
ment of,  150,  151. 

Anthrophobia,  1109. 

Antitoxin,  diphtheria,  as  a  preventive 
measure,  70;  diphtheria,  as  a  curative 
measure,  72-74;  effect  of,  in  asthma  sub- 
jects, 629 ;  hay  fever,  613 ;  tetanus,  145. 

Antivenene,  154. 

Anuria,  680,  681. 

"Anxiety     conditions"     in    neurasthenia 

1108,  1109. 

Aorta,  abdominal,  aneurism  of,  895; 
aneurism  of,  852;  dilatation  of,  849; 
dynamic  pulsation  of,  856;  rupture  of, 
850;  splits  of  intima  of,  850;  tuberculo- 
sis of,  221. 

Aortic  arch,  aneurism  of,  851. 
Aortic  incompetency,  aneurism  of  the  sinu- 
ses of  Valsalva  and,  851;  differentiation 
ot  aneurism  from,  856;  dilatation  and 
hypertrophy  of  the  heart  due  to,  783; 
dilatation  aneurism  of  the  thoracic  aorta 
and,  849,  850;  effects  of,  810,  811;  etiol- 
ogy and  morbid  anatomy  of,  808-810;  in 


aneurism,  855;  prognosis  of,  825;  symp- 
toms of,  811-814. 

Aortic  orifice,  congenital  lesions  of,  834. 
Aortic  stenosis,  diagnosis  of,  816,  817;  eti- 
ology and  morbid  anatomy  of,  814,  815; 
prognosis  of,  827;  symptoms  of,  815,  816. 
Aortitis  in  angina  pectoris,  839. 
Apex  pneumonia,  92. 

Aphasia,  auditory,  979,  980;  due  to  block- 
ing of  the  middle  cerebral  artery,  1001; 
in  arterio-sclerosis,  transient,  845,  846. 
in  brain  abscess,  1017;  in  cerebral  soft- 
ening, 1000;  in  general  paralysis,  924; 
in  hemiplegia  in  children,  1007;  in  lobar 
pneumonia,  90;  in  migraine,  1088;  in 
mitral  stenosis,  824;  in  pulmonary  tuber- 
culosis, 205;  in  Eaynaud's  disease,  tran- 
sient, 1121;  in  right  hemiplegia,  993;  in 
small-pox,  322;  in  tuberculous  menin- 
gitis, 173;  in  tumors  of  the  brain,  1011; 
in  typhoid  fever,  29 ;  lesions  of  the  cere- 
bial  cortex  in,  970;  lesions  of  the  in- 
ternal capsule  and,  972;  motor,  981,  982; 
optic,  1034,  1035;  prognosis  and  treat- 
ment of,  982;  sensory,  following  epi- 
lepsy, 1083;  speech  centres  and,  976- 
979;  subcortical  motor,  977;  visual,  980, 
981. 

Aphemia,  977. 

Aphonia,  due  to  adductor  paralysis,  1050; 
hysterical,  1100;  in  pericarditis  with  ef- 
fusion, 764;  in  pulmonary  tuberculosis, 
202;  spastic,  1051. 

Aphthae.     (See  Stomatitis,  aphthous.) 
Aphthous  fever,  387. 
Aplastic  anaemia,  735,  738. 
Apoplectic  stroke,  991. 
Apoplectiform  attacks  in  general  paralysis, 

923 ;  in  sclerosis  of  the  brain,  953. 
Apoplexia  serosa,  987. 
" Apoplexie  foudroyante,"  990. 
Apoplexy,  bradycardia  in,   777;   capillary, 
999;    cerebral    (see    Haemorrhage,    cere- 
bral) ;  cerebral,  hypostatic  congestion  of 
the   lungs   in,    634;    chronic   interstitial 
nephritis  and,   708;    confusion   of,   with 
acute  alcoholism,  396;   in  chronic  inter- 
stitial nephritis,  705;  in  gout,  421,  423; 
meningeal,  957,  958. 

Appendicitis,  abscess  of  the  liver  follow- 
ing, 583;  actinomycotic,  232;  and  peri- 
tonitis, 602;  confusion  of  cholecystis 
and,  566;  confusion  of,  with  typhoid 
fever,  38;  diagnosis  of,  536,  537;  dys- 
pepsia and,  536;  etiology  of,  531,  532; 
experimental,  532;  faecal  concretions  in, 
533;  foreign  bodies  and,  533;  haemor- 
rhage from  the  stomach  following  opera- 
tion for,  506;  haemorrhagie  erosion1?  and 


1154 


INDEX 


490;  indicanuria  in,  691;  influenza  and, 
118;  lead  poisoning  confused  with,  404; 
leucocytosis  in,  534;  localized  peritonitis 
due  to,  605;  necrotic,  532;  obliteration 
of,  532;  perforative  appendicitis  follow- 
ing, 600;  pregnancy  and,  537;  prognosis 
of,  537;  purpura  confused  with,  752;  re- 
mote effects  of,  536 ;  symptoms  of,  533- 
536;  treatment  of,  537,  538;  tuberculous 
peritonitis  confused  with,  180;  varieties 
of,  532. 

Appendicular  peritonitis,  605. 

Appendix,  in  actinomycosis,  232;  disease 
of,  differentiation  of  intestinal  obstruc- 
tion from,  544;  in  typhoid  fever,  12; 
lesions  of,  and  cholecystitis,  566;  oblit- 
eration of,  532. 

Apraxia  in  cerebral  softening,  1000. 

Aprosexia,  468-471. 

Arachnida,  parasitic,  310,  311. 

Aran-Duchenne  paralysis  in  lead  poison- 
ing, 404. 

Aran-Duchenne  type  of  progressive  mus- 
cular atrophy,  928. 

Argas  monbata,  311. 

Argyll-Robertson  pupil,  1036;  in  general 
paralysis,  923;  in  locomotor  ataxia,  915, 
916,  919;  in  neuritis,  1023. 

Arithmomania,  1076. 

Armed  tapeworm,  284. 

Arrhythmia,  771-774;  in  cardiac  insuffi- 
ciency, 790;  treatment  of,  779,  780. 

Arsenic,  neuritis  due  to,  1024. 

Arsenical  poisoning,  acute,  406;  chronic, 
406,  407;  chronic,  secondary  anaemia  in, 
730. 

Arseniuretted  hydrogen,  haemoglobinuria 
due  to,  683. 

Arteries,  cerebral,  aneurism  of,  1003;  cere- 
bral, blocking  of,  1000;  diseases  of,  841- 
862;  in  aortic  incompetency,  813,  814; 
in  chronic  alcoholism,  398;  in  rickets, 
443;  spasm  of,  in  migraine,  1088;  syph- 
ilis of,  275,  276;  tuberculosis  of,  221. 

Arteriocapillary  fibrosis.  (See  Arterio- 
sclerosis.) 

Arterio-sclerosis,  abdominal,  846;  albu- 
minurie  retinitis  and,  1029;  alcohol  and, 
398;  angina  pectoris  and,  837;  aortic 
incompetency  and,  809;  cardiac  hyper- 
trophy in,  781;  cardiac  insufficiency  and, 
792;  cardio-vascular  epilepsy  in,  1081; 
eerebral  anaemia  in,  986;  cerebral 
haemorrhage  and,  988;  chronic  cardiac 
insufficiency  in,  786;  chronic  endocardi- 
tis and,  804;  chronic  interacinar  pancre- 
atitis and,  596;  coronary  artery  disease 
and,  787;  definition  of,  841;  diabetes 
and,  431;  due  to  injection  of  epinephrin, 


864;  etiology  of,  841-843;  family  form 
of,  842;  gastric  ulcer  and,  491;  hyper- 
plasia  of  adrenal  cortex  in,  867;  in  atro- 
phic  cirrhosis  of  liver,  577;  in  chronic 
interstitial  nephritis,  705,  706,  707;  in 
gout,  420,  422;  in  lead  workers,  405;  in 
pulmonary  tuberculosis,  209;  intermit- 
tent claudication  in,  846 ;  involution 
form  of,  842;  mitral  incompetence  con- 
fused with,  820;  morbid  anatomy  of, 
843-845;  redema  of  lungs  in,  635;  of 
cerebral  arteries,  1004;  of  temporal  ar- 
tery in  migraine,  1088,  1089;  pericarditis 
in,  760;  peritonitis  terminating,  600; 
senile  form  of,  844;  Stokes-Adams  dis- 
ease and,  779 ;  symptoms  of,  845,  846 ; 
syphilis  in,  275;  spyhilitic  form  of,  844; 
terminal  acute  tuberculosis  in,  159 ;  ter- 
minal infections  in,  53;  terminal  pneu- 
monia in,  93 ;  treatment  of,  846,  847. 

Arterio-sclerotic  kidney.  (See  Chronic  in- 
terstitial nephritis.) 

Arterio-venous  aneurism,  847,  861,  862. 

Arteritis,  270;  obliterans  of  spinal  cord, 
957;  syphilitic,  cerebral  thrombosis  due 
to,  998. 

Artery  of  cerebral  haemorrhage,  987. 

Arthralgias,  saturnine,  405. 

Arthritic  purpura,  751-753. 

Arthritis,  acute,  acute  chorea  and,  1067; 
acute,  in  scurvy,  449 ;  and  cerebro-spinal 
meningitis,  113,  115;;  Bacillus  coli  and, 
48,  chronic,  in  pulmonary  tuberculo- 
sis, 209;  complicating  amoebiasis,  241; 
gonorrhceal,  123,  124;  haemoptysis  with, 
636;  in  acute  diffuse  myelitis,  967; 
in  bronchiectasis,  627;  in  lobar  pneu- 
monia, 91;  in  measles,  346;  in  mumps, 
351;  in  Raynaud's  disease,  1122;  in 
rubella,  349;  in  scarlet  fever,  338;  in 
small-pox,  322;  in  syphilis,  267;  in  ty- 
phoid fever,  31;  ochronosis  and,  455; 
pericarditis  in,  760;  pneumonia  and,  91, 
94;  post-febrile,  52;  rheumatoid,  1135; 
sciatic  due  to,  1061;  secondary  to  acute 
infection,  1142;  villous,  1136. 

Arthritis  deformans,  definition  of,  1134; 
diagnosis  of,  1140;  differentiation  of  gout 
from,  424;  differentiation  of  rheumatic 
fever  from,  378;  etiology  of,  1134, 
1135;  in  children,  1138,  1140;  morbid 
anatomy  of,  1135,  1136;  prognosis  of, 
1140,  1141;  symptoms  of,  1136-1140; 
treatment  of,  1141,  1142. 

Arthropathies,  in  hemiplegia,  996 ;  in  loco- 
motor  ataxia,  918;  in  syringomyelia,  965. 

Arthropathy,  hypertrophic  pulmonary,  1143, 
1144. 

Ascariasis,  294-296. 


INDEX 


1155 


Asearis  lumbricoides,  294,  295. 
Ascending  degeneration  of  the  spinal  cord 

in  spondylitis,  1138. 
Ascending  neuritis,  1022. 
Ascending     (Landry's)     paralysis,     acute, 
definition    of,    941;    diagnosis    of,    942; 
etiology  and   pathology   of,  941;    symp- 
toms of,  941,  942. 

Ascites,  chronic  adhesive  pericarditis  and, 
768;  chylous,  610;  confusion  of  dilated 
stomach  and,  489 ;  definition  of,  608 ; 
differential  diagnosis  of,  609,  610;  dif- 
ferentiation of  hydronephrosis  from, 
717;  enteroptosis  and,  549;  etiology  of, 
608;  hypostatic  congestion  of  lungs  in, 
634;  in  alcoholic  cirrhosis,  578,  580;  in 
aneurism  of  the  ascending  arch,  851;  in 
cancer  of  peritoneum,  608;  in  cancer  of 
stomach,  503 ;  in  congestion  of  liver, 
562;  in  erythraemia,  758;  in  leukaemia, 
743;  in  mitral  stenosis,  824;  in  perihep- 
atitis,  581;  in  peritonitis,  602;  in  pro- 
liferative  peritonitis,  606;  in  splenic 
anaemia,  887;  in  tuberculous  peritonitis, 
180;  in  typhoid  fever,  26;  nature  of 
fluid  in,  610;  symptoms  of,  608,  609; 
treatment  of,  611. 
Asiatic  amphistome,  283, 
Asiatic  cholera,  132. 
Aspergillosis,  236. 
Aspergillus  fumigatus,  236;  in  bronchial 

casts,  632. 

Asphyxia,  death  by,  in  pulmonary  tuber- 
culosis, 210;  in  carcinoma  of  lung,  654; 
in  Eaynaud's  disease,  1120,  1121;  in 
tracheo-bronchial  adenitis,  177;  local,  in 
writer's  cramp,  1094. 

Aspiration,  in  acute  pleurisy,  665;  in  hy« 
dronephrosis,  717;  in  pneumothorax,  672. 
Aspiration  pneumonia,  102,  104,  106. 
"Association  cortex,"  970. 
Astasia,  1119,  1120. 
Astasia-abasia,  neurasthenic,  1110. 
Asteriognosis  in  tumors  of  the  brain,  1011, 

1012. 

Asthenia    in    Addison's    disease,    865;    in 
adiposis  dolorosa,  452 ;  in  Hodgkin  's  dis- 
ease, 748;   in  ileo-colitis,  528;  in  infan- 
tile scurvy,  450;   in  pulmonary  tubercu- 
losis, 210;  morphia  habit  and,  401. 
Asthenic  bulbar  paralysis,  1133. 
Asthenic  form  of  malaria,  254 
Asthenic  pneumonia,  93. 
Asthenopia,  neurasthenic,  1109. 
Asthma,  acute  bronchitis  and,  620;   aden- 
oids and,  469;   bronchial,  627-631;   car- 
diac, acute  vesicular  emphysema  in,  650; 
cardiac,  in  fatty  heart,  791;  chronic  car- 
diac insufficiency  due  to,   786;    Copp's, 


869;    following    whooping    cough,    122; 
hay  fever  and,  613;   Miller's,  869;   pul- 
monary branches  of  the  vagi  and,  1051; 
thymic,  617,  869. 
Astrophobia,  1109. 
Asymmetry,  facial,  in  congenital  torticollis. 

1052. 

Ataxia   due  to  lesion   of   the   crura,   973; 
hereditary,  944,  945 ;  hysterical,  1098 ;  in 
malaria,   254;    in   tumors   of  the   brain, 
1012;  in  tumors  of  the  cerebellum,  975. 
Ataxic  paraplegia,  942,  943 ; ;   differentia- 
tion of  locomotor  ataxia  from,  919. 
Ataxie  variolique,  322. 
Atheroma,     chronic,     aneurism     following, 
848 ;  of  the  aorta,  cerebral  embolism  due 
to,  998. 

Atheromatous  abscess,  843. 
Athetosis,  bilateral,   938;   following  hemi- 
plegia  in  children,  1008;  in  hemiplegia, 
996. 
Athletes,    cardiac    hypertrophy    in,     780; 

large  heart  of,  783. 
Athletes'  heart,  809. 
Athletic  albuminuria,  685. 
Atony,  intestinal,  constipation  due  to,  545; 
of   muscular   coats    of   stomach   causing 
dilatation,  487;  of  the  stomach,  511,  515. 
Atremia,  1110. 

Atresia  of  the  pulmonary  orifice,  834. 
Atrophic  cirrhosis  of  the  liver,  577. 
Atrophic  emphysema,  650. 
Atrophy,  bony,  in  arthritis  deformans, 
1136,  1139;  cerebral,  hemiplegia  in  chil- 
dren due  to,  1006;  muscular  (see  Mus- 
cular dystrophies) ;  muscular,  following 
dengue,  363;  muscular,  in  arthritis  de- 
formans, 1136,  1139;  muscular,  in  beri- 
beri, 415;  muscular,  in  hemiplegia, 
996;  muscular,  in  localized  neuritis, 
1022;  muscular,  in  locomotor  ataxia, 
918;  muscular,  in  spinal  haemorrhagic 
pachymeningitis,  948;  muscular,  in  spon- 
dylitis, 1138;  muscular,  in  syringomyelia, 
965;  of  convolutions  of  the  brain, 
in  haemorrhagic  pachymeningitis,  947;  of 
convolutions  of  the  brain,  redema  and, 
986;  of  gall-bladder,  572;  of  mucous 
membrane  of  stomach,  480,  481;  of 
Eerves,  in  optic  neuritis,  1030;  of  stom- 
ach, pernicious  anaemia  and,  734;  of  su- 
prarenal bodies,  due  to  Addison's  dis- 
ease, 864;  of  thymus,  869;  of  tongue, 
1055;  of  tongue,  glossy  flat,  461  Coptic, 
1031;  optic,  in  amaurotic  family  idiocy, 
939;  optic,  in  general  paralysis,  923; 
optic,  in  locomotor  ataxia,  914,  915,  919, 
920;  optic,  in  oxycephaly,  1147;  optic, 
in  sclerosis  of  the  brain,  953;  optic,  in 


1156 


INDEX 


tabo-paralysis,  924;  progressive  (cen- 
tral) muscular  (see  Progressive  central 
muscular  paralysis)  ;  progressive  neural 
muscular,  931,  932. 

Attitude  in  paralysis  agitans,  1064,  1065. 

Auditory  aphasia,  979,  980. 

Auditory  nerve,  affections  of,  1045-1048. 

Auditory  vertigo,  1047,  1048. 

Aura,  in  epilepsy,  1081. 

Auricular  fibrillation,  775. 

Autochthonous  sinus-thrombosis,  1004. 

Auto-hasmolytic  action,  684. 

Autumnal  catarrh,  612,  613. 

Azotorrhoea,  592;  in  chronic  pancreatitis, 
596. 


B 


Babinski's  reflex  in  cerebral  haemorrhage, 
995;  in  sclerosis  of  the  brain,  953;  in 
tuberculous  meningitis,  173. 

Babinski's  theory  of  hysteria,  1095. 

Bacillary  dysentery,  clinical  types  of,  128; 
complications  and  sequelae  of,  128;  defi- 
nition of,  126;  diagnosis  of,  128,  129; 
etiology  of,  126,  127;  morbid  anatomy 
of,  127;  symptoms  of,  127,  128;  treat- 
ment of,  129,  130. 

Bacilluria,  687;    in  typhoid  fever,  30,  45. 

Bacillus  aerogenes,  in  peritonitis,  601 ; 
aerogenea  capsulatus,  692;  anthracis, 
148 ;  anthracis,  in  endocarditis,  800 ;  bot- 
ulinus,  409 ;  coli,  4 ;  coli,  in  appendicitis, 
532;  coli,  in  diarrhoea  of  children, 
525;  coli,  in  diphtheria,  59;  coli,  infec- 
tions with,  46;  coli,  septico-pyaemia  due 
to,  51;  coli  communis,  infections  due  to, 
46-48;  diphtherias,  causing  pneumonia, 
78;  diphtheriae,  in  endocarditis,  800; 
dystenterias,  126,  127,  128;  enteritidis, 
in  meat  poisoning,  408 ;  Hoffmann 's,  60 ; 
influenzae,  116,  117;  influenzas,  causing 
pneumonia,  78;  influenzas,  in  broncho- 
pneumonia,  104;  influenzae  in  pulmonary 
tuberculosis,  208,  209;  influenzae,  septi- 
caemia due  to,  50 ;  influenzae,  septicopyae- 
mia  due  to,  51;  Klebs-LoefHer,  58,  59; 
lactimorbi,  385;  lactis  aerogenes  in  diar- 
rhoea of  children,  525 ;  leprae,  152 ;  mallei, 
146;  Oppler-Boas,  502;  pertussis,  120; 
pestis,  139 ;  pneumonias,  in  broncho-pneu- 
monia, 104;  pneumoniae,  of  Friedlander, 
77;  proteus,  general  septicaemia  due  to, 
50;  proteus,  septico-pyaemia  due  to,  51; 
proteus,  terminal  infections  due  to,  53; 
pseudo-diphtheria,  59,  60;  pyocyaneus, 
in  peritonitis,  601;  pyocyaneus,  in  pul- 
monary tuberculosis,  208;  pyocyaneus, 
gepticaemia  due  to,  50;  pyocyaneus,  sep- 


tico-pyaemia due  to,  51;  pyocyaneus,  ter- 
minal infections  due  to,  53 ;  tetani,  142, 
143;  tuberculosis,  in  acute  pleurisy,  655, 
656;  tuberculosis,  in  endocarditis,  800; 
tuberculosis,  modes  of  infection  by,  161- 
165;  tuberculosis,  occurrence  of,  156, 
157;  tuberculosis,  specific  reactions  of, 
159-161;  tuberculosis,  varieties  of,  156; 
typhosus,  4,  5 ;  typhosus,  causing  pneu- 
monia, 78;  typhosus,  in  endocarditis, 
800;  typhosus,  isolation  of,  for  diagno- 
sis, 35,  36;  typhosus,  products  of  growth 
of,  9;  typhosus,  septico-pyaemia  due  to, 
51;  Vincent's,  60;  xerosis,  59. 

Bacteria  in  appendicitis,  432;  in  diarrhoea 
of  children,  524,  525 ;  in  renal  calculi.. 
718;  pyelitis  due  to,  712. 

Bacterium  solaniferum,  410. 

Bacteriuria,  687. 

Bagdad   sore,   261. 

Balanitis  in  diabetes,  434. 

Balantidium  coli,  281. 

Ball-valve  stone,  573. 

Balne's  cough,  469. 

Balz's  disease,  462. 

Bandage,  use  of,  in  enteroptosis,  550. 

Bandaging  in  movable  kidney,  678. 

Banting's  diet  for  obesity,  452. 

Banti's  disease.     (See  Splenomegaly.) 

Barauy's  caloric  test,  1048. 

"Barben  cholera,"  409. 

Barlow's  disease,  449,  450. 

Barrel  chest  in  adenoids,  469,  470 ;  in 
asthmatic  attacks,  629 ;  in  emphysema, 
648;  in  hypertrophie  emphysema,  647. 

Basedow's  disease  (see  Exophthalmic 
goitre)  ;  tetany  in,  881. 

Basilar  artery,  symptoms  of  blocking  of, 
1000. 

Basilar  meningitis  (see  Meningeal  form  of 
acute  miliary  tuberculosis) ;  in  pulmo- 
nary tuberculosis,  205. 

Bastian's  symptom  in  compression  myelitis, 
961. 

Baths  in  typhoid  fever,  42. 

Batophobia,   1109. 

Beaumes'  law,  265. 

Bedbug,  312;  in  transmission  of  kala-azar, 
260;  in  transmission  of  relapsing  fever, 
262. 

Bednar's  aphthae,  458. 

Bed-sores  in  acute  diffuse  myelitis,  967; 
in  acute  transverse  myelitis,  967,  968 ;  in 
cerebral  apoplexy,  998;  in  cerebro-spinal 
meningitis,  114,  115;  in  general  paraly- 
sis, 924;  in  typhoid  fever,  19,  45. 

Beef  tapeworm,  285. 

"Beefsteak"  hand,  1121. 

Beer,   chronic  cardiac  insufficiency  due  to, 


INDEX 


1157 


786;   dilatation  and  hypertrophy  of  the 
heart  due  to,  781,  784. 

Beer-drinkers,  dilatation  of  the  stomach 
in,  487. 

Belladonna,  purpura  due  to,  751. 

Bell's  palsy,  1041-1044. 

"Bends,"  394. 

Benzol,  purpura  due  to,  751. 

Beri-beri,  definition  of,  414;  diagnosis  of, 
416;  distribution  of,  414;  etiology  of, 
414,  415;  history  of,  414;  morbid  anat- 
omy of,  415,  416;  prophylaxis  of,  416; 
symptoms  of,  415 ;  treatment  of,  416. 

"Big-jaw,"  232. 

Bile,  influence  of,  in  catarrhal  enteritis, 
517. 

Bilo  ducts,  acute  catarrh  of,  563,  564; 
cancer  of,  567;  congenital  obliteration 
of,  568;  stenosis  and  obstruction  of, 
567,  568;  tuberculosis  of,  214. 

Bilharzia  haematobia,  283;  haematuria  due 
to,  681. 

Bilharziasis,  283,  284. 

Bilary  calculi.     (See  Cholelithiasis.) 

Biliary  colic,  570,  571. 

Biliary  fistulae,  574. 

Biliousness,  gouty,  422. 

Birds,  aspergillosis  in,  236. 

Birth  palsies,  936-938. 

Black  death,  138,  140. 

Black  small-pox,  320. 

"Black  spit"  of  anthracosis,  645. 

Black  vomit,  358,  360;  in  toxaemic  jaun- 
dice, 557. 

Black-water  fever,  243,  254. 

Bladder,  affections  of,  haematuria  due  to, 
681;  in  diabetes  insipidus,  440;  in  loco- 
motor  ataxia,  915;  in  typhoid  fever,  12; 
irritability  of,  in  appendicitis,  534;  tu- 
berculosis of,  219. 

Bladder  stone,  differentiation  of  renal  cal- 
culus from,  721. 

Blastomycosis,  235. 

Bleeding  in  treatment  of  erythraemia,  758; 
in  treatment  of  hypertrophic  emphysema. 
649;  in  treatment  of  hypostatie  conges- 
tion of  the  lungs,  635;  in  treatment  of 
cedema  of  the  lungs,  635;  in  treatment 
of  pneumonia,  99;  in  treatment  of  tho- 
racic aneurism,  859. 

Blepharospasm,  1044. 

Blindness,  due  to  disease  of  the  chiasma:, 
1032;  due  to  gonococcus  infection,  123; 
due  to  lesion  of  cuneus,  1032;  due  to 
lesion  of  optic  nerve,  1033;  following 
haemorrhage  from  the  stomach,  508;  in 
amaurotic  family  idiocy,  939 ;  in  chronic 
interstitial  nephritis,  708;  in  locomotor 


ataxia,    915;    in    tumors    of   the    brain, 
1012;  in  uraemia,  694. 

Blood  as  a  means  of  infection  in  genito- 
urinary tuberculosis,  215;  in  acute  sec- 
ondary anaemia,  728;  in  cerebral  haemor- 
rhage, 990;  in  erythraemia,  757,  758;  in 
lead  poisoning,  403 ;  in  myeloid  leukaemia, 
741-744;  in  pulmonary  tuberculosis, 
204;  in  typhoid  fever,  19,  20;  foul 
breath  and,  461 ;  in  atypical  leukaemias, 
745;  in  chlorosis,  731,  732;  in  cholera 
asiatica,  135;  in  diabetes,  431,  433;  in 
gout,  419;  in  lobar  pneumonia,  87,  88; 
in  lymphoid  leukaemia,  745;  in  mycosis 
intestinalis,  150;  in  pellagra,  413;  in 
pernicious  anaemia,  737,  738;  in  pro- 
gressive septicaemia,  49;  in  relapsing 
fever,  262;  in  rheumatic  fever,  374;  in 
secondary  anaemia,  730 ;  in  typhus  fever, 
353;  in  yellow  fever,  358. 

Blood  casts,  differentiation  of,  from  fibrin- 
oua  casts  with  haemorrhage,  632. 

Blood-count  in  acute  sero-fibrinous  pleurisy, 
659;  in  diagnosis  of  leukaemia,  745,  746. 

Blood  cysts  in  hook-worm  disease,  302. 

Blood  pressure,  arterio-sclerosis  and,  841, 
842.  845;  extra-systoles  due  to,  774;  in 
Addison's  disease,  865;  in  cardiac  insuf- 
ficiency, 785;  in  chronic  interstitial 
nephritis,  707;  in  lobar  pneumonia,  86; 
relation  of  supra-renal  bodies  to,  864. 

Blood  serum  in  treatment  of  pernicious 
anaemia,  740. 

Blood-vessels,  changes  in,  in  splenic  anae- 
mia, 886 ;  in  hydrophobia,  369  ;  in  typhoid 
fever,  13,  21;  of  brain,  affections  of,  982- 
1009;  of  liver,  diseases  of,  561-563;  of 
spinal  cord,  affections  of,  956-959 ;  thick- 
ening of,  in  chronic  parenchymatous 
nephritis,  703. 

"Blue  disease,"  834. 

Blue  line  in  lead  poisoning,  403. 

Boas  test  meal,  502. 

Boils  in  convalescence  from  small-pox,  322 ; 
in  diabetes,  433;  in  Hodgkin's  disease, 
748;  in  obstructive  jaundice,  556;  in 
typhoid  fever,  19. 

Bone  lesions  of  congenital  syphilis,  269, 
270. 

Bone-marrow,  hyperplasia  of,  in  splenic 
anaemia,  886;  in  anaemia,  735,  738;  in 
eiythraemia,  757;  in  Hodgkin's  disease, 
747,  749;  in  lymphatism,  870;  in  myeloid 
leukaemia,  742;  in  relapsing  fever,  262; 
in  typhoid  fever,  12. 

Bones,  changes  in,  in  acromegaly,  891; 
changes  in,  in  rickets,  442-445;  diseases 
of,  1143-1147;  in  infantile  scurvy,  449f 


1158 


INDEX 


450;  in  scurvy,  448;  in  typhoid  fever,  31, 
45. 

Bony  tumors  of  the  brain,  1010. 

Bordet  bacillus,  119,  120. 

Bothriocephalus,  chronic  secondary  anaemia 
in,  729;  pernicious  anaemia  due  to,  734. 

Bovine  heart,  810. 

Bowditch's  law  of  maximal  contraction, 
773. 

Bowels,  care  of,  in  broncho-pneumonia, 
107;  care  .of,  in  pneumonia,  99;  in  al- 
coholic cirrhosis,  578;  in  cancer  of  the 
stomach,  503;  in  cerebro-spinal  fever, 
112,  114;  in  influenza,  119;  obstruction 
of,  by  gall-stones,  574;  perforation  of 
(see  Perforation)  ;  torpidity  of,  causing 
constipation,  545. 

Brachial  plexus,  lesions  of,  1057-1060;  neu- 
ralgia involving  nerves  of,  1091. 

Brachy cephalic  skull  in  endemic  cretinism, 
874. 

Bradyeardia,  777;  in  paroxysmal,  arryth- 
mia  due  to,  772 ;  typhoid  fever,  20. 

Bradypnoea,  hysterical,  1100. 

Brain,  abscess  of  (see  Abscess)  ;  actinomy- 
cosis  of,  233;  changes  in,  in  acromegaly, 
891 ;  changes  in,  in  general  paralysis, 
922;  cysticereus  cellulosae  in,  288;  diffuse 
and  focal  diseases  of,  968-1020;  effect 
of  lead  poisoning  on,  405;  hypostatic 
congestion  of  the  lungs  and,  634;  in 
acute  poliomyelitis,  365;  in  cerebro- 
spinal  fever,  110;  in  hydrophobia,  369; 
in  pellagra,  412;  infarcts  in,  in  acute 
endocarditis,  800;  local  anaemia  of,  727; 
syphilis  of,  270,  271;  tuberculosis  of, 
214;  tuberculous  lesions  in,  in  chronic 
ulcerative  tuberculosis,  190. 

Break-bone  fever.     (See  Dengue.) 

Breast,  hypertrophy  of,  in  pulmonary  tu- 
berculosis, 221. 

Breast  pang.     (See  Angina  pectoris.) 

Breath-sounds  in  acute  sero-fibrinous  pleu- 
risy, 659;  in  chronic  ulcerative  tubercu- 
losis, 200;  in  empyema,  661;  in  pneumo- 
thorax,  671. 

Breuer-Freud  theory  of  hysteria,  1096. 

Bright  'a  disease,  acute,  696,  697;  acute, 
diagnosis  of,  699;  acute,  etiology  of, 
697;  acute,  morbid  anatomy  of,  697, 
698;  acute,  prognosis  of,  699,  700;  acute, 
symptoms  of,  698,  699;  acute,  treatment 
of,  700-702;  acute  endocarditis  in,  797; 
albuminuria  in,  686 ;  anaemia  resembling, 
739 ;  ascitic  fluid  in,  609 ;  bronchitis  and, 
620;  catarrhal  jaundice  in,  563;  chronic, 
702-711;  chronic  gastritis  and,  480;  con- 
gestion of  the  kidney  in,  679;  differen- 
tiation of  chlorosis  from,  733;  differen- 


tiation of  diabetes  insipidus  from,  441; 
differentiation  of  myxo3dema  fiom,  876; 
diphtheroid  enteritis  in,  520:  leemorrha- 
gic  pleurisy  in,  661 ;  in  lobar  paeumonia, 
91;  intestinal  catarrh  in,  517;  Jipuria  in, 
693;  mitral  incompetency  and.  818;  neu- 
ralgia in,  1090;  ffidema  of  the  brain  in, 
986;  (Edema  of  the  glottis  in,  616; 
osdema  of  the  lungs  in,  635;  '(edema  of 
the  pharynx  in,  464;  optic  neuritis  in, 
1030;  parotitis  in,  463;  pericarditis  in, 
760,  761;  peritonitis  terminating,  600; 
purpura  in,  751;  terminal  infections  in, 
53 ;  terminal  pneumonia  in,  93,  97. 

« '  Brill 'a  disease, ' '  38,  352. 

Briquet's  syndrome,  1100. 

Brissaud  type  of  infantilism,  893. 

Broca's  centre,  978. 

Bromism,  1086. 

Bronchi,  diseases  of,  620-633;  in  chronic 
ulcerative  tuberculosis,  190;  in  hyper- 
trophic  emphysema,  647;  in  lobar  pneu- 
monia, 80;  in  small-pox,  317;  syphilis 
of,  272. 

Bronchial   asthma.      (See   Asthma.) 

Bronchial  catarrh  in  typhus  fever,  353. 

Bronchial  glands  in  chronic  ulcerative  tu- 
berculosis, 190;  in  pneumonokoniosis, 
643 ;  in  whooping  cough,  121. 

Bronchiectasis,  brain  abscess  in,  1016; 
chronic  dry  pleurisy  and,  667;  cirrhosis 
of  the  lung  and,  640;  complicating 
whooping  cough,  121;  diagnosis  of,  627; 
etiology  of,  625;  following  influenza, 
118;  gangrene  of  the  lung  and,  651; 
haemoptysis  in,  636;  hypertrophic  em- 
physema and,  647;  hypertrophic  pul- 
monary arthropathy  in,  1143;  Lamblia 
intestinalis  in,  281;  morbid  anatomy  of, 
625,  626;  putrid  bronchitis  and,  624; 
symptoms  of,  626,  627;  treatment  of,  627. 

Bronchiolectasis,  626. 

Bronchiolitis,  103;  exudativa,  628. 

Bronchitis,  actinomycosis  and,  233;  active 
congestion  of  the  lungs  in,  633;  acute, 
620-622;  acute  vesicular  emphysema  in, 
650;  bronchiolectasis  following,  626; 
broncho-pneumonia  secondary  to,  101; 
chronic,  622-625;  chronic,  in  asthma, 
630;  chronic  cardiac  insufficiency  due  to, 
786;  chronic  ulcerative  tuberculosis  and, 
192;  croupous,  631-633;  fibrinous,  631, 
633;  gouty,  624;  hypertrophie  emphy- 
sema and,  647 ;  in  aneurism  of  the  thoracic 
aorta,  855;  in  cancer  of  the  oasophagus, 
475 ;  in  chronic  interstitial  nephritis,  707 ; 
in  diphtheria,  67;  in  fatty  heart,  791; 
in  gangrene  of  the  lung,  651,  652;  in 
gout,  423;  in  hypertrophie  emphysema, 


INDEX 


1159 


647-649;  in  malaria,  250,  252;  in 
measles,  346;  in  osteitis  deformans, 
1145;  in  pneumonokoniosis,  644;  in  pul- 
monary tuberculosis,  203;  in  scarlet 
fever,  338 ;  in  trichiniasis,  299 ;  in  ty- 
phoid fever,  26;  in  typhoid  form  of 
tuberculosis,  169;  influenza,  117;  plastic, 
631-633;  tendency  to,  in  mitral  incom- 
petency,  818. 

Broncho-biliary  fistula,  574. 

Bronchocele.     (See  Goitre.) 

Broncophony,  659;  in  chronic  ulcerative 
tuberculosis,  201;  in  trac'ieo-bronchial 
adenitis,  177. 

Broncho-pneumonia,  acute  tuberculous,  185- 
187;  and  bronchiectasis,  626;  aspiration, 
102;  bacteriology  of,  104;  chronic,  104, 
640,  641;  compensatory  emphysema  in, 
645;  complicating  acute  bronchitis,  621, 
622 ;  complicating  small-pox,  322 ;  defi- 
nition of,  101;  diagnosis  of,  105,  106; 
etiology  of,  101 ;  fibroid,  644 ;  in  cancer  of 
the  oesophagus,  475;  in  diabetes,  431, 
434;  in  diarrhosa  of  children,  525;  in 
diphtheria,  62,  67 ;  in  ileo-colitis,  528 ;  in 
measles,  344,  346;  in  scarlet  fever,  334, 
338;  in  typhus  fever,  355;  in  whooping 
cough,  120,  122;  morbid  anatomy  of, 
102-104;  prognosis  of,  106;  prophylaxis 
of,  106;  pulmonary  actinomycosis  and, 
233 ;  streptococcus  pleurisy  and,  656 ; 
symptoms  of,  104,  105;  terminations  of, 
104;  treatment  of,  106,  107;  tuberculous, 
185. 

Broncho-pulmonary  haemorrhage,  636,  637. 

Bronchorrhagia,  636,  637. 

Bronchorrhoea,  623,  624. 

Brown  atrophy  of  the  heart,  789. 

Brown  induration  of  the  lung,  634;  due  to 
mitral  incompetency,  817. 

Brown-Sequard  syndrome,  959. 

Brown-Sequard 's  paralysis,  956;  in  com- 
pression myelitis,  961. 

Brudzinski's  sign  in  acute  cerebro-spinal 
leptomeningitis,  950;  in  cerebro-spinal 
fever,  114. 

Bruit  in  acute  endocarditis,  801;  in  aortic 
incompetency,  812;  in  lobar  pneumonia, 
86;  oesophageal,  474. 

Bruit  d'airain,  671. 

Bruit  de  cuir  neuf  in  acute  fibrinous  peri- 
carditis, 762. 

Bruit  de  drapeau,  632. 

Bruit  de  moulin,  770. 

Bubonic  plague,  140. 

Buccal  spots,  in  measles,  345. 

Buhl's  disease,  754. 

Bulbar  form  of  acute  polio-myelitis,  366. 

Bulbar    paralysis,    930;     asthenic,    1133; 


course  of,  931;  diagnosis  of,  931;  laryn- 
geal  paralysis  in,  1050;  pneumogastric 
nerve  and,  1049 ;  symptoms  of,  931. 

Bulimia,  432,  514. 

Burns,  acute  Bright 's  disease  due  to,  697; 
duodenal  ulcer  following,  491,  493; 
hsemoglobinuria  following,  683. 

Bursas  in  gonococcus  infections,  125. 

Bursitis,  sub-deltoid,  differentiation  of 
arthritis  deformans  from,  1140. 


C 


Cachectic  infantilism,  892,  893. 

Cachexia,  amyloid  liver  and,  590;  fatty 
liver  and,  590;  in  Hodgkin's  disease, 
750 ;  in  pancreatic  cancer,  599 ;  malarial, 
248,  252,  254;  strumipriva,  873,  875, 
876;  syphilitic,  266. 

Caisson  disease,  definition  of,  393;  etiol- 
ogy of,  393;  history  of,  393;  pathology 
of,  393,  394;  prophylaxis  of,  394;  symp- 
toms of,  394;  treatment  of,  394. 

Calcareous  degeneration  of  the  heart,  789. 

Calcareous  fragments  in  tuberculous  spu- 
tum, 194. 

Calcification  of  the  gall-bladder,  572. ' 

Calcified  pericardium,  770. 

Calculus,  coral,  718;  cystinuria  and,  690; 
dendritic,  718;  haematuria  due  to,  681; 
hydronephrosis  due  to,  715;  oxaluria 
and  690. 

Calculus,  gall-bladder  (see  Gall-stones) ; 
chronic  pancreatitis  following,  596. 

Calculus,  renal  (see  Nephrolithiasis) ;  re- 
nal, pyuria  and,  687;  gout  and,  423;  in 
kidney  and  bladder  complicating  bilharzi- 
asis,  283. 

Calculus,  pancreatic,  599,  600. 

Cammidge's  reaction,  592,  593;  in  chronic 
pancreatitis,  596. 

Cancer,  ascites  in,  610 ;  causing  obstruction 
of  bile-ducts,  567,  568;  chronic  haemor- 
rhagie  peritonitis  and,  607;  confusion  of 
symptoms  of,  with  septico-pyaemia,  52; 
echinococcus  of  liver  differentiated  from, 
292;  endocarditis  in,  797;  diphtheroid 
enteritis  in,  520;  gastric,  subphrenic 
abscess  following,  604;  haemorrhagic 
pleurisy  in,  661;  hydronephrosis  due  to, 
716;  intestinal  catarrh  in,  517;  intesti- 
nal ulceration  in,  521;  of  bile-passages, 
567 ;  of  heart,  831 ;  of  kidney,  722,  723 ; 
of  lung,  acute  plastic  pleurisy  in,  654; 
of  mediastinum,  673,  674;  of  pancreas, 
pancreatic  calculi  and,  599;  of  peritone- 
um, 607,  608 ;  of  spine,  acute  myelitis  due 
to,  966;  of  thyroid,  871;  pharyngeal  ul- 


1160 


INDEX 


cers  and,  466;  pulmonary,  haemoptysis  in, 
636;  purpura  in,  751;  suppurative  an- 
giocholitis  and,  565;  terminal  pneu- 
monia in,  97;  thrombosis  of  cerebral 
sinuses  and  veins  and,  1005;  thrombosis 
of  portal  vein  in,  562. 

Cancer  of  liver,  etiology  of,  587;  localized 
peritonitis  in,  604;  primary,  587;  sec- 
ondary, 587. 

Cancer  of  O3sophagus,  475;  abscess  of  lung 
in,  652 ;  chronic  secondary  anaemia  in, 
729 ;  cesophagitis  and,  472. 

Cancer  of  stomach,  acute  suppurative  gas- 
tritis and,  478;  bradycardia  in,  777; 
chronic  gastritis  and,  480;  complica- 
tions of,  503,  504;  confusion  of,  with 
chronic  gastritis,  481,  482;  course  of, 
504;  diagnosis  of,  504;  differentiation 
of  anaemia  from,  739 ;  etiology  of,  498, 
499;  fungi  in,  479;  haemorrhage  in,  506; 
morbid  anatomy  of,  499,  500;  pneu- 
mopericardium  due  to  rupture  of,  769; 
symptoms  of,  500-503;  subacidity  in, 
512;  treatment  of,  504,  505. 

Cancerous  pleurisy,  haemorrhagic,  662. 

Cancrum  oris,  in  measles,  346;  in  typhus 
fever,  355. 

Canities  in  neuralgia,  1090. 

Cantharides,  acute  Bright 's  disease  due 
to,  697;  congestion  of  kidney  due  to, 
679 ;  haematuria  due  to,  681. 

Capillary  apoplexy,  999. 

Capillary  bronchitis,  101. 

Capsular  cirrhosis  of  liver,  581,  582. 

Capsulitis  of  liver,  581. 

Caput  medusae,  577;  in  ascites,  609. 

Caput  quadratum,  444. 

Carbohydrate  metabolism,  426. 

Carbolic  acid,  acute  Bright 's  disease  due 
to,  697;  haematuria  due  to,  681;  haemo- 
globinuria  due  to,  683. 

Carboluria,  692. 

Carbon  monoxide,  haemoglobinuria  due  to, 
683. 

Carbonate  of  lime,  calculi  of,  718. 

Carbuncle,  thrombosis  of  cerebral  sinuses 
and  veins  due  to,  1005. 

Carbuncles  in  diabetes, -433. 

Carcinoma  of  brain,  1009;  of  kidney,  722; 
of  lung,  653,  654;  of  pancreas,  598, 
599;  of  stomach  (see  Cancer);  of  supra- 
renal glands,  868;  pressure  paralysis  fol- 
lowing, 961 ;  ulcer  of  stomach  and,  493. 

"Cardiac  asthma"  in  fatty  heart,  791. 

Cardiac  dilatation.  (See  Dilatation,  car- 
diac.) 

Cardiac  flutter,  774,  775. 

Cardiac  hypertrophy.  (See  Hypertrophy, 
cardia.) 


Cardiac  insufficiency,  anatomical  basis  of, 
786-789;  etiology  of,  784-786;  prognosis 
of,  792;  Schott  treatment  of,  796,  797; 
symptoms  of,  789-792;  treatment  of, 
792-794;  treatment  of  special  symptoms 
in,  794-796. 

Cardiac  kidney,  680. 

Cardiac  liver,  561. 

Cardialgia,  480;  in  angio-neurotic  oedema, 
1124. 

Cardiocentesis,  831,  832. 

Cardiolysis  in  chronic  adhesive  pericarditis, 
769. 

Cardio-respiratory  murmur,  201. 

Cardio-sclerosis,  symptoms  of,  790. 

Cardio-stenosis,  cardiac  flutter  in,  775- 

Cardio-vascular  epilepsy,  1081. 

Caries,  differentiation  of  tumors  of  spinal 
cord  from,  964;  lesions  of  cauda  equina 
and  conus  medullaris  due  to,  902 ;  of. 
bodies  of  cervical  vertebrae,  retro-pharyn- 
geal  abscess  in,  466;  of  bone,  pachy 
meningitis  externa  due  to,  946;  of  nasal 
bones,  loss  of  sense  of  smell  due  to, 
1028;  of  temporal  bone,  thrombosis  of 
cerebral  veins  and  sinuses  due  to,  1005 ; 
spastic  paralysis  secondary  to,  939,  940. 

Caries  of  spine,  acute  myelitis  due  to,  966; 
compression  myelitis  due  to,  959-961 ; 
tuberculous,  pachymeningitis  and,  946. 

Carious  teeth,  convulsive  tic  due  to,  1044; 
neuralgia  due  to,  1090. 

Carnification  of  lung,  103. 

Carpo-pedal  spasms  in  spasmodic  laryn- 
gitis, 617. 

Carriers,  cerebro-spinal,  134;  cholera,  134; 
diphtheria,  57,  59,  70;  meningitis,  109; 
poliomyelitis,  365;  typhoid,  6,  7,  46. 

Caseation  of  tubercle,  166. 

Casts  in  fibrinous  bronchitis,  631,  632. 

Catalepsy  in  hysteria,  1103. 

Cataract  in  diabetes,  434. 

Catarrh,  acute  gastric,  476-479;  autumnal, 
612,  613;  chronic  gastric,  dilatation  of 
stomach  and,  487;  chronic,  in  alcoholic 
cirrhosis,  578;  chronic  intestinal,  treat- 
ment of,  522,  523 ;  chronic  nasal  and 
adenoids,  468,  470;  chronic  nasal, 
epistaxis  in,  613;  chronic  nasal,  loss  of 
sense  of  smell  in,  1028;  chronic  nasal, 
pharyngitis  and,  465;  chronic,  phuryn- 
geal  ulcers  and,  465;  dry,  624;  gastro- 
duodenal,  catarrhal  jaundice  and,  563 ; 
gastro-duodenal,  in  acute  yellow  atrophy, 
560;  gastro-intestinal,  in  congestion  of 
liver,  562;  in  arsenical  poisoning,  407; 
intestinal,  in  measles,  346;  laryngeal, 
laryngeal  paralysis  following,  1050;  li- 
thogenous,  568,  569;  of  bile  ducts,  acute, 


INDEX 


1161 


d63,  564;  of  bladder  in  typhoid  fever, 
12,  of  mucous  membranes,  predisposing 
to  tuberculous  adenitis  174,  175;  of 
stomach,  chronic,  479-486;  of  stomach, 
chronic,  subacidity  in,  512;  of  stomach, 
in  alcoholism,  397;  pharyngeal,  inflam- 
mation of  oesophagus  and,  472;  predis- 
posing to  tuberculosis,  159. 

Catarrhal  angiocholitis,  chronic,  564,  565. 

Catarrhal  dysentery,  acute,  128. 

Catarrhal  enteritis,  diagnosis  of,  519;  eti- 
ology of,  316,  317;  morbid  anatomy  of, 
518;  symptoms  of,  518,  519. 

Catarrhal  fever,  acute,  definition  of,  382; 
diagnosis  of,  383;  etiology  of,  382; 
symptoms  of,  382,  383 ;  treatment  of, 
383. 

Catarrhal  jaundice,  563,  564. 

Catarrhal  laryngitis,  acute,  614,  615. 

Caterpillar  rash,  314. 

Cathartic  method  in  treatment  of  hysteria, 
1105,  1106. 

Cattle,  actinomycosis  in,  232;  anthrax  in, 
148;  aspergillosis  in,  236;  foot-and- 
mouth  disease  in,  387 ;  milk-sickness  and, 
385;  tuberculosis  in,  155. 

Cauda  equina,  lesions  of,  962,  963. 

Cavernous  sounds  in  chronic  ulcerative 
tuberculosis,  201. 

Cavities  in  chronic  ulcerative  tuberculosis, 
189,  190;  signs  of,  201. 

Cell  systems,  895. 

Cellulitis,  (Edema  of  glottis  in,  616;  of 
neck,  466. 

Central  pneumonia,  92. 

Centrum  semiovale,  lesions  of,  970. 

Cephalic  tetanus,  144. 

Cephalodynia,  1130. 

Cercomonas  hominis,  281. 

Cerebellar  ataxia,  differentiation  of  loco- 
motor  ataxia  from,  919. 

Cerebellar  heredo-ataxia,  945. 

Cerebellum,  lesions  of,  974,  975. 

Ctrebral  actinomycosis,  233. 

Cerebral  adiposity,  453. 

Cerebral  atrophy,  differentiation  of  mus- 
cular dystrophies  from,  934. 

Cerebral  circulation,  982-985. 

Cerebral  cortex,  lesions  of,  969,  970. 

Ctrebral  haemorrhage  (see  Haemorrhage) ; 
differentiation  of  uraemia  from,  696. 

Cerebral  nerves,  diseases  of,  1028-1055. 

Cerebral  peduncle,  hemiplegia  due  to  lesion 

of,  992. 

Cerebral  peduncles,  lesions  of,  972,  973. 
Cerebral  rheumatism,  376. 
Cerebral   softening,   998,   999;    anatomical 
changes    in,    999,    1000;    symptoms    of, 
1000,  1001;  treatment  of,  1001-1003. 
75 


Cerebral  symptoms  in  obstructive  jaundice. 
556. 

Cerebral  type  of  acute  polio-myelitis,  366. 

Cerebro-spinal  fever,  acute  endocarditis 
mistaken  for,  803 ;  bacteriology  of,  109 ; 
Brudzinski's  sign  in,  114;  chronic,  112; 
complications  of,  112,  113;  definition  of, 
108;  diagnosis  of,  113,  114;  differentia- 
tion of  small-pox  from,  324;  differentia- 
tion of  typhus  from,  355;  encephalitis 
in,  1015;  etiology  of,  109;  herpes  zoster 
in,  926;  history  of,  108,  109;  hydro- 
cephalus  in,  1020;  lumbar  puncture  in, 
114;  morbid  anatomy  of,  109,  110;  prog- 
nosis of,  114;  prophylaxis  of,  114;  pur- 
puric  rash  in,  751;  skin  in,  114;  symp- 
toms of,  110-112;  treatment  of,  111-115. 

Cc-rebro-spinal  meningitis,  confusion  of, 
with  typhoid  fever,  36,  37;  in  pulmonary 
tuberculosis,  205. 

Cerebro-spinal  leptomeningitis.  (See  Lep- 
tomeningitia.) 

Cervical  adenitis,  176. 

Cervical  glands  in  Hodgkin's  disease,  747, 
748. 

Cervical  meningitis,  differentiation  of  tu- 
mors of  spinal  cord  from,  964. 

Cervical  plexus,  lesions  of,  1055-1057. 

Cervical  rib  pressure,  1057.  •  • 

Cervico-axillary  glands,  in  chronic  ulcera- 
tive tuberculosis,  192. 

Cervico-brachial  neuralgia,  1091. 

Cervico-occipital  neuralgia,  109L 

Chalicosis,  642,  644. 

Chancre,  265,  266. 

Charbon.     (See  Anthrax.) 

Charcot's  joints,  915,  918. 

Charcot's  theory  of  hysteria,  1095. 

Cheese  poisoning,  409. 

Cheyne-Stokes  breathing  in  aortic  stenosis, 
816;  in  cardiac  insufficiency,  790,  791; 
in  cerebro-spinal  fever,  111;  in  chronic 
Bright 's  disease,  711;  in  chronic  inter- 
stitial nephritis,  707;  in  dyspnoea,  695; 
in  general  tuberculosis,  169. 

Chiasma,  disease  of,  1032. 

Chicken  breast  in  adenoids,  469 ;  in  rickets, 
444. 

Chicken-pox  (see  Varicella) ;  scarlet  fever 
and,  340;  typhoid  fever  and,  32. 

Chilblain,  1120. 

"Child-crowing,"  617. 

Children,  pulmonary  tuberculosis  in,  210; 
tuberculous  broncho-pneumonia  in,  186, 
187 ;  typhoid  fever  in,  33. 

Chills,  in  acute  Bright 's  disease,  698;  in 
acute  congestion  of  the  lungs,  633:  in 
acute  diffuse  myelitis,  966;  in  acute  fe- 
brile polyneuritis,  1022;  in  ball-valve 


1162 


INDEX 


stone,  573;  in  cancer  of  stomach,  501;  in 
chronic  infective  endocarditis,  802;  in 
lobar  pneumonia,  81;  in  malaria,  249; 
in  mediastinal  abscess,  675;  in  movable 
kidney,  678 ;  in  paroxysmal  hffimoglobin- 
uria,  683;  in  peritonitis,  601;  in  pyelitis, 
714;  in  relapsing  fever,  262;  in  rheu- 
matic fever,  372,  373;  in  septico-pyaemia, 
51;  in  subphrenic  abscess,  605;  in  tu- 
berculous broncho-pneumonia,  186;  in 
typhoid  fever,  18;  in  typhus  fever,  353. 

Chloasma  phthisicorum,  206. 

Chloroma,  745. 

Chloroform,  albuminuria  following  inhala- 
tion of,  685;  vaso-motor  paralysis  due 
to,  984. 

Chloroform  poisoning,  necrosis  of  liver  in, 
559. 

Chlorosis,  bradycardia  in,  777;  chronic  gas- 
tritis and,  480;  definition  of,  730;  diag- 
nosis of,  733;  dilatation  of  heart  in, 
784;  etiology  of,  730,  731;  gastric  ulcer 
and,  491;  in  constipation,  546;  mitral 
stenosis  and,  821;  symptoms  of,  731- 
733;  thrombosis  of  cerebral  sinuses  and 
veins  and,  1004;  treatment  of,  73S,  740; 
tropical,  and  Egyptian,  300. 

Choked  disk,  1030,  1031;  in  congenital 
hydrocephalus,  1019;  in  serous  menin- 
gitis, 1018;  in  tumors  of  brain,  1010. 

Cholaemia,  557;  hsematemesis  in,  507. 

Cholangitis,  due  to  Bacillus  coli,  47;  gall- 
stones and,  572,  573;  in  acute  yellow 
atrophy,  559;  in  typhoid  fever,  26;  sup- 
purative,  583,  584. 

Cholecystitis,  acute,  due  to  gall-stones, 
572;  acute  infectious,  565-567;  biliary 
colic  and,  570;  due  to  Bacillus  coli,  47; 
in  typhoid  fever,  26;  in  typhoid  fever, 
treatment  of,  45;  suppurative,  angiocho- 
Htis  following,  565;  suppurative,  gall- 
stones and,  572;  tuberculous  peritonitis 
confused  with,  180. 

Cholelithiasis  (see  Gall-stones)  ;  complicat- 
ing influenza,  118;  gastralgia  and,  514. 

Cholelithic  chronic  pancreatitis,  596. 

Cholera,  anuria  in,  680;  intestinal  catarrh 
and,  517. 

Cholera  asiatica,  carriers  in,  134;  compli- 
cations and  sequela?  of,  136;  definition 
of,  132;  diagnosis  of,  136;  etiology  of, 
132,  133;  history  of,  132;  modes  of  in- 
fection in,  133-134;  morbid  anatomy  of, 
134,  135;  prognosis  of,  136;  prophylaxis 
of,  137;  symptoms  of,  135,  136;  treat- 
ment of,  137,  138. 

Cholera  infantum,  526,  527;  treatment  of, 
531. 

Cholera  nostras,  136. 


Cholera  sicca,  136. 

Cholerine,  136. 

Cholesteatoma  of  brain,  1010. 

Cholesteramia,  557. 

Chclesterin,  568. 

Chondrodystrophia  fetalis,  1146,  1147. 

Chvostek's  symptom,  882. 

Chorea,  acute,  definition  of,  1066;  acute 
diagnosis  of,  1072,  1073;  acute,  duration 
and  termination  of,  1072 ;  acute,  endo 
carditis  in,  797,  798;  acute,  morbid  anat- 
omy and  pathology  of,  1068,  1069 ;  acute, 
symptoms  of,  1069-1072;  acute,  treat- 
ment of,  1073,  1074;  arthritis  and,  1066; 
chronic,  1072,  1076,  1077;  elonic  spasm 
of  muscles  supplied  by  fifth  nerve  in, 
1040;  habit,  1075;  in  pericarditis,  764; 
in  rheumatic  fever,  376;  in  scarlet  fever, 
338,  339;  insaniens,  1070,  1071;  major, 
1074,  1075;  neuritis  from  arsenic  in, 
1024;  pandemic,  1074,  1075;  pericarditis 
in,  760;  post-hemiplegic,  1008;  post- 
paralytic,  in  hemiplegia,  996;  prehemi- 
plegic,  990;  rhythmic  or  hysterical,  1077 ; 
spasm  of  the  oesophagus  in,  473;  spasm 
of  the  tongue  in,  1055;  spastica,  938; 
typhoid  fever  and,  32. 

Choroiditis  in  syphilis,  267. 

Choroido-iritis  in  cerebro-spinal  fever,  113. 

Chromaffin  system,  863. 

Chylangiomata,  554. 

Chyle  vessels,  disorders  of,  554. 

Chylous  ascites,  610. 

Chyluria,  lipuria  in,  693;  non-parasitic, 
688. 

Cicatrices  completes,  224;  fistuleuses,  224. 

Cicatrization  of  an  ulcer,  followed  by  dila- 
tation of  the  stomach,  487,  492. 

Cimex  lectularius,  312. 

Cimex  rotundalis,  312. 

Circulation,   cerebral,  982-985. 

Circulatory  disturbances  of  kidney,  679, 
680. 

Circulatory  system  in  lobar  pneumonia,  86, 
87,  100;  in  typhoid  fever,  13,  19-21. 

Circumflex  nerve,  lesions  of,  1058,  1059; 
neuralgia  of,  1091. 

Cirrhosis  of  liver,  affections  of  mesenteric 
veins  in,  554;  alcoholic,  397,  398,  576- 
580;  ascitic  fluid  in,  610;  capsular,  581, 
582;  chronic  adhesive  pericarditis  and, 
768;  chronic  interacinar  pancreatitis 
and,  596;  diabetic,  431,  432;  differentia- 
tion of  cancer  from,  589;  diphtheroid 
enteritis  in,  520;  enlargement  of  hepatic 
artery  in,  563;  epistaxis  in,  614;  eti- 
ology of,  575,  576;  general  considera- 
tions of,  575;  hsematemesis  in,  507,  508. 
509;  hypertrophic,  580,  581;  hypertro 


INDEX 


1163 


phic,  differentiation  of  acute  yellow 
atrophy  from,  560;  in  bilharziasis,  284; 
in  hepatic  distomiasis,  282 ;  in  splenic 
anaemia,  887;  infections  and,  576;  in- 
testinal catarrh  in,  517;  necrosis  and 
jaundice  in,  559;  cesophageal  varices  in, 
473;  pigment  in,  576;  pigmentaire,  431; 
predisposing  to  tuberculous  peritonitis, 
180;  proliferative  peritonitis  and,  606, 
607 ;  sclerosis  of  veins  in,  845 ;  splenome- 
galy and,  888;  syphilitic,  274,  576,  581; 
terminal  acute  tuberculosis  in,  159;  ter- 
minal infections  in,  53;  thrombosis  of 
mesenteric  vessels  in,  554;  thrombosis  of 
portal  vein  in,  562;  toxic,  576;  treatment 
of,  582;  tuberculous,  214. 

Cirrhosis  of  lung,  639  (see  also  Pneu- 
monia, chronic  interstitial)  ;  cardiac  hy- 
pertrophy in,  781;  compensatory  emphy- 
sema in,  645;  congestion  of  liver  in,  56; 
following  pleurisy,  668;  in  tuberculosis, 
202 ;  tricuspid  regurgitation  and,  824,825. 

Cirrhosis  ventriculi,  486. 

Clapotage,  488,  489;  in  enteroptosis,  549. 

Classes,  tuberculosis,  225. 

Claudication  in  arterio-sclerosis,  846. 

Claustrophobia,  1109. 

Claw-hand,  in  paralysis  due  to  lesion  of,  the 
ulnar  nerve,  1059 ;  in  spinal  haemorrhagic 
pachymeningitis,  948. 

Clavus  hystericus,  1100. 

Climacteric,  palpitation  at,  770. 

Climate,  asthma  and,  631;  pneumonia  and, 
76. 

Climatic  treatment  of  tuberculosis,  226, 
227. 

Clownism  in  hystero-epilepsy,  1098. 

Club  foot  in  progressive  neural  muscular 
atrophy,  932. 

Clubbed  fingers,  and  toes  in  congenital 
heart  disease,  835 ;  in  aneurism  of  tho- 
racic aorta,  855 ;  in  bronchiectasis,  627 ; 
in  hypertrophic  pulmonary  arthropathy, 
1143;  in  mediastinal  abscess,  673;  in  mi- 
tral incompetency,  818. 

Coccidiosis,  237. 

Coccidioidal  dermatitis,  235. 

Coccydynia,  1091. 

Cochlear  nerve,  affections  of,  1045-1047. 

Cod-liver  oil  in  tuberculosis,  229. 

Creliac  affection,  519. 

Coeliac  axis,  aneurism  involving,  860. 

"Cog- wheel"  rhythm,  200. 

Coin  sound  in  pneumo-thorax,  671. 

Cold,  acute  Bright 's  disease  due  to,  697, 
699;  acute  bronchitis  and,  620;  acute 
laryngitis  due  to,  614;  haemoglobinuria 


due  to,  683;  myalgia  due  to,  1129;  neu- 
ritis due  to,  1020;  pneumonia  and,  76. 

Colds,  adenoids  and,  470 ;  asthma  and,  629. 

Colic,  appendicular,  533;  biliary,  570,  571; 
biliary  and  kidney,  confusion  of,  with 
appendicitis,  536;  in  acute  arsenical 
poisoning,  406;  in  angio-neurotic  oedema, 
1124;  in  cysts  of  mesentery,  554;  in  lead 
poisoning,  404;  in  thrombosis  of  mesen- 
teric vessels,  554;  renal,  719,  720. 

Colitis,  acute,  in  measles,  346;  in  rubella, 
349;  mucous,  551,  552;  simple  ulcera- 
tive,  521. 

Colles'  law,  265. 

Colloid  cancer,  of  heart,  831;  of  perito- 
neum, 607,  608 ;  of  stomach,  499. 

Colon,  dilatation  of,  552,  553;  displace- 
ment of,  in  enteroptosis,  550. 

Colon  bacillus,  in  acute  bronchitis,  621;  in 
cholecystitis,  566;  in  chronic  pancreati- 
tis, 596;  in  cirrhosis  of  liver,  576;  in 
endocarditis,  800 ;  in  gall-stones,  569 ;  in 
methaemoglobinuria,  758;  in  peritonitis, 
601;  in  pneumaturia,  692;  in  pyelitis, 
712;  in  urine,  687;  infections  by,  46-48; 
meat  poisoning  and,  408. 

Coloptosis,  550. 

Coma,  diabetic,  433 ;  diabetic,  treatment  of, 
.  439;  hypostatie  congestion  of  lungs  in, 
634,  635;  in  acquired  chronic  hydro- 
cephalus,  1020;  in  acute  dyspepsia  of 
children,  526;  in  acute  yellow  atrophy, 
560;  in  alcoholic  cirrhosis,  579;  in  apo- 
plexy, 991,  992;  in  cancer  of  stomach, 
501;  in  epilepsy,  1082;  in  haemorrhagic 
pachymeningitis,  947;  in  mumps,  351; 
in  myeloid  leukaemia,  743;  in  peri- 
carditis with  effusion,  764;  in  pernicious 
malaria,  253;  in  pyelitis,  714;  in  rheu- 
matic fever,  376;  in  small-pox,  322;  in 
thermic  fever,  391;  urasmic,  694,  695, 
696,  710. 

Coma-vigil  in  typhus  fever,  354. 

Comatose  form  of  pernicious  malaria,  253. 

Combined  system  diseases,  942-945. 

Comma  bacillus,  132. 

Compensatory  circulation  in  cirrhosis  of 
liver,  577,  578. 

Compensatory  emphysema,  645. 

Compressed  air,  in  asthma,  631;  treatment 
by,  in  tuberculosis,  230. 

Compressed  air  disease.  (See  Caisson  dis- 
ease). 

Compression  of  spinal  cord,  definition  of, 
959;  diagnosis  of,  961;  due  to  tumors, 
963;  etiology  of,  959,  960;  symptoms  of, 
960,  961;  treatment  of,  961,  962. 


1164 


INDEX 


Concato  's  disease,  607. 

Concretions,  faecal,  in  appendicitis,  533. 

t'oiulylomata,  267. 

Congenital  affections  of  heart,  832-836; 
symptoms  of,  834. 

Congenital  syphilis,  268;  of  liver,  273; 
symptoms  of,  268. 

Congestion,  of  brain,  infantile  convulsions 
due  to,  1078;  of  liver,  561;  of  skin  in 
acute  diffuse  myelitis,  967;  of  spinal 
cord,  956;  of  systemic  veins  due  to 
mitral  incompetency,  818;  of  systemic 
veins  in  mitral  stenosis,  822;  of  thyroid 
gland,  870,  871. 

Congestion  •  of  kidney,  679,  680 ;  albumi- 
nuria  and,  686;  haematuria  and,  681; 
pyelitis  and,  712. 

Congestion  of  lungs,  active,  633,  634;  in 
aortic  stenosis,  815,  in  apoplexy,  992;  in 
rheumatic  fever,  376;  in  typhoid  fever, 
13,  27;  passive,  634,  635;  treatment  of, 
635. 

Conjugate  deviation,  of  eyes  in  paralysis 
of  sixth  nerve,  1037;  of  eyes,  in  tumors 
of  brain,  1012 ;  of  head  and  eyes,  in  hemi- 
plegia,  992. 

Conjunctiva,  diphtheria  of,  66;  in  leprosy, 
153. 

Conjunctivitis,  associated  with  cervical 
adenitis,  176;  in  cerebro-spinal  fever, 
113;  in  influenza,  118;  in  measles,  346; 
in  small-pox,  322. 

Consecutive  nephritis.      (See  Pyelitis.) 

Constipation,  chlorosis  and,  730,  732,  740; 
definition  of,  545;  diverticulitis  and, 
553;  in  abscess  of  liver,  585;  in  acute 
cerebral  leptomeningitis,  950;  in  acute 
gastritis,  477;  in  acute  pancreatitis, 
595;  in  acute  transverse  myelitis,  968; 
in  adults,  545,  547 ;  in  appendicitis,  533 ; 
in  arterio-sclerosis,  846;  in  cancer  of 
stomach,  501;  in  cardiac  insufficiency, 
790;  in  chronic  gastritis,  481,  485;  in 
cysts  of  mesentery,  554;  in  diabetes, 
432;  in  dilatation  of  the  colon,  552;  in 
erythrsemia,  758;  in  hyperchlorhydria, 
512;  in  hysteria,  1101;  in  infants,  547; 
in  intestinal  obstruction,  541,  542;  in 
lead  poisoning,  404;  in  lobar  pneumonia, 
88;  in  locomotor  ataxia,  918;  in  milk- 
sickness,  385;  in  movable  kidney,  677; 
in  mucous  colitis,  551;  in  obstructive 
jaundice,  556;  in  pancreatic  haemor- 
rhage, 594;  in  pellagra,  412;  in  pyloric 
obstruction,  488;  in  pyloric  stenosis, 
506 ;  in  scurvy,  448 ;  in  tuberculous 
meningitis,  172;  in  typhoid  fever,  23;  in 
typhoid  fever,  treatment  of,  44;  ster- 


coral  ulcers  in,  521;  treatment  of,  547 
548. 

Consumption.  (Sec  Pulmonary  tubercu- 
losis.) 

Contracted  kidney  in  gout,  420. 

Contraction  of  the  arm  and  leg  in  cerebral 
haemorrhage,  996. 

Ccntractures,  following  neuritis,  1023 ;  hys- 
terical, 1098,  1099;  in  arthritis  defor- 
mans,  1136;  in  localized  neuritis,  1022. 

Contusion-pneumonia,  76. 

Conus  medullaris,  lesions  of,  962,  963. 

Convalescence,  from  acute  Bright 's  dis- 
ease, 701,  702;  from  cerebro-spinal  fever, 
112;  from  dengue,  363;  from  diphtheria, 
antitoxin  in,  74;  from  influenza,  119; 
from  lobar  pneumonia,  91,  92;  from 
pneumonia,  101;  from  relapsing  fever, 
263 ;  from  whooping  cough,  122. 

Convulsions,  during  exploratory  aspiration 
in  pleurisy,  666;  following  haemorrhage 
in  peptic  ulcer,  494 ;  in  acute  Bright 's 
disease,  698;  in  acute  cerebro-spinal  lep' 
tomeningitis,  950;  in  acute  diffuse  my- 
elitis, 966;  in  acute  dyspepsia  of  chil- 
dren, 526;  in  acute  polio-myelitis,  366; 
in  acute  secondary  anaemia,  728 ;  in 
acute  yellow  atrophy,  560 ;  in  Addison  's 
disease,  865;  in  alcoholic  neuritis,  1023; 
in  anaesthesia  paralysis,  1025;  in  brain 
abscess,  1017;  in  cerebral  apoplexy,  997; 
in  cerebral  syphilis,  271 ;  in  congenital 
hydrocephalus,  1019;  in  dengue,  363;  in 
ergotism,  410;  in  haemorrhage  from 
stomach,  508;  in  hemiplegia  in  children, 
1006,  1007;  in  hysteria,  1097;  in  hy- 
stero-epilepsy,  1098;  in  lead  poisoning, 
403,  405;  in  lobar  pneumonia,  88;  in 
mumps,  351;  in  relapsing  fever,  262, 
263;  in  rheumatic  fever,  376;  in  scarlet 
fever,  335,  339 ;  in  scurvy,  448 ;  in  small- 
pox, 318,  322;  in  spasmodic  laryngitis, 
617;  in  spastic  paralysis  of  infants, 
937;  in  thermic  fever,  391;  in  throm- 
bosis of  the  cerebral  veins  and  sinuses, 
1005;  in  toxaemic  jaundice,  557;  in  tu- 
berculous meningitis,  172,  173;  in  tu- 
mor of  brain,  1011,  1013;  in  typhoid 
fever,  28;  in  uraemia,  694;  in  whooping 
cough,  121;  infantile,  diagnosis  of,  1078, 
1079;  infantile,  etiology  of,  1077,  1078; 
infantile,  prognosis  of,  1079 ;  infantile, 
symptoms  of,  1078;  infantile,  treatment 
of,  1079;  muscular,  due  to  lesions  of 
cerebral  cortex,  969 ;  rickets  and,  445. 
Convulsive  tic,  1044,  1075. 
Copaiba,  congestion  of  kidneys  due  to, 
679;  purpura  due  to,  751. 


INDEX 


1165 


Copp'3  asthma,  869. 

Coprolalia,  1075,  1076. 

Coproliths,  533. 

Cor  adiposum,  789;  biloculare,  832;  bovi- 
num,  810;  villosum,  761. 

Ccral  calculi,  718. 

Corn,  pellagra  and,  411,  413. 

Corona  radiata,  hemiplegia  due  to  lesion 
of,  992. 

Coronary  artery  disease,  in  angina  pectoris, 
839;  lesions  due  to,  786,  787. 

Corpora  quadrigemina ;  lesions  of,  973. 

Corpulence.      (See  Obesity.) 

Corpus  callosum,  lesions  of,  970,  971. 

Coryza,  acute  (see  Catarrhal  fever,  acute)  ; 
associated  with  cervical  adenitis,  176; 
chronic  glanders  confused  with,  147;  in 
acute  bronchitis,  621;  in  eerebro-spinal 
fever,  113 ;  in  measles,  344,  346. 

Costiveness.      (See  Constipation.) 

Cough,  hysterical,  1100;  in  actinomycosis, 
233;  in  acute  bronchitis,  621;  in  acute 
congestion  of  lungs,  633;  in  acute  sero- 
fibrinous  pleurisy,  657;  in  adenoids, 
•169 ;  in  aneurism  of  thoracic  aorta,  855 ; 
in  aneurism  of  transverse  arch,  851;  in 
asthma,  629;  in  aortic  incompetency, 
811;  in  aortic  stenosis,  816;  in  carci- 
noma of  lung,  653,  654;  in  cardiac  in- 
sufficiency, treatment  of,  795;  in  chronic 
bronchitis,  623;  in  chronic  gastritis, 
481;  in  chronic  interstitial  pneumonia, 
641 ;  in  chronic  ulcerative  tuberculosis, 
192-193;  in  congenital  heart  disease, 
834;  in  diagnosis  of  pulmonary  tuber- 
culosis, 207;  in  empyema,  660;  in  fibrin- 
ous  bronchitis,  632;  in 'fibroid  phthisis, 
202;  in  goitre,  873;  in  haemoptysis,  639; 
in  hay  fever,  613;  in  Hodgkin's  disease, 
748 ;  in  laryngitis,  615 ;  in  lobar  pneu- 
monia, 84;  in  mediastinal  tumors,  673, 
674;  in  mitral  incompetency,  819;  in 
mitral  stenosis,  824;  in  oedema  of  lungs, 
635;  in  perforation  of  lung  in  abscess 
of  liver,  585;  in  pericarditis  with  effu- 
sion, 754;  in  pneumonokoniosis,  644;  in 
pulmonary  form  of  acute  general  tuber- 
culosis, 170;  in  relapsing  fever,  262;  in 
saccular  bronchiectasis,  626;  in  tubercu- 
lous laryngitis,  618;  in  tuberculosis, 
treatment  of,  230,  231. 

Courvoisier  's  law,  568,  573. 

Cow-pox.     (See  Vaccinia.) 

Cnimp,  telegrapher's,  1093;  writer's,  1C93- 
1095. 

Cramps,  heat,  393;  in  ergotism,  410;  in 
gout,  422,  423;  muscular,  in  cholera 


asiatica,  136;  muscular,  in  chronic  inter- 
stitial nephritis,  708;  muscular,  in 
uraemia,  695. 

Cranio-tabes,  443,  444. 

Craniotomy  in  cerebral  apoplexy,  1002. 

Craw-craw,  305. 

Creeping  eruption,  314. 

Creeping  pneumonia,  92. 

Crepitus,  gall-stone,  572;  in  acute  sero- 
fibrinous  pneumonia*  659. 

Cretinism,  endemic,  874,  875;  sporadic, 
874.  (See  also  Hypothyroidism.) 

Cricoid  cartilage,  involvement  of,  in  tuber- 
culous laryngitis,  618. 

Crises,  tabetic,  917. 

Crisis,  in  lobar  pneumonia,  83,  101;  in 
relapsing  fever,  262,  263;  in  typhus  fe- 
ver, 354. 

Crossed  hemiplegia,  993,  995. 

Croup,  membranous,  65,  66;  spasmodic, 
617,  618. 

Croupons  bronchitis,  631-633. 

Croupons  enteritis,  520. 

Croupous  pneumonia.  (See  Lobar  pneu- 
monia.) 

Crura  cerebri,  lesions  of,  972,  973. 

Crural  angina,  846. 

Cms,  haemorrhage  in,  993. 

Cruveilhier 's  palsy,  928. 

Cry,  epileptic,  1082;  hysterical,  1100. 

Cryptogenetic  septicaemia,  50. 

Crystals,  asthma,  630. 

Cuban  itch,  316. 

Cubebs,  congestion  of  kidney  due  to,  679. 

Culex,  mosquito,  246,  247;  fatigans,  362. 

Curschmann's  spirals,  in  fibrinous  bron- 
chitis, 632;  in  asthma,  630. 

Curvature  of  the  spine,  spasmodic  wry: 
neck  and,  1053. 

Cutaneous  actinomycosis,  233. 

Cutaneous  reaction,  in  syphilis,  277;  of  von 
Pirquet,  159. 

Cyano-pyaemia,  50. 

Cyanosis,  due  to  failure  of  the  right  auricle 
and  ventricle,  785;  enterogenous,  758, 
759;  in  aortic  incompetency,  811;  in  apo- 
plectic attacks,  991;  in  arterio-venous 
aneurism,  861;  in  bronchiectasis,  627;  in 
cardiac  insufficiency,  790;  in  cholera 
asiatica,  135;  in  congenital  heart  dis- 
ease, 834,  835;  in  epileptic  attack,  1082; 
in  erythraemia,  757;  in  general  tubercu- 
losis, 169;  in  Hodgkin's  disease,  748; 
in  hypertrophic  emphysema,  648;  in  hys- 
teria, 1100;  in  laryngeal  spasm,  1050; 
in  mediastinal  tumor,  673;  in  mitral  in- 
competency, 819;  in  mycosis  intestinalis, 
150;  in  pneumonic  plague,  140;  in  pul- 


1166 


INDEX 


monary  form  of  acute  miliary  tubercu- 
losis, 170;  in  Kaynaud's  disease,  1121; 
in  scleroderma,  1126;  in  spasmodic 
laryngitis,  617;  in  tetany,  882;  in  tri- 
cuspid  stenosis,  825. 

Cyclic  albuminuria,  685. 

Cycloplegia,  1036. 

Cynobex  hebetica,  1100. 

Cyst,  in  the  meningee  due  to  serebral  haem- 
orrhage, 990;  ovarian,  confusion  of  di- 
lated stomach  and,  489. 

Cysticercus  cellulose,  287-289;  in  the  heart, 
831;  compression  myelitis  due  to,  960. 

Cy&tine,  calculi  of,  718. 

Cystinuria,  690. 

Cystitis,  bacilluric,  687;  differentiation  of 
pyelitis  from,  714,  715;  following  gono- 
coccus  infection,  124;  haemorrhagic,  Tri- 
chomonas  hominis  in,  281;  in  acute 
transverse  myelitis,  968;  in  bilharziasis, 
283;  in  diabetes,.  434;  in  locomotor 
ataxia,  918;  phosphaturia  and,  690;  pye- 
litis and,  712,  713;  pyuria  in,  688;  tu- 
berculosis of  the  kidneys  confused  with, 
218. 

Cysts,  abdominal,  simulating  ascites,  610; 
echinococcus,  289-294;  in  goitre,  872;  in 
heart,  831;  of  chyle  vessels,  554;  of 
brain,  1010;  of  cerebellum,  tetany  in, 
881;  of  kidney,  723-725;  of  liver,  588;  of 
mediastinum,  675;  of  stomach,  505;  of 
mesentery,  554,  555;  of  omentum,  cysts 
of  mesentery  confused  with,  555;  of 
spleen,  885;  of  supra- renal  glands,  868; 
pancreatic,  597,  598. 

Cytodiagnosis  in  general  paralysis,  and 
tabes,  925,  926;  of  cerebro-spinal  fluid, 
925,  950. 

Cytoryctes,  vaccinia?,  327;  variolse,  317. 


D 


Dandy  fever.     (See  Dengue.) 

Davainea  madagascariensis,  285. 

Day-blindness  in  scurvy,  448. 

Deafness,  adenoids  and,  470;  due  to  af- 
fection of  the  cortical  centre,  1045;  fol- 
lowing epidemic  cerebro-spinal  menin- 
gitis, 1046;  following  Meniere's  disease, 
1048;  following  scarlet  fever,  338;  hys- 
terical, 1100;  in  acromegaly,  891;  in 
acute  pharyngitis,  465;  in  cerebro-spinal 
fever,  113;  in  chronic  interstitial  ne- 
phritis, 708;  in  congenital  syphilis,  269; 
in  locomotor  ataxia,  917;  in  mumps,  351; 
in  myeloid  leukaemia,  743;  in  tumors  of 
the  brain,  1012;  nervous,  1046,  1047; 
uraemic,  694. 


Debove's  forced  alimentation,  228;  in  pul- 
monary tuberculosis,  204. 

Decapsulation  of  the  kidneys,  711. 

Defibrinated  blood,  injection  of,  in  haemo- 
philia, 757;  in  pernicious  anaemia,  740. 

Deformity,  in  compression  myelitis,  960. 

Deglutition  pneumonia,  102,  104,  106. 

Delhi  boil,  261. 

Delirium,  in  abscess  of  the  brain,  1016;  in 
acute  cerebro-spinal  leptomeningitis,  950; 
in  acute  diffuse  myelitis,  967;  in  acute 
endocarditis,  801,  802;  in  acute  pan- 
creatitis, 595;  in  acute  yellow  atrophy, 
560;  in  alcoholic  cirrhosis  of  the  liver, 
579;  in  alcoholic  neuritis,  1024;  in  aor- 
tic incompetency,  812;  in  cerebral  anae- 
mia, 986;  in  cerebral  syphilis,  271;  in 
cerebro-spinal  fever,  111;  in  chronic 
Bright 's  disease,  710;  in  dengue,  363; 
in  ergotism,  410;  in  erysipelas,  55;  in 
general  paralysis,  923;  in  gout,  421;  in 
hysteria,  1102;  in  hystero-epilepsy,  1098; 
in  lead  poisoning,  403,  405;  in  lobar 
pneumonia,  88,  89 ;  in  malaria,  249,  253 ; 
in  miliary  fever,  387;  in  mumps,  350, 
351;  in  pericarditis  with  effusion,  764; 
in  rat-bite  fever,  389;  in  relapsing  fever, 
262;  in  rheumatic  fever,  376;  in  Eocky 
Mountain  spotted  fever,  388;  in  scurvy, 
448;  in  serous  meningitis,  1019;  in  small- 
pox, 322;  in  suppurative  tonsillitis,  467; 
in  toxaemie  jaundice,  557;  in  tuberculous 
meningitis,  172;  in  typhoid  fever,  28, 
29;  in  typhus  fever,  353,  354;  in  urae- 
mia, 694;  in  yellow  fever,  360. 

Delirium  cordis,  770. 

Delirium  tremens,  398-400;  in  lobar  pneu- 
monia, 89,  92;  pericarditis  resembling, 
764. 

Delusions  in  cardiac  insufficiency,  790;  in 
fatty  heart,  791;  in  general  paralysis, 
923;  in  myxoedema,  875;  in  uraemia,  694. 

Demarche  d'ivresse,  975. 

Dementia  following  traumatic  neuroses, 
1118;  in  acromegaly,  891;  in  ergotism, 
410;  in  locomotor  ataxia,  918;  in  myx- 
cedema,  875;  in  pellagra,  412. 

Dementia  paralytica,  921  (see  also  Paraly- 
sis, general)  ;  in  locomotor  ataxia,  918. 

Demodex  folliculorum,  310. 

Dengue,  complications  of,  363 ;  definition 
of,  362;  diagnosis  of,  363;  differentia- 
tion of  yellow  fever  from,  360;  etiology 
of,  362;  history  and  geographical  dis- 
tribution of,  362;  symptoms  of,  362, 
363 ;  treatment  of,  363,  364. 

Dentition,  acute  stomatitis  and,  457;  de- 
layed, in  cretinism,  874;  epilepsy  and, 
1081;  in  rickets,  444;  infantile  convul- 


INDEX 


11G? 


sions  and,  1077;  uleerative  stomatitis 
and,  457. 

Depletion  in  cardiac  failure,  792. 

Depression  in  acute  gastritis,  477;  in  gout, 
421;  in  the  morphia  habit,  401;  in  pel- 
lagra, 412;  in  scurvy,  448. 

Dcrcum's  disease,  452,  453. 

Dermacentor  americanus,  311. 

Dermacentor  occidentalis,  311,  388. 

Dermamyiasis  linearis  migrans  cestrosa, 
314. 

Dermatitis,  acute  exfoliating,  differentia- 
tion of  scarlet  fever  from,  339;  cocci- 
dioidal,  235;  in  dermato-myositis,  1128; 
protozoic,  235. 

Dermato-myositis,    1128. 

Dtrmatosa  parasitaire,  305. 

Dermoid  cyst  of  the  brain,  1010;  of  the 
mediastinum,  675. 

Descensus  ventriculi,  549. 

Desquamation  in  measles,  346;  in  scarlet 
fever,  336,  337;  in  typhoid  fever,  18. 

Dextrocardia,  832. 

Diabete  'bronze,  434,  454;  gras,  432. 

Diabetes  insipidus,  clinical  classification  of, 

439,  440 ;   course  x>f ,  441 ;   definition  of, 
439 ;  diagnosis  of,  441 ;  etiology  of,  439 ; 
morbid  anatomy  of,  440;  symptoms  of, 

440,  441;  treatment  of,  441. 
Diabetes    mellitus,    acute    endocarditis    in, 

797;  adrenal,  428;  and  typhoid  fever, 
32;  bradycardia  in,  777;  chronic  gas- 
tritis and,  480;  chronic  pancreatitis  and, 
596 ;  coma  in,  433 ;  complications  of, 
433-435 ;  definition  of,  426 ;  diagnosis  of, 
435 ;  differentiation  of  diabetes  insipidus 
from,  441;  dilatation  of  stomach  in, 
487 ;  etiology  of,  426-430 ;  excessive  hun- 
ger in,  514;  haemochromatosis  and,  453, 
454;  history  of,  426;  hypophysis  and, 
428;  in  acromegaly,  892;  in  children, 
430 ;  in  exophthalmic  goitre,  879 ;  lipuria 
in,  693;  metabolism  in,  430,  431;  mor- 
bid anatomy  of,  431,  432;  multiple  neu- 
ritis in,  1024;  neuralgia  in,  1090;  pan- 
creatic secretion  in,  428;  parotitis  in, 
463;  pericarditis  in,  76jO;  phosphatic, 
691;  predisposing  to  tuberculosis,  159; 
renal  form  of,  428;  retinitis  in,  1030; 
symptoms  of,  432,  433;  terminal  pneu- 
monia in,  93,  97;  treatment  of,  435-439. 

Diaphragm,  paralysis  of,  1056. 

Diaphragmatic  pleurisy,  662. 

Diarrhoea,  acute  dyspeptic,  treatment  of, 
522;  alba,  519;  associated  with  consti- 
pation, 547;  caused  by  Trichomonas 
hominis,  281;  chronic,  Marie's  syndrome 
in,  1143;  chronic,  treatment  of,  522-524; 


chylosa,  519;  diseases  of  the  intestines 
associated  with,  516-524;  fatty,  in  pan- 
creatic cysts,  598;  hysterical,  1101;  in 
abscess  of  the  liver,  585;  in  acute  ar- 
senical poisoning,  406;  in  acute  gastritis, 
477;  in  Addison's  disease,  865,  867;  in 
amyloid  disease  of  the  kidneys,  712;  in 
appendicitis,  534 ;  in  cancer  of  the  stom- 
ach, 501 ;  in  cancrum  oris,  459 ;  in  cardiac 
insufficiency,  790;  in  catarrhal  enteritis, 
518;  in  children,  clinical  forms  of,  524- 
531;  in  cholera  asiatica,  135;  in  chronic 
gastritis,  481 ;  in  chrome  interstitial 
nephritis,  708;  in  chronic  parenchyma- 
tous  nephritis,  703;  in  dilatation  of  the 
colon,  552;  in  exophthalmic  goitre,  878, 
879;  in  general  tuberculosis,  169;  in 
gout,  421;  in  hepatic  distomiasis,  282; 
in  lead  poisoning,  404;  in  leukaemia, 
743;  in  methaemoglobinsemia,  758;  in 
mucous  colitis,  551 ;  in  obstructive  jaun- 
dice, 556;  in  paroxysmal  haemoglobinu- 
ria,  683;  in  pellagra,  412;  in  pernicious 
anaemia,  734,  736;  in  pernicious  malaria, 
253;  in  pulmonary  tuberculosis,  204;  in 
purpura,  752;  in  simple  ulcerative  coli- 
tis, 521;  in  small-pox,  319,  320,  322;  in 
tabes  mesenterica,  177;  in  thrombosis  of 
the  mesenteric  vessels,  554;  in  tubercu- 
losis, treatment  of,  231;  in  tuberculous 
meningitis,  172;  in  typhoid  fever,  22,  23, 
44;  in  uraemia,  695;  in  yellow  fever,  360; 
inflammatory,  527,  528;  predisposing  to 
broncho-pneumonia,  102;  strongyloides 
intestinalis  and,  309 ;  tetany  due  to,  881 ; 
thrombosis  of  the  cerebral  sinuses  and 
veins  and,  1004;  tubular,  551. 

Diathesis,  oxalic  acid,  689. 

Diazo-reaction  of  Ehrlich,  in  general  tu- 
berculosis, 169;  in  typhoid  fever,  30. 

Dibothriocephalus  latus,  285. 

Dicotophyme  renale,  309. 

Dicroccelium  lanceatum,  282. 

Diet  and  appendicitis,  532;  and  constipa- 
tion in  infants,  548;  and  prevention  of 
diarrhoea  in  children,  528;  in  acute 
Bright 'a  disease,  700;  in  acute  pleurisy, 
665;  in  amoebiasis,  242;  in  arthritis  de- 
formans,  1141;  in  asthma,  629,  631;  in 
bacillary  dysentery,  129,  130;  in  bron- 
cho-pneumonia, 107;  in  cardiac  insuffi- 
ciency, 796;  in  cerebro-spinal  fever,  114; 
in  chronic  gastritis,  482;  in  chronic  in- 
terstitial nephritis,  709;  in  chronic  pa- 
renchymatous  nephritis,  704;  in  convales- 
cence from  typhoid  fever,  45,  46 ;  in  dia- 
betes mellitus,  436-438;  in  diarrhoea  in 


llf.8 


INDEX 


children,  530,  531;  in  diphtheria,  71;  in 
epilepsy,  1086;  in  erysipelas,  56;  in 
gout,  424,  425 ;  in  infantile  scurvy,  450 ; 
in  migraine,  1089 ;  in  morphia  habit, 
401;  in  obesity,  451,  452;  in  palpitation 
and  arrhythmia,  780;  in  peptic  ulcer, 
496,  497;  in  pneumonia,  99;  in  renal 
calculus,  721 ;  in  rheumatic  fever,  378, 
379;  in  scarlet  fever,  342;  in  thoracic 
aneurism,  857;  in  treatment  of  cardiac 
failure,  792;  in  typhoid  fever,  41,  42; 
relation  of,  to  acute  gastritis,  476,  477; 
relation  of,  to  chronic  gastritis,  479, 
480;  relation  of,  to  constipation,  545; 
relation  of,  to  constipation  in  infants, 
547;  relation  of,  to  diarrhoea  in  children, 
524;  relation  of,  to  scurvy,  446;  rickets 
and,  442. 

Dietetic  albuminuria,  685. 

Dietl's  crises  in  movable  kidney,  537,  678; 
pyelitis  and,  712. 

Diffuse  adhesive  peritonitis,  606. 

Diffuse  sclerosis  of  the  brain,  952. 

Diffuse  symmetrical  lipomatosis  of  the 
neck,  453. 

Digestive  system,  diseases  of,  456-611. 

Dilatation,  bronchial  (see  Bronchiectasis)  ; 
bronchial,  in  chronic  bronchitis,  623;  of 
aortic  ring,  aortic  incompetency  due  to, 
809,  810;  of  bladder,  and  ureters  in  hy- 
dronephrosis,  715;  of  colon,  552,  553;  of 
gall-bladder,  echinococcus  of  the  liver 
differentiated  from,  292;  of  gall-bladder, 
from  gall-stones,  571,  572;  of  gall-blad- 
der, in  pancreatic  cancer,  599 ;  of  the 
hepatic  veins,  562;  of  the  left  ventricle, 
muscular  incompetency  in,  817;  of  the 
mesenteric  veins,  554;  of  the  oesophagus, 
476;  of  the  pulmonary  vessels  in  mitral 
incompetency,  817;  of  the  pupil,  due  to 
paralysis  of  the  third  nerve,  1035;  of 
the  veins,  oedema  of  the  brain  and,  986. 

Dilatation  of  the  heart,  782-784;  chronic 
adhesive  pericarditis  and,  768;  differen- 
tiation of  perieardial  effusion  from,  766 ; 
due  to  aortic  incompetency,  810,  811; 
due  to  mitral  incompetency,  817,  818, 
819;  due  to  valve  lesions,  805,  806;  idio- 
pathic;  mitral  incompetency  confused 
•with,  820 ;  in  acute  Bright 's  disease,  698 ; 
in  aneurism,  850;  in  aortic  stenosis,  815; 
in  arterio-sclerosis,  845;  in  chronic 
Bright 's  disease,  710;  in  exophthalmic 
goitre,  878;  in  fatty  heart,  291;  in  mi- 
tral stenosis,  821,  822;  in  pernicious 
anaemia,  736. 

Dilatation  of  the  stomach,  chronic  gastritis 
and,  480 ;  diagnosis  of,  489 ;  etiology  of, 
486,  487;  fungi  in,  479;  in  alcoholism, 


397;  in  pancreatic  cancer,  599;  in  pneu- 
monia, 90;  symptoms  of,  487-489; 
treatment  of,  489,  490. 

Dioxy-diamido-arsenobenzol,  279,  280. 

Diphtheria,  acute  bulbar  paralysis  follow- 
ing, 931;  acute  cardiac  insufficiency  in, 
785;  acute  interstitial  myocarditis  in, 
787;  adenoids  and,  470;  albuminuria  in, 
685;  anaphylaxis  in,'  73;  antitoxin  in, 
72;  bradycardia  following,  777;  broncho- 
pneumonia  secondary  to,  101,  102;  car- 
riers of,  57,  59,  70;  complications  and 
sequela?  of,  66-68;  definition  of,  57;  di- 
agnosis of,  68,  69;  differentiation  of  ton- 
sillitis from,  381;  emphysema  of  the  me- 
diastinum in,  675;  etiology  of,  57;  facial 
paralysis  in,  1041;  history  of,  57;  im- 
munization in,  70 ;  inflammation  of  the 
oesophagus  in,  472,  473;  Klebs-Loeffler 
bacillus  in,  58-60;  Ludwig's  angina  in, 
466;  membranous  gastritis  in,  479; 
modes  of  infection  in,  57,  58;  morbid 
anatomy  of,  61-63 ;  multiple  neuritis  in, 
1024;  necrosis  of  the  liver  in,  559; 
oedema  of  glottis  in,  616;  of  wounds,  66; 
paralysis  in,  67;  predisposing  causes  of, 
58;  prognosis  of,  69;  prophylaxis  of,  69, 
70 ;  retro-pharyngeal  abscess  following, 
466 ;  scarlet  fever  and,  340 ;  secondary 
pneumonia  in,  93;  sensitization  in,  73; 
septiceemia  in,  50;  symptoms  of,  63-66; 
treatment  of,  70-74. 

Diphtheria  antitoxin,  anaphylaxis  from, 
73;  serum  disease  from,  73. 

Diphtheria  bacillus,  58;  in  acute  sero- 
fibrinous  pleurisy,  656. 

Diphtheritic  dysentery,  128. 

Diphtheritic  gastritis,  479. 

Diphtheritic  inflammation  in  amoebiasis, 
239;  in  cholera  asiatica,  136;  in  lobar 
pneumonia,  81;  pharyngeal  ulcers  and, 
466. 

Diphtheritic  paralysis,  cycloplegia  in,  1036. 

' '  Diphtheritis, "  60 ;  of  pharynx  and  larynx 
in  typhoid  fever,  13. 

Diphtheroid  angina  in  scarlet  fever,  336. 

Diphtheroid  enteritis,  520. 

Diphtheroid  inflammations,  60,  61;  sequelae 
of,  61. 

Diplegia,  facial,   1042. 

Diplococcus,  intracellularis  meningitis,  109. 

Diplococcus  pneumonia?  of  Fraenkel  and 
"Weichselbaum,  76,  77. 

Diplopia,  1038;  due  to  paralysis  of  the 
sixth  nerve,  1037;  due  to  paralysis  of  the 
third  nerve,  1035;  in  chronic  interstitial 
nephritis,  708. 

Dipsomania,  396. 

Dipylidium  caninun>  285. 


INDEX 


1169 


Dirt-eating,  303. 

Disk,  choked,  1010.  (See  also  Choked 
disk.) 

Displacement  of  the  kidney,  676;  pyelitis 
due  to,  712. 

Distended  bladder,  differentiation  of  ascites 
from,  609. 

Distention,  of  the  lung  in  treatment  of  em- 
pyema,  666 ;  of  the  veins  in  arterio- 
venous  aneurism,  861,  862;  of  the  veins 
of  the  neck,  in  pericarditis  with  effusion, 
764. 

Distomiasis,  haemic,  283;  hepatic,  282;  in- 
testinal, 283;  pulmonary,  282. 

Distomum  conjuncture,  282. 

Dittrich's  plugs,   624. 

Diver 's  paralysis.      (See  Caisson  disease.) 

Diverticula  of  gall-bladder,  572. 

Diverticulitis,  550. 

Diverticulum  of  oesophagus,  476;  follow- 
ing tracheo-bronchial  adenitis,  177. 

Dizziness  in  aortic  incompetency,  811;  in 
aortic  stenosis,  816;  in  fatty  heart,  791; 
in  migraine,  1088. 

Dogs,  aspergillosis  in,  236;  hydrophobia 
and,  368-370. 

Doliocephalic  skull  in  sporadic  cretinism, 
874. 

Dolor  pectoris  in  angina  pectoris,  838. 

Dorsodynia,  1130. 

Double  heart,  832. 

Double  pneumonia,  92. 

Double  vision.      (See  Diplopia.) 

Dracontiasis,  307,  308. 

Dracunculus  mediensis,  307,  308. 

Drainage  in  acute  pleurisy,  665;  in  empy- 
ema,  666,  667;  in  perinephric  abscess, 
726. 

Dropsy,  ascites  and,  608 ;  cardiac,  digitalis 
in,  793;  cardiac,  in  mitral  incompetency, 
818,  819 ;  cardiac,  in  tricuspid  regurgita- 
tion,  825;  epidemic,  416;  hydropericar- 
dium  and,  769;  hydrothorax  in,  668;  in 
acute  Bright 's  disease,  698,  699;  in  al- 
coholic cirrhosis,  578;  in  amyloid  disease 
of  the  kidneys,  712;  in  cardiac  insuffi- 
ciency, treatment  of,  794;  in  chronic 
parenchymatous  nephritis,  703,  704;  in 
fibroid  phthisis,  202,  205;  in  hepatic  dis- 
tomiasis,  282;  in  hypertrophic  emphy- 
sema, 649;  in  mitral  stenosis,  824;  in 
myeloid  leukaemia,  741. 
Drowsiness,  in  brain  abscess,  1016;  in  cere- 
bral anaemia,  986. 
Drug  eruptions,  differentiation  of  measles 

from,  347. 

Drug  habit,  neurasthenia  and,  1107. 
Drug    poisoning,    methaemoglobinsemia    in, 
758. 


Drunkards,  erysipelas  in,  56. 

Dry  catarrh,  624. 

Dry  mouth,  463. 

Duchenne's  main  en  griff e,  929. 

Ductless  glands,  diseases  of,  863-893;   gly- 

cosuria  and,  427-429. 

Dulness  in  acute  sero-fibrinous  pneumonia, 
658 ;  in  aneurism  of  the  abdominal  aorta, 
860 ;  in  aneurism  of  the  thoracic  aorta, 
853;  in  aortic  incompetency,  812;  in 
aortic  stenosis,  815;  in  ascites,  609;  in 
cardiac  hypertrophy,  781,  782;  in  chronic 
adhesive  pericarditis,  768 ;  in  congenital 
heart  disease,  835 ;  in  dilatation  aneur- 
ism of  the  thoracic  aorta,  850;  in  mi- 
tral incompetency,  819 ;  in  mitral  steno- 
sis, 822;  in  pericarditis  with  effusion, 
764,  765,  766;  in  pneumo-thorax,  670, 
671;  in  tricuspid  regurgitation,  825;  in 
tricuspid  stenosis,  825;  liver,  in  perito- 
nitis, 602. 

Duodenal   ulcer,    490-498;    subphrenic   ab- 
scess  following,  604. 
Duodenitis,  519. 
Dupre's  syndrome,  951. 
Dura-arachnitis,  946. 
Dust,    conditions    due    to    inhalation    of. 

(See  Pneumonokoniosis.) 
Dysacusis,  1046. 
Dyssesthesia,    in    lesions    of    the    cochlear 

nerve,  1046. 

Dysbasia  angio-sclerotica,  846. 
Dysentery,  acute  endocarditis  in,  798; 
amoebic  (see  Amoebiasis)  ;  amoebic,  liver 
abscess  in,  239,  241;  bacillary,  126-130; 
Balantidium  coli  in,  281;  constipation 
following,  545;  intestinal  catarrh  and, 
517;  pyaemic  abscess  of  the  liver  follow- 
ing, 583. 

Dysmenorrhoea  in  chlorosis,  733. 
Dyspepsia,  acute,  476-479 ;  acute,  in  chil- 
dren, 526:  appendicular,  536,  537;  ar- 
thritis deformans  and,  1140;  bradycar- 
dia  in,  777;  cancer  of  the  stomach  and, 
498;  chronic,  479-486;  chronic,  chronic 
secondary  anaemia  in,  729;  ephemeral 
fever  and,  383;  extra-systole  in,  774; 
following  dysentery,  128;  in  chronic  in- 
terstitial nephritis,  707;  in  chronic  ul- 
cerative  tuberculosis,  191;  in  gout,  420, 
422;  in  hysteria,  1101;  in  peptic  ulcer, 
493;  in  pyloric  obstruction,  488;  loss  of 
sense  of  taste  in,  1049;  nervous,  509- 
516;  oxaluria  and,  689;  pancreatic  cysts 
following,  597;  phosphaturia  and,  690; 
renal  calculus  and,  721;  tetany  due  to, 
881. 

Dyspeptic  chronic  pancreatitis,  596. 
Dysphagia  in  cancer    of    the    esophagus, 


1170 


INDEX 


475;  in  mediastinal  tumors,  673;  in 
cesophagitis,  472,  473;  in  pericarditis 
with  effusion,  764;  in  pulmonary  tuber- 
culosis, 202;  in  transverse  myelitis,  968; 
in  tuberculous  laryngitis,  618. 

Dyspituitarism,  889. 

Dyspnoea,  cardiac,  due  to  aortic  incompe- 
tency,  810,  811 ;  due  to  failure  of  the  right 
auricle  and  ventricle,  785;  due  to  failure 
of  the  right  ventricle,  789 ;  hysterical, 
1100;  in  acute  congestion  of  the 
lungs,  633;  in  acute  laryngitis,  (515;  in 
acute  secondary  anaemia,  728;  in  acute 
sero-fibrinous  pleurisy,  657;  in  aneurism 
of  the  thoracic  aorta,  855,  859;  in  an- 
gina pectoris,  838;  in  aortic  stenosis, 
816;  in  arterio-sclerosis,  845;  in  asthma, 
629 ;  in  carcinoma  of  the  lung,  653 ;  in 
cardiac  flutter,  775;  in  cardiac  hyper- 
trophy, 781;  in  cardiac  insufficiency,  790, 
791,  794;  in  chronic  Bright 's  disease, 
711;  in  chronic  interstitial  pneumonia, 
642;  in  chronic  ulcerative  tuberculosis, 
196;  in  congenital  heart  disease,  834;  in 
diaphragmatic  pleurisy,  662;  in  fibrinous 
bronchitis,  632;  in  fibroid  phthisis,  202; 
in  goitre,  873;  in  Hodgkin's  disease, 
748;  in  hypertrophic  emphysema,  648; 
in  laryngeal  spasm,  1050;  in  lobar  pneu- 
monia, 84;  in  mediastinal  abscess,  675; 
in  mediastinal  tumor,  673,  674;  in  mitral 
incompetency,  819;  in  mycosis  intesti- 
nalis,  150;  in  oedema  of  the  glottis,  616; 
in  oadema  of  the  lungs,  635;  in  paralysis 
of  the  diaphragm,  1056;  in  pericarditis 
with  effusion,  764;  in  pernicious  anaemia, 
736;  in  pneumonic  tuberculosis,  184;  in 
pneumothorax,  670;  in  pulmonary  form 
of  acute  miliary  tuberculosis,  170;  in 
pyelitis,  714;  in  tetany,  882;  in  trans- 
verse myelitis,  968;  in  tricuspid  steno- 
sis, 825;  in  tuberculosis,  treatment  of, 
231 ;  in  tuberculous  aspiration  pneu- 
monia, 185;  uraemic,  695. 

Dystrophia  adiposo-genitalis,  453,  893; 
muscularia  progressiva,  932. 


E 


Ear,  care  of  in  scarlet  fever,  343;  in  cere- 
bro-spinal  fever,  113;  in  diabetes,  434; 
in  typhoid  fever,  29. 

Ecchymoses,  751;  cutaneous,  in  acute 
Bright 's  disease,  698;  in  hook-worm  dis- 
ease, 302;  in  infantile  scurvy,  450;  in 
relapsing  fever,  262;  in  scurvy,  447. 

Ecchymosis  of  the  conjunctiva  in  whooping 
cough,  121, 


Echinococcus,  causing  obstruction  of  the 
bile-ducts,  567;  compression  myelitis  due 
to,  960;  multilocular,  293,  294;  of  kid- 
neys, 293;  of  liver,  differentiation  of 
cancer  from,  589;  of  nervous  system, 
293;  of  respiratory  system,  292,  293; 
treatment  of,  294. 

Echinococcus  cyst,  liver  abscess  and,  583, 
584;  of  heart,  831;  of  spinal  cord,  963. 

Echinococcus  disease,  of  liver,  291;  para- 
site of,  289-291. 

Echinorhynchus  gigas,  310;  moniliformis, 
310. 

Echokinesis,  1076. 

Echolalia,  1075;   in  saltatory  spasm,  1076. 

Eck,  fistula  of,  582. 

Eclampsia.      (See   Convulsions,    infantile.) 

Ecthyma  following  small-pox,  322;  in  cere- 
bro-spinal  fever,  112. 

Ectopia  cordis,  832. 

Eczema,  gouty,  422;  in  chronic  interstitial 
nephritis,  708;  in  diabetes,  433,  439;  of 
scalp,  associated  with  cervical  adenitis, 
176;  of  tongue,  460. 

Education,  hysteria  and,  1096,  1097. 

Efferent  tract,  diseases  of,  927-942. 

Effusion  in  acute  sero-fibrinous  pleurisy, 
656;  in  arthritis  deformans,  1135;  in  dia- 
phragmatic pleurisy,  662;  in  empyema, 
660;  in  pleuro-pulmonary  carcinoma, 
654;  percarditis  with,  763-767. 

Eighth  nerve.     (See  Auditory  nerve.) 

Elastic  tissue  in  tuberculous  sputum,  193, 
194. 

Electrical  reaction  in  acute  polio-myelitis, 
367;  in  facial  paralysis,  1043;  in  mul- 
tiple neuritis,  1025;  in  periodical  paraly- 
sis, 1119;  in  Thomsen's  disease,  1132. 

Electricity  in  treatment  of  acute  polio- 
myelitis, 368;  in  treatment  of  hysteria, 
1105;  in  treatment  of  neurasthenia, 
1115;  in  treatment  of  sciatica,  1063. 

Electrolysis  and  wiring  in  aneurism,  858, 
860. 

Elephantiasis  neuromatosa,  1027;  sporadic, 
306,  307. 

Emaciation  due  to  anorexia  nervosa,  1101; 
in  acute  cerebro-spinal  leptomeningitis, 
950;  in  cancer  of  liver,  588;  in  cancer 
of  peritoneum,  608;  in  cancer  of  stom- 
ach, 500 ;  in  carcinoma  of  lung,  653,  654 ; 
in  chronic  ulcerative  tuberculosis,  197, 
198;  in  diabetes,  432;  in  exophthalmic 
goitre,  879;  in  Hodgkin's  disease,  748; 
in  pancreatic  cancer,  599 ;  in  phosphatu- 
ria,  691;  in  primary  combined  sclerosis, 
944 ;  in  pyloric  obstruction,  488 ;  in  py- 
loric  stenosis,  506;  in  subphrenic-abscess, 
605  j  in  suppurative  angiocholitis,  565 ;  in 


INDEX 


1171 


tuberculous  broncho-pneumonia,  186;  in 
tumors  of  kidney,  723. 

Emanations,  animal,  asthma  and,  628. 

Embolic  abscess,  51;  of  liver,  583;  of  lung 
652,  653. 

Embolic  pneumonia,  94. 

Embolism,  aneurism  due  to,  848,  849; 
hemiplegia  in  children  due  to,  1006;  in 
acute  endocarditis,  800,  801;  in  angina 
pectoris,  839;  in  lobar  pneumonia,  90; 
in  peptic  ulcer,  492;  of  cerebral  ar- 
teries, 998  (see  also  Cerebral  softening)  ; 
in  pulmonary  apoplexy,  637;  of  cere- 
bral blood  vessels,  aneurism  due  to, 
1003;  of  cerebral  blood  vessels,  in  acute 
chorea,  1068,  1069;  of  hepatic  veins,  562; 
of  mesenteric  vessels,  553,  554;  of  pul- 
monary artery,  gangrene  following,  651; 
of  spinal  blood  vessels,  957;  of  superior 
mesenteric  artery,  603,  860;  pulmonary, 
in  appendicitis,  536;  pulmonary,  in 
chlorosis,  733. 

Emphysema,  acute  vesicular,  650;  asthma 
and,  629;  atrophic,  650;  bradycardia  in, 
777;  bronchiectasia  and,  626;  cardiac 
hypertrophy  in,  781;  chronic  cardiac  in- 
sufficiency due  to,  786;  compensatory, 
645;  congestion  of  the  liver  in,  561; 
definition  of,  645;  erythraemia  and,  757; 
fibroid  changes  due  to,  640;  following 
exploratory  puncture  in  pleurisy,  666; 
hypertrophic,  646-650;  in  angina  pec- 
toris, 839;  in  asthma,  630;  in  chronic 
bronchitis,  623;  in  fibrinous  bronchitis, 
633;  in  peptic  ulcer,  492;  in  pneumono- 
koniosis,  644;  in  pulmonary  form  of 
acute  milary  tuberculosis,  170;  in  pul- 
monary tuberculosis,  203,  206 ;  in  whoop- 
ing cough,  121;  interstitial,  650;  of 
mediastinum,  675;  of  neck,  in  asthma, 
629 ;  of  unaffected  lung  in  cirrhosis  of 
the  lung,  641 ;  pneumothorax  and,  669 ; 
trieuspid  regurgitation  and,  824,  825. 

Emprosthotonos,  144. 

Empyema,  660-662;  and  lobar  pneumonia, 
89;  brain  abscess  in,  1016;  chronic  dry 
pleurisy  following,  667;  confusion  of 
liver  abscess  with,  586 ;  confusion  of  sub- 
phrenic  abscess  with,  605;  in  scarlet  fe- 
ver, 338;  in  typhoid  fever,  13;  indica- 
nuria  in,  691;  Marie's  syndrome  in, 
1043;  peritonitis  in  children  and,  603; 
putrid  bronchitis  and,  624;  treatment  of 
666,  667. 

Empyema  necessitas,  661 ;  associated  with 
actinomycosis,  233;  tumor  in,  differenti- 
ated from  aneurism,  857. 

Encephalitis,  acute,  366,  1014,  1015;  acute, 


cortical  sclerosis  and,  952;  in  influenza, 
118;  in  syphilis  of  the  brain,  271. 

Encephalo-meningitis,  in  alcoholism,  397. 

Encephalopathy  in  lead  poisoning,  405; 
general  paralysis  and,  925. 

Encysted  amrebae,  239. 

Encysted  pleurisy,  663. 

Endarteritis,  cerebral,  thrombosis  due  to, 
998;  diffuse,  in  peptic  ulcer,  492;  due 
to  acute  endocarditis,  799;  in  angina 
pectoris,  839;  in  typhoid  fever,  13; 
obliterans,  275;  of  cerebral  blood  ves- 
sels, 1004;  of  cerebral  blood  vessels, 
aneurism  due  to,  1003 ;  of  cerebral  blood 
vessels,  apoplexy  due  to,  989 ;  of  cerebral 
blood  vessels,  syphilitic,  1004;  of  coro- 
nary vessels  in  small-pox,  322;  of  spinal 
cord,  957. 

Endemic  index,  255. 

Endocarditis,  acute,  797-803;  acute  chorea 
and,  1067,  1068,  1070,  1071;  acute  en- 
cephalitis in,  1014;  acute  interstitial 
myocarditis  in,  787;  aneurism  and,  849; 
aneurism  of  the  cerebral  blood  vessels 
and,  1003;  aneurism  of  the  heart  due  to, 
829,  830;  aortic  incompetency  due  to, 
809;  aortic  stenosis  due  to,  815;  as  a 
terminal  infection,  53;  Bacillus  coli  in, 
48;  cerebral  embolism  and,  998;  cere- 
bral haemorrhage  due  to,  988;  chronic, 
804,  805;  chronic  infectious,  802;  com- 
plicating bacillary  dysentery,  128;  com- 
plicating gonococcus  infections,  125; 
complicating  influenza,  118;  diabetes  and, 
431;  dilatation  of  the  heart  in,  784; 
due  to  congenital  malformation  of  the 
heart,  808,  809;  fetal,  833,  834;  in 
chronic  ulcerative  tuberculosis,  191;  in 
diphtheria,  62;  in  external  anthrax, 
149 ;  in  gonococcus  septicaemia,  124, 
125;  in  lobar  pneumonia,  81,  90,  97;  in 
measles,  346;  in  mumps,  351;  in  rheu- 
matic fever,  375;  in  scarlet  fever,  334, 
338;  in  Schonlein's  disease,  752;  in  sep- 
ticaemia, 51;  in  tonsillitis,  381;  in  ty- 
phoid fever,  13,  21;  infarcts  of  the 
spleen  in,  885;  malignant  ecchymoses  in, 
751;  mitral  incompetency  due  to,  817; 
mitral  stenosis  due  to,  820,  821;  paren- 
chymatous  degeneration  of  the  heart  in, 
788;  pericarditis  and,  763;  pulmonary 
insufficiency  in,  826;  recurring,  in  aortic 
incompetency,  812;  recurring,  in  mitral 
stenosis,  823,  824;  secondary  to  ery- 
sipelas, 54,  56 ;  stenosis  of  the  pulmonary 
valve  and,  826 ;  terminal,  in  uraemia,  695 ; 
tricuspid  regurgitation  due  to,  824;  tu- 
berculous, 221;  ulcerative,  brain  abscess 
in,  1016;  ulcerative,  confusion  of,  with 


1172 


INDEX 


septico-pyaemia,  52;  ulcerative,  pericar- 
ditis and,  760. 

Endocervicitis,  gonorrhea!,   123. 

Endothelioma  of  the  brain,  1009;  of  the 
lung,  653;  of  the  peritoneum,  607;  of 
the  spleen,  887." 

Engorgement,  stage  of,  in  pneumonia,  79. 

Entamceba  coli,  238;  dysenteriae,  238;  his- 
tolytica,  238. 

Enteric  fever  (see  Typhoid  fever). 

Enteritis,  acute,  caused  by  Trichomonas 
hominis,  281 ;  acute,  differentiation  of 
intestinal  obstruction  from,  544;  ca- 
tarrhal,  516-519;  constipation  due  to, 
545;  diphtheroid  or  croupous,  520;  in 
constipation,  546;  in  external  anthrax, 
149 ;  in  scarlet  fever,  339 ;  phlegmonous, 
520;  ulcerative,  520-522. 

Ectero-colitis,  527,  528;  differentiation  of 
acute  peritonitis  from,  603;  infantile 
convulsions  following,  1077;  terminal, 
53. 

Enterogenous  cyanosis,  758,  759. 

Enteroliths,  533;  causing  intestinal  ob- 
struction, 541;  constipation  and,  546. 

Enteroptosis,  chlorosis  and,  732;  definition 
of,  548,  549;  gall-stones  and,  569;  local 
anaemia  and,  727;  movable  kidney  and, 
677;  symptoms  and  physical  signs  of, 
549,  550;  treatment  of,  550. 

Enuresis,  adenoids  and,  470. 

Eosinophilia,  in  asthma,  630;  in  hook-worm 
disease,  303,  304;  in  trichiniasis,  299. 

Ephemeral  fever,  383,  384. 

Epidemic  catarrhal  jaundice,  384,  385. 

Epidemic  cerebro-spinal  fever,  108,  109. 

Epidemic  haemoglobinuria,  683,  754. 

Epidemic  influenza,  116. 

Epidemic  pneumonia,  78,  93. 

Epidemic  stomatitis,  387. 

Epidemic  tetany,  881. 

Epidemic  tonsillitis,  380. 

Epididymitis  following  dysentery,  128;  in 
syphilis,  267. 

Epiglottis,  destruction  of,  in  tuberculous 
laryngitis,  618;  in  pulmonary  tubercu- 
losis, 202. 

Epilepsia  larvata,  1083. 

Epilepsia  procursiva,  1082. 

Epilepsy,  and  typhoid  fever,  32;  and  urae- 
mia, 694;  asthma  and,  628;  bradycardia 
in,  777;  cardio-vascular,  1081;;  defini- 
tion of,  1079,  1080;  diagnosis  of,  1084; 
differentiation  of  auditory  vertigo  from, 
1048;  differentiation  of  cerebral  apo- 
plexy from,  997;  etiology  of,  1080,  1081; 
excessive  hunger  in,  514;  following  small- 
pox, 322;  haematemesis  in,  507;  in  alco- 


holism, 397;  in  ergotism,  410;  in  lead 
poisoning,  403,  405 ;  in  pericarditis,  764 ; 
infantile  convulsions  and,  1078;  Jack- 
sonian,  233;  nodding  spasm  in,  1054; 
o?dema  of  the  lungs  and,  635;  parosmia, 
1028;  post-hemiplegic,  1084;  post-hemi- 
plegic,  in  children,  1008;  prognosis  of, 
1085;  purpura  in,  751;  Eaynaud's  dis- 
ease and,  1122;  spasm  of  the  oesophagus 
in,  473;  spasm  of  the  tongue  in,  1055; 
spinal,  936;  symptoms  of,  1081-1085; 
treatment  of,  1085-1087. 

Epileptic  convulsions  in  anaesthesia  paraly- 
sis, 1025. 

Epileptiform  attacks  in  acute  cerebro- 
spinal  leptomeningitis,  950;  in  general 
paralysis,  923,  924;  in  Stokes-Adams, 
disease,  779. 

Epinephrin,  and  high  blood  pressure,  863, 
864. 

Epistaxis,  613,  614;  in  acromegaly,  891; 
in  acute  Bright 's  disease,  698;  in  alco- 
holic cirrhosis,  578;  in  chronic  intersti- 
tial nephritis,  708;  in  haemophilia,  756; 
in  lymphoid  leukaemia,  745;  in  myeloid 
leukaemia,  742,  743;  in  purpura  haemor- 
rhagica,  753;  in  scarlet  fever,  337;  in 
scurvy,  448;  in  typhoid  fever,  26;  in 
whooping  cough,  121 :  pernicious  anaemia 
and,  734;  renal,  681. 

Epithelioma,  cylindrical,  causing  intestinal 
obstruction,  541 ;  leukoplakia  buccalis 
and,  461 ;  of  the  o?sophagus,  475. 

Erb-Goldflam 's  symptom  complex,   1133. 

Erb's  syphilitic  spinal  paralysis,  939. 

Ergot,  purpura  due  to,  751;  sclerosis  of  the 
brain  due  to,  951. 

Ergotism,  409,  410;  toxic  combined  sclero- 
sis in,  945. 

Erosion,   460;    haemorrhagic,   gastric,   490; 
of  blood  vessels,  haemoptysis  from,  639; 
of  blood  vessels,  in  peptic  ulcer,  492. 

Erosion  aneurism,  849. 

Eructations  in  acute  gastritis,  477;  in 
chronic  gastritis,  480;  in  gastric  super- 
secretion,  512;  nervous,  510. 

Eruption  in  acute  chorea,  1072;  in  acute 
glanders,  146;  in  dengue,  363;  in  foot- 
and-mouth  disease,  387;  in  measles,  345, 
346;  in  pellagra,  412;  in  rat-bite  fever, 
389;  in  rheumatic  fever,  377;  in  Eocky 
Mountain  spotted  fever,  388;  in  rubella, 
348,  349;  in  scarlet  fever,  335,  336;  in 
small-pox,  318-320,  325;  in  typhoid  fe- 
ver, 18;  in  typhus  fever,  353;  in  vari- 
cella, 331,  332. 

Erysipelas,  acute  endocarditis  in,  798;  as- 
sociated with  pulmonary  tuberculosis, 
209;  broncho-pneumonia  secondary  to, 


INDEX 


1173 


101,  102;  complicating  typhoid  fever, 
32;  complications  of,  55,  56;  definition 
of,  54;  diagnosis  of,  56;  dilatation  of 
the  heart  in,  784;  etiology  of,  54;  leu- 
kaemia and,  747;  mediastinal  abscess 
following,  675;  migrans,  55;  morbid 
anatomy  of,  54,  55;  of  the  neck,  oedema 
of  the  glottis  and,  616;  prognosis  of, 
56;  scarlet  fever  and,  340;  symptoms 
of,  55 ;  thrombosis  of  the  cerebral  veins 
and  sinuses  due  to,  1005;  treatment  of, 
56. 

Erythema,  autumnale,  314;  exudativum,  in 
Schonlein's  disease,  752;  in  cerebro- 
spinal  fever,  111;  in  diphtheria,  66;  in 
exophthalmic  goitre,  878;  in  influenza, 
118;  in  intermittent  hydrarthrosis,  1143; 
in  leprosy,  153;  in  lobar  pneumonia,  88; 
in  neuralgia,  1090;  in  pellagra,  410;  in 
tonsillitis,  381;  in  tuberculous  meningi- 
tis, 172;  in  typhoid  fever,  19;  in 
uraemia,  695 ;  inf ectiosum,  349 ;  multi- 
forme,  resembling  measles,  347 ;  nodosum, 
in  acute  chorea,  1072;  nodosum,  in 
cerebro-spinal  fever,  112;  of  the  larynx, 
in  syphilitic  laryngitis,  619. 

Erythrsemia,  definition  of,  757;  diagnosis 
of,  758;  pathology  of,  757;  prognosis  of, 
758;  symptoms  of,  757,  758;  treatment 
of,  758. 

Erythromelalgia,  definition  of,  1123;  in 
arsenical  poisoning,  407;  in  metatarsal- 
gia,  1092;  symptoms  of,  1123. 

£tat  mamelone,  480. 

Ether,  albuminuria  following  inhalation  of, 
685;  vasomotor  paralysis  due  to,  984. 

Eustrongylus  gigas,  309. 

Ewald  test  meal,  502. 

Exanthem  in  ulcerative  stomatitis,  457. 

Exercise  in  cardiac  insufficiency,  796;  in 
treatment  of  constipation,  547;  in  tuber- 
culosis, 228,  229. 

Exophthalmic  goitre,  anatomical  changes 
in,  878;  cardiac  hypertrophy  in,  781; 
chronic  cardiac  insufficiency  due  to,  786; 
definition  of,  877;  diagnosis  of,  880; 
differentiation  of  neurasthenia  from, 
1112;  etiology  of,  877;  history  of,  877; 
myxffidema  following,  875;  pathology  of, 
877,  878;  prognosis  of,  880;  scleroder- 
ma  and,  1126;  symptoms  of,  878-880; 
treatment  of,  880. 

Exophthalmos,  879;  in  acromegaly,  891; 
in  congenital  hydrocephalus,  1019;  in 
oxycephaly,  1147;  in  serous  meningitis, 
1019;  in  tumors  of  the  brain,  1011. 

Expectoration,  albuminous,  after  tapping 
in  pleurisy,  666;  in  abscess  of  the  lung, 
653;  in  acute  bronchitis,  621;  in  acute 


sero-fibrinous  pleurisy,  657;  in  aortic 
stenosis,  816;  in  asthma,  629;  in  bron- 
chiectasis,  626;  in  chronic  bronchitis, 
623;  in  chronic  interstitial  pneumonia, 
641;  in  fibroid  phthisis,  202;  in  gan- 
grene of  the  lung,  651,  652;  in  mitral 
incompetency,  819;  in  cedema  of  the 
lungs,  635 ;  in  perforation  of  the  lung  in 
liver  abscess,  585;  in  pneumonokoniosis, 
644,  645;  in  pneumonic  tuberculosis, 
184;  in  putrid  bronchitis,  624. 

Expiratory  theory  of  hypertrophic  emphy- 
sema, 646. 

Extensor  paralysis  in  pulmonary  tubercu- 
losis, 205. 

External  auditory  meatus,  diphtheria  of, 
66. 

External  cutaneous  nerve,  affections  of, 
1060. 

External  popliteal  nerve,  lesions  of,  1061. 

Extra-systoles,  772-774. 

Exudate  in  acute  fibrinous  pericarditis, 
761;  in  pericarditis  with  effusion,  763. 

Exudation  in  acute  peritonitis,  600;  in 
myalgia,  1129. 

Exudative  erythema,  acute  Bright 's  dis- 
ease in,  697. 

Eye  strain,  epilepsy  and,  1081. 

Eyes,  care  of,  in  small-pox,  325,  326;  com- 
plications in,  in  small-pox,  322;  cyster- 
cus  cellulosae  in,  289;  in  acromegaly, 
891;  in  cerebro-spinal  fever,  113;  in 
chlorosis,  731;  in  diabetes,  434;  in  ex- 
ophthalmic goitre,  879 ;  in  infantile 
scurvy,  450;  in  tuberculous  meningitis. 
173 ;  in  typhoid  fever,  29. 


Facial  hemiatrophy,  1125. 

Facial  nerve,  paralysis  of,  1041-1044; 
spasm  of  muscles  supplied  by,  1044, 
1045. 

Facies,  Hippocratic,  in  peritonitis,  602;  in 
abscess  of  the  liver,  585;  in  adenoids, 
469;  in  alcoholic  cirrhosis  of  the  liver, 
579;  in  general  paralysis,  923;  in  myx- 
03dema,  875;  in  paralysis  agitans,  1064, 
1065;  in  pernicious  anaemia,  736;  in 
sporadic  cretinism,  874;  leontina,  153; 
of  yellow  fever,  359. 

Faeces,  accumulation  of,  causing  intestinal 
obstruction,  541,  544;  accumulation  of, 
causing  obstructive  jaundice,  555;  caus- 
ing dilatation  of  the  colon,  552;  concre- 
tions of,  in  appendicitis,  533;  in  cholera 
asiatica,  135. 


1174 


INDEX 


Fainting,  983;  due  to  failure  of  the  left 
ventricle,  789;  in  aortic  stenosis,  816; 
in  chlorosis,  731. 

Faintness,  in  acute  secondary  anaemia,  728; 
in  aortic  incompetency,  811. 

Fallopian  tubes,  tuberculosis  of,  220. 

False  aneurism,  847. 

Family  form  of  spastic  spinal  paralysis, 
938,  939. 

Famine  fever,   261. 

Farcy.     (See  Glanders.) 

"Farre's  tubercles,"  587. 

Fasciola  hepatica,  282. 

Fasciolopsis  buskii,  283. 

Fat  embolism  of  the  pulmonary  vessels  in 
diabetes,  431. 

Fat  necrosis,  pancreatic,  593. 

Fat  tapeworm,  285. 

Fatty  cirrhotic  liver,  577. 

Fatty  degeneration,  of  heart,  788,  789;  of 
heart,  in  pernicious  anemia,  734;  of 
heart,  symptoms  of,  791;  of  kidney,  al- 
buminuria  in,  686. 

Fatty  heart,  rupture  associated  with,  830. 

Fatty  liver,  590;  differentiation  of  cancer 
from,  589. 

Fatty  overgrowth  of  heart,  789;  symptoms 
of,  791. 

Favus  fungus  causing  gastritis,  479. 

Febricula,  383,  384. 

Febrile  influenza,  118. 

Febris  recurrens.      (See  Eelapsing  fever.) 

Feeble-mindedness  following  hemiplegia  in 
children,  1008. 

Feeding  in  rickets,  445. 

Fermentation  and  flatulency,  treatment  of, 
485. 

Fermentative  diarrhosa  in  children,  526. 

Fetal  endocarditis,  833,  834. 

Fetid   stomatitis,  457. 

Fetor  oris,  461;  in  adenoids,  470;  in  gan- 
grene of  the  lung,  652. 

Fetus,  typhoid  fever  in,  34. 

Fever,  hysterical,  1103;  in  acquired  syph- 
ilis, 266;  in  actinomycosis,  233;  in  acute 
Bright 's  disease,  698;  in  acute  bron- 
chitis, 621;  in  acute  cerebro-spinal  lepto- 
meningitis,  950;  in  acute  chorea,  1072; 
in  acute  diffuse  myelitis,  967;  in  acute 
endocarditis,  800,  801,  802;  in  acute  feb- 
rile polyneuritis,  1022;  in  acute  fibrin- 
ous  pericarditis,  761;  in  acute  gastritis, 
477;  in  acute  pancreatitis,  595;  in  acute 
pharyngitis,  465;  in  acute  sero-fibrinous 
pleurisy,  657;  in  acute  tonsillitis,  381; 
in  aestivo-autumnal  fever,  252,  253;  in 
anthrax,  149;  in  appendicitis,  533,  535; 
in  arthritis  deformans,  1138,  1139;  in 
ball- valve  stone,  573;  in  biliary  colic, 


570;  in  broncho-pneumonia,  105;  in  can- 
cer of  liver,  588;  in  cancer  of  stomach, 
501;  in  cancrum  oris,  459;  in  cholera  in- 
fantum,  526;  in  chronic  secondary  ane- 
mia, 730;  in  chronic  ulcerative  tuber- 
culosis, 196,  197,  198;  in  dengue,  362, 
363;  in  diagnosis  of  pulmonary  tubercu- 
losis, 206;  in  empyema,  660;  in  erysip- 
elas, 55 ;  in  exophthalmic  goitre,  879 ;  in 
fibrinous  bronchitis,  632;  in  gangrene  of 
the  lung,  652;  in  gout,  421;  in  haemo- 
globinuria,  683;  in  herpes  zoster,  926, 
927;  in  Hodgkin's  disease,  748,  749;  in 
hypertrophic  cirrhosis,  581 ;  in  Indian 
kala-azar,  260;  in  infantile  scurvy,  450; 
in  influenza,  118;  in  large  solitary  ab- 
scess of  liver,  584;  in  lobar  pneumonia, 
82,  83;  in  lymphoid  leukaemia,  745;  in 
malaria,  249;  in  malarial  cachexia,  254; 
in  Malta  fever,  131;  in  measles,  344, 
345;  in  mediastinal  abscess,  678;  in 
miliary  fever,  387;  in  milk-sickness,  385; 
in  movable  kidney,  678;  in  mumps,  350, 
351;  in  myeloid  leukaemia,  743;  in  peri- 
tonitis, 601;  in  purpura  haemorrhagica, 
753;  in  relapsing  fever,  262;  in  rheu- 
matic fever,  374;  in  rickets,  443;  in 
scarlet  fever,  335,  336;  in  Schonlein's 
disease,  752;  in  serous  meningitis,  1019; 
in  simple  ulcerative  colitis,  521;  in 
small-pox,  318;  in  subphrenic  abscess, 
605;  in  suppurative  angiocholitis,  565; 
in  suppurative  tonsillitis,  467;  in  ther- 
mic fever,  391;  in  toxaemic  jaundice, 
557;  in  tuberculosis,  treatment  of,  230; 
in  tuberculous  aspiration  pneumonia, 
185;  in  tuberculous  meningitis,  172, 173; 
in  tuberculous  peritonitis,  181;  in 
typhoid  fever,  17,  18;  in  typhus  fever, 
353,  354,  355;  in  yellow  fever,  359;  in- 
termittent, in  pyelitis,  714;  intermittent 
renal,  720. 

Fibrillation,  of  heart,  774,  775;  of  muscles 
in  progressive  central  muscular  atrophy, 
929. 

Fibrinous  bronchitis,  clinical  description 
of,  632;  definition  of,  631. 

Fibrinous  pleurisy,  654,  655. 

Fibrinous  pneumonia.  (See  Lobar  pneu- 
monia.) 

Fibrinous  rhinitis,  64,  65. 

Fibroid  broncho-pneumonia,  644. 

Fibroid  degeneration  of  heart  in  arterio- 
sclerosis, 845. 

Fibroid  growths  of  brain,  1010. 

Fibroid  heart,  symptoms  of,  790. 

Fibroid  phthisis,  202  (see  Pneumonia, 
chronic  interstitial). 

Fibroma,    causing    intestinal    obstruction, 


INDEX 


1175 


541;  of  kidney,  722;  of  mediastinum, 
675;  of  pituitary  gland,  891;  of  spinal 
cord,  963;  of  the  stomach,  505. 

Fibrosarcoma  of  brain,  1009. 

Fibrositis,   1129;    myositis    (see  Myalgia). 

Fibrous  myocarditis,  786,  787;  arterio- 
sclerosis and,  844;  fragmentation  in, 
788. 

Fifth  nerve,  disease  of,  diagnosis  of,  1040; 
disease  of,  treatment  of,  1041;  neuralgia 
of,  1090,  1091;  paralysis  of,  1039-1041. 

Filaria  bancrofti,  305,  306;  bronchialis, 
308;  diurna,  305;  hominis  oris,  308;  im- 
miiis,  309 ;  labialis,  308 ;  lentis,  308 ;  loa, 
305,  308;  perstans,  305;  sanguinis,  309; 
sanguinis  hominis,  haematuria  due  to, 
681. 

Filariasis,   305-307. 

Fingers  in  pulmonary  tuberculosis,  206. 

Finsen  light,  in  treatment  of  leprosy,  154. 

Fish  poisoning,  409. 

Fisher's  brain  murmur  in  congenital  hy- 
drocephalus,  1019. 

Fistula,  bronchial,  in  empyema,  661;  in 
ano,  in  pulmonary  tuberculosis,  209;  in 
ano,  in  tuberculosis  of  rectum,  213; 
oesophago-pleuro-cutaneous,  476;  of  Eck, 
582;  periueal,  in  bilharziasis,  283; 
pleuro-oesophageal,  in  empyema,  662. 

Fistulae,  biliary,  due  to  gall-stones,  574. 

Flat-foot,  neuralgia  of  nerves  of  feet  and, 
1092. 

Flatulence  in  cardiac  insufficiency,  790; 
treatment  of,  485. 

Flatulent  distention  of  stomach  causing 
angina  pectoris,  838. 

Flea,  312,  313. 

Fleas,  in  transmission  of  infantile  kala- 
azar,  261;  plague  and,  139,  140. 

Flexner-Harris  type  of  Bacillus  dysenterise, 
127,  128. 

Flies,  in  transmission  of  trypanosomes, 
259;  in  transmission  of  typhoid  fever,  7, 
39;  parasitic,  313-315. 

Flint  murmur,  in  mitral  stenosis,  812,  823. 

Floating  kidney  (see  Movable  kidney) ; 
confusion  of,  with  appendicitis,  536;  di- 
latation of  the  stomach  due  to,  487;  in 
enteroptosis,  549. 

Fluctuation  in  ascites,  609. 

Flukes,  blood,  283;  bronchial,  282;  liver, 
282;  lung,  282. 

Flushing,  in  erythrsemia,  758;  in  palpita- 
tion of  heart,  771. 

Folie  Brightique,  694. 

Follicular  stomatitis,  456,  457. 

Follicular  ulceration  of  the  intestines,  521. 
Follicular  ulcers,   of   eescphagus,   473;    of 
pharynx,  465. 


Food,  infected,  and  typhoid  fever,  7,  39; 
relation  of,  to  catarrhal  enteritis,  516; 
517;  relation  of,  to  scurvy,  446,  447. 

Food  poisoning,  407-411;  poliencephalitis 
in,  1014. 

Foot-and-mouth  disease,  387;  ulcerative 
stomatitis  and,  457. 

Foot  and  wrist  drop  in  acute  febrile  poly- 
neuritis,  1023. 

Foot-drop,  in  alcoholic  neuritis,  1023;  in 
paralysis  of  the  external  popliteal  nerve, 
1061. 

Foreign  bodies,  abscess  of  liver  due  to, 
583;  abscess  of  lung  due  to,  653;  acute 
laryngitis  due  to,  615;  causing  dilata- 
tion of  colon,  552;  causing  epistaxis, 
613;  causing  intestinal  obstruction,  541; 
causing  obstructive  jaundice,  555;  caus- 
ing stenosis  of  bile-ducts,  567;  constipa- 
tion due  to,  545;  in  ear  or  nose,  epilepsy 
and,  1081,  1087;  in  heart,  831,  832;  in 
03sophagus,  472,  473;  in  stomach,  tumors 
due  to,  505;  indurative  changes  in  lung 
due  to,  641;  pericarditis  due  to,  760; 
suppurative  angiocholitis  and,  565. 

"Fourth  disease,"  349. 

Fourth  nerve,  paralysis  of,  1036,  1037. 

Fowler's  solution,  neuritis  due  to,  1024. 

Fracture  of  the  skull,  meningeal  haemor- 
rhage due  to,  989. 

Fragilitas  ossium,  1145,  1146. 

Fremitus,  bronchial,  621;  decrease  in,  in 
acute  sero-fibrinous  pleurisy,  657;  de- 
crease in,  in  pneumo-thorax,  670;  in 
acute  fibrinous  pericarditis,  761;  in 
mitral  stenosis,  822. 

Frenkel's  reeducation  in  locomotor  ataxia, 
921. 

Freund  's  operation  in  emphysema,  650. 

Freund's  theory  of  hypertrophic  emphy- 
sema, 646. 

Friction,  in  acute  fibrinous  pericarditis, 
762;  in  acute  sero-fibrinous  pleurisy, 
658,  659;  in  pericarditis  with  effusion, 
765;  pleuritic,  in  chronic  ulcerative  tu- 
berculosis, 201;  pleuro-pericardial,  in 
chronic  ulcerative  tuberculosis,  201. 

Friedlander  's  bacillus,  in  acute  sero-fibrin- 
ous pleurisy,  656;  in  broncho-pneumonia, 
104. 

Friedreich's  ataxia,  944,  945;  differentia- 
tion of  chorea  from,  1072;  sclerosis  of 
the  dorsal  columns  in,  952. 

Frolich  type  of  infantilism,  893. 

Frolich's  syndrome,  451,  453. 

Frost-bite,  1120. 

Fungi,  gastritis  and,  479. 

Funnel  breast  in  adenoids,  470. 


1176 


INDEX 


G 


Gaertner  's  bacillus,  methsemoglobinsemia 
produced  by,  759. 

Gait,  ataxic,  916;  hemiplegic,  following 
hemiplegia  in  children,  1007;  in  chronic 
chorea,  1077;  in  general  paralysis,  924; 
in  muscular  dystrophies,  932;  in  paraly- 
sis agitans,  1065;  spastic,  in  hysteria, 
1099;  stoppage,  in  alcoholic  neuritis, 
1024. 

Gall-bladder,  condition  of,  in  cholecystitis, 
566;  enlargement  of,  in  suppurative 
cholangitis,  565;  in  typhoid  fever,  12. 

Galloping  consumption,  183-187. 

Gall-stone  colic,  differentiation  of  acute 
gastritis  from,  477;  indicanuria  in,  691. 

Gall-stones,  abscess  of  liver  due  to,  583, 
584;  acute  pancreatitis  and,  594;  cancer 
of  liver  due  to,  587;  catarrhal  jaundice 
and,  563;  causing  dilatation  of  the 
colon,  552;  causing  intestinal  obstruc- 
tion, 541,  544;  causing  obstructive  jaun- 
dice, 555;  chronic  catarrhal  angiocho- 
litis  and,  565;  chronic  pancreatitis  and, 
596;  confusion  of  cholecystitis  and,  566; 
confusion  of  symptoms  of,  with  septico- 
pyaemia,  52;  differentiation  of  liver  ab- 
scess from,  586;  following  constipation, 
546;  in  cancer  of  bile-passages,  567;  in 
obstruction  of  bile-ducts,  568;  origin  of, 
568,  569;  physical  characters  of,  569, 
570;  seat  of  formation  of,  570;  sup- 
purative angiocholitis  following,  565; 
symptoms  of,  570-574;  thrombosis  of 
portal  vein  in,  562;  treatment  and  ef- 
fects of,  574,  575;  typhoid  fever  and, 
26. 

Ganglionitis,   acute  posterior,   926-927. 

Gangrene,  arterial,  in  typhoid  fever,  21; 
broncho-pneumonia  terminating  in,  104; 
•  differentiation  of  Eaynaud's  disease 
from,  1122;  due  to  emboli  in  acute  endo- 
carditis, 801;  following  pulmonary  apo- 
plexy, 638;  in  bronchiectasis,  626;  in 
diabetes,  434;  in  diphtheria,  64,  67;  in 
ergotism,  409;  in  herpes  zoster,  927;  in 
malaria,  254;  in  mumps,  351;  in  mye- 
loid  leukaemia,  743;  in  scarlet  fever, 
339 ;  in  small-pox,  322 ;  in  typhus  fever, 
355;  in  varicella,  332;  local,  in  cholera 
asiatica,  136;  of  extremities  in  arterio- 
sclerosis, 846;  of  skin  in  cerebrospinal 
fever,  112;  of  skin  in  typhoid  fever,  19; 
pneumonia  and,  96;  putrid  bronchitis 
and,  624. 

Gangrene  of  lung,  acute  plastic  pleurisy  in, 
654;  echinococcus  and,  293;  etiology  of, 
650,  651;  haemoptysis  in,  636;  in  dia- 


betes, 434;  in  typhoid  fever,  13;  Lam- 
blia  intestinalis  in,  281;  morbid  anat- 
omy of,  651 ;  in  pulmonary  tuberculosis, 
203;  symptoms  and  course  of,  651,  652; 
treatment  of,  652. 

Gangrenous  pancreatitis,   595,  596. 

Grangrenous  stomatitis,  459. 

Gas  poisoning,  poliencephalitis  in,  1014. 

Gaseous  tumors  of  Steno 's  duct  and  of  the 
parotid  gland,  464. 

Gastralgia,  513,  514;  differentiation  of 
biliary  colic  from,  571;  due  to  disturb- 
ance of  pneumogastric  nerve,  1051;  loco- 
motor  ataxia  and,  920. 

Gastrectasis  (see  Dilatation  of  stomach)  ; 
tetauy  due  to,  881. 

Gastric  crises  in  locomotor  ataxia,  917. 

Gastric  ulcer,  490-498;  cancer  of  stomach 
and,  499 ;  perforation  of,  producing  peri- 
tonitis, 603;  subphrenic  abscess  follow- 
ing, 604. 

Gastritis,  acida,  481;  acute,  476-479;  an- 
acida,  481;  atrophicans,  481;  chronic, 
479-486;  chronic,  differentiation  of  can- 
cer from,  504;  haemorrhage  from  stom- 
ach in,  506;  mucipara,  481;  polyposa, 
480. 

Gastrodiseus  hominis,  283. 

Gastrodynia,  513,  514. 

Gastro-intestinal  complications  of  pulmo- 
nary tuberculosis,  204,  205. 

Gastro-intestinal  fistula  due  to  gall-stones, 
574. 

Gastro-intestinal   influenza,  118. 

Gastroptosis,  chlorosis  and,  732. 

Gastrorrhagia.  (See  Haemorrhage  from 
stomach.) 

Gastrorrhexis,  confusion  of,  with  peptic 
ulcer,  496. 

Gastrostaxis,  507. 

Gastrostomy  in  oesophageal  tumor,   475. 

Gastroxynsis,   512. 

Gaucher  type  of  splenomegaly,  887. 

Gavage  in  diarrhosa  in  children,  531. 

General  infection,  due  to  Bacillus  coli, 
47;  in  diphtheria,  63. 

General  paralysis  of  the  insane,  922-926 
(see  Paralysis,  general,  of  insane) ;  oph- 
thalmoplegia  externa  in,  1038. 

General  tuberculosis,  168,  169  (see  Typhoid 
form  of  tuberculosis). 

Generative  system  in  typhoid  fever,  30,  31. 

Genitals,  diphtheria  of,  66. 

Genito-urinary  system,  complications  of 
pulmonary  tuberculosis  in,  205;  tuber- 
culosis of,  215-220. 

Geographical  tongue,  460. 

German  measles.      (See  Rubella.) 

Gestation,  ptyalism  during,  462. 


INDEX 


1177 


Giddiness,  in  cardiac  hypertrophy,  781;  in 
cerebral  anaemia,  986;  in  erythrsemia, 
758;  in  tumors  of  brain,  1010,  1013. 

Gigantisin,  hyperpituitarism  leading  to, 
890. 

Gigantorhynchus,  310. 

Gilles  de  la  Tourette's  disease,  1075,  1076. 

Gland,  mammary,  tuberculosis  of,  220,  221. 

Glanders,  definition  of,  146;  etiology  of, 
146;  meningitis,  147;  morbid  anatomy 
of,  146;  pneumonia,  146;  pustular,  re- 
sembling small-pox,  324;  symptoms  of, 
146,  147;  treatment  of,  147. 

Glands,  enlargement  of,  in  arthritis  defor- 
mans,  1138;  of  Bartholin,  inflammation 
of,  123;  of  neck  in  tonsillitis,  467;  of 
Peyer,  leukaemic  enlargements  of,  742. 

Glandular  fever,  386. 

Glaucoma,  gout  and,  423. 

Glenard's  disease.     (See  Enteroptosis.) 

Glioma  of  brain,  1009. 

Gliosarcoma  of  spinal  cord,  963. 

Globulin  test,  in  cerebro-spinal  fluid,  367. 

Globus  hystericus,  1097. 

Glossina  palpalis,  259. 

Glossitis,  in  pernicious  anaemia,  736;  M61- 
ler's,  460. 

Glosso-labio-laryngeal  paralysis.  (See  Bui- 
bar  paralysis.) 

Glosso-pharyngeal  nerve,  affections  of, 
1048,  1049. 

Glottis,  imperfect  closure  of,  in  pulmonary 
tuberculosis,  203;  oedema  of,  616;  cedema 
of,  in  typhoid  fever,  13;  spasm  of,  617. 

Gluteal  nerve,  paralysis  of,  1060. 

Glycosuria,  albuminuria  and,  685;  condi- 
tions causing,  427-429;  differentiation 
of,  from  diabetes,  435;  due  to  injection 
of  epinephrin,  863;  gouty,  420,  423;  in 
acromegaly,  892;  in  cerebro-spinal 
fever,  112;  in  chronic  pancreatitis,  596; 
in  exophthalmic  goitre,  879;  in  tumor  of 
the  cerebellum,  976;  internal  secretions 
and,  428;  pneumaturia  and,  692. 

Goats  and  Malta  fever,  131. 

Goitre,  cretinism  and,  874;  definition  of, 
872;  distribution  of,  872;  etiology  of, 
872;  exophthalmic,  877-880;  in  acromeg- 
aly, 892;  morbid  anatomy  of,  872; 
prognosis  of,  873;  symptoms  of,  872, 
873;  treatment  of,  873. 

"Goitre  heart,"  873. 

Gonococcus,  123;  in  endocarditis,  800;  in 
peritonitis,  601;  in  septico-pyaemia,  51; 
in  terminal  infections,  53;  in  urine,  687. 

Gouococcu's  arthritis,  124,  125;  differentia- 
tion of  arthritis  deformans  from,  1140. 

Goiiococcus  infection,  clinical  course  of, 
125;  complications  of,  125;  definition  of.. 
76 


123;  etiology  of,  123;  primary  lesion 
of,  123;  spread  of,  123,  124;  systemic, 
124,  125;  treatment  of,  125. 

Gonococcus  septicaemia  and  pyaemia,  124. 

Gonorrhoea,  acute  chorea  following,  1067. 
1069;  acute  endocarditis  in,  798;  acute 
interstitial  myocarditis  in,  787;  acute 
myelitis  due  to,  966;  hematuria  due 
to,  681;  pelvic  peritonitis  and,  605; 
pyuria  in,  688;  septico-pysemia  follow- 
ing, 52. 

Gout,  acute  cerebro-spinal  leptomeningitis 
in,  949 ;  acute,  in  lead  workers,  405 ; 
amyloid  degeneration  of  kidneys  in,  711; 
arterio-sclerosis  and,  843;  bronchitis 
and,  620,  622;  chronic  gastritis  ^and, 
480;  definition  of,  417;  diagnosis  of, 
423,  424;  differentiation  of  chronic 
arthritis  deformans  from,  1140;  differen- 
tiation of  rheumatic  fever  from,  378; 
endocarditis  in,  797;  etiology  of,  417- 
419;  morbid  anatomy  of,  419,  420;  neu- 
ralgia in,  1090;  oxaluria  and,  690;  peri- 
carditis in,  760,  761 ;  peritonitis  termi- 
nating, 600 ;  prognosis  of,  424 ;  sciatica 
in,  1061;  symptoms  of,  420-423;  treat- 
ment of,  424-426. 

Gouty  diathesis,  422. 

Gouty  kidney.  (See  Chronic  interstitial 
nephritis.) 

Graefe's  sign,  879. 

Grain  poisoning,  409,  410. 

Grand  mal,  1080   (see  Epilepsy). 

Granulomata,  infections  of  brain  and, 
1009;  of  thyroid,  871. 

Graves'  disease,  dilatation  of  heart  in, 
783;  excessive  hunger  in,  514;  (see  also 
Exophthalmic  goitre). 

Gray  induration  of  lungs,  640. 

' '  Green  sickness, ' '  731. 

Ground-itch,  302,  303. 

Gruebler's  tumor,  404. 

Guinea- worm  disease,   307,  308. 

Gull's  disease,  875. 

Gum-lancing  in  spasmodic  laryngitis,  617. 

Gummata,  265,  266,  277;  of  brain,  270;  of 
brain  and  cord,  270;  of  heart,  275;  of 
kidneys,  270,  276;  of  larynx,  619;  of 
liver,  274;  of  lungs,  272;  of  medias- 
tinum, 675;  of  spinal  cord,  963;  of 
spleen,  885;  pulmonary  fibroid  changes 
due  to,  640. 

Gummatous  periarteritis,  276. 

Gums,  blue  line  on,  in  lead  poisoning,  403; 
in  diabetes,  432;  in  mercurial  stomatitis. 
459;  in  pulmonary  tuberculosis,  204;  in 
scurvy,  447;  in  ulcerative  stomatitis, 
457. 


1178 


INDEX 


Habit,  constipation  and,  547. 

Habit  chorea,  1068. 

Habit  spasm,  1075;  of  face,  adenoids  and, 
470. 

Habits,  sedentary,  and  constipation,  545. 

Habitus  phthisicus,  158. 

Haemarthrosis,  756. 

'Haematemesis,  differentiation  of  haemop- 
tysis from,  508,  509;  in  congestion  of 
liver,  562;  in  hysteria,  1102;  in  myeloid 
leukaemia,  742,  743;  in  peptic  ulcer,  496; 
in  relapsing  fever,  263;  in  scurvy,  448; 
in  small-pox,  320;  in  splenic  anaemia, 
886;  in  typhus  fever,  355;  (see  also 
Haemorrhage  from  stomach). 

Haematochyluria,  688;  produced  by  filaria, 
306;  treatment  of,  307. 

Haematogenous  jaundice,  557. 

Haematoma,  553;  of  dura  mater,  948  \ 
pharyngeal,  464. 

Haematomyelia,  958,  959. 

Haematoporphyrin  in  urine,  693. 

Haematorrachis,  957,  958. 

Haematuria,  diagnosis  of,  682;  endemic, 
283;  etiology  of,  681,  682;  in  acute 
Bright 's  disease,  699;  in  aortic  incompe- 
tency,  812;  in  cerebro-spinal  fever,  112; 
in  chronic  interstitial  nephritis,  706;  in 
lobar  pneumonia,  88;  in  polycystic  kid- 
neys, 724;  in  pulmonary  tuberculosis, 
205;  in  purpura  haemorrhagica,  753;  in 
relapsing  fever,  263 ;  in  renal  calculus, 
720;  in  renal  cancer,  722;  in  scarlet 
fever,  337;  in  scurvy,  448;  in  small-pox, 
320;  in  splenic  anaemia,  887;  in  tuber- 
culosis of  kidney,  218,  219;  treatment 
of,  684. 

Haemic  distomiasis,  283,  284. 

Haemochromatosis,  434,  453,  454;  chronic 
interstitial  pancreatitis  and,  596. 

Haemoglobinuria,  682;  epidemic,  754;  in 
angio-neurotic  redema,  1124;  in  malarial 
fever,  254;  in  Raynaud's  disease,  1122; 
in  typhoid  fever,  30;  malarial,  254; 
paroxysmal,  683,  684;  toxic,  683;  toxic, 
parenchymatous  degeneration  of  heart 
in,  788;  treatment  of,  684. 

Haemoglobinurie  fever,  254.- 

Haemolysis,  acute  secondary  anaemia  fol- 
lowing, 728;  theory  of  pernicious  anae- 
mia, 735. 

Haemolytic  jaundice,   557. 

Haemopericardium,   769. 

Haemophilia,  definition  of,  755;  diagnosis 
of,  756;  distribution  of,  755;  epistaxis 
in,  614;  etiology  of.  755;  haematemesis 
in,  507;  history  of,  755;  pathology  of, 


755,  756;  renal,  681;  symptoms  of,  756; 
treatment  of,  757. 

Haemoptysis,  636,  637;  aneurismal,  636, 
855;  differentiation  of  haematemesis 
from,  508,  509;  due  to  aortic  incompe- 
tency,  810,  811;  following  epilepsy, 
1082;  hysterical,  1101;  in  bubonic 
plague,  140 ;  in  cardiac  insufficiency,  790 ; 
in  cardiac  insufficiency,  treatment  of, 
795;  in  chronic  ulcerative  tuberculosis, 
191,  192,  194-196;  in  diagnosis  of  pul- 
monary tuberculosis,  207;  in  fibrinous 
bronchitis,  632;  in  fibroid  phthisis,  202; 
in  hysteria,  1100;  in  mitral  stenosis, 
824;  in  pulmonary  form  of  acute  mili- 
ary  tuberculosis,  170;  in  purpura 
haemorrhagica,  753;  in  scurvy,  448;  in 
small-pox,  321;  in  tuberculosis,  194, 
231;  in  typhoid  fever,  27;  in  whooping 
cough,  121;  parasitic,  282;  tendency  to, 
in  mitral  incompetency,  818;  tubercu- 
lous aspiration  pneumonia  and,  185. 

Haemorrhage,  acute  secondary  ansemia  due 
to,  728;  appendicitis  and,  536;  chronic 
secondary  anaemia  due  to,  730;  compli- 
cating diphtheria,  66;  cutaneous,  in  tox- 
aemic  jaundice,  557;  death  from,  in  pul- 
monary tuberculosis,  210;  fatal,  in 
emphysema,  649;  from  the  cord  in 
icterus  neonatorum,  558;  from  nose  (see 
Epis<  axis)  ;  hemiplegia  in  children  due 
to,  "/.006;  in  acute  yellow  atrophy,  559, 
560;  in  alcoholic  cirrhosis,  578;  in 
aneurism  of  the  thoracic  aorta,  855;  in 
aplastic  anaemia,  738;  in  bronchiectasis, 
627;  in  cancer  of  liver,  587;  in  cancer 
of  stomach,  501 ;  in  chronic  interstitial 
'  nephritis,  708 ;  in  chronic  interstitial 
pneumonia,  641,  642;  in  chronic  ulcera- 
tive tuberculosis,  194-196;  in  congenital 
obliteration  of  bile-ducts,  568;  in 
dengue,  363 ;  in  erythraemia,  758 ;  in  foot- 
and-mouth  disease,  387;  in  gangrene  of 
lung,  651,  652;  in  haemophilia,  756;  in 
hypertrophic  cirrhosis,  581;  in  intesti- 
nal ulcers,  522;  in  lymphoid  leukaemia, 
745;  in  malarial  cachexia,  254;  in  mili- 
ary  fever,  387;  in  myeloid  leukaemia, 
742,  743;  in  obstructive  jaundice,  556; 
in  optic  neuritis,  1030;  in  peptic  ulcer, 
492-494,  497;  in  pernicious  anaemia, 
734,  736;  in  plague,  140;  in  polymyosi- 
tis  haemorrhagica,  1129;  in  purpura 
hsemorrhagica,  753;  in  progressive  septi- 
caemia, 49;  in  retinitis,  1029;  in  Rocky 
Mountain  spotted  fever,  388;  in  scarlet 
fever,  337 ;  in  scurvy,  447 ;  in  skin,  in  hys- 
teria, 1102;  in  small-pox,  320,  321;  in 
splenic  anaemia,  886,  887;  in  syphilitie 


INDEX 


1179 


laryngitis,  619;  in  tuberculous  broncho- 
pneumonia,  186;  in  typhoid  fever,  12;  in 
typhoid  fever,  treatment  of,  44;  in  ul- 
ceration  of  oesophagus,  473 ;  in  whooping 
cough,  121;  in  yellow  fever,  360;  intes- 
tinal, in  amoebiasis,  241;  intestinal, 
hematoporphyrin  in  urine  in,  693;  in- 
testinal, in  typhoid  fever,  23;  into  the 
spinal  cord,  958,  959 ;  into  the  spinal 
membranes,  957,  958;  intra-cerebral, 
989;  Jacksonian  epilepsy  due  to,  1084; 
meningeal,  989 ;  meningeal,  birth  pal- 
sies due  to,  937;  mesenteric,  553; 
oesophageal,  507;  of  new-born,  754,  755; 
pancreatic,  593,  594;  pernicious  anaemia 
and,  734;  petechial,  in  epilepsy,  1082; 
pharyngeal,  464;  pulmonary,  636-638; 
punctiform,  in  traumatic  neurasthenia, 
1118;  retinal,  in  chronic  interstitial 
nephritis,  708;  syphilitic,  269;  thymic, 
869;  ventricular,  989,  990. 

Haemorrhage,  cerebral,  diabetes  insipidus 
and,  440;  diagnosis  of,  996,  997;  etiology 
of,  987,  988;  in  arterio-sclerosis,  845; 
morbid  anatomy  of,  988-990 ;  symptoms 
of,  990-996;  treatment  of,  1001-1003. 

Haemorrhage  from  stomach,  diagnosis  of, 
508;  etiology  of,  506,  507;  morbid  anat- 
omy of,  507,  508;  prognosis  of,  509; 
symptoms  of,  508. 

Haemorrhagic  adrenalitis,  868. 

Haemorrhagic  forms  of  pernicious  malaria, 
254. 

Haemorrhagic   infarct,  637,  638. 

Haemorrhagic  infarction  in  typhoid  fever, 
13. 

Haemorrhagic  pachymeningitis,  cerebral 
form  of,  946,  947;  spinal  form  of,  947, 
948. 

Haemorrhagic  pleurisy,  662. 

Haemorrhagic  small-pox,  320,   321. 

Haemorrhagic  typhoid  fever,  33. 

Haemorrhagic  varicella,  332. 

Haemorrhoids,  chronic  secondary  anaemia 
due  to,  730;  in  alcoholic  cirrhosis,  578; 
in  cardiac  insufficiency,  790;  pernicious 
anaemia  and,  734. 

Haffkine's  plague  serum,  142. 

Hair,  in  pulmonary  tuberculosis,  206;  in 
rickets,  444;  in  typhoid  fever,  19. 

Hair  tumor,  505. 

Hallucinations,  in  acute  chorea,  1071;  in 
alcoholic  neuritis,  1024;  in  aortic  in- 
competency,  812;  in  chronic  alcoholism, 
397;  in  delirium  tremens,  398;  in  hys- 
teria, 1102;  in  hystero-epilepsy,  1098;  in 
lead  poisoning,  405 ;  in  myxcedema,  875 ; 
in  pellagra,  412;  of  smell,  1028;  visual, 
in  tumors  of  brain,  1012. 


Hallucinosis,   acute,   399. 

Halzoun,  282. 

Harrison's  groove,  in  adenoids,  469;  in 
rickets,  444. 

Harvest  bug,  311. 

Harvest  rash,  314. 

Hay  fever,  612,  613;  asthma  and,  628. 

Headache,  adenoids  and,  470;  in  abscess 
of  the  brain,  1016;  in  acquired  chronic 
hydrocephalus,  1019;  in  acromegaly, 
891;  in  acute  cerebro-spinal  leptomenin- 
gitis,  949,  950;  in  acute  febrile  poly- 
neuritis,  1022;  in  acute  gastritis,  477; 
in  acute  poliomyelitis,  365,  366;  in  acute 
yellow  atrophy,  560;  in  Addison's  dis- 
ease, 865;  in  aortic  incompetency.  811; 
in  cardiac  hypertrophy,  781;  in  cerebral 
anaemia,  986;  in  cerebral  syphilis,  271; 
in  cerebro-spinal  fever,  111,  113,  114;  in 
chlorosis,  733;  in  chronic  gastritis,  481; 
in  chronic  interstitial  nephritis,  708;  in 
constipation,  546;  in  erythraemia,  758; 
in  gout,  423 ;  in  hsemorrhagic  pachymen- 
ingitis, 947;  in  hay  fever,  613;  in  ma- 
laria, 249;  in  migraine,  1088;  in  myx- 
ffidema,  875 ;  in  osteitis  deformans, 
1145;  in  oxycephaly,  1147;  in  pella- 
gra, 412;  in  pernicious  anaemia,  736; 
in  pneumonia,  88;  in  renal  calculus, 
721;  in  serous  meningitis,  1018,  1019; 
in  small-pox,  318 ;  in  softening  of  brain, 
1000;  in  thrombosis  of  cerebral  veins 
and  sinuses,  1005;  in  traumatic  neuras- 
thenia, 1116,  1117;  in  tuberculous 
meningitis,  172;  in  tumor  of  cerebellum, 
975;  in  tumors  of  brain,  1010,  1013;  in 
uraemia,  695;  indurative,  1130;  sick  (see 
Migraine). 

Head-tetanus,   143. 

Healed  dissecting  aneurism,  851. 

Heart,  changes  in,  in  endocarditis,  798, 
799,  804,  805;  changes  in,  in  hyper- 
trophic  emphysema,  647;  complications 
in,  in  rheumatic  fever,  375,  376;  compli- 
cations of  pulmonary  tuberculosis  in,  203, 
204;  diseases  of,  770-862;  dislocation 
of,  in  empyema,  661 ;  displacement  of,  in 
acute  sero-fibrinous  pleurisy,  656;  dis- 
placement of,  in  pneumothorax,  671; 
fatty,  788,  789;  in  beri-beri,  415;  in 
chronic  alcoholism,  398;  in  chronic 
gout,  422;  in  chronic  interstitial  pneu- 
monia, 641,  642;  in  diabetes,  431;  in 
diphtheria,  62,  67,  68 ;  in  goitre,  873 ;  in 
gout,  420,  421 ;  in  lobar  pneumonia,  .80, 
81,  86,  87;  in  lymphatism,  870;  in  mye- 
loid  leukaemia,  741;  in  pernicious  anae- 
mia, 734;  in  relapsing  fever,  262;  in 
scurvy,  448;  in  small-pox,  317,  322;  in 


1180 


INDEX 


typhoid  fever,  13,  20,  21;  in  typhus 
fever,  355;  in  whooping  cough,  121;  in 
yellow  fever,  358;  syphilis  of,  275. 

Heart-block,  778,  779;  arrhythmia  due  to, 
772. 

Heart-burn,  480. 

Heart  disease,  620,  622;  acute  cerebro- 
spinal  leptomeningitis  in,  949 ;  acute 
chorea  and,  1067;  anaemia  resembling, 
739;  catarrhal  jaundice  in,  563;  cerebral 
embolism  in,  998;  chronic,  fibrinous 
casts  in  expectoration  of,  632;  chronic 
gastritis  and,  480;  chronic,  resophageal 
varices  and,  473;  chronic  pulmonary 
apoplexy  in,  637;  congenital  infantilism 
and,  892,  893;  congenital,  hypertrophic 
pulmonary  arthropathy  in,  1143;  differ- 
entiation of  chlorosis  from,  733;  ery- 
thraemia  and,  757;  hydrothorax  in,  668, 
669 ;  in  pulmonary  tuberculosis,  209 ; 
ffidema  of  lungs  in,  635;  terminal  infec- 
tions in,  53;  terminal  pneumonia  in,  93, 
97. 

Heart  failure,  due  to  dilatation  of  colon, 
552;  in  tachycardia,  777. 

Heart  murmurs,  in  acute  chorea,  1070, 
1071;  in  acute  endocarditis,  801;  in 
•aneurism  of  abdominal  aorta,  860;  in 
aneurism  of  thoracic  aorta,  853,  854;  in 
aortic  incompetency,  812,  813 ;  in  aortic 
stenosis,  815,  816;  in  arterio-sclerosis, 
845;  in  arterio-venous  aneurism,  861, 
862;  in  case  of  imperfect  septum,  832; 
in  chronic  adhesive  pericarditis,  769 ;  in 
congenital  heart  disease,  835,  836;  in 
dilatation  aneurism  of  the  thoracic 
aorta,  850 ;  in  exophthalmic  goitre,  878 ; 
in  mitral  incompetency,  819,  820;  in  mi- 
tral stenosis,  822,  823 ;  in  palpitation, 
771 ;  in  pernicious  anaemia,  736 ;  in  pul- 
monary valve  region,  825,  826 ;  in  tricus- 
pid  regurgitation,  825;  in  tricuspid 
stenosis,  825. 

Heart  shock,  783. 

Heart  sounds,  in  acute  chorea,  1071 ;  in 
acute  fibrinous  pericarditis,  761,  762; 
in  acute  sero-fibrinous  pleurisy,  659 ;  in 
aneurism  of  the  thoracic  aorta,  853 ;  in 
aortic  incompetency,  812,  813,  814;  in 
arterio-sclerosis,  845;  in  cardiac  hyper- 
trophy, 782 ;  in  cardiac  insufficiency, 
790;  in  chlorosis,  732;  in  chronic  in- 
terstitial nephritis,  707;  in  dilatation 
aneurism  of  the  thoracic  aorta,  850;  in 
exophthalmic  goitre,  878;  in  fatty  heart, 
791;  in  hypertrophic  emphysema,  649; 
in  lobar  pneumonia,  86;  in  mitral  in- 
competency, 819,  820;  in  mitral  stenosis, 
822,  823;  in  palpitation,  771;  in  peri- 


carditis with  effusion,  765,  766;  in  tri- 
cuspid stenosis,  825;  in  typhoid  fever, 
20,  21. 

Heart  stimulants  in  cardiac  failure,  793, 
794. 

Heart  strain  due  to  excessive  dilatation, 
783. 

Heat  cramps,  393. 

Heat  exhaustion,  390;    treatment  of,  392. 

Heberden's  nodes,  in  arthritis  deformans, 
1136,  1137,  1140;  treatment  of,  1142. 

Heel,  painful,  of  gonorrhosa,  125. 

Heine-Medin 's  disease,  364,  940,  941  (see 
also  Polio-myelitis,  acute)  ;  poliencepha- 
litis  in,  1014. 

Helminthiasis,   tetany   due  to,   881. 

Hemeralopia,   1030. 

HemianEesthesia,  due  to  lesions  in  the  cen- 
trum ovale,  970;  hemianopia  and,  1034; 
in  cerebral  haemorrhage,  995;  in  cerebral 
softening,  1000;  in  lesion  of  the  internal 
capsule,  972;  in  traumatic  hysteria, 
1117;  in  tumors  of  brain,  1012. 

Hemianopia,  bitemporal, ,  in  acromegaly, 
891;  diagnosis  of,  1034;  due  to  aneu- 
rism of  cerebral  blood-vessels,  1004;  due 
to  blocking  of  posterior  cerebral,  1000; 
due  to  lesion  in  centrum  ovale,  970; 
due  to  lesion  of  crura,  973;  due  to  lesion 
of  internal  capsule,  972;  due  to  lesions 
of  optic  tract  and  nerve,  1032,  1033; 
heteronymous,  1031;  homonymous,  1031; 
in  brain  abscess,  1017 ;  in  cerebral 
haemorrhage,  995;  in  cerebral  tumors, 
1011,  1012;  in  diabetes  insipidus,  440; 
in  haemorrhage  in  crus,  993 ;  in  hysteria, 
1099 ;  in  migraine,  1088 ;  in  tumor  of 
pituitary  gland,  1013;  lateral,  1081; 
nasal,  1032;  temporal,  1032. 

Hemi-ataxia,  due  to  lesion  of  the  crura, 
973;  due  to  lesion  of  pons  and  medulla 
oblongata,  974. 

Hemiathetosis,  due  to  lesion  of  internal 
capsule,  972. 

Hemiatrophy,  facial,  1125;  of  tongue,  due 
to  paralysis  of  hypoglossal  nerve,  1055. 

Hemi-chorea,  1070;  due  to  lesion  of  in- 
ternal capsule,  972. 

Hemichromatopsia,   1034. 

Hemicrania.      (See  Migraine.) 

Hemiopia  in  migraine,  1088. 

Hemiplegia,  910;  due  to  blocking  of  in- 
ternal carotid,  1001 ;  due  to  blocking  of 
middle  cerebral  artery,  1001;  due  to 
lesion  of  crura,  973;  due  to  lesion  of  in- 
ternal capsule,  972;  due  to  lesions  of 
motor  cortex,  969;  epilepsy  following, 
1084;  facial  paralysis  and,  1041;  fol- 
lowing acute  polio-myelitis,  366;  follow- 


INDEX 


1181 


ing  aspiration  in  pleurisy,  666;  hemi- 
anopia  and,  1034;  hysterical,  1098;  in 
acute  bulbar  paralysis,  931;  in  arterio- 
sclerosis, 845;  in  cerebral  haemorrhage, 
991-996;  in  cerebral  syphilis,  271;  in, 
children,  etiology  of,  1006;  in  children, 
morbid  anatomy  of,  1006,  1007;  in  chil- 
dren, symptoms  of,  1007,  1008;  in  chil- 
dren, treatment  of,  1008,  1009;  in 
chronic  Bright 's  disease,  695,  696;  in 
haemorrhage  from  the  stomach,  508;  in 
haemorrhagic  pachymeningitis,  947;  in 
lead  poisoning,  403 ;  in  locomotor  ataxia, 
918;  in  malaria,  254;  in  measles,  347; 
in  migraine,  1088;  in  mitral  stenosis, 
824;  in  mumps,  351;  in  pulmonary  tu- 
berculosis, 205;  in  scarlet  fever,  339;  in 
scurvy,  448;  in  small-pox,  332;  in  soft- 
ening of  brain,  1000;  in  tuberculous 
meningitis,  173;  in  tumors  of  the  brain, 
1012,  1013;  in  typhoid  fever,  29;  infan- 
tile, convulsions  in,  1079;  infantile,  con- 
vulsions preceding,  1078;  infantile,  in 
varicella,  332;  infantile,  poliencephalitis 
in,  1015 ;  paralysis  of  tongue  in,  1054, 
1055;  spastica  cerebralis,  1007;  tran- 
sient, in  Eaynaud's  disease,  1121. 

Hemiplegie  flasque,  996. 

Henoch's  purpura,  753. 

Hepatic  abscess,  239,  240,  243. 

Hepatic  artery,  563 ;  aneurism  of,  861. 

Hepatic   distomiasis,  282,  283. 

Hepatic  duct,  congenital  absence  o±,  558. 

Hepatic  intermittent  fever,  in  chronic  ca- 
tarrhal  angiocholitis,  565;  in  gall-stones, 
573;  in  obstruction  of  the  bile-ducts, 
567. 

Hepatic  splenomegaly,  888. 

Hepatic  veins,  affections  of,  562,  563. 

Hepatitis,  amoebic  (-see  Amosbiasis)  ;  con- 
genital syphilitic,  anc1  icterus  neona- 
torum,  558;  in  general  septic^mia,  50; 
in  malaria,  248;  in  syphilis,  273.. 

Hepatization,  gray,  in  lobar  pneumonia, 
79;  red,  stage  of,  in  lobar  pneumonia, 
79;  white,  272. 

Hereditary  ataxia,  944;  cerebellar  type  of, 
945;  diagnosis  of,  945;  morbid  anat- 
omy of,  944;  symptoms  of,  944. 

Hereditary  icterus,  557,  558. 

Hereditary  spastic  paraplegia,  938,  939. 

Heredity,  in  angina  pectoris,  837;  in  an- 
gio-neurotic  oedema,  1123,  1124;  in  can- 
cer of  liver,  587;  in  cancer  of  stomach, 
498;  in  chlorosis,  730;  in  chronic  chorea, 
1076;  in  cystinuria,  690;  in  diabetes, 
429,  430;  in  diabetes  insipidus,  439;  in 
epilepsy,  1080;  in  general  paralysis, 
922;  in  gout,  418,  420;  in  .haemophilia, 


755,  756;  in  hay  fever,  612;  in  hyper- 
trophic  emphysema,  646;  in  hysteria, 
1096;  in  leprosy,  152;  in  migraine, 
1087;  in  muscular  dystrophies,  932;  in 
myotonia,  1131;  in  myxcedema,  875;  in 
neurasthenia,  1107;  in  obesity,  451;  in 
optic  atrophy,  1031;  in  paramyoclonus 
multiplex,  1133;  in  periodical  paralysis, 
1119;  in  progressive  central  muscular 
atrophy,  928;  in  rheumatic  fever,  372; 
in  tuberculosis,  158,  161,  162;  in  tu- 
berculosis of  the  genito-urinary  tract, 
215;  peptic  ulcer  and,  491. 

Hernia,  exclusion  of,  in  diagnosis  of  in- 
testinal obstruction,  543;  in  appendi- 
citis, 536;  intestinal  catarrh  in,  517; 
phlegmonous  enteritis  in,  520;  resem- 
bling pneumothorax,  671;  strangulated, 
tuberculous  peritonitis  confused  with,  180. 

Hernial  sacs  and  tuberculous  peritonitis, 
180. 

Herpes,  in  acute  cerebro-spinal  pachymen- 
ingitis, 950;  in  acute  gastritis,  477;  in 
arsenical  poisoning,  407;  in  cerebro- 
spinal  fever,  111;  in  compression  mye- 
litis, 960;  in  disease  of  fifth  nerve, 
1039;  in  facial  paralysis,  1043;  in  gen- 
eral tuberculosis,  169;  in  influenza,  118; 
in  lobar  pneumonia,  88;  in  locomotor 
ataxia,  915,  918;  in  malaria,  250;  in 
relapsing  fever,  262;  in  typhoid  fever, 
19. 

Herpes  zoster,  fifth  nerve  in,  1039;  in 
acute  chorea,  1072;  in  diabetes,  434;  in- 
tercostal neuralgia  following,  1091;  (see 
Posterior  ganglionitis,  acute). 

Herpetic  stomatitis,  458. 

Hiccough,  in  hysteria,  1100;  in  transverse 
myelitis  in  the  cervical  region,  968;  in- 
flammatory, 1056;  irritative,  1056;  neu- 
rotic, 1056;  specific,  1056;  treatment  of, 
1057. 

Hip- joint  disease,  differentiation  of  peri- 
nephric  abscess  from,  726;  differentia- 
tion of  sciatica  from,  1062. 

Hippocratic  fingers,  206. 

Hippus  in  migraine,  1088. 

Hirschsprung 's   disease,   552,  553. 

Hoarseness,  in  acute  bronchitis,  621;  in 
acute  pharyngitis,  465;  in  aneurism  of 
the  thoracic  aorta,  855;  in  laryngitis, 
615,  616,  618;  in  unilateral  abductor 
paralysis,  1050. 

Hodgkin's  disease,  acute  form  of,  748; 
confusion  of,  with  septico-pysemia,  52; 
course  of,  750;  definition  of,  746,  747; 
diagnosis  of,  749,  750;  etiology  of,  747; 
histology  of,  748;  history  of,  747;  latent 
type  of,  749;  localized  form  of,  748; 


1182 


INDEX 


lymphadenitis  and,  672 ;  morbid  anat- 
omy of,  747;  purpura  in,  751;  spleno- 
megalic  form  of,  749;  symptoms  of, 
748,  749 ;  terminal  infections  in,  53 ; 
treatment  of,  750;  tumors  of  spleen  in, 
885;  with  relapsing  pyrexia,  749. 

Hodgson,  maladie  de,  849. 

Hoffmann's  bacillus,  60. 

Hook-worm,  301,  302;  pernicious  anaemia 
due  to,  734;  infantilism  and,  892;  (see 
Ankylostomiasis) . 

Horses,  glanders  in,  146;  haemoglobinuria 
in,  683. 

Hour-glass  contraction  of  stomach  follow- 
ing peptic  ulcer,  492,  495. 

Hunger,  bradycardia  and,  777;  excessive, 
514;  pneumogastric  nerve  and,  1051. 

Huntington's  chorea,  1076,  1077. 

Hutchinson's  teeth,  269. 

Hyaline  casts  in  albuminuria,   685. 

Hyaline  transformation  of  Zenker,  789. 

Hydatid  cyst,  of  brain,  1010;  of  medias- 
tinum, 675 ;  of  spleen,  885. 

Hydatid  disease  of  liver,  localized  perito- 
nitis and,  604. 

Hydatids,  289,  290;  pulmonary,  fibroid 
changes  due  to,  640 ;  (see  Echinococcus) . 

Hydrarthrosis,  chronic,  125;  in  hysteria, 
1102;  intermittent,  1143. 

Hydrencephaloid  state,  527,  986,  1078. 

Hydrocephalie   cry,   172. 

Hydrocephalus,  acquired  chronic,  1019; 
1020;  acute,  171  (see  also  Meningeal 
form  of  acute  miliary  tuberculosis) ; 
cerebro-spinal  fever  and,  113;  congeni- 
tal, 1019;  definition  of,  1018;  due  to 
tumor  of  cerebellum,  976;  externus,  or 
ex  vacuo,  1018;  hypophysial  symptoms 
in,  890;  idiopathic  internal  or  angio- 
neurotic,  1018,  1019;  treatment  of, 
1020. 

Hydromyelus,  948;  syringomyelia  distin- 
guished from,  964. 

Hydronephrosis,  cyst  of  mesentery  con- 
fused with,  555;  definition  of,  715; 
echinococcus  of  liver  differentiated  from, 
292;  etiology  of,  715,  716;  intermittent, 
following  movable  kidney,  678;  symp- 
toms of,  716,  717;  treatment  of,  717. 

Hydropericardium,  769. 

Hydro-peritoneum.     (See  Ascites.) 

Hydrophobia,  definition  of,  368;  diagnosis 
of,  370;  distribution  of,  368;  etiology 
of,  368,  369;  morbid  anatomy  of,  369; 
pharyngeal  spasm  in,  1050 ;  spasm  of  the 
cesophagus  in,  473;  symptoms  of,  369, 
370;  treatment  of,  370,  371. 

Fydro-pneumothorax.  (See  Pneumotho- 
rax.) 


Hydrops  vesiese  felleae,  571. 

Hydrotherapy,  in  acute  Bright 's  disease. 
700;  in  acute  bronchitis,  622;  in  an- 
gina pectoris,  840;  in  arthritis  defor- 
mans,  1141,  1142;  in  asthma,  631;  in 
broncho-pneumonia,  107;  in  cerebro- 
spinal  fever,  115;  in  dengue,  363;  in 
diarrhoea,  528;  in  gastric  neuroses,  514; 
in  heat  exhaustion,  392,  393;  in  Malta 
fever,  132;  in  plague,  141;  in  pneu- 
monia, 100;  in  scarlet  fever,  342;  in 
sciatica,  1063;  in  septico-pyaemia,  52; 
in  spasmodic  laryngitis,  617;  in  treat- 
ment of  hysteria,  1105,  1106;  in  treat- 
ment of  neurasthenia,  1115;  in  typhoid 
fever,  42-43;  in  typhus  fever,  356;  in 
yellow  fever,  360. 

Hydrothorax,  668,  669;  in  cardiac  insuffi- 
ciency, 794;  in  mitral  incompetency, 
819;  simulating  pleural  effusion,  664. 

Hymenolepis  diminuta,  285;  nana,  285. 

Hyperacidity,  511,  512;  treatment  of,  515. 

Hyperacusis,  1046;   in  neurasthenia,  1109. 

Hypersemia,  679;  fluctionary,  asthma  due 
to,  628;  in  gonococcus  infection,  125; 
in  Raynaud's  disease,  1120,  1121;  me- 
chanical, 679,  680;  of  brain,  985,  986; 
of  liver,  561,  562;  of  mucosa  in  asthma, 
628,  629;  of  pharynx,  464;  of  skin  in 
neurasthenia,  1110;  of  skin  in  sclero- 
derma,  1125. 

Hyperaesthesia,  due  to  lesion  of  the  coch- 
lear  nerve,  1046;  in  acute  diffuse  mye- 
litis, 966 ;  in  acute  transverse  myelitis, 
967;  in  cervical  rib  pressure,  1057;  in 
haematomyelia,  959;  in  hydrophobia, 
370;  in  hysteria,  1097,  1100;  in  Lan- 
dry's  paralysis,  942;  in  locomotor 
ataxia,  917;  in  neurasthenia,  1108;  in 
neuritis,  1023;  in  spinal  haemorrhagic 
pachymeningitis,  948;  in  traumatic 
neuroses,  1117;  in  unilateral  lesions  of 
the  spinal  cord,  955;  in  writer's  cramp, 
1094;  of  skin  and  muscles  in  acute  cere- 
bro-spinal leptomeningitis,  950;  of 
stomach,  513;  of  stomach,  treatment  of, 
515,  516;  retinal,  1030. 

Hyperalgesia  in   neurasthenia,   1109. 

Hyperchlorhydria,  511,  512;  indicanuria 
in,  691. 

Hyperglobulism  in  erythraemia,  757. 

Hyperglycsemia  in  diabetes,  427.  428,  430, 
433. 

Hyperkinesis,  509. 

Hypernephroma,  722. 

Hyperosmia,  1028. 

Hyperpituitarism,  890. 

Hyperplasia,  in  typhoid  fever,  9,  10;  of 
lymphatic  tissues  in  lymphatism,  869; 


INDEX 


1183 


of   pituitary  gland,  891;    of  suprarenal 
glands,   867. 

Hyperpyesis,  842. 

Hyperpyrexia,  hysterical,  1103;  in  rheu- 
matic fever,  375. 

Hypertension,  arterio-sclerosis  due  to,  841, 
842. 

Hypertrophic  cirrhosis  of  liver,  580,  581; 
splenomegaly  in,  888. 

Hypertrophic,  emphysema,  course  of,  649 ; 
etiology  of,  646,  647;  morbid  anatomy 
of,  647;  symptoms  of,  647-649;  treat- 
ment of,  649,  650. 

Hypertrophic  pulmonary  arthropathy,  defi- 
nition of,  1143;  diagnosis  of,  1144;  eti- 
ology of,  1143,  1144;  symptoms  of,  1144. 

Hypertrophic  sclerosis  of  brain,  952. 

Hypertrophic  stenosis  of  pylorus,  505,  506. 

Hypertrophy,  concentric,  in  aortic  stenosis, 
815;  general,  in  acromegaly,  891,  892; 
of  adenoid  tissue  in  the  vault  of  the 
pharynx,  468,  471;  of  bladder  and 
ureters  in  hydro nephrosis,  715;  of  breast 
in  pulmonary  tuberculosis,  221;  of  coats 
of  stomach,  perigastric  adhesions  and, 
493 ;  of  the  left  heart,  in  chronic  paren- 
chymatous  nephritis,  703;  of  left  ven- 
tricle in  arterio-sclerosis,  845;  of  pros- 
tate, hydronephrosis  due  to,  716;  of 
stomach  wall,  486;  of  thymus  gland, 
868,  869. 

Hypertrophy,  cardiac,  cerebral  haemor- 
rhage and,  988;  chronic  adhesive  peri- 
carditis and,  768;  compensatory,  806, 
807;  dilatation  and,  782;  due  to  aortic 
incompetency,  810,  811 ;  due  to  mitral 
incompetency,  817,  818;  fibrous  myo- 
carditis and,  787;  idiopathic,  mitral  in- 
competency confused  with,  820;  in  ar- 
terio-sclerosis, 844;  in  chronic  intersti- 
tial nephritis,  705,  706,  707;  in  congeni- 
tal heart  disease,  835;  in  hydronephro- 
sis, 716;  in  mitral  stenosis,  821,  822;  in 
polycystic  kidneys,  724;  in  stenosis  of 
pulmonary  valve,  826;  symptoms  of, 
781,  782;  varieties  of,  780,  781. 

Hypertrophy,  muscular,  in  muscular  dys- 
trophies, 932,  933;  in  myotonia,  1132; 
in  spasmodic  wryneck,  1053;  in  spastic 
paralysis  of  adults,  936. 

Hypnosis  in  treatment  of  hysteria,  1104. 

Hypochondriasis,  appendicular,  537;  dif- 
ferentiation of  neurasthenia  from,  1112; 
in  general  paralysis,  923;  in  mucous 
colitis,  551 ;  oxaluria  and,  689 ;  spasm 
of  O3sophagus  in,  473. 

Hypoglossal  nerve,  lesions  of,  1054,  1055. 

Hypophysis,  functions  of,  889;  glycosuria 
and,  428. 


Hypophysis  cerebri,  889. 

Hypopituitarism,  890. 

Hypoplasia  of  the  suprarenal  glands,  867, 
868. 

Hypostatic  congestion  of  the  lungs,  94, 
634,  635. 

Hypothermia  in  typhoid  fever,  18. 

Hypothyroidism,  clinical  forms  of,  874- 
876;  definition  of,  873;  history  of,  873, 
874;  treatment  of,  876,  877. 

Hypotonia  in  locomotor  ataxia,  916. 

Hysteria,  adductor  paralysis  in,  1050; 
Babinski's  theory  of,  1095;  Breuer- 
Freud  theory  of,  1096;  causing  consti- 
pation, 545;  cough  in,  1100;  definition 
of,  1095;  diagnosis  of,  1103,  1104;  dif- 
ferentiation %of  chorea  from,  1073 ;  dif- 
ferentiation of  epilepsy  from,  1084, 
1085;  differentiation  of  neurasthenia 
from,  1112;  differentiation  of  sclero- 
sis of  brain  from,  953 ;  etiology  of,  1095- 
1097;  excessive  hunger  in,  514;  gastric 
hyperaesthesia  in,  513;  haematemesis  in, 
507;  hemianopia  in,  1034;  haemoptysis 
in,  1100;  in  lead  poisoning,  405;  in 
mucous  colitis,  551 ;  intestinal  obstruc- 
tion and,  542;  laryngeal  paralysis  in, 
1050;  morphia  habit  and,  401;  muscular 
spasm  in,  1056;  palpitation  due  to,  770; 
reeducation  in,  1105;  simulating  ap- 
pendicitis, 537;  spasm  of  O3sophagus  in, 
473;  spasm  of  tongue  in,  1055;  symp- 
toms of,  1097-1103;  traumatic,  1116- 
1119;  treatment  of,  1104-1106;  trismua 
in,  1040;  tympanites  in,  1101;  visceral 
neuralgias  in,  1092. 

Hysterical  amaurosis,  1030. 

Hysterical  anuria,  680. 

Hysterical  peritonitis,  603. 

Hysterical  polyuria,  differentiation  of  dia- 
betes insipidus  from,  441. 

Hysterical  purpura,  751. 

Hysterical  spastic  paraplegia,  940. 

Hystero-epilepsy,    1097. 

Hysterogenic  points,  1097,  1100. 


Ice,  use  of,  in  heat  exhaustion,  392,  393. 
Ice-cream,   poisoning   from,   409. 
Ichthyosis  lingualis,  460. 
Icterus   (see  Jaundice) ;   gravis,  557,  559- 

561;    hereditary,   557,   558;    in   rubella, 

349;   neonatorum,  557,  558;   syphiliticu3 

praecox,  267. 
Idiocy,   amaurotic   family,  939;   following 

hemiplegia  in  children,  1008. 


1184 


INDEX 


Ileitis,  519. 

Ileo-colitis,  527,  528;  acute,  broncho- 
pneumonia  secondary  to,  101. 

Ileus,  hysterical,  542,  1101;  paralytic,  541. 

Imbecility,  cretinism  and,  874;  following 
hemiplegia  in  children,  1008;  in  con- 
genital hydrocephalus,  1019;  in  tumors 
of  the  brain,  1011. 

Immunity,  to  cholera,  133;  to  tuberculo- 
sis, 157,  158,  159-161;  to  typhoid  fever, 
3. 

Immunization  to  diphtheria,  70. 

Impetigo  contagiosa,  resembling  small-pox, 
324. 

Impotence,  in  acromegaly,  892;  in  dia- 
betes, 434;  in  Erb's  syphilitic  spinal  pa- 
ralysis, 939. 

Inanition,  chronic  secondary  anaemia  due 
to,  729. 

Incoordination,  cerebellar,  in  brain  abscess, 
1017;  due  to  lesion  of  vestibular  nerve, 
1047;  in  chorea,  1069;  in  chronic 
chorea,  1077;  in  neurasthenia,  1110;  in 
tumors  of  brain,  1013;  muscular,  due  to 
lesion  of  cerebellum,  974;  muscular,  in 
ataxic  paraplegia,  943;  muscular,  in 
hereditary  ataxia,  944;  muscular,  in  lo- 
comotor  ataxia,  916. 

Indicanuria,   691. 

Indigestion,  acute  intestinal,  in  children, 
526;  due  to  gall-stones,  570;  foul  breath 
and,  461;  in  cardiac  insufficiency,  790; 
in  epilepsy,  1081. 

Indigo,  calculi  of,  718. 

Induration,  fibroid,  of  heart,  275;  of  skin 
in  scleroderma,  1126. 

Indurative  headache,  1130. 

Indurative  mediastino-pericarditis,  675, 
767-769. 

Infantile  convulsions.      (See  Convulsions.) 

Infantile   meningeal  haemorrhage,   997. 

Infantile  spinal  paralysis,  940,  941. 

Infantilism,  angioplastic,  893 ;  Brissaud 
type  of,  890,  893;  cachectic,  892,  893; 
cretinoid,  893;  definition  of,  892;  etiol- 
ogy of,  893;  Frolich  type  of,  890,  893; 
hormonic  type  of,  893;  hypopituitarism 
and,  890;  hypoplasia  of  suprarenal 
bodies  in,  864;  idiopathic,  893;  intes- 
tinal, 893;  jaundice  and,  558;  Lorain 
type  of,  890,  893;  of  congenital  syph- 
ilis, 269;  pancreatico-intestinal,  893; 
progeria,  893. 

Infarct,  hsemorrhagic,  of  lung,  637;  in 
acute  endocarditis,  800;  in  bowels, 
553,  554;  in  kidney,  718;  in  liver, 
562;  in  spleen,  885;  septic,  787; 
white,  786. 

Infarction,     fragmentation    in,     788;     of 


bowel,  553,  554;  renal,  hsematuria  and, 
681. 

Infection  theory  of  pernicious  anaemia, 
735. 

Infectious  cirrhosis  of  liver,  576. 

Inferior  occipital  nerve,  neuralgia  of,  1091. 

Infiltration  tuberculeuse,   189 ;  jaune,  167. 

Inflammation,  of  brain,  1014-1018;  of  cord, 
peritonitis  and,  603;  of  salivary  glands, 
463,  464. 

Inflammatory   diarrhoea,  527,  528. 

Influenza,  angina  pectoris  following,  837; 
appendicitis  and,  532;  bacteriology  of, 
117;  brain  abscess  following,  1016; 
bronchiectasis  and,  625;  broncho-pneu- 
monia secondary  to,  101,  102;  complica- 
tions of,  118;  definition  of,  115;  diagno- 
sis of,  118;  differentiation  of  simple 
coryza  from,  383;  encephalitis  follow- 
ing, 1015;  etiology  of,  116;  history  of, 
116;  laryngitis  in,  615;  leukaemia  and, 
746;  neurasthenia  following,  1107;  nos- 
tras,  116;  secondary  pneumonia  in,  93; 
suppurative  cholangitis  and,  565;  symp- 
toms of,  117;  treatment  of,  119;  types 
of,  117;  typhoid  fever  and,  32;  vera, 
116. 

Influenza  bacillus  in  bronchitis,  620;  in 
empyema,  660. 

Inhalation,  pneumonia,  94,  102. 

Injury,  aneurism  due  to,  849;  appendicitis 
and,  532;  cancer  of  stomach  and,  489; 
delirium  tremens  and,  398,  399 ;  haema- 
temesis  following,  507;  haematuria  due 
to,  682;  of  head  and  spine,  dilatation  of 
stomach  following,  486;  parotitis  follow- 
ing, 463;  peptic  ulcer  following,  491; 
tetanus  and,  143. 

Insanity,  delusional,  in  uraemia,  694;  di- 
latation of  stomach  and,  487;  following 
mumps,  351 ;  haemorrhagic  pachymenin- 
gitis  and,  946,  947;  in  pulmonary  tu- 
berculosis, 205;  movable  kidney  and, 
677;  parosmia  in,  1028;  post-febrile,  in 
small-pox,  322;  post-typhoid,  46;  rela- 
tion of  alcoholism  to,  397. 

Insolation.      (See  Sunstroke.) 

Insomnia,  in  delirium  tremens,  399;  in 
dengue,  363;  in  pericarditis  with  effu- 
sion, 764;  morphia  habit  and,  401. 

Inspiratory  theory  of  hypertrophic  emphy- 
sema, 646. 

Insufficiency,  cardiac,  784;  cardiap,  due  to 
valve  lesions,  805;  of  pylorus,  511;  pan- 
creatic, 592,  593. 

Intention  tremor,  so-called,  in  multiple 
sclerosis  of  brain,  953. 

Intercostal  neuralgia,  1091. 

Interlobar  pleurisy,  663. 


INDEX 


1185 


Intermittent  albuminuria,  685. 

Intermittent  cerebro-spinal  fever,  112. 

Intermittent  claudication,  846. 

Intermittent  fever,  248-252;  confusion  of 
abscess  of  liver  with,  585;  renal,  720. 

Intermittent  hydrarthrosis,   1143. 

Intermittent  hydronephrosis,  716. 

Internal  capsule,  hemiplegia  due  to  lesion 
of,  992;  lesions  of,  971,  972. 

Internal  carotid,  symptoms  of  blocking  of, 
1000. 

Internal  ear,  auditory  nerve,  lesions  in, 
1046. 

Internal  popliteal  nerve,  lesions  of,  1061. 

Interstitial   emphysema,  650. 

Interstitial  neuritis,   1021. 

Interstitial   orchitis,   276. 

Intestinal  anthrax,  149,  150. 

Intestinal  distomiasis,  283. 

Intestinal  obstruction,  confusion  of  chole- 
cystitis and,  566;  diagnosis  of',  543, 
544;  dilatation  of  mesenteric  veins  in, 
554;  due  to  local  adhesive  peritonitis, 
606;  etiology  and  pathology  of,  538-542; 
symptoms  of,  542,  543;  treatment  of 
544,  545;  tuberculous  peritonitis  and, 
180. 

Intestinal  sand,  553. 

Intestinal  worms,  convulsive  tic  due  to, 
1044. 

Intestines,  amyloid  degeneration  of,  in 
fibroid  phthisis,  202;  as  a  means  of  in- 
fection in  genito-urinary  tuberculosis, 
216;  diseases  of,  515-555;  haemorrhage 
from,  in  amoebiasis,  241;  in  actinomy- 
cosis,  232;  in  bacillary  dysentery,  127; 
in  cerebro-spinal  meningitis,  110;  in 
cholera  asiatica,  135;  in  chronic  ulcer- 
ative  tuberculosis,  190;  in  Hodgkin's 
disease,  747;  in  malarial  cachexia,  248; 
in  pellagra,  412;  in  pulmonary  tubercu- 
losis, 204,  205;  in  typhoid  fever,  9-11, 
22,  23 ;  inf arcts  in,  in  acute  endocarditis, 
800 ;  infections  of,  due  to  Bacillus  coli, 
48;  irritability  of,  following  dysentery, 
128 ;  kinks  of,  546 ;  lesions,  in,  in  amo3- 
biasis,  239 ;  perforation  of,  in  amosbia- 
sis,  241;  stricture  of,  following  dysen- 
tery, 128;  tuberculosis  of,  212,  213. 
Intoxications,  acute  secondary  anaemia 
following,  728;  arterio-sclerosis  due  to, 
843 ;  chronic  secondary  anaemia  in,  730. 
Intracerebral  haemorrhage,  989. 
Intracranial  pressure,  983. 
•Intravenous  injections  in  cholera  asiatica, 

138. 

Intubation  in  diphtheria,  71. 
Intussusception  causing  intestinal  obstruc- 
tion, 539,  540;  diagnosis  of,  544;  phleg- 


monous  enteritis  in,  520;  purpura  con- 
fused with,  752. 

Invagination  (see  Intussusception),  intes- 
tinal catarrh  in,  517. 

Iodide  of  potassium  in  treatment  of  syph- 
ilis, 280,  281;  purpura  due  to,  751. 

Iridoplegia,   1036. 

Iritis,  complicating  gonococcus  infection, 
125;  gout  and,  423;  in  congenital  syph- 
ilis, 269;  in  influenza,  118;  in  small- 
pox, 322;  in  syphilis,  267. 

Iron,  in  treatment  of  cardiac  insufficiency, 
794;  in  treatment  of  chlorosis,  739,  740. 

"Irritable  eye"  in  neurasthenia,  1109. 

Irritable  heart,  771. 

"Irritable  humor,"  in  neurasthenia,  1108. 

Irritable  testis,  1091. 

Irritable  weakness  in  cerebral  anaemia, 
986. 

Ischaemia  in  Kaynaud's  disease,  1120. 

Itch  insect,  310,  311. 

Itching,  in  diabetes,  433,  434;  in  morphia 
habit,  401;  of  eyeballs  in  gout,  423;  of 
feet  in  gout,  423 ;  of  skin  in  chronic  in- 
terstitial nephritis,  708;  of  skin  in  urae- 
mia, 695. 

Ixodes  ricinus,  311. 

Ixodiasis,  311. 


Jacksonian  epilepsy,  1080;  associated  with 
actinomycosis,  233;  diagnosis  of,  1084; 
due  to  lesions  of  cerebral  cortex,  969; 
in  general  paralysis,  924;  in  tuberculous 
meningitis,  173;  symptoms  of,  1084; 
(see  also  Epilepsy). 

Jaundice,  alcoholic,  887;  bradycardia  in, 
777;  catarrhal,  563,  564;  chronic,  hyper- 
trophic  pulmonary  arthropathy  in,  1143; 
chronic  secondary  anaemia  and,  730;  defi- 
nition of,  555;  due  to  pancreatic  cancer, 
599;  following  malaria,  252;  gastralgia 
and,  514;  haemohepatogenous,  557;  hae- 
molytic,  557;  in  acute  endocarditis, 
802;  in  alcoholic  cirrhosis,  578;  in  bil- 
iary colic,  570,  571;  in  cancer  of  bile- 
passages,  567;  in  cancer  of  liver,  588; 

,  in  chronic  catarrhal  angiocholitis,  565; 
in  chronic  pancreatitis,  596;  in  con- 
genital obliteration  of  bile  ducts,  568 ;  in 
congestion  of  liver,  562;  in  diphtheria, 
67;  in  epidemic  haemoglobinuria,  754;  in 
general  tuberculosis,  109;  in  hepatic  dis- 
tomiasis, 282;  in  hypertrophic  cirrhosis, 
580;  in  leukaemia,  743;  in  lobar  pneu- 
monia, 88,  91;  in  malaria,  253;  in  mitral 
incompetency,  819;  in  morbus  maculosus 


1186 


INDEX 


neonatorum,  755;  in  multilocular  echino- 
coccus,  293,  294;  in  obstruction  of  com- 
mon duct,  572,  573;  in  pancreatic  cysts, 
598;  in  paroxysmal  haemoglobinuria, 
683;  in  pneumonia,  91;  in  relapsing  fe- 
ver, 262;  in  splenic  anaemia,  887;  in 
suppurative  angiocholitis,  565;  in  syph- 
ilis, 267;  in  syphilis  haemorrhagica  neo- 
natorum, 754;  in  syphilis  of  liver,  273; 
in  typhoid  fever,  26;  in  yellow  fever, 
358,  359;  infectious,  384,  385;  intra- 
hepatic,  557;  malignant,  559-561;  mela- 
nuria  in,  691,  692;  obstructive,  555-557; 
pernicious  anaemia  resembling,  739; 
purpura  in,  751;  toxaemic  and  haemo- 
lytic,  557. 

Jejunal  peptic  ulcer,   493. 

Jejunitis,  519. 

Jigger,  313. 

Joints,  affections  of,  hysterical,  1102;  af- 
•fections  of,  with  bacillary  dysentery, 
128;  changes  in,  in  gout,  420;  diseases 
of,  1134-1143;  in  gonococcus  infections, 
125;  in  rheumatic  fever,  373,  374. 

Jumpers,  1076. 


Kahler's  disease,  686. 

Kakke.     (See  Beri-beri.) 

Kala-azar,  260,  261;  differentiation  of 
splenic  anaemia  from,  888. 

Kamitachi  disease,  1103. 

Katayama  disease,  284. 

Keratitis,  associated  with  cervical  adeni- 
tis, 176;  in  cerebro-spinal  fever,  113;  in 
congenital  syphilis,  269;  in  measles,  346; 
in  small-pox,  322;  leprous,  153. 

Keratosis  in  arsenical  poisoning,  407. 

Kernig's  sign,  in  acute  cerebro-spinal 
leptomeningitis,  950;  in  acute  polio- 
myelitis, 366;  in  cerebro-spinal  fever, 
114;  in  tuberculous  meningitis,  173. 

Kidneys,  amyloid  degeneration  of,  711, 
712;  changes  in,  in  Bright 's  disease, 
697,  698;  changes  in,  in  chronic  intersti- 
tial nephritis,  704,  705;  changes  in,  in 
chronic  parenchymatous  nephritis,  702, 
703;  changes  in,  in  hydronephrosis,  716, 
717;  changes  in,  in  perinephric  abscess, 
725;  changes  in,  in  pyelitis,  712,  713; 
changes  in,  in  thermic  fever,  391 ;  coc- 
cidia  in,  237;  congenital  cystic,  724; 
cysts  of,  723-726;  diseases  of,  676-726; 
displacement  of,  549;  echinococcus  of, 
293;  glycosuria  and,  429,  432,  434;  in 
acute  yellow  atrophy,  560;  in  appendi- 
citis, 534;  in  arterio-sclerosis,  844,  846; 


in  cholera  asiatica,  135;  in  chronic  al- 
coholism, 398 ;  in  diabetes  insipidus, 
440;  in  diphtheria,  62,  63;  in  erysipe- 
las, 54;  in  gout,  420;  in  Hodgkin's  dis- 
ease, 747;  in  lobar  pneumonia,  81;  in 
malarial  cachexia,  248 ;  in  myeloid  leu- 
kaemia, 742;  in  pernicious  anosmia,  734; 
in  pulmonary  tuberculosis,  205;  in  re- 
lapsing fever,  262;  in  scurvy,  447;  in 
small-pox,  317;  in  typhoid  fever,  12;  in 
typhus  fever,  353;  in  yellow  fever,  359; 
infarcts  in,  in  acute  endocarditis,  800; 
metastases  in,  in  cancer  of  stomach, 
503;  polycystic,  724;  syphilis  of,  276; 
tuberculosis  of,  217-219;  tumors  of,  722. 

Kink,  bowel,  540;  duodenal,  546;  of  the 
ileum,  540,  546;  of  sigmoid  flexure,  546; 
traction,  540. 

Klebs-Loeffler  bacillus,  bacteria  associated 
with  59;  in  non-membranous  angina 
and  healthy  throats,  59;  morphological 
characters  of,  58,  59;  occurrence  of,  58; 
toxins  of,  59. 

Knee-jerk,  abolition  of,  in  complete  trans- 
verse lesions  of  spinal  cord,  955;  loss  of, 
in  locomotor  ataxia,  915,  917,  919. 

Koplik's  sign,  345,  347.    • 

Korsakoff's  psychosis,  397,  1024. 

Kubisagari,  1048. 

Kyphosis  in  acromegaly,  892;  in  osteitis 
deformans,  1144. 


Labor,  hemiplegia  in  children  caused  dur- 
ing, 1006. 

"Laboratory  cholera,"  133. 

"Lacing"   liver,  591. 

Lactation,  prolonged,  chronic  secondary 
anaemia  in,  730. 

La  Grippe.      (See  Influenza.) 

Lamblia  intestinalis,  281. 

Lameness,  intermittent,  in  arterio-sclerosis, 
846. 

Laminectomy,  in  compression  myelitis, 
962;  in  tumors  of  spinal  cord,  904; 

Landouzy-Dejerine  type  of  muscular  dys- 
trophies, 933. 

Landry's  paralysis,  941,  942;  differentia- 
tion of  acute  diffuse  myelitis  from,  967. 

Langerhans,  islands  of,  428. 

Lardaceous  degeneration  of  kidneys,  711, 
712. 

Lardaceous  liver,  590,  591. 

Large  white  kidney,  702. 

Larva  migrans,  314. 

Larval  pneumonia,  93. 

Laryngeal  crises  in  locomotor  ataxia,  917. 


INDEX 


1187 


Laryngeal    diphtheria,    65,    66;    treatment 

of,   71. 

Laryngismus,  differentiation  of  acute  lar- 
yngitis from,  615;  stridulus,  617,  618, 
1050;  stridulus,  rickets  and,  445. 
Laryngitis,  acute  catarrhal,  614,  615; 
acute  oedema  of  glottis  following,  616; 
chronic,  615,  616;  complicating  small- 
pox, 321,  323;  in  measles,  346;  cedema- 
tous,  616;  spasmodic,  617,  618;  syphi- 
litic, 619,  620;  tuberculous,  618,  619. 
Larynx,  complications  in,  in  leprosy,  153; 
diseases  of,  614-620;  in  erysipelas,  55; 
in  hydrophobia,  369,  370;  in  pulmonary 
tuberculosis,  191,  202;  in  small-pox,  317; 
in  typhoid  fever,  26;  oedema  of,  in 
angio-neurotic  oedema,  1124;  paralysis 
of,  in  paralysis  of  hypoglossal  nerve, 
1055;  ulceration  of,  in  typhoid  fever, 
12,  13. 

Lasegue's  sign,  1062. 
Latah,  1076. 

"Latent  diphtheria,"  64. 
Lathyrism,  410. 

Lavage,  in  cancer  of  stomach,  505;  in 
chronic  gastritis,  484;  in  diarrhoea,  529; 
in  dilatation  of  stomach,  489;  in  gastric 
supersecretion,  515;  in  peptic  ulcer,  496; 
in  pyloric  stenosis,  506. 
Lead,  neuritis  from,  1024;  sclerosis  of  the 

brain  due  to,  951. 
Lead  palsy,  404,  405. 

Lead  poisoning,  albuminuria  in,  685 ;  amy- 
loid degeneration  of  kidneys  in,  711; 
anuria  in,  680;  arterio-sclerosis  and, 
843;  chronic  secondary  anaemia  in,  730; 
epilepsy  due  to,  1081 ;  etiology  of,  402, 
403;  hematoporphyrin  in  urine  in,  693; 
morbid  anatomy  of,  403;  neuralgia  and, 
1090;  optic  neuritis  in,  1030;  paralysis 
in,  1059;  prognosis  of,  405,  406;  re- 
tinitis  in,  1030;  symptoms  of,  403-405; 
toxic  amaurosis  in,  1030;  treatment  of, 
406. 

Legs,  persistent  hereditary  oedema  of,  1124. 
Leishmania  donovani,  260;  infantum,  260; 

tropica,  261. 
Leishmaniasis,  260,  261. 
Leontiasis  ossea,  1145. 
Lepra  alba,  153;  mutilans,  153. 
Leprosy,     anaesthetic,     differentiation     of 
syringomyelia  from,  965;   clinical  forms 
of,  153,  154;  definition  of,  151;  diagno- 
sis of,   154;   etiology  of,  152,  153;  geo- 
graphical   distribution   of,    151;    history 
of,  151;  morbid  anatomy  of,  153;  treat- 
ment of,  154. 

Leptomeningitis,    acute    cerebral,    etiology 
of,  948,  949;   morbid  anatomy  of,  949; 


symptoms   of,   949,   950;    treatment   of, 
950,  951. 

Leptomeningitis,  chronic,  951. 
Leptus  autuinnalis,  311. 
Leucocytosis,  absence  of,  in  measles,  346; 
in  acute  sero-fibrinous  pleurisy,  659 ;  in 
amcebiasis,  242;  in  appendicitis,  534;  in 
cerebro-spinal    fever,    112;    in    diabetic 
coma,  433 ;  in  diphtheria,  64 ;  in  empy- 
ema,  660;   in  general  tuberculosis,  170; 
in  gout,  421;   in  hypertrophic  cirrhosis, 
581;   in  intestinal  obstruction,   542;   in 
lobar  pneumonia,  87,  88,  97;  in  myeloid 
leukaemia,  743;  in  relapsing  fever,  262; 
in  rickets,  445;  in  scarlet  fever,  336;  in 
small-pox,   321;    in   suppurative   cholan- 
gitis,  565 ;  in  trichiniasis,  299 ;  in  typhus 
fever,  355;  in  whooping  cough,  122. 
Leucoderma  in  scleroderma,  1120. 
Leuco-keratosis  mucosae  oris,  460. 
Leuconychia  in  neuritis  from  arsenic,  1024. 
Leucorrhrea,  pyuria  in,  688. 
Leukaemia,   albuminuria  in,  685;    amyloid 
degeneration  of  kidneys  in,   711;   asso- 
ciation of  other  diseases  with,  746;  cere- 
bral haemorrhage  in,  988;  definition  of, 
741;  diagnosis  of,  745,  746;  differentia- 
tion  of   Hodgkin's    disease    from,   749; 
dilatation  of  heart  in,  784;  enlargement 
of  liver  in,  591;  haematuria  in,  681;  his-  ' 
tory    of,    741;    lymphoid,    744;    mixed, 
atypical,   745;    myeloid,   741;   phosphat- 
uria   in,    691;    prognosis    of,    746;    ter- 
minal  infections  in,   53;    treatment   of, 
746;   varieties  of,  741-745. 
Leukanaemia,  745. 
Leukoplakia  buccalis,  460,  461. 
Leyden's    crystals,    in    asthma,    630;    in 

fibrinous  bronchitis,  632. 
Lice,  in  transmission  of  relapsing  fever,  262. 
Lichen  in  hypertrophic  cirrhosis,  581;   in 

obstructive  jaundice,  556. 
Lightning  pains  of  locomotor  ataxia,  915, 

917,  919. 

Lineae   albicantes,  in   ascites,   609;    in  ty- 
phoid fever,  19. 
Lingual  thyroid,  821. 
Linguatula  rhinaria,  310;  serrata,  310. 
Linitis  plastica,  486. 
Lipaciduria,  693. 
Lipaemia  in  diabetes,  433. 
Lipoma,     causing    intestinal     obstruction, 
540,  541 ;    of  kidney,  722 ;  of  mediasti- 
num, 675;  of  spinal  cord,  963;  of  stom- 
ach, 505. 

Lipomatoses,  452,  453. 
Lipomatosis,    hypertrophic,    934;    nodular 
circumscribed,    453;     of    neck,    diffuse 
symmetrical,  453. 


1188 


INDEX 


Lipomatous  neuritis,  1021. 

Lipothymia,  602. 

Lips,  paralysis  of,  in  bulbar  paralysis,  931; 
tuberculosis  of,  211. 

Lipuria,  433,  693. 

Lithaamia,  oxaluria  and,  690. 

Lithaemic  neurasthenia,  1111. 

Lithaemic  state,  422. 

Lithuria,  688,  689. 

Litten  phenomenon,  199. 

Little's  disease,  936,  938  (see  Spastic  pa- 
ralysis of  infants). 

Liver,  abscess  of,  complicating  amoebiasis, 
241;  abscess  of,  in  bacillary  dysentery, 
128;  actinomycosis  of,  232;  affections  of 
blood  vessels  of,  561-563;  amyloid  de- 
generation of,  in  fibroid  phthisis,  202; 
change  in  size  of,  in  obstruction  of  bile- 
ducts,  567;  changes  in,  in  thermic  fever, 
391 ;  cirrhosis  of,  infectious,  556 ;  cirrho- 
sis of,  pigment,  576;  cirrhosis  of,  toxic, 
556;  depression  of,  in  acute  sero-fibrin- 
ous  pleurisy,  656;  diseases  of,  555-592; 
displacement  of,  in  empyema,  661;  dis- 
placement of,  in  enteroptosis,  550;  dis- 
placement of,  in  pneumothorax,  671 ;  dis- 
tention  of,  in  tricuspid  regurgitation, 
825;  fatty  degeneration  of,  due  to  Tri- 
china spiralis,  297;  fatty,  in  diarrhosa  of 
children,  525;  fatty,  in  pernicious  anae- 
mia, 734;  glycosuria  and,  429 j  hyda- 
tids  of,  291,  292;  in  acute  yellow 
atrophy,  559;  in  alcoholism,  397,  398; 
in  cerebro-spinal  meningitis,  110;  in  . 
cholera  asiatica,  135 ;  in  chronic  ul- 
cerative  tuberculosis,  190;  in  coccidiosis, 
237;  in  diabetes,  431,  432;  in  diph- 
theria, 63;  in  haemochromatosis,  454;  in 
Hodgkin's  disease,  747;  in  infectious 
jaundice,  384;  in  lobar  pneumonia,  81, 
88;  in  malaria,  248;  in  myeloid  leukae- 
mia, 742;  in  relapsing  fever,  262;  in 
rickets,  443;  in  scurvy,  447;  in  suppu- 
rative  angio-cholitis,  565;  in  typhoid 
fever,  12,  26;  in  typhus  fever,  353;  in 
yellow  fever,  358;  involvement  of,  in 
cancer  of  stomach,  503 ;  lesions  in,  in 
amcebiasis,  239,  240;  multilocular  echi- 
nococcus  and,  293,  294;  syphilis  of,  273- 
275;  tuberculosis  of,  214,  215. 

Liver,  enlargement  of,  in  cardiac  insuffi- 
ciency, 795 ;  in  congenital  syphilis,  269 ; 
in  general  septicaemia,  50;  in  hereditary 
icterus,  558;  in  mitral  stenosis,  824;  in 
suppurative  cholangitis  due  to  gall- 
stones, 573;  in  tricuspid  stenosis,  825. 

Liver  flukes  causing  obstruction  of  bile 
ducts,  567. 

Lobar  pneumonia,  acute,  bacteriology  of, 


76,  78;  clinical  varieties  of,  92-96;  com- 
plications of,  89-91;  definition  of,  74; 
diagnosis  of,  97,  98;  differentiation  of, 
from  broncho-pneumonia,  105,  106 ;  eti- 
ology of,  75,  76;  history  of,  74;  immu- 
nity, serum  and  vaccine  therapy  in,  78, 
79;  incidence  of,  75;  lesions  in  other 
organs  in,  80,  81 ;  morbid  anatomy  of, 
79,  80;  pneumonic  tuberculosis  confused 
with,  184,  185;  prognosis  of,  96,  97; 
prophylaxis  of,  98;  relapse  in,  91,  92; 
symptoms  of,  81-89;  treatment  of,  98- 
101. 

Lobestein's  disease,  1146. 

Lobstein's  cancer,  723. 

Lobular  pneumonia.  (See  Broncho-pneu- 
monia.) 

Local  adhesive  peritonitis,  606. 

Local  infections,  due  to  Bacillus  coli,  47; 
with  development  of  toxins,  48,  49. 

Local  pneumococcic  infections,  108. 

Local  pyogenic  infections,  48,  49. 

Localization  of  functions  in  segments  of 
spinal  cord,  898-900. 

Lock-jaw,  1040   (see  Tetanus). 

Locomotor  ataxia,  268;  aneurism  in,  918; 
cytodiagnosis  in,  925;  definition  of,  913; 
diagnosis  of,  919,920;  differentiation  of 
gastric  crisis  of,  477,  513;  differentia- 
tion of  neuritis  from,  1026;  disturbance 
of  pneumogastric  nerve  causing  gastric 
•  crises  in,  1051;  etiology  of,  913;  gastric 
crises  in,  917;  gastric  supersecretion 
and,  512;  laryngeal  spasm  in,  1050, 
1051;  loss  of  sense  of  smell  in,  1028; 
morbid  anatomy  and  pathology  of,  913- 
915;  neuritis  in,  914;  ophthalmoplegia 
externa  in,  1038;  optic  atrophy  in,  1031; 
prognosis  of,  920;  purpura  in,  751;  root 
fibers  in,  914;  symptoms  of,  915-919; 
treatment  of,  920,  921;  vomiting  in,  511. 

Long  thoracic  nerve,  lesions  of,  1058. 

Lorain  type  of  infantilism,  893. 

Lordosis  in  progressive  central  muscular 
atrophy,  929. 

Lucilia  macellaria,  313. 

Ludwig's  angina,  466. 

Lues  venerea.     (See  Syphilis.) 

Lumbago,  1129, 1130;  confusion  of  sciatica 
and,  1062;  in  compression  of  spinal 
cord,  961. 

Lumbar  neuralgia,  1091. 

Lumbar  plexus,  lesions  of,  1060;  neuralgia 
of  nerves  of,  1091. 

Lumbar  puncture,  in  acute  cerebro-spinal 
pachymeningitis,  950;  in  acute  polio- 
myelitis, 367,  368;  in  cerebro-spinal  fe- 
ver, 114,  115;  in  diagnosis  of  tubercu- 
lous meningitis,  174;  in  haemorrhage  in- 


INDEX 


1189 


to    spinal    membranes,    958;     lesion    of 
conus  medullaris  following,  962. 

Lumbo-sacral  articulation,  lesions  of,  1061. 

Lungs,  actinomycosis  of,  233;  complica- 
tions in,  in  rheumatic  fever,  376;  con- 
gestion of,  in  typhus  fever,  355;  dis- 
eases of,  633-654;  echinococcus  of,  292, 
293;  in  diabetes,  431,434;  in  diphtheria, 
62;  in  erysipelas,  54;  in  lobar  pneu- 
monia, 79;  in  scurvy,  448;  in  thermic 
fever,  391;  in  typhoid  fever,  13;  in  ty- 
phus fever,  353;  infarcts  in,  in  acute 
endocarditis,  800;  involvement  of,  in 
cancer  of  stomach,  503;  lesions  in,  in 
amcebiasis,  240;  syphilis  of,  272,  273. 

Lung  fever.     (See  Lobar  pneumonia.) 

Lupinosis,  410. 

Lupus,  pharyngeal  ulcers  and,  466. 

Lymph  glands,  cervical,  in  cancer  of  oeso- 
phagus, 475;  enlargement  of,  in  Hodg- 
kin's  disease,  747,  748;  in  acute  pha- 
ryngitis, 465 ;  in  dengue,  363;  in  glandu- 
lar disease,  386;  in  measles,  344,  in  per- 
nicious anaemia,  734;  involvement  of,  in 
cancer  of  stomach,  503;  of  neck,  in 
glanders,  146;  swelling  of,  in  lymphoid 
leukaemia,  745. 

Lymph  nodes  in  haemochromatosis,  454. 

Lymphadenia  ossium,  749. 

Lymphadenitis,  672;  generalized  tubercu- 
lous, 175,  176;  in  scarlet  fever,  334,339; 
suppurative,  672,  673. 

Lymphadenoma,  generalized,  747;  of  kid- 
ney, 722. 

Lymphatic  constitution,  869. 

Lymphatism,  adenoids  and,  468,  471  (see 
Status  thymico-lymphaticus). 

Lymphocytosis  in  lymphatism,  870;  in 
spinal  fluid  in-  tabes  and  general  paraly- 
sis, 925. 

Lymphoid  leukaemia,   744,  745. 

Lymphoma  of  pancreas,  599. 

Lympho-sarcoma,  differentiation  of  Hodg- 
kin's  disease  from,  750. 

Lyssa.     (See  Hydrophobia.) 

Lyssophobia,  371. 


M 


McBurney  's  point,  534,  537. 

Maculae  ceruleae,  312;  in  typhoid  fever,  19. 

Macular  leprosy,  153. 

Macular  syphilide,  266. 

Madura  disease,  236. 

Main  en  griff e,  929 ;  in  spinal  haemorrhagic 

pachymeningitis,  948. 
Maize,  pellagra  and,  411,  413. 
Mai  de  caderas,  258. 


Mai  de  la  rosa,  411. 
Maladie  de  Hanoi,  580. 
Maladie  de  Hodgson,  849. 
Malarial  fever,  acute  Bright 's  disease  in, 
697;  acute  bronchitis  and,  620;  al- 
buminuria  in,  685;  bacillary  dysentery 
and,  128;  catarrhal  jaundice  in,  563; 
chronic  parenchymatous  nephritis  due  to, 
702;  chronic  secondary  anaemia  in,  729; 
clinical  forms  of,  248-254;  complicating 
amcebiasis,  241;  complications  of,  254; 
confusion  of,  with  abscess  of  liver, 
584;  confusion  of,  with  septico-pyaemiaj 
52;  confusion  of,  with  typhoid  fever,  37; 
definition  of,  243;  differentiation  of 
acute  endocarditis  from,  803;  differ- 
entiation of  yellow  fever  from,  360; 
endemic  index  of,  255;  etiology  of,  244- 
247;  geographical  distribution  of,  243; 
haemoglobinuria  and,  254,  683;  herpes 
zoster  in,  926;  infantilism  and,  892; 
jaundice  in,  557;  morbid  anatomy  of, 
247,  248 ;  pernicious,  253 ;  pneumonia  as- 
sociated with,  93,  94;  prophylaxis  of, 
255-257;  pyelitis  resembling,  714;  re- 
lapse in,  254,  255;  retinitis  in,  1029, 
1030 ;  spleen  rate  in,  255 ;  splenic  anaemia 
and,  886;  treatment  of,  257,  258;  ty- 
phoid fever  and,  32. 

Malarial  cachexia,  254. 

Malarial  haemoglobinuria,  254. 

Malarial  symptoms  in  chronic  ulcerative 
tuberculosis,  191. 

Malformation,  of  heart,  congenital  aortic 
incompetency  due  to,  808,  809;  of  kid- 
ney, 676. 

Malignant  anthrax  oedema,  149. 

Malignant  cerebro-spinal  meningitis,  110, 
111. 

M'alignant  jaundice,  559-561. 

Malignant  purpuric  fever,  108  (see  Cere- 
bro-spinal  fever). 

Malignant  pustule,  149. 

Mallein   for  diagnosing  glanders,   147. 

Malnutrition,  pyelitis  and,  712. 

Malta  fever,  definition  of,  130;  distribu- 
tion of,  130;  etiology  of,  130,  131;  mi- 
crococcus  melitensis  in,  131;  symptoms 
of,  131,  132;  treatment  of,  132. 

Mammary  gland,  hypertrophy  of,  in  pul- 
monary tuberculosis,  205;  tuberculosis 
of,  220,  221. 

Mammitis,  205. 

Mania  a  potu,  398,  399. 

Mania,  acute,  in  exophthalmic  goitre,  879; 
bradycardia  in,  777;  in  acute  chorea, 
1070,  1071;  in  hydrophobia,  370;  in 
measles,  347;  in  lobar  pneumonia,  89 ;  in 
mumps,  351;  in  pellagra,  412;  in  pro- 


1190 


INDEX 


gressive  central  muscular  atrophy,  930; 
in  scarlet  fever,  339;  in  uraemia,  694; 
post-epileptic,  1083. 

Marantic  thrombus,  1005. 

Marasmus  in  amaurotic  family  idiocy,  939. 

Marie 's  syndrome,  1143,  1144. 

Marriage,  epilepsy  and,  1085;  syphilis  and, 
281;  tuberculosis  and,  222. 

Massage,  in  arthritis  deformans,  1141;  in 
gonococcus  infection,  125;  in  treatment 
of  constipation,  547,  548;  in  treatment 
of  hysteria,  1105. 

Massive  pneumonia,  92. 

Mastitis,  in  pulmonary  tuberculosis,  205; 
chronic,  following  constipation,  546;  in 
mumps,  351;  in  typhoid  fever,  31. 

Mastitis  adolescentium,  205. 

Mastoiditis  in  cerebro-spinal  fever,  113. 

Masturbation,  epilepsy  due  to,  1081. 

Measles,  abortive,  346;  acute  bronchitis 
and,  620,  621;  acute  myelitis  due  to, 
966;  attenuated,  346;  broncho-pneu- 
monia secondary  to,  101,  106,  346; 
complications  of,  346,  347;  cancrum  oris 
following,  459;  concurrent  with  scarlet 
fever,  339,  340;  diagnosis  of,  347;  defi- 
nition of,  343;  differentiation  of  pur- 
pura  haemorrhagica  from,  754;  differen- 
tiation of  rubella  from,  349;  differenti- 
ation of  scarlet  fever  from,  340;  differ- 
entiation of  simple  coryza  from,  383; 
differentiation  of  small-pox  from,  323; 
diphtheroid  inflammation  in,  60;  etiol- 
ogy of,  343,  344;  haematemesis  in,  507; 
history  of,  343;  convulsions  preceding, 
1078;  malignant  or  black,  346;  morbid 
anatomy  of,  244;  predisposing  to  tuber- 
culosis, 159;  prognosis  of,  347;  prophy- 
laxis of,  347,  348;  pulmonary  tubercu- 
losis and,  209;  purpuric  rash  in,  751; 
symptoms  of,  344-346 ;  thyroiditis  in,  871 ; 
treatment  of,  348;  tuberculous  adenitis 
and,  175;  tuberculous  bronchopneumonia 
and,  186;  typhoid  fever  and,  32. 

Meat  poisoning,  408,  409. 

Median  nerve,  lesions  of,  1059,  1060. 

Mediastinal  glands,  involvement  of,  in  car- 
cinoma of  lung,  654. 

Mediastinitis,  perihepatitis  and,  582. 

Mediastinopericarditis,  indurative,  767-769. 

Mediastinum,  affections  of,  672-675. 

Mediterranean  fever,  130-132  (see  Malta 
fever). 

Medulla,  hemiplegia  due  to  haemorrhage  in, 
993,  995. 

Medullary  carcinoma  of  the  stomach,  499. 

Megalo-cephaly,  1145. 

Megalogastria,  487. 

Melsena,    in   purpura,    752;    in   small-pox, 


320;  in  splenic  anaemia,  887;  neonato- 
rum,  755. 

Melancholia,  bradycardia  in,  777;  follow- 
ing traumatic  neuroses,  1116,  1118;  in 
acute  chorea,  1071;  in  cardiac  insuffi- 
ciency, 790;  in  chronic  gastritis,  481;  in 
ergotism,  410;  in  general  paralysis,  923; 
in  locomotor  ataxia,  918;  in  mucous 
colitis,  551;  in  obstructive  jaundice,  556; 
in  pericarditis,  764;  in  scarlet  fever, 
339;  in  uraemia,  694. 

Melano-sarcoma  of  liver,  588. 

Melanuria,  691,  692;  in  melano-sarcoma  of 
liver,  589. 

Melituria,  433. 

Membrane,  in  diphtheria,  61,  62;  in  phar- 
yngeal  diphtheria,  63. 

Membranous  colitis,  528. 

Membranous  croup,  65,  66. 

Membranous  enteritis,  551. 

Membranous  gastritis,  479. 

Membranous  laryngitis,  differentiation  of 
acute  laryngitis  from,  615. 

Membranous  rhinitis,  64,  65. 

Memory,  defective,  in  myxoedema,  875;  in 
progressive  central  muscular  atrophy, 
930. 

Meniere's  disease,  diagnosis  of,  1047, 
1048;  prognosis  of,  1048;  symptoms  of, 
1047. 

Meningeal  form  of  acute  miliary  tubercu- 
losis, 171;  diagnosis  of,  173,  174;  mor- 
,'id  anatomy  of,  171,  172;  symptoms  of, 
172,  173. 

Meningeal  haemorrhage,  989 ;  infantile,  997. 

Meninges,  affections  of,  946-957. 

Meningism,  951. 

Meningitic  form  of  acute  polio-myelitis, 
366. 

Meningitis,  abscess  of  brain  and,  1015; 
acute,  Bacillus  coli  in,  48;  acute  suppu- 
rative,  in  acute  endocarditis,  800;  al- 
buminuria  in,  685;  as  a  terminal  infec- 
tion, 53;  basilar,  170-174;  basilar,  in 
pulmonary  tuberculosis,  205;  cerebro- 
spinal,  108;  cerebro-spinal,  in  pulmo- 
nary tuberculosis,  205 ;  complicating  ery- 
sipelas, 55;  delirium  tremens  confused 
with,  399;  differentiation  of  acute  gas- 
tritis from,  477;  differentiation  of  urae- 
mia from,  696;  due  to  glanders  infec- 
tion, 147;  following  scarlet  fever,  339; 
gummatous  cerebral,  1009;  gummous, 
270;  in  cerebro-spinal  fever,  113,  114; 
in  cerebro-spinal  fever,  encephalitis  and, 
1015;  in  gout,  422,  423;  in  influenza, 
118;  in  lobar  pneumonia,  81,  90,  97;  in 
measles,  347;  in  mumps,  351;  in  oidio- 
mycosis,  235;  in  rheumatic  fever,  376; 


INDEX 


1191 


in  typhoid  fever,  13;  in  typhus  fever, 
355;  infantile  convulsions  in,  1078; 
Jacksonian  epilepsy  due  to,  1084;  loss 
of  sense  of  smell  in,  1028;  meningococ- 
cus,  108;  muscular  spasm  in,  1036; 
optic  neuritis  in,  1030;  pneumonia  and, 
98;  serosa,  951;  serous,  1018,  1019; 
terminal,  in  uraemia,  695;  tuberculous, 
170-174;  tuberculous,  differentiation  of 
broncho-pneumonia  from,  106. 

Meningo-encephalitis,  172;  chronic,  214; 
fetal,  birth  palsies  due  to,  937. 

Meningo-myelitis,  spastic  paralysis  second- 
ary to,  939. 

Menopause,  arthritis  deformans  at,  1139, 
1140;  gastralgia  at,  513;  tachycardia 
at,  776. 

Menstrual  disturbances,  chlorosis  and,  730, 
733. 

Menstruation,  congestion  of  thyroid  gland 
and,  870;  constipation  and,  546;  in  neu- 
rasthenia, 1111;  palpitation  during,  770; 
ptyalism  during,  462. 

Mental  development,  adenoids  and,  470. 

Meralgia  paraesthetica,  1060. 

Mercurial  stomatitis,  459,  460. 

Mercury  in  treatment  of  syphilis,  278,  279, 
280;  neuritis  due  to,  1024;  ptyalism 
and,  463 ;  purpura  due  to,  751. 

Mercury  poisoning,  albuminuria  in,  685; 
chronic  secondary  anaemia  in,  730. 

Merycismus,  511. 

Mesaortitis,  aneurism  and,  848;  aneurism 
of  sinuses  of  Valsalva  and,  851. 

Mesenteric  glands,  enlargement  of,  due  to 
Trichina  spiralis,  297;  in  rickets,  443; 
in  typhoid  fever,  12;  in  tuberculous 
peritonitis,  181. 

Mesenteric  veins,  diseases  of,  554. 

Mesenteric  vessels,  embolism  and  thrombo- 
sis of,  552,  553. 

Mesentery,  affections  of,  553-555;  cysts  of, 
554,  555. 

Mesogonimus  heterophyes,  283. 

Metabolism,  diseases  of,  417. 

Metastasis  in  cancer  of  stomach,  500. 

Metastatic  abscesses,  51;  of  lung,  652,653. 

Meta-s/philitic  affections,  268. 

Metatarsalgia,  1092. 

Meteorism,  hypostatic  congestion  of  lungs 
in,  634;  in  lobar  pneumonia,  88,  91;  in 
typhoid  fever,  23. 

Methaemoglobinaemia,  758,  759. 

Metritis  following  gonococcus  infection, 
123. 

Metrorrhagia  in  small-pox,  320. 
Micrococcus    catarrhalis,     382;     in     acute 
bronchitis,  620;    in  pulmonary   tubercu- 
losis, 208,  209. 


Micrococcus  gonorrheae,  123. 

Micrococcus  lanceolatus,  in  chronic  ulcer- 
ative  tuberculosis,  190;  in  broncho- 
pneumonia,  104;  in  diphtheria,  59;  in 
pulmonary  tuberculosis,  208,  209;  septi- 
caemia due  to,  50;  septico-pyaemia  due 
to,  51. 

Micrococcus  melitensis,  131. 

Micrococcus  rheumaticus,  373. 

Micrococcus  thecalis,  941. 

Micro-organisms  and  gall-stones,  568,  569. 

Micturition  in  renal  colic,  720. 

Middle  cerebral  artery,  symptoms  of  block- 
ing of,  1001. 

Middle-ear  disease,  acute  cerebro-spinal 
leptomeningitis  in,  949 ;  in  scarlet  fever, 
339;  meningism  in,  950. 

Migraine,  definition  of,  1087;  etiology  of, 
1087,  1088;  hemianopia  in,  1034;  in 
gout,  423 ;  ophthalmoplegic,  1089 ;  symp- 
toms of,  1088,  1089 ;  treatment  of,  1089. 

Migratory  neuritis,  1022. 

Migratory  pneumonia,  92. 

Mikulicz's  disease,  464;  mucous  glands  in, 
462. 

Miliary  aneurisms,  cerebral  haemorrhage 
due  to,  988,  989. 

Miliary  fever,  386,  387. 

Miliary  sclerosis  of  brain,  952. 

Miliary  tubercle  of  pancreas,  599. 

Miliary  tuberculosis,  167-174;  uraemia  oim- 
ulating,  696. 

Milk,  diphtheria  infection  and,  58;  in 
transmission  of  scarlet  fever,  334;  in 
transmission  of  tuberculosis,  157,  164, 
165. 

Milk  poisoning,  409. 

Milk-sickness,  385. 

Miller's  asthma,  869. 

Milroy's  disease,  1124. 

Mimic  spasm,  1044. 

Mind-blindness,  981;  due  to  lesion  of  an- 
gular gyrus,  1032,  1033;  in  tumors  of 
brain,  1011,  1012. 

Mind-deafness,  980,  981. 

Mineral  waters  for  gout,  425. 

Miscarriage  due  to  lead  poisoning,  403. 

Mitral  disease,  chronic  cardiac  insuffi- 
ciency in,  786. 

Mitral  insufficiency,  cardiac  hypertrophy 
in,  781;  diagnosis  of,  820;  dilatation  of 
heart  in,  784;  etiology  of,  817;  morbid 
anatomy  of,  817,  818;  prognosis  wf,  828; 
symptoms  of,  818-820;  with  aortic 
stenosis,  816. 

Mitral  stenosis,  cardiac  flutter  in,  774, 
775;  cardiac  hypertrophy  in,  781;  dila- 
tation of  heart  in,  784 ;  etiology  of,  820, 
821;  morbid  anatomy  of,  821,  822; 


1192 


INDEX 


prognosis  of,  828 ;  sclerosis  of  veins  in, 
845;   symptoms  of,  822-824. 

Mixed  leukemia,  745. 

Modification  of  milk  in  diarrhoea  of  chil- 
dren, 530,  531. 

Monophobia,   1109. 

Monoplegia,  910;  due  to  blocking  of  an- 
terior cerebral  artery,  1001;  due  to 
lesions  of  motor  cortex,  969;  facialis, 
1041;  hysterical,  1098;  in  arterio-scle- 
rosis,  845,'  846 ;  in  chronic  Bright 's  dis- 
ease, 695,  696;  in  tuberculous  menin- 
gitis, 173;  in  tumors  of  brain,  1011. 

Morbilli, 343-348  (see  Measles). 

"Morbus  cseruleus, "  834. 

Morbus,  coxae  senilis,  1137;  errorum,  312; 
maculosus,  753;  maculosus  neonatorum, 

-    754,  755. 

Morphia,  in  cardiac  insufficiency,  794,  795. 

Morphia  habit,  400;  symptoms  of,  401; 
treatment  of,  401,  402. 

Morphia  poisoning,  hypostatic  congestion 
of  the  lungs  in,  634. 

Morphinism,  400-402. 

Morvan's  disease,  965. 

Mosquito,  eradication  of,  256;  in  trans- 
mission of  dengue,  362;  in  transmission 
of  malaria,  244-247;  in  transmission  of 
malaria,  prophylactic  measures  in  rela- 
tion to,  255,  256;  in  transmission  of 
yellow  fever,  356,  357,  358;  role  of,  in 
filariasis,  305,  306. 

Motor  aphasia,  981,  982. 

Motor  cortex,  hemiplegia  due  to  lesions  of, 
992. 

Motor  insufficiency  of  stomach,  511. 

Motor  nerves  of  eyeball,  affections  of, 
1035-1039. 

Motor  system,  895-903. 

Mountain  sickness,  395. 

Mouth,  care  of,  462;  diseases  of,  456-462; 
in  small-pox,  319;  in  sprue,  519. 

Mouth  breathing,  468-471. 

Movable  kidney,  676,  677;  cyst  of  the 
mesentery  confused  with,  555;  diagnosis 
of,  678;  hydronephrosis  in,  716,  717;  in 
enteroptosis,  549;  symptoms  of,  677, 
678;  treatment  of,  678. 

Movable  liver,  592. 

Movable  spleen,  884. 

Mucous  colitis,  551,  552;  confusion  of, 
with  appendicitis,  537. 

Mucous  glands,  affections  of,  462. 

Mucous  patches  in  syphilis,  267. 
Muguet,  458. 

Multiple  neuritis,  differentiation  of  acute 
myelitis  from,  967;  differentiation  of 
Landry  's  paralysis  from,  942 ;  differen- 
tiation of  radial  paralysis  from,  1059. 


Multiple  sclerosis,  definition  of,  952;  diag- 
nosis of,  953;  etiology  of,  952;  morbid 
anatomy  of,  952,  953;  prognosis  of,  954; 
symptoms  of,  953;  treatment  of,  954. 

Mumps,  349-351;   thyroiditis  in,  871. 

Muscarine,  hsemoglobinuria  due  to,  683. 

Muscles,  diseases  of,  1128-1134;  effects  of 
arsenical  poisoning  on,  407;  in  beri- 
beri, 416;  in  typhoid  fever,  14,  29,  31; 
in  typhus  fever,  353. 

Muscular  incompetency  of  heart,  817,  818. 

Musculo-spiral   paralysis,   1059. 

Mussel  poisoning,  409. 

Mutism  in  acute  chorea,  1070. 

Myalgia,  definition  of,  1129;  etiology  of, 
1129;  pathology  of,  1129,  1130;  symp- 
toms of,  1130,  1131;  treatment  of,  1131. 

Myasthenia  gravis,  1133. 

Myatonia,  1133. 

Mycetoma,  236. 

Mycosis,  231;  intestinalis,  149. 

Mycotic  aneurism,  848. 

Mycotic  gastritis,  479. 

Myelitis,  acute,  etiology  of,  965,  963; 
acute,  morbid  anatomy  of,  966;  acute, 
symptoms  of,  966-968;  acute,  treatment 
of,  96;  chronic  transverse,  differentia- 
tion of  tumor  of  the  spinal  cord  from, 
964;  compression  (see  Compression  of 
spinal  cord)  ;  due  to  localized  neuritis, 
1022;  in  syphilis  of  the  brain,  271;  spas- 
tic paralysis  secondary  to,  939,  940. 

Myeloid  leukaemia,  blood  changes  in,  743, 
744 ;  etiology  of,  741 ;  morbid  anatomy 
of,  741,  742;  symptoms  of,  742,  743. 

Myelomata,   686. 

Myelopathic  albumosuria,  686. 

Myiasis,   313-315. 

Myiosis.     (See  Myiasis.) 

Myocarditis,  acute  interstitial,  787;  aneu- 
rism of  the  heart  due  to,  830;  chronic 
endocarditis  and,  805 ;  complicating  in- 
fluenza, 118 ;  complicating  small-pox, 
322;  dilatation  of  heart  and,  783,  784; 
endocarditis  and,  800;  fibroid,  following 
aortic  incompetency,  811;  fibrous,  786, 
787;  fibrous,  arterio-sclerosis  and,  844; 
in  lobar  pneumonia,  81;  in  rheumatic 
fever,  376,  377;  in  scarlet  fever,  338; 
in  typhoid  fever,  13,  21;  oedema  of  lungs 
in,  635;  purulent,  pericarditis  and,  760; 
sclerotic,  cardiac  hypertrophy  in,  781; 
Stokes- Adams  disease  and,  779;  tuber- 
culous, 221. 

Myocardium,  affections  of,  780-797;  tu- 
berculosis of,  221. 

Myoclonia,  1132,  1133. 

Myoidema,  20f 


INDEX 


1193 


Myosis,  in  transverse  myelitis,  968;  spinal, 
915,  1036. 

Myositis,  definition  of,  1128;  dermato, 
1128,  1129;  due  to  Trichina  spiralis, 
297;  in  trichiniasis,  299;  indurative, 
1130;  ossificaus  progressiva,  1129;  pri- 
mary, acute,  interstitial,  in  diphtheria, 
62;  suppurative,  1128. 

Myotonia,  definition  of,  1131;  etiology  of, 
1131;  symptoms  of,  1132. 

Myriachit,  1076. 

Mytilotoxin,  409. 

Myxcedema,  exophthalmic  goitre  and,  878, 
879;  following  thyroiditis,  871;  juvenile, 
874;  of  adults,  875;  operative,  875; 
(see  also  Hypothyroidism) . 

Myxoma  of  the  spinal  cord,  963. 

Myxoneurosis  intestinalis,  551. 


N 


Naevi,  capillary,  of  papillae,  hsematuria  due 
to.  682;  congenital,  in  neuro-fibroma- 
tosis,  1027;  in  cirrhosis  of  liver,  579. 

Nagana,  258. 

Naphthol,  hffimoglobinuria  due  to,  683. 

Narcolepsy,  451. 

Nasal  diphtheria,  64;   treatment  of,  71. 

Naso-pharyngeal  obstruction,  468-471. 

Nasse,  law  of,  755. 

Nastin,  154. 

Nausea,  in  acute  Bright 's  disease,  698;  in 
acute  gastritis,  477;  in  acute  pancrea- 
titis, 595;  in  acute  secondary  anaemia, 
728;  in  Addison's  disease,  865;  in  al- 
coholic cirrhosis  of  liver,  578;  in  angio- 
neurotic  oedema,  1124;  in  appendicitis, 
533,  535 ;  in  cancer  of  liver,  588 ;  in 
cancer  of  stomach,  501;  in  cholecystitis, 
566;  in  chronic  gastritis,  480;  in  con- 
stipation, 547;  in  glandular  fever,  386; 
in  leukaemia,  743;  in  malaria,  249;  in 
migraine,  1088 ;  in  milk-sickness,  385 ;  in 
movable  kidney,  678;  in  pancreatic  can- 
cer, 599;  in  pancreatic  cysts,  598;  in 
pancreatic  haemorrhage,  594 ;  in  pellagra, 
412 ;  in  peptic  ulcer,  493 ;  in  pulmonary 
tuberculosis,  204;  in  relapsing  fever, 
262;  in  renal  colic,  719;  in  thrombosis 
of  mesenteric  vessels,  554;  in  tubercu- 
losis, treatment  of,  231;  in  uraemia,  695; 
in  yellow  fever,  359. 

Necator  americanus,  301. 

Necrosis,  acute,  differentiation  of  rheu- 
matic fever  from,  378;  anaemia,  786;  in 
movable  spleen,  884;  in  pneumonokonio- 

•  sis,  644;  intestinal,  in  amcebiasis,  239; 
T 


intestinal,  in  typhoid  fever,  10;  in  Eay- 
naud's  disease,  1121;  liver,  in  amoebi- 
asis,  239;  of  alveolar  process  in  ulcera- 
tive  stomatitis,  457;  of  bone  in  small- 
pox, 322;  of  bone  in  scurvy,  448;  of 
heart  valve,  due  to  ulcerative  endocardi- 
tis, 799,  800;  of  jaw  in  mercurial 
stomatitis,  459;  of  jaw  in  scurvy,  447; 
of  liver,  559 ;  of  pancreas,  593,  595. 

Nematodes,  diseases  caused  by,  294-310. 

Nephralgia,  1092. 

Nephrectomy  in  pyelitis,  715. 

Nephritic   colic,   differentiation   of   biliary 
colic  from,  571. 

Nephritis,  acute  cerebro-spinal  leptomen- 
ingitis  in,  949 ;  acute  diffuse  (see  Acute 
Bright 's  disease);  acute  suppurative, 
713;  acute  syphilitic,  276;  albuminuria 
in,  687;  anuria  in,  680;  ascites  and, 
610;  bradycardia  in,  777;  chronic  de- 
squamative  (see  Nephritis,  chronic  pa- 
renchymatous) ;  chronic  haemorrhagic, 
703;  chronic  interstitial,  704-711; 
chronic  interstitial,  epistaxis  in,  614; 
chronic  parenchymatous,  702-704; 
chronic  secondary  anaemia  and,  730; 
complicating  erysipelas,  55,  56;  compli- 
cating influenza,  118;  consecutive  (see 
Pyelitis)  ;  following  bacillary  dysentery, 
128;  following  cholera  asiatica,  136; 
gouty,  422;  haamorrhagic,  in  glandular 
fever,  386;  hydrothorax  and,  668; 
hyperplasia  of  adrenal  cortex  in,  867; 
in  appendicitis,  534;  in  cerebro-spinal 
meningitis,  ^10;  in  diabetes,  432;  in 
diphtheria,  6^,  67;  in  gout,  420;  in  ma- 
laria, 248;  in  measles,  346;  in  mumps, 
351;  in  purpura,  753;  in  rubella,  349; 
in  scarlet  fever,  337,  338,  341 ;  in  small- 
,  pox,  317,  322;  in  tonsillitis,  381;  in 
typhoid  fever,  30;  in  typhus  fever,  355; 
in  varicella,  332;  migraine  in,  1088; 
periliepatitis  and,  581;  pyelitis  due  to, 
712;  retinitis  in,  1029;  suppurative,  715. 

Nephrolithiasis,  definition  of,  717;  diag- 
nosis of,  721;  etiology  and  pathology 

'  of,  717-719;  symptoms  of,  719-721; 
treatment  of,  721,  722. 

Nephroptosis,  549;  gall-stones  and,  569; 
(see  Movable  kidney). 

Nephrorrhaphy,  678. 

Nephrotomy  in  pyelitis,  715. 

Nervous  diarrhoea,  517. 

Nervous  dyspepsia,  509-516;  due  to  dis- 
turbance of  pneumogastric  nerve,  1051. 

Nervous  influenza,  117,  118. 

Nervous  system,  diabetes  insipidus  and, 
440;  diseases  of,  894-1127;  effect  of 
chronic  alcoholism  on,  397;  glycosuria 


1194 


INDEX 


and,  427,  431,  434;  in  beri-beri,  415;  in 
lead  poisoning,  403;  in  pellagra,  412; 
in  pernicious  anamiia,  736;  in  pneu- 
monia, 101;  in  pulmonary  tuberculosis, 
205;  in  typhoid  fever,  13,  27-29;  lesions 
in,  in  hydrophobia,  369;  unilateral 
lesions  of,  911,  955. 

Neuralgia,  asthma  and,  628;  cervico- 
brachial,  1091;  cervico-occipital,  1091; 
definition  of,  1089;  etiology  of,  1090; 
in  chlorosis,  733;  in  chronic  interstitial 
nephritis,  708;  in  diabetes,  434;  in 
facial  paralysis,  1043;  in  gout,  423;  in 
hysteria,  1100;  intercostal,  1091;  inter- 
costal, differentiation  of  pleurodynia 
from,  1130;  intercostal,  in  chronic 
ulcerative  tuberculosis,  192;  intercostal, 
in  movable  kidney,  677;  lumbar,  1091; 
malaria  and,  1090;  occipito-cervical, 
1055;  purpura  in,  751;  of  coccygeal 
plexus,  1091,  1092;  of  nerves  of  the 
feet,  1092;  of  phrenic  nerve,  1091;  of 
sacral  nerves,  constipation  and,  546; 
plantar,  1092;  post-zonal,  927;  red, 
1123;  symptoms  of,  1090;  treatment  of, 
1092,  1093;  trigeminal,  1090,  1091, 
1093;  visceral,  1092;  visceral,  in  neu- 
rasthenia, 1110. 

Neurasthenia,  causing  constipation,  545; 
definition  of,  1106,  1107;  enteroptosis 
and,  549;  etiology  of,  1107;  extra-sys- 
tole in,  774;  gastralgia  and,  513;  gas- 
tric hyperaesthesia  in,  513;  gastric 
super-secretion  in,  512;  morphia  habit 
and,  401;  movable  kidney  and,  677; 
mucous  colitis  and,  551;  oxaluria  and, 
690;  palpitation  due  to,  770;  phobias 
and,  1109;  phosphaturia  and,  690;  post- 
typhoid,  29;  symptoms  of,  1108-1111; 
systolic  brain  murmur  in,  1046;  treat- 
ment of,  113-116;  visceral  neuralgias 
and,  1092. 

Neuritic  muscular  atrophies,  differentia- 
tion of  muscular  dystrophies  from,  934. 

Neuritis,  acute,  in  lead  poisoning,  403; 
arthritis  deformans  and,  1136;  diag- 
nosis of,  1025-1026;  due  to  aneurism  of 
the  cerebral  blood-vessels,  1004;  etiology 
of,  1020,  1021;  fascians,  1021;  in  ar- 
senical poisoning,  407;  in  leprosy,  153; 
in  locomotor  ataxia,  914;  in  mumps, 
351;  in  small-pox,  322;  in  typhoid 
fever,  13,  14,  28,  29;  localized,  1021; 
morbid  anatomy  of,  1021;  multiple, 
1022;  multiple,  in  diabetes,  431;  multi- 
ple, reactions  in,  1025;  of  brachial 
plexus,  1058;  of  dorsal  roots  in  loco- 
motor  ataxia,  914;  of  sacral  plexus, 
1061;  post-diphtheritie,  67;  post- ty- 


phoid, 46;  progressive  interstitial  hyper- 
trophic,  in  infants,  945;  symptoms  of, 
1021-1025;  treatment  of,  1026;  ulnar, 
1059. 

Neuritis,  optic,  1030,  1031;  in  brain  ab- 
scess, 1016;  in  cerebral  syphilis,  271;  in 
endocarditis,  801;  in  influenza,  118;  in 
lead  poisoning,  405;  in  oxycephaly,  114; 
in  tuberculous  meningitis,  173;  in  tu- 
mors of  brain,  1010,  1012,  1013;  in  tu- 
mor of  cerebellum,  975. 

Neuritis,  peripheral,  1020;  differentiation 
of  acute  polio-myelitis  from,  367;  dif- 
ferentiation of  locomotor  ataxia  from, 
919;  in  chronic  alcoholism,  397;  in 
diabetes,  434;  in  lobar  pneumonia,  90; 
in  pulmonary  tuberculosis,  205;  paroti 
tis  and,  463. 

Neuro-fibromatosis,  generalized,   1027. 

Neuroglioma  of  brain,  1009. 

Neuroma  of  spinal  cord,  963. 

Neuromata,  1026,  1027. 

Neuro-myositis,  1129. 

Neurones,  degeneration  and  regeneration 
of,  895;  function  of,  894,  895;  struc- 
ture of,  894. 

Neuro-retinitis,  1030;  in  lead  poisoning, 
405. 

Neurosis,  bronchial  asthma  and,  627,  628; 
occupation,  1093-1095;  of  stomach, 
motor,  509-511;  of  stomach,  secretory, 
511-513;  of  stomach,  sensory,  513,  514; 
of  stomach,  treatment  of,  514-516;  trau- 
matic, 1116-1119. 

Neurotic   albuminuria,  685. 

New  growths,  causing  epistaxis,  613;  in 
lungs,  653,  654;  of  heart,  831;  of  liver, 
diagnosis  of,  589;  of  liver,  etiology  of, 
587;  of  liver,  morbid  anatomy  of,  587, 
588;  of  liver,  symptoms  of,  588,  589;  of 
liver,  treatment  of,  589;  of  peritoneum, 
607,  608. 

Night-blindness,  1030;  in  scurvy,  448. 

Nile  sore,  261. 

Nitroglycerin,  in  cardiac  insufficiency, 
794;  in  chronic  Bright 's  disease,  710. 

Nocardiosis,  235. 

Nodal  rhythm,  774,  775. 

Nodding  spasm  of  children,  1054. 

Nodular  circumscribed  lipomatosis,  453. 

Noguchi's  butyric  test  for  globulin  in 
acute  polio-myelitis,  367. 

Noma,  456 ;  in  scarlet  fever,  339 ;  in  ty- 
phus fever,  355;  typhoid  fever  and,  32. 

von  Noorden's  dietary  in  obesity,  452. 

Nose,  diseases  of,  612-614;  in  cerebro- 
spinal  fever,  113;  in  glanders,  146. 

Nostalgia,  scurvy  and,  447. 

Numbness,  in  Landry  's  paralysis,  942 ;  in 


INDEX 


1195 


pernicious  anaemia,  736;  of  fingers  in 
urasmia,  695. 

Nyctalopia,  1030. 

Nystagmus,  1036;  due  to  tumor  of  cere- 
bellum, 976;  in  hereditary  ataxia,  945; 
in  Meniere's  disease,  1047;  in  sclerosis 
of  brain,  953;  in  tumors  of  brain,  1012. 


Oatmeal  diet  in  diabetes,  436,  437. 

Obesity,  451,  452;  constipation  due  to, 
545;  fatty  liver  and,  590. 

Obliteration,  of  the  appendix,  532;  of 
bile-ducts,  congenital,  568. 

Obstetrical  palsy,  1058. 

Obstruction,  of  bile-ducts,  567,  568;  of 
bowel,  by  gall-stones,  574;  of  bowel, 
chronic,  phlegmonous  enteritis  and,  520; 
of  bowel,  differentiation  of  acute  peri- 
tonitis from,  603;  of  bowel  (see  also 
Intestinal  obstruction) ;  of  common 
duct,  chronic  catarrhal  angiocholitis 
and,  564,  565;  of  common  duct,  due  to 
gall-stones,  572,  573;  of  cystic  duct,  by 
gall-stones,  571,  572;  of  ureter,  causing 
hydronephrosis,  715,  716. 

Obstructive  jaundice,  555-557. 

Obstructive    suppression    of    urine,    680. 

Obturator  nerve,  injury  to,  1060. 

Occipito-cervical  neuralgia,  1055. 

Occlusion,  of  colon  due  to  constipation, 
546;  of  duct,  chronic  pancreatitis  and, 
596. 

Occupation,  angina  pectoris  and,  837;  an- 
thrax and,  148;  appendicitis  and,  532; 
glanders  and,  147;  in  aneurism,  848;  in 
gout,  418;  influence  of,  in  tuberculosis, 
159;  peptic  ulcer  and,  481;  relation  of, 
to  hypertrophic  emphysema,  646. 

Occupation  neuroses,   1093-1095. 

Ochronosis,  454,  455. 

Oculo-motor  paralysis  due  to  lesion  of  the 
crura,  973;  recurring,  1035. 

Odors,  asthma  and,  628. 

OZdema,  anasmic  in  bacillary  dysentery, 
128;  angio-neurotic,  1123,  1124;  blue, 
453;  due  to  failure  of  the  right  auricle 
and  ventricle,  785;  following  diarrhoea 
in  infants,  1124;  hysterical,  453;  in 
acute  Bright 's  disease,  698,  699;  in  ar- 
terio-venous  aneurism,  861;  in  beri-beri, 
415;  in  cancer  of  stomach,  501;  in 
chlorosis,  731;  in  chronic  interstitial 
nephritis,  708;  in  chronic  parenchy- 
matous  nephritis,  703;  in  dermato-myo- 
sitis,  1128;  in  exophthalmic  goitre, 
878,  879;  in  intermittent  hydrarthrosis, 


1143;  in  locomotor  ataxia,  918;  in 
malignant  anthrax,  149;  in  malignant 
pustule,  149;  in  neuralgia,  1090;  in  per- 
nicious ansemia,  735,  736;  in  scarlet 
fever,  334,  338;  in  Schonlein's  disease, 
752;  in  thrombosis  of  the  cerebral  veins 
and  sinuses,  1005;  in  trichiniasis,  299; 
in  tumors  of  brain,  1010;  of  ankles  in 
scurvy,  447;  of  brain,  986,  987;  of 
brain,  uraemia  and,  694,  695;  of  chest 
walls  in  empyema,  661;  of  eyelids  ia 
scarlet  fever,  339;  of  glottis,  615,  616; 
of  glottis  in  chronic  interstitial  nephri- 
tis, 707;  of  glottis  in  typhoid  fever,  13; 
of  hands  and  arms  in  asthma,  628;  of 
legs,  persistent  hereditary,  1124;  of 
pharynx,  464;  of  skin  in  neuritis,  1021, 
1022;  of  skin  in  typhoid  fever,  19; 
white,  453. 

(Edema  of  feet,  due  to  cardiac  insuffi- 
ciency, 790;  in  alcoholic  cirrhosis,  578; 
in  aneurism  of  ascending  arch,  851;  in 
aortic  incompetency,  811;  in  cancer  of 
liver,  589;  in  diabetes,  434;  in  Hodg- 
kin's  disease,  750;  in  myeloid  leukae- 
mia, 743. 

(Edema  of  lungs,  635;  associated  with 
gangrene,  651;  failure  of  left  auricle 
causing,  784;  in  angina  pectoris,  839; 
in  chronic  interstitial  nephritis,  707;  in 
leukaemia,  743;  in  paralysis  of  dia- 
phragm, 1056;  in  typhoid  fever,  27. 

QEdematous  laryngitis,  616. 

Oertel  diet  in  cardiac  insufficiency,  796; 
in  obesity,  452. 

(Esophagismus,  473. 

(Esophagitis,  472,  473. 

(Esophago-malacia,  476. 

(Esophago-pleuro-cutaneous  fistula,  476. 

(Esophagus,  cancer  of,  475 ;  dilatations  and 
diverticula  of,  476;  in  small-pox,  317; 
inflammation  of,  472,  473;  rupture  of, 
475,  476;  spasm  of,  473,  1051;  stricture 
of,  474;  syphilis  of,  275;  tuberculosis 
of,  212;  ulcers  of,  in  typhoid  fever,  22. 

Oidiomycosis,  235,  236. 

Oldium  albicans,  458. 

Olfactory  nerves  and  tracts,  diseases  of, 
1028. 

Omental  tumor  and  tuberculous  peritoni- 
tis, 181. 

Omentopexy,  582. 

Omodynia,  1130. 

Onomatomania,  1076. 

Onychia,  in  chronic  arthritis  deformans, 
1139;  in  diabetes  mellitus,  433;  in  loco- 
motor  ataxia,  918;  syphilitic,  267,  269. 

Open-air  treatment,  of  broncho-pneumonia, 
107;  of  pleurisy,  665;  of  pneumonia. 


1196 


INDEX 


99;   of  tuberculosis,  224-227; 'of  typhus 
fever,  356. 

Ophthalmia,  gonococcic,  123;  in  relapsing 
fever,  2(53;  neonatorum,  123. 

Ophthalmic   zoster,  927. 

Ophthalmo-reaction,  in  tuberculosis,  159; 
in  typhoid  fever,  36. 

Ophthalmoplegia,  940,  1035;  externa, 
1038;  interna,  1038. 

Opisthorchis  felineus,  282. 

Opisthorchis  noverca,  282. 

Opisthorchis  sinensis,   282. 

Opisthotonos,  144;  in  hystero-epilepsy, 
1098. 

Opium,  effects  of,  400. 

Opium  eating.      (See  Morphia  habit.) 

Opium  poisoning,  differentiation  of  cere- 
bral apoplexy  from,  997;  differentiation 
of  ursemic  coma  from,  696. 

Oppenheim's  disease,  1133,  1134. 

Oppler-Boas  bacillus,  502. 

Opsonic   index  in   tuberculosis,   160,   161. 

Optic  aphasia,  1034. 

Optic  atrophy,  1031;  in  acromegaly,  891; 
in  amaurotic  family  idiocy,  939 ;  in  gen- 
eral paralysis,  923;  in  locomotor  ataxia, 
914,  915,  919,  920;  in  oxycephaly,  1147; 
in  sclerosis  of  brain,  953;  in  tabo- 
paralysis,  924. 

Optic  nerve  and  tract,  lesions  of,  1029- 
1035. 

Optic  neuritis,  1030,  1031;  in  acquired 
chronic  neuritis,  1020;  in  acute  cerebro- 
spinal  leptomeningitis,  950;  in  brain 
abscess,  1016;  in  endocarditis,  801;  in 
oxycephaly,  1147;  in  serous  meningitis, 
1019;  in  thrombosis  of  cerebral  veins 
and  sinuses,  1005;  in  tumors  of  brain, 
1010,  1012,  1013. 

Oral  sepsis,  462. 

Orchids,  complicating  influenza,  118;  in 
malaria,  254;  in  mumps,  350,  351;  in 
typhoid  fever,  12,  30,  45;  syphilitic,  276. 

Ornithodorus,  311;   monbata,  261. 

Orthopncoa,  in  adenoids,  469;  in  cardiac 
insufficiency,  790;  in  localized  Hodg- 
kin's  disease,  748;  in  mediastinal  tu- 
mor, 673. 

Orthostatic   albuminuria,   684,   685. 

Orthotonos,  144. 

Osseous  system,  in  typhoid  fever,  31. 

Osteitis  deformans,  definition  of,  1144; 
diagnosis  of,  1145;  etiology  of,  1144; 
pathology  of,  1144;  symptoms  of, 
1144,  1145. 

Osteo-arthritis,  1135. 

Osteo-arthropathy,  pulmonary,  627. 
Osteogenesis  imperfecta,   1145. 
Osteomyelitis,   confusion  of,  with   septico- 


pyaemia,  "52;  differentiation  of  rheu- 
matic fever  from,  378;  ulcerative,  in. 
sporotrichosis,  235. 

Osteopsathyrosis,   1146. 

Otitis,  chronic,  acute  cerebro-spinal  lepto- 
meningitis due  to,  948,  949;  in  scarlet 
fever,  338;  infantile  convulsions  due  to, 
1077. 

Otitis  media,  complicating  influenza,  118; 
in  cerebro-spinal  fever,  113,  115 ;  in  dia- 
betes, 434;  in  glandular  fever,  386;  in 
measles,  346,  347;  in  mumps,  350;  in 
small-pox,  322;  in  tonsillitis,  381;  in 
typhoid  fever,  29. 

Ovarian  tumor,  and  tuberculous  peritoni- 
tis, 180;  cyst  of  mesentery  confused 
with,  555;  differentiation  of  ascites 
from,  609;  tuberculous  peritonitis  eon- 
fused  with,  181,  182. 

Ovaries,  tuberculosis  of,  220. 

Ovaritis  following  gonococcus  infection, 
123. 

Overeating,  arterio-sclerosis  due  to,  843, 
846;  gout  and,  418. 

Oxalate  of  lime,  calculi  of,   718. 

Oxaluria,  689,  690;  in  gout,  423. 

Oxycephaly,  1147. 

Oxygen,  use  of,  in  pneumonia,  101. 

Oxyuris  vermicularis,  295,  296. 


Pachymeningitis,  externa,  cerebral,  946; 
externa,  spinal,  946;  ha?morrhagic,  in  al- 
coholism, 397;  hypertrophic,  in  general 
paralysis,  922;  in  pulmonary  tubercu- 
losis, 211;  interna,  946,  947;  pressure 
paralysis  due  to,  961. 

Paget  's  disease,  1144,  1145. 

Pain,  heart,  due  to  failure  of  left  ven- 
tricle, 789;  in  abscess  of  liver,  584;  in 
acute  arsenical  poisoning,  406;  in  acute 
Bright 's  disease,  698 ;  in  acute  bronchi- 
tis, 621;  in  acute  chorea,  1071;  in  acute 
congestion  of  lungs,  633;  in  acute  dif- 
fuse myelitis,  966;  in  acute  febrile  poly- 
neuritis,  1022;  in  acute  fibrinous  peri- 
carditis, 761;  in  acute  gastritis,  477;  in 
acute  pancreatitis,  595;  in  acute  peri- 
tonitis, treatment  of,  610;  in  acute  pol- 
iomyelitis, 365,  366;  in  acute  sero-fi- 
brinous  pleurisy,  657;  in  acute  transverse 
myelitis,  967;  in  Addison's  disease, 
865;  in  adiposis  dolorosa,  252;  in  alco- 
holic neuritis,  1023 ;  in  aneurism  of  ab- 
dominal aorta,  859,  860 ;  in  aneurism 
of  thoracic  aorta,  854;  iu  angina 
pectoris.  837,  838;  in  angio-neurotic 


1197 


.oedema,  1124;  in  aortic  incompetency, 
811;  in  aortic  stenosis,  816;  in  appen- 
dicitis, 533,  535;  in  arthritis  defor- 
mans,  1137,  1138;  in  biliary  colic,  570, 
571;  in  cancer  of  bile-passages,  567; 
in  cancer  of  liver,  588 ;  in  cancer  of 
oesophagus,  475 ;  in  cancer  of  stomach, 
502 ;  in  cardiac  insufficiency,  790 ;  in 
catarrhal  enteritis,  518;  in  cervical  rib 
pressure,  1057;  in  chronic  arthritis  de- 
f ormans,  1139 ;  in  chronic  dry  pleurisy, 
667;  in  chronic  gastritis,  480;  in  chron- 
ic pancreatitis,  596;  in  chronic  pleuro- 
pulmonary  carcinoma,  654;  in  chronic 
ulcerative  tuberculosis,  192;  in  compres- 
sion myelitis,  960;  in  dengue,  362,  363; 
in  dermato-myositis,  1128;  in  diaphrag- 
matic pleurisy,  662;  in  dilatation  of  the 
colon,  552;  in  disease  of  fifth  nerve, 
1039;  in  erythromelalgia,  1123;  in  gas- 
tralgia,  513;  in  gastric  neuroses,  516; 
in  gastric  supersecretion,  512;  in 
gout,  420,  421;  in  haemorrhage  into, 
spinal  membranes,  958;  in  herpes  zoster, 
926,  927;  in  hypertrophic  cirrhosis,  580; 
in  hysteria,  1100;  in  inflammation  of 
oesophagus,  472;  in  intestinal  obstruc- 
tion, 542;  in  intestinal  ulcers,  522;  in 
lead  poisoning,  404;  in  lobar  pneu- 
monia, 83,  90;  in  local  adhesive  peri- 
tonitis, 606;  in  localized  Hodgkin's  dis- 
ease, 748;  in  localized  neuritis,  1021, 
1022;  in  locomotor  ataxia,  915,  917, 
919;  in  meat  poisoning,  408;  in  medias- 
tinal  abscess,  675;  in  migraine,  1088; 
in  movable  kidney,  677,  678;  in  myalgia, 
1130;  in  myeloid  leukaemia,  742;  in 
neuralgia,  1090;  in  neurasthenia,  1109, 
1110;  in  occipito-cervical  neuralgia, 
1055 ;  in  oedema  of  lungs,  635 ;  in  pan- 
creatic cancer,  599;  in  pancreatic  haem- 
orrhage, 594;  in  paroxysmal  haemoglobi- 
nuria,  683;  in  peptic  ulcer,  494,  495;  in 
pericarditis  with  effusion,  763;  in  peri- 
gastric  adhesions,  493;  in  perinephric 
abscess,  725;  in  peritonitis,  601;  in  per- 
nicious anaemia,  736;  in  pneumo-thorax, 
670;  in  pneumonia,  treatment  of,  100; 
in  progressive  central  muscular  atrophy, 
929;  in  purpura,  752;  in  pyelitis,  713; 
in  Kaynaud's  disease,  1121;  in  relaps- 
ing fever,  262 ;  in  renal  calculus,  720 ; 
in  renal  colic,  719,  720;  in  Schonlein's 
disease,  752;  in  sciatica,  1062;  in  simple 
ulcerative  colitis,  521;  in  small-pox,  318; 
in  spasmodic  wryneck,  1054;  in  spinal 
haemorrhagic  pachymeningitis,  948;  in 
subphrenic  abscess,  .605;  in  syringomy- 
elia,  965;  in  tic  douloureux,  1090,  1091; 


in  tuberculous  meningitis,  172;  in  tu- 
mors of  brain,  1012;  in  tumors  of  cere- 
bellum, 976;  in  tumors  of  kidney,  722, 
723;  in  tumors  of  spinal  cord,  963,  964; 
in  ulceration  of  oesophagus,  473;  in 
writer's  cramp,  1094;  .paroxysmal,  in 
cholecystitis,  566. 

Painful  heel,  1092. 

"Painful  testicle"  in  neurasthenia,  1111. 

Palate,  in  small-pox,  317;  tuberculosis  of, 
211. 

Pallor,  in  acute  secondary  anaemia,  728;  in 
arteria-sclerosis,  845 ;  in  cardiac  insuffi- 
ciency, 790;  in  pernicious  anaemia,  735. 

Palpable  kidney  (see  Movable  kidney) ;  in 
enteroptosis,  549. 

Palpitation,  etiology  of,  770,  771;  in 
acute  endocarditis,  801;  in  aortic  in- 
competency, 811;  in  aortic  stenosis, 
816;  in  cardiac  hypertrophy,  781;  in 
cardiac  insufficiency,  treatment  of,  795; 
in  chlorosis,  732;  in  mitral  incompe- 
tency, 818,  819;  in  neurasthenia,  1110; 
in  pernicious  anaemia,  735,  736;  in  pul- 
monary tuberculosis,  199 ;  nervous,  car- 
diac, hypertrophy  in,  781;  prognosis  of, 
771;  symptoms  of,  771;  treatment  of, 
779,  780. 

Palsies,  birth,  936,  937;  local,  in  uraemia, 
695. 

Palsy,  Cruveilhier 's,  928;  in  haematomy- 
elia,  959;  in  tumors  of  spinal  cord, 
963;  scrivener's,  1093. 

Paludal  hepatitis  in  malaria,  248. 

Pancreas,  autodigestion  of,  593 ;  diseases 
of,  592-600;  glycosuria  and,  428,  432; 
in  cancer  of  stomach,  503 ;  in  haemochro- 
matosis,  454;  in  typhoid  fever,  26;  ne- 
crosis of,  593;  ptyalism  in  disease  of, 
462. 

Pancreatic  abscess,  595. 

Pancreatic  calculi,  599,  600. 

Pancreatic  cysts,  diagnosis  of,  598;  gen- 
eral symptoms  of,  598;  morbid  anatomy 
of,  597;  operation  in,  598;  situation  of, 
,597,  598;  varieties  of,  597. 

Pancreatic  insufficiency,  592,  593. 

Pancreatic  necrosis,  593. 

Pancreatico-intestinal  type  of  infantilism, 
893. 

Pancreatitis,  acute,  594-596;  acute  haemor- 
rhagic, 594,  595;  acute  haemorrhagic, 
confusion  of,  with  appendicitis,  536; 
acute  suppurative,  595;  chronic,  596, 
597;  chronic,  following  constipation, 
546;  differentiation  of  intestinal  ob- 
struction from,  544;  in  diabetes,  432; 
mumps  and,  351;  perforation  in,  521. 

Panophthalmitis    in    exophthalmic    goitre, 


1198 


INDEX 


879;  in  herpes  zoster,  927;  suppurative, 
in  gout,  423. 

Pantophobia,  1109. 

Papillitis,  1030,  1031;  acute,  in  cerebro- 
spinal  fever,  113;  in  acute  Bright 's  dis- 
ease, 698;  in  chronic  interstitial  ne- 
phritis, 708. 

Papilloma  causing  intestinal  obstruction, 
541. 

Pappataci  fever,  314. 

Papular  syphilide,  266. 

Parsesthesia,  in  beri-beri,  415 ;  in  Erb  's 
syphilitic  spinal  paralysis,  939;  in  gout, 
423;  in  locomotor  ataxia,  915;  in  meral- 
gia  paraesthetica,  1060. 

Parageusis,  1049. 

Paragonimus  westermanii,  282. 

Paralysis,  acute  ascending  (Landry's), 
941,  942;  adductor,  1050;  alternate,  in 
tumors  of  brain,  1012;  amyotrophic,  in 
syringomyelia,  965;  anaesthesia,  1025; 
arsenical,  407;  asthenic  bulbar,  1133; 
bulbar  (see  Bulbar  paralysis) ;  com- 
bined, of  brachial  plexus,  1058;  due  to 
aneurism  of  cerebral  blood-vessels,  1004; 
due  to  cerebral  embolism  and  thrombo- 
sis, 1000;  due  to  lesions  of  centrum 
ovale,  970;  due  to  lesions  of  crura,  972, 
973;  due  to  lesions  of  internal  capsule, 
972;  due  to  lesions  of  median  nerve, 
1060;  due  to  lesions  of  motor  cortex, 
909;  due  to  lesions  of  pons  and  medulla 
oblongata,  973,  974;  due  to  lesions  of 
sacral  plexus,  1061;  due  to  lesions  of  ul- 
nar  nerve,  1059;  Erb's  syphilitic  spinal, 
939 ;  extensor,  in  pulmonary  tuberculo- 
sis, 205;  following  acute  arsenical  pois- 
oning, 406;  following  bacillary  dysen- 
tery, 128;  following  encephalitis,  1015; 
following  epilepsy,  1083;  following  in- 
fantile convulsions,  1078;  hereditary 
spastic  spinal,  938,  939;  hysterical, 
1098;  in  acute  chorea,  1070;  in  acute 
diffuse  myelitis,  966;  in  acute  endo- 
carditis, 801;  in  acute  febrile  polyneu- 
ritis,  1023;  in  acute  poliomyelitis,  365, 
366;  in  acute  transverse  myelitis,  967, 
968;  in  alcoholic  neuritis,  1023;  in 
amaurotic  family  idiocy,  939;  in  aortic 
incompetency,  812;  in  arterio-sclerosis, 
846;  in  beri-beri,  415;  in  brain  abscess, 
1017;  in  cerebral  haemorrhage,  991-996; 
in  compression  myelitis,  960,  961;  in 
haematomyelia,  959;  in  haemorrhage  into 
spinal  membrane,  958;  in  haemorrhagic 
pachymeningitis,  947;  in  hereditary 
ataxia,  945;  in  herpes  zoster,  927;  in 
lead  poisoning,  404,  405;  in  locomotor 
ataxia,  918;  in  myasthenia  gravis,  1133; 


in  pellagra,  412;  in  scarlet  fever,  339; 
in  tonsillitis,  381 ;  in  traumatic  neuro- 
ses, 1117;  in  tuberculous  meningitis, 
112,  173;  in  tumors  of  brain,  1011;  in 
tumors  of  cerebellum,  976;  in  tumors  of 
spinal  cord,  963;  in  typhus  fever,  355; 
in  whooping  cough,  121 ;  in  writer 's 
cramp,  1094;  infantile  spinal,  940,  941; 
laryngeal,  1050 ;  laryngeal,  due  to  pa- 
ralysis of  hypoglossal  nerve,  1055;  mus- 
culo-spiral,  1059 ;  oculo-motor,  1035 ; 
oculo-motor,  in  tumors  of  brain,  1012; 
of  abductors,  bilateral,  1050 ;  of  abduc- 
tors, unilateral,  1050;  of  arm,  due  to  le- 
sions of  circumflex  nerve,  1058;  of  arm 
due  to  rupture  of  brachial  plexus,  1058; 
of  cerebral  nerves  in  serous  meningitis, 
1019;  of  diaphragm,  1056;  of  extensors 
of  knee  due  to  affection  of  anterior 
crural  nerve,  1060;  of  external  eye 
muscles  in  locomotor  ataxia,  915,  916; 
of  heart  in  neuritis,  1023;  of  heart  in 
peritonitis,  602;  of  hypoglossal  iierve, 
1054,  1055;  of  lower  or  spino-muscular 
segment,  908,  909;  of  lumbar  plexus, 
1060;  of  motor  nerves  of  eye,  1037, 
1038;  of  nerves  in  cerebro-spinal  fever, 
113;  of  nerves  in  tumors  of  brain,  1012, 
1013;  of  esophagus,  473;  of  spinal  ac- 
cessory nerve,  1052;  of  third  nerve, 
1035,  1036;  of  upper  motor  segment, 
909,  910;  of  vocal  cord  in  mitral  sten- 
osis, 824;  partial,  of  hand  in  cervical 
rib  pressure,  1057;  periodical,  1119; 
pharyngeal,  1049;  post-diphtheritic,  67; 
post-febrile,  in  relapsing  fever,  263; 
progressive,  haematemesis  in,  507;  ra- 
dial, 1059;  secondary  spastic,  939,  940; 
serratus,  1058;  spastic,  in  lesions  of 
spinal  cord,  954,  955;  spastic,  of  adults, 
935,  936;  spastic,  of  infants,  936-938; 
temporary,  in  migraine,  1088;  total,  in 
complete  transverse  lesions  of  spinal 
cord,  955;  vaso-motor,  984. 

Paralysis  agitans,  definition  of,  1063 ; 
diagnosis  of,  1065;  etiology  of,  1063; 
1064;  morbid  anatomy  of,  1064;  symp- 
toms of,  1064;  treatment  of,  1065,  1066. 

Paralysis,  facial,  alternating,  1041;  course 
of,  1043,  1044;  crossed,  1041;  diagnosis 
of,  1044;  etiology  of,  1041,  1042;  fol- 
lowing scarlet  fever,  339 ;  in  acute 
cerebro-spinal  leptomeningitis,  950;  in 
hemiplegia,  992,  993;  in  lesions  of  sixth 
nerve,  1037;  in  mumps,  351;  in  myeloid 
leukaemia,  743;  in  tetanus,  143;  in  tu- 
mors of  brain,  1012;  parotitis  and,  463; 
symptoms  of,  1042,  1043;  treatment  of, 
1044. 


INDEX 


1109 


Paralysis,  general,  of  insane,  cytodiagnosia 
in,  925;  definition  of,  922;  diagnosis  of, 
924-926;    etiology    of,    922;     locomotor 
ataxia    and,    921 ;    morbid   anatomy    of, 
922,    923;     prognosis    of,    926;    spastic 
paralysis   and,   936;    symptoms  of,  923, 
924;  treatment  of,  926. 
Paralytic  ileus,  541,  542. 
Paranephric  cysts,  725. 
Paraphasia,  980 ;  in  tumors  of  brain,  1011. 
Paraplegia,  ataxic,  differentiation  of  loco- 
motor  ataxia  from,  919 ;  cerebralis  spas- 
tica  (see  Spastic  paralysis  of  infants)  ; 
cervical,    968;    diabetic,    434;    dolorosa, 
961 ;  due  to  anaemia  of  spinal  cord,  956, 
957;     due    to    displacement     of    sacral 
plexus,    1061 ;    hereditary    spastic,    938, 
939;  hysterical,  1098;  hysterical  spastic, 
940;  in  abscess  of  kidney,  714;  in  acute 
diffuse   myelitis,  966;   in  alcoholic   neu- 
ritis,   1023;    in   aneurism   of   abdominal 
aorta,  860;    in  arterio-sclerosis,  846;  in 
compression    myelitis,    961;    in   haemor- 
rhage  into   spinal   membranes,   958;    in 
influenza,     118;     in    malaria,    254;     in 
measles,     347;     in     primary     combined 
sclerosis,    944;     in    spinal    haemorrhagic 
pachymeningitis,  948;   spastic,  in  lathy- 
rism,  410. 

Paramyoclonus  multiplex,  1132,  1133. 
Paranoia  in  locomotor  ataxia,  918. 
Parasites,  abscess  of  liver  due  to,  583;  ac- 
quired   chronic    hydrocephalus    due    to, 
1020;  compression  myelitis  due  to,  960; 
haematuria  due  to,  681;   in  bilharziasis, 
283;    intestinal,   pernicious  anaemia  due 
to,  734;   malarial,  244-247;   malarial,  in 
mosquito,  246,  247;   of  aestivo-autumnal 
fever,  246,  252;   of  quartan  fever,  245, 
246;    of   syphilis,   264,   265;    of   tertian 
fever,  245,  250,  251. 
Parasitic  aneurism,  849. 
Parasitic   gastritis,  479. 
Parasitic  haemoptysis,  282. 
Parasitic  stomatitis,  458,  459. 
Para-syphilitic  affections,  268. 
Parathyroid  extract  in  treatment  of  par- 
alysis agitans,   1065. 

Parathyroid   glands,   diseases   of,    880-883. 
Paratyphoid  infections,  8. 
Parenchymatous    degeneration,    of    heart, 
788;  of  heart  walls,  dilatation  and,  784. 
Parenchymatous  nephritis,  702. 
Parenchymatous  neuritis,  1021. 
Paresis,  bradycardia   in,   777;   differentia- 
tion of  pellagra  from,  413 ;  general,  dif- 
ferentiation  of   locomotor   ataxia   from, 
919,    920;     general,    differentiation    of 
neurasthenia   from,   1112;    general    (see 


Paralysis,     general) ;     in     haemorrhagic 
pachymeningitis,  947 ;  in  tumor  of  cere- 
bellum, 976;   in  writer's  cramp,  1094. 
Parkinson's  disease,  1063-1066.     (See  Pa- 
ralysis   agitans.) 
Parosmia,  1028. 
Parotid   bubo,   463. 
Parotid  gland,  gaseous  tumors  of,  464. 
Parotitis,  acute  suppurative,  in  acute  en- 
docarditis, 800;  chronic,  463,  464;  com- 
plicating     cerebro-spinal      fever,      112; 
complicating  small-pox,  322 ;  gouty,  422 ; 
in  cholera  asiatica,  136;   in  lobar  pneu- 
monia,  91;    in   measles,   346;    in   peptic 
ulcer,  495;  in  suppurative  angiocholitis, 
565;  in  syphilis,  267;  in  typhoid  fever, 
22,   355;   in  yellow  fever,   360;    specific 
(see      Mumps) ;       symptomatic,      463 ; 
thrombosis  of  cerebral  sinuses  and  veins 
due  to,  1005. 

Parotitis,     epidemic,     complications     and 
sequelae  of,  351;  definition  of,  349;  diag- 
nosis  of,   350;    etiology    of,    349,    350; 
orchitis  in,  350,  351;  symptoms  of,  350; 
treatment  of,  351. 
Paroxysmal   albuminuria,   685. 
Paroxysmal  haemoglobinuria,   683,  684. 
Paroxysmal  tachycardia,  776,  777. 
Parrot's  disease,  confusion  of,  with  infan- 
tile scurvy,  450. 
Parry's      disease.        (See      Exophthalmic 

goitre.) 

Parturition,  acute  pancreatitis  and,   594. 
Pasteur's    preventive    inoculation    against 

hydrophobia,   371. 
Pathomimia,  1103. 
Pathophobia,  1109. 
Pectoriloquy    in    pulmonary    tuberculosis, 

201. 

Pediculosis,  311,  312. 
Pediculus  capitis,  311,  312;  corporis,  312; 

vestimentorum,   312. 
Pel-Ebstein  pyrexia,  748. 
Peliomata  in  typhoid  fever,  19. 
Peliosis,  752;   rheumatica,  1072. 
Pellagra,  clinical  forms  of,  413;  definition 
of,  411;   diagnosis  of,  413;   distribution 
of,  411;   etiology  of,  411,  412;   history 
of,  411;  pathology  of,  412;  prognosis  of 
413;  prophylaxis  of,  413;  symptoms  of, 
412,   413;    toxic   combined   sclerosis   in, 
945;   treatment  of,  413,  414. 
Pelvic    abscess,    rupture    of,    and   pyuria, 

688. 

Pelvic  peritonitis,  605. 
Pemphigoid  purpura,  752. 
Pemphigoid  stomatitis,  458. 
Pemphigus,   in  cerebro-spinal  fever,  112; 


1200 


INDEX 


neonatorum   syphiliticus,   268;   vegetans, 
458. 

Pentastoma  taenoides,  310. 

Peutastomum  constrictum,  310;  denticula- 
turn,  310. 

Peptic  ulcer,  gastric  and  duodenal,  diag- 
nosis of,  496;  erosions  in,  490;  etiology 
of,  490,  491;  in  the  oesophagus,  473; 
morbid  anatomy  and  pathology  of,  491- 
493;  prognosis  of,  495,  496;  symptoms 
of,  493-495;  treatment  of,  496-498. 

Perforation  of  aorta,  in  abscess  of  lymph 
gland,  673;  of  blood  vessels  in  tracheo- 
bronchial  adenitis,  177;  of  bowel,  due  to 
solitary  ulcer,  521;  of  bowel  in  typhoid 
fever,  11,  24,  25;  of  bowel,  perinephric 
abscess  following,  725;  of  bowel,  treat- 
ment of,  44;  of  bronchi  in  interlobar 
pleurisy,  663 ;  of  chest  wall  in  empyema, 
661 ;  of  chest  wall  in  mediastinal  tu- 
mors, 673;  of  cystic  duct,  gall-stones 
and,  572;  of  ear-drum  in  scarlet  fever, 
338 ;  of  glands  in  tracheo-bronchial  ade- 
nitis, 177;  of  heart  in  ulcerative  endo- 
carditis, 799;  of  intestine  in  ameer"  asis, 
241;  of  intestine  in  pulmonary  tuber- 
culosis, 205;  of  lung,  abscess  due  to, 
653;  of  lung  in  abscess  of  liver,  585;  of 
lung  in  empyema,  661 ;  of  lung,  pneumo- 
thorax  following,  670,  671;  of  oesopha- 
gus, in  empyema,  662 ;  of  oasophagus  in 
tracheo-bronchial  adenitis,  177;  of 
oesophagus,  pneumopericardium  due  to, 
770;  of  pericardium  in  empyema,  662; 
of  peritoneum  in  empyema,  662;  of 
pleura  in  gangrene  of  lung,  651; 
of  pleura,  pneumo-thorax  due  to,  669 ; 
of  soft  palate  in  scarlet  fever,  339;  of 
stomach  in  empyema,  662;  of  stomach 
in  tuberculosis,  212. 

Perforative  peritonitis,  600. 

Peri-appendicitis  acuta,   532. 

Periarteritis,  gummatous,  276;  in  cerebral 
vessels,  apoplexy  due  to,  989 ;  nodosa, 
862;  of  spinal  cord,  957. 

Perica3cal  abscess,  differentiation  of,  from 
appendicitis,,  537. 

Pericardial  adhesions,  cardiac  hypertrophy 
and,  781;  dilatation  of  heart  in,  784. 

Pericardial  effusion,  763-767;  acute  car- 
diac insufficiency  due  to,  785 ;  differen- 
tiation of  pleural  effusion  from,  664; 
03sophageal  stricture  and,  474. 

Pericarditis,  acute  cardiac  insufficiency  in, 
785;  acute  fibrinous,  761-763;  acute  in- 
terstitial myocarditis  in,  787;  as  a  ter- 
minal infection,  53 ;  chronic  adhesive, 
767-769 ;  complicating  bacillary  dysen- 
tery, 128;  complicating  cerebro-spinal 


fever,  112;  complicating  gonococcus  in- 
fection, 125 ;  complicating  influenza, 
118;  dilatation  of  heart  in,  784;  eti- 
ology of,  760,  761;  fatty  •  degeneration 
of  heart  in,  788;  following  tracheo- 
bronchial  adenitis,  177;  in  acute  chorea, 
1071;  in  chronic  gout,  422;  in  diph- 
theria, 62 ;  in  gout,  421 ;  in  lobar  pneu- 
monia, 81,  89,  90;  in  pneumonia,  treat- 
ment of,  101;  in  rheumatic  fever,  376-, 
in  scarlet  fever,  334,  338 ;  in  Schonlein  'b 
disease,  752;  in  tonsillitis,  381;  in  ty- 
phoid fever,  13,  21 ;  indurative  medias- 
tino,  675 ;  neuralgia  of  phrenic  nerve  ifi 
1091 ;  parenchymatous  degeneration  of 
heart  in,  788;  secondary  to  erysipelas, 
54;  terminal,  in  uremia,  695;  with  ef- 
fusion, 763-767. 

Pericardium,  diseases  of,  760-770;  in  sep- 
tico-pyaemia,  51;  tuberculosis  of,  179, 
760. 

Perichondritis,   618. 

Perihepatitis,  581,  582;  chronic  adhesive 
pericarditis  and,  768;  chronic,  prolifera- 
tive  peritonitis  and,  606. 

Perinephric  abscess,  725,  726;  differentia- 
tion of  appendicitis  from,  537;  differ- 
entiation of  pyonephrosis  from,  714; 
following  rupture  of  a  cyst  in  polycystic 
kidneys,  724;  typhoid  fever  and,  30. 

Perinephritis,  chronic,  perinephric  abscess 
and,  725. 

Periodical  paralysis,  1119. 

Peri-pancreatic  abscess,  following  pancre- 
atic abscess,  595. 

Peripheral   nerves,   diseases  of,   1020-1063. 

Peripheral  neuritis,  1020;  differentiation 
of  locomotor  ataxia  from,  919. 

Periproctitis  following  bacillary  dysen- 
tery, 128. 

Perisigmoiditis,  553. 

Perisplenitis,  chronic,  and  proliferative 
peritonitis,  606. 

Peristalsis,  in  enteroptosis,  549;  in  pyloric 
stenosis,  506;  intussusception  and,  539. 

Peristaltic  unrest,  510. 

Peritoneum,  diseases  of,  600-611 ;  in  can- 
cer of  stomach,  503 ;  in  genito-urinary 
tuberculosis,  215,  216;  in  malarial  ca- 
chexia,  248;  tuberculosis  of,  179-182. 

Peritonitis,  actinomycotic,  232;  acute 
general,  600-603 ;  acute,  treatment  of, 
610,  611;  appendicular,  605;  as  a  ter- 
minal infection,  53;  causing  ascites, 
608;  chronic,  606,  607;  chronic  hgemor- 
rhagic,  607;  chronic  plastic,  perigastric 
adhesions  and,  493 ;  chronic,  treatment 
of,  611;  circumscribed,  differentiation 
of,  from  appendicitis,  537;  colon  bacil- 


INDEX 


1201 


lus  in,  47;  complicating  bacillary  dysen- 
tery, 128;  complicating  influenza,  118; 
complicating  typhoid  fever,  12;  differen- 
tiation of  intestinal  obstruction  from, 
544;  due  to  acute  puerperal  infection, 
603;  due  to  Bacillus  coli,  47;  due  to 
infarction  in  acute  endocarditis,  801; 
following  gonococcus  infection,  124; 
following  rupture  of  a  cyst  in  polycys- 
tic  kidney,  724;  in  amrebiasis,  241;  in 
appendicitis,  535,  536;  in  cancer  of 
stomach,  503;  in  chronic  adhesive  peri- 
carditis, 768;  in  chronic  gout,  422;  in 
external  anthrax,  149 ;  in  infants,  603, 
604;  in  intestinal  ulcers,  522;  in  lobar 
pneumonia,  91;  in  perihepatitis,  581; 
in  typhoid  fever,  25,  44,  45;  in  uraemia, 
695;  indicanuria  in,  691;  intestinal  ca- 
tarrh in,  517;  leukaemic,  743;  localized, 
604,  605 ;  pelvic,  605 ;  pelvic,  confusion 
of,  with  appendicitis,  536;  perforation 
in,  521;  pneumococcic,  in  tonsillitis, 
381;  subphrenic,  604,  605;  thrombosis 
of  portal  vein  in,  562;  tuberculous,  179- 
182;  tuberculosis,  confusion  of,  with 
typhoid  fever,  38;  tuberculous  salpin- 
gitis  and,  220. 

Perityphlitic  abscess,  rupture  of,  pyuria 
and,  688. 

Perityphlitis  following  bacillary  dysentery, 
128. 

Periurethral  abscess,  123. 

Perles  of  Laennec  in  asthma,  629,  630. 

Pernicious  anaemia,  definition  of,  733;  di- 
agnosis of,  739;  distribution  of,  733; 
etiology  of,  733,  734;  fatty  degeneration 
of  heart  in,  788;  history  of,  733;  path- 
ology and  morbid  anatomy  of,  734,  735; 
prognosis  of,  738,  739;  splenomegaly  in, 
888;  symptoms  of,  735-738;  treatment 
of,  740. 

Pernicious  malarial  fever,  248,  253,  254. 

Pestis  minor,  140. 

Petechiae,  751;  in  bubonic  plague,  140;  in 
cerebro-spinal  fever,  111;  in  chronic  sec- 
ondary anaemia,  730;  in  measles,  345; 
in  mycosis  intestinalis,  150;  in  perni- 
cious anaemia,  736;  in  relapsing  fever, 
262;  in  scarlet  fever,  335,  337;  in  ther- 
mic fever,  391;  in  typhus  fever,  353; 
in  whooping  cough,  121. 

Petechial  fever,  108.  (See  also  Cerebro- 
spinal  fever.) 

Petit  mal,  1080;  diagnosis  of,  1083;  dif- 
ferentiation of  auditory  vertigo  from, 
1048;  differentiation  of  neurasthenia 
from,  1112;  symptoms  of,  1083. 

Pfeiffer's  bacillus,  116,  117. 
Pfeiffer's  phenomenon,  36, 


Phantom   tumor  in   hysteria,   1099. 

Pharyngeal  diphtheria,  63,  64. 

Pharyngeal  tonsil,  468,  471. 

Pharyngitis,  acute,  464,  465;  chronic,  465; 
complicating  small-pox,  323;  in  typhoid 
fever,  22;  sicca,  465. 

Pharynx,  diseases  of,  464-466;  in  pulmo- 
nary tuberculosis,  202,  204;  in  small- 
pox, 317,  319;  ifi  tuberculous  laryn- 
gitis, 618;  in  typhoid  fever,  13,  22; 
spasm  of,  due  to  lesion  of  pneumogas- 
tric  nerve,  1050;  tuberculosis  of,  211, 
212. 

Phenol-sulphonephthalein  test,  695. 

Philippine  itch,  316. 

Phimosis,   convulsions  due   to,   1077. 

Phlebitis  complicating  influenza,  118;  in 
gout,  423;  in  typhoid  fever,  21,  45,  46; 
of  umbilical  vein,  icterus  neonatorum 
and,  558. 

Phlebo-sclerosis,  845;  in  pulmonary  tuber- 
culosis, 209. 

Phlebotomus  fever,  314. 

Phlegmon,  acute  infectious,  of  pharynx, 
466. 

Phlegmonous  enteritis,  520. 

Phlegmonous   gastritis,  478. 

Phobias  in  neurasthenia,   1109. 

Phosphatic  calculi,  718. 

Phosphatic  diabetes,  691. 

Phosphaturia,  690,  691. 

Phosphoric  acid  in  gout,  419,  421. 

Phosphorus  poisoning,  anuria  in,  680;  dif- 
ferentiation of  acute  yellow  atrophy 
from,  560;  fatty  degeneration  of  heart 
in,  788;  fatty  liver  and,  590;  hsemate- 
mesis  in,  507;  lipuria  in,  693;  necrosis 
of  liver  in,  559. 

Phrenic  nerve,  affections  of,  1055,  1056; 
neuralgia  of,  1091. 

Phthiriasis,  311,  312. 

Phthirius  pubis,  312. 

Phthisis  (see  Pulmonary  tuberculosis) ; 
calculeuse,  194;  diabetic,  431;  fibroid, 
202,  639-642;  florida,  185;  gold  miners', 
644;  renum,  217-219;  stone  cutters', 
642. 

Pia  mater,  diseases  of,  948-951. 

Pick's   disease,   768. 

Pigeon  breast,  in  adenoids,  469 ;  in  rickets, 
444. 

Pigment  cirrhosis  of  liver,  576. 

Pigmentation  of  skin,  865,  1145;  in  Addi- 
son's  disease,  865;  in  arsenical  poison- 
ing, 407;  in  arthritis  deformans,  1138; 
in  chlorosis,  731;  in  chorea,  1072;  in. 
exophthalmic  goitre,  866,  879;  in  haemo- 
chromatosis,  453,  454;  in  neuritis  from 
arsenic,  1024;  in  neuro-fibromatosia, 


1202 


INDEX 


1027;  in  ochronosis,  454;  in  other  con- 
ditions than  Addison's  disease,  865, 
866;  in  pellagra,  412;  in  peptic  ulcer, 
495;  in  scleroderma,  1126  j  relation  of 
suprarenal  bodies  to,  864. 

Pigs,   actinomycosis  in,  232. 

Pin-worm,  296. 

Pithiatisme,    1095. 

Pituitarism,  hypo-,  890;  hyper-,  890. 

Pituitary  body,  carbohydrate  metabolism 
and,  890,  891;  diseases  of,  889-892;  re- 
lation of,  to  achondroplasia,  1147;  re- 
lation of,  to  obesity,  451;  tumors  of, 
1013. 

Pituitary  gland  extract,  in  treatment,  892; 
in  treatment  of  obesity,  452. 

Pityriasis  versicolor,  206. 

Placenta,  tuberculosis  of,  220. 

Plague,  clinical  forms  of,  140;  definition 
of,  138;  diagnosis  of,  141;  etiology  of, 
139,  140;  fleas  and,  139;  history  and 
geographical  distribution  of,  138,  139; 
Manchurian,  139;  pneumonic,  140;  pre- 
ventive inoculation  against,  142;  pro 
phylaxis  of,  141;  rats  and,  138;  secon- 
dary pneumonia  in,  93;  treatment  of, 
141. 

Plague  serum,  140. 

Plantar  neuralgia,  1092. 

Plaques  jaunes,   999,  1000. 

Plasmodium  falciparum,  246;  malariae, 
245,  246;  vivax,  245. 

Plastic  bronchitis,   631-633. 

Plastic  linitis,  486. 

Plastic  perigastritis,  493. 

Plastic  pleurisy,  654-655;  chronic  dry 
pleurisy  following,  667,  668. 

Plethora  in  erythraemia,  757. 

Pleura,  complications  of  pulmonary  tuber- 
culosis in,  203;  diseases  of,  654-675; 
echinococcus  of,  292,  293;  in  amoebiasis, 
240;  in  broncho-pneumonia,  102,  103; 
in  carcinoma  of  lung,  654;  in  chronic 
ulcerative  tuberculosis,  190;  in  cirrhosis 
of  lung,  641 ;  in  hypertrophic  emphy- 
sema, 647;  in  lobar  pneumonia,  80;  in 
septico-pyaemia,  51;  metastases  in,  in 
cancer  of  stomach,  503;  tuberculosis  of, 
178,  179. 

Pleural  adhesions,  compensatory  emphy- 
sema and,  645. 

Pleural  effusion,  diagnosis  of,  663;  differ- 
entiation of  pericardial  effusion  from, 
766;  echinococcus  of  liver  confused 
with,  292;  etiology  of,  655;  failure  of 
left  auricle  causing,  785;  morbid  anat- 
omy of,  656;  symptoms  of,  657;  treat- 
ment of,  604. 

Pleurisy,  abscess  of  liver  and,  585;  active 


congestion  of  lungs  in,  633;  acute  dia- 
phragmatic, 662;  acute  encysted,  663,- 
acute  fibrinous  or  serous,  654,  655 ;  acute 
hasmorrhagic,  662;  acute  interlobar,  663; 
acute  purulent,  660-662;  acute  sero-fi- 
brinous,  655-660;  acute  tuberculous,  178, 
662;  as  a  terminal  infection,  53;  asso- 
ciated with  fibrinous  bronchitis,  633; 
chronic,  667,  668;  chronic  adhesive,  178; 
chronic  bronchiectasis  and,  626;  chronic 
dry,  667,  668;  chronic  tuberculpus,  178; 
chronic  ulcerative  tuberculosis  and,  190, 
191;  chronic,  with  effusion,  667;  cirrho- 
sis of  lung  following,  640;  compensa- 
tory emphysema  in,  645;  complicating 
bacillary  dysentery,  128;  complicating 
cerebro-spinal  fever,  112;  complicat- 
ing gonococcus  infections,  125;  compli- 
cating small-pox,  322;  complicating 
whooping  cough,  121 ;  diagnosis  of,  663, 
664;  diaphragmatic,  662;  encysted,  663; 
following  cholera  asiatica,  136;  hsemor- 
rhagic,  662;  hematoporphyrin  in  urine 
in,  693;  in  cerebro-spinal  fever,  110;  in 
chronic  gout,  422;  in  chronic  intersti- 
tial nephritis,  707;  in  mumps,  351;  in 
pulmonary  tuberculosis,  203 ;  in  rheu- 
matic fever,  376;  in  scarlet  fever,  338; 
in  trichiniasis,  299;  in  typhoid  fever, 
13,  27;  influenza,  117;  interlobar,  663; 
lamblia  intestinals  in,  281;  lobar  pneu- 
monia and,  89 ;  neuralgia  of  phrenic 
nerve  in,  1091;  pericarditis  with  effu- 
sion confused  with,  764;  pneumonia 
and,  98,  101;  pulsating,  differentiation 
of  thoracic  aneurism  from,  857;  puru- 
lent, 660-662;  secondary  to  erysipelas, 
54;  secondary  tuberculous,  179;  sero- 
fibrinous,  655;  subacute  tuberculous, 
178;  suppurative,  caused  by  perforation 
of  echinococcus  cysts,  292;  terminal,  in 
ureemia,  695;  treatment  of,  664-667;  tu- 
berculous, 662;  tuberculous,  following 
cervical  adenitis,  176;  tuberculous  peri- 
tonitis and,  180. 

Pleurodynia,   1129,   1130. 

Pleurogenous   interstitial  pneumonia,   640. 

Pleuro-pericardial  friction  in  acute  fibrin- 
ous  pericarditis,  763. 

Pleuro-pneumonia,  pericarditis  and,  760. 

Pleurothotonos,   144. 

Plexiform  neuroma,  1026,  1027. 

Plica  polonica,   312. 

Plumbism.     (See  Lead  poisoning.) 

Pneumatosis,   511. 

Pneumaturia,    433,    692. 

Pneumo-bacillus,  Friedlander  's,   77. 

Pneumococcic  infections,  74-108. 

Pneumococcus,  in   acute   suppurative  gaa- 


INDEX 


1203 


tritis,  478;  in  bronchitis,  620;  in  bron- 
cho-pneumonia, 104 ;  in  cholecystitis,  566 ; 
in  diphtheria,  62 ;  in  empyema,  660,  664 ; 
in  endocarditis,  800;  in  gall-stones,  569; 
in  pericarditis,  761;  in  peritonitis,  601; 
in  pleurisy,  656;  in  septico-pyaemia,  51; 
local  affections  from,  108;  of  Fraenkel 
and  Weichselbaum,  76,  77;  septicaemia 
due  to,  50,  108;  septico-pyaemia  due  to, 
51;  terminal  infections  due  to,  53. 

Pneumogastric   nerve,  affections  of,   1049- 
1051. 

Pneumonia,  abscess  formation  in,  652, 
653;  active  congestion  of  lungs  in,  633; 
acute  cerebro-spinal  leptomeningitis  due 
to,  949;  acute  endocarditis  in,  797,  798; 
acute  plastic  pleurisy  in,  654;  albumi- 
nuria  in,  685;  albumosuria  in,  686;  ap- 
pendicitis and,  532;  aspiration,  in  can- 
crum  oris,  459;  aspiration,  in  leprosy, 
153;  association  of,  with  other  diseases, 
93;  blood  pressure  in,  86;  bradycardia 
following,  777;  bronchitis  following, 
620;  broncho-,  101;  catarrhal  jaundice 
in,  563 ;  chronic,  95 ;  chronic  interstitial, 
639-642;  chronic  ulcerative  tuberculo- 
sis and,  188,  189;  confusion  of,  with 
typhoid  fever,  37;  contusion,  76;  death 
from,  in  hypertrophic  emphysema,  649 ; 
differentiation  of  pleurisy  from,  663; 
dilatation  of  colon  in,  552;  diphtheroid 
enteritis  in,  520;  empyema  and,  660; 
fibrinous  casts  in  expectoration  of,  632; 
fibrous  interstitial,  273;  following  chol- 
era asiatica,  136;  following  putrid  bron- 
chitis, 624;  gangrene  of  lung  follow- 
ing, 650,  651;  haemoptysis  in,  636; 
herpes  zoster  in,  926;  history  of,  74;  in 
bulbar  paralysis,  931;  in  cerebro-spinal 
fever,  110-113;  in  chronic  interstitial 
nephritis,  707;  in  diabetes,  431,  434;  in 
diphtheria,  62;  in  glanders,  146;  in 
leukaemia,  743 ;  in  malaria,  248 ;  in  mea- 
sles, 346;  in  psittacosis,  388;  in  pulmo- 
nary tuberculosis,  203,  208,  209;  in  re- 
lapsing fever,  263;  in  rheumatic  fever, 
376;  in  rubella,  349;  in  small-pox,  322; 
in  tonsillitis,  381;  in  trichiniasis,  299; 
in  typhoid  fever,  13,  27;  in  whooping 
cough,  121;  infantile  convulsions  pre- 
ceding, 1078;  inflammation  of  esopha- 
gus in,  472,  473;  influenza,  118;  inter- 
stitial bronchiectasis  following,  625;  in- 
testinal catarrh  and,  517;  jaundice  in, 
91;  lobar,  74;  lobar,  abdominal  pain  in, 
83;  lobar,  dilatation  of  stomach  in,  90; 
membranous  gastritis  in,  479;  meningi- 
tis in,  951;  mycotic  aneurism  and,  848; 
pericardial  effusion  in,  766;  pericarditis 


in,  760,  761;  plague  and,  141;  post- 
operative, 94;  prophylaxis  in,  98;  sec- 
ondary to  erysipelas,  54,  56;  streptococ- 
cus pleurisy  and,  656;  subphrenic  ab- 
scess following,  604;  suppurative  cholan- 
gitis  and,  565;  thyroiditis  in,  871;  vac- 
cine therapy  in,  78;  varieties  of,  92; 
white,  of  fetus,  272. 

Pneumonic  infections,  108. 

Pneumonic  plague,   140. 

Pneumonic  tuberculosis,  183-187. 

Pneumonokoniosis,  definition  of,  642;  di- 
agnosis of,  645;  etiology  of,  642,  643; 
morbid  anatomy  of,  643,  644;  prophy- 
laxis of,  645;  symptoms  of,  644,  645; 
treatment  of,  645. 

Pneumopericardium,  769,  770. 

Pneumothorax,  aneurism  and,  854;  com- 
pensatory emphysema  in,  645;  diagnosis 
of,  671;  emphysema  of  lung  and,  647, 
675;  etiology  of,  669,  670;  following  ex- 
ploratory puncture  in  pleurisy,  666; 
from  interstitial  emphysema,  650;  in 
chronic  ulcerative  tuberculosis,  189,  190; 
in  empyema,  661 ;  in  pulmonary  tubercu- 
losis, 203;  in  tuberculosis,  229;  in  ty- 
phoid fever,  27;  induction  of,  in  treat- 
ment of  tuberculosis,  229;  morbid  anat- 
omy of,  670;  prognosis  of,  672;  subphre- 
nic abscess  stimulating,  604,  605;  symp- 
toms of,  670,  671;  treatment  of,  672. 

Pneumo-typhus,    27,    98. 

Podagra.     (See  Gout.) 

Pododynia,   125,   1092. 

Poikilocytosis,  732,  737. 

Poisoning,  arsenical,  406,  407;  bradycar- 
dia in,  777;  cheese,  409;  drug,  parotitis 
and,  463;  fish,  409;  grain  and  vege- 
table, 409,  410;  haematemesis  in,  507; 
lead,  402-406;  meat,  407,  408;  mercury, 
lead,  arsenic,  diphtheroid  enteritis  in, 
520;  metallic,  parotitis  and,  463;  milk, 
409;  tea,  coffee,  etc.,  cardiac  hypertro- 
phy in,  781;  tetany  and,  881. 

Poisons,  acute  cardiac  insufficiency  due 
to,  785;  causing  catarrhal  enteritis,  517; 
chronic  cardiac  insufficiency  due  to,  786 ; 
jaundice  due  to,  557;  sclerosis  of  heart 
valves  due  to,  804;  toxic  gastritis  due 
to,  478,  479. 

Polio-encephalitis,  366,  1014,  1015;  hemi- 
plegia  in  children  and,  1007. 

Polio-myelitis,  acute,  364,  940,  941;  abor- 
tive form  of,  365;  acute  bulbar  paraly- 
sis in,  931;  acute  myelitis  and,  966; 
anterior  chronica  (see  Progressive  cen- 
tral muscular  atrophy)  ;  bulbar  form  of, 
366;  cerebral  type  of,  366;  chronic  an- 
terior, 940;  course  of,  367;  definition 


1204 


INDEX 


of  364;  diagnosis  of,  367;  differentia- 
tion of  chorea  from,  1072,  1073;  etiol- 
ogy of,  364,  365;  facial  paralysis  in 
1041;  globulin,  test  in,  367;  history  of, 
364;  in  typhoid  fever,  29;  meningitic 
form  of,  366;  morbid  anatomy  of,  365; 
polio-myelitic  or  sporadic  form  of,  366; 
polyneuritic  forms  of,  366;  progres- 
sive ascending  type  of,  366;  prognosis 
of,  367;  prophylaxis  of,  368;  symptoms 
of,  365-367;  treatment  of,  368. 

Polio-myeloencephalitis  hemiplegia  in  chil- 
dren and,  1007. 

Pollantin,  613. 

Pollen,  hay  fever  due  to,  612. 

Polyadenitis  in  measles,   346. 

Polyadenome  en  nappe,  505. 

Polyaemia  in  myeloid  leukaemia,  741. 

Polyarteritis   acuta   nodosa,   862. 

Polychromatophilia,    738. 

Polycystic  kidneys,  724. 

Polycythaemia,  hypertonica,  758;  in  con- 
genital disease,  834;  in  diabetes,  433; 
in  high  altitudes,  395;  vera,  757,  758. 

Polymyositis  haemorrhagica,   1129. 

Polyneuritic  form  of  acute  polio-myelitis, 
366. 

Polyneuritis,  acute  febrile,  1022,  1023 ;  fol- 
lowing whooping  cough,  121;  in  measles, 
347;  in  rheumatic  fever,  376,  377;  re- 
currens,  1023. 

Polyorrhomenitis,  178;  in  chronic  perito- 
nitis, 607. 

Polyphagia,   432. 

Polypi,  nasal,  asthma  associated  with,  629 ; 
nasal,  loss  of  sense  of  smell  in,  1028;  of 
stomach,  505. 

Polyserositis  in  chronic  peritonitis,  607. 

Polyuria,  hydronephrosis  due  to,  716;  in 
myeloid  disease  of  kidneys,  712;  in 
chronic  interstitial  nephritis,  706;  in 
diabetes  insipidus,  440;  in  "essential 
phosphaturia, "  691;  in  neurasthenia, 
1111;  in  pyelitis,  714;  in  typhoid  fever, 
30. 

Pons,  hemiplegia  due  to  haemorrhage  in, 
993,  995;  medulla  oblongata  and  lesions 
of,  973,  974;  Varolii,  hemiplegia  due 
to  lesion  of,  992. 

Porencephalus,  1007,  1010. 

Pork  tapeworm,  284. 

Porocephalus  constrictus,  310. 

Portal  obstruction  causing  ascites,  608. 

Portal  vein,  diseases  of,  562. 

Post-hemiplegic    movements,    1008. 

Post-mortem  wart,  162. 

Post-operative   broncho-pneumonia,   102. 

Post-operative  pneumonia,  94. 

Post-operative  tetanus,  144. 


Post-typhoid  insanity,  46. 

Post-typhoid  neuritis,  46. 

Post-typhoid  pyaemia,   31,  32. 

Post-typhoid   septicaemia,   31. 

Posterior  basic  meningitis,  951. 

Posterior  cerebral  artery,  symptoms  of 
blocking  of,  1000. 

Posterior  spinal  sclerosis.  (See  Locomo- 
tor  ataxia.) 

Potassium  chlorate,  acute  Bright 's  disease 
due  to,  697;  haemoglobinuria  due  to, 
683. 

Potato-poisoning,  410. 

Pott 's  disease,  Addison  's  disease  and,  863 ; 
compression  of  spinal  cord  and,  959-961. 

Pregnancy,  acute  Bright 's  disease  and, 
697,  699;  acute  chorea  and,  1067;  acute 
yellow  atrophy  and,  559;  albuminuria 
of,  685;  Bacillus  coli  infections  in,  47; 
causing  obstructive  jaundice,  555;  con- 
stipation and,  545;  decrease  of  phos- 
phoric output  in,  691;  enteroptosis  and, 
549 ;  gall-stones  and,  569 ;  glycosuria  in., 
429;  maniacal  chorea  in,  1070;  meralgia 
paraesthetica  and,  1060;  mitral  lesions 
and,  828;  myeloid  leukaemia  and,  741; 
oedema  of  lungs  in,  635;  pernicious  anae- 
mia and,  733,  734;  pyelitis  and,  712; 
relapsing  fever  in,  263 ;  relation  of,  to 
floating  kidney,  677 ;  rickets  and,  445 ; 
spasm  of  oesophagus  in,  473;  suprarenal 
bodies  and,  864;  tetany  in,  881;  tuber- 
culosis and,  222;  typhoid  fever  in,  34; 
valvular  disease  and,  827. 

Prepuce,  adherent,  epilepsy  and,  1081, 
1087. 

Priapism  in  myeloid  leukaemia,   743. 

Primary   combined  sclerosis,  943,   944. 

Primary  lateral  sclerosis,  935,  936. 

Professional  spasms,  1093-1095. 

Prof  eta's  law,  265. 

Progeria,  893. 

Progressive  bulbar  paralysis,  atrophy  of 
tongue  in,  1055. 

Progressive  central  muscular  atrophy,  940 ; 
definition  of,  927,  928;  diagnosis  of, 
930;  differentiation  of  muscular  dystro- 
phies from,  934;  etiology  of,  928;  mor- 
bid anatomy  of,  928,  929;  symptoms  of, 
929,  930;  treatment  of,  930. 

Progressive  interstitial  hypertrophic  neu- 
ritis of  infants,  945. 

Progressive  muscular  atrophy,  atrophy  of 
tongue,  in,  1055;  ophthalmoplegia  ex- 
terna  in,  1038;  paralysis  in,  1052. 

Progressive  neural  muscular  atrophy,  931, 
932;  differentiation  of  muscular  dystro- 
phies from,  934. 


INDEX 


1205 


Progressive  paralysis  of  insane,  Jacksonian 

epilepsy  due  to,  1084. 
Progressive    paresis    following    traumatic 

neuroses,  1118. 
Proliferative  peritonitis,  606,  607. 

Prostate,  tuberculosis  of,  219. 

Prostatic  abscess,  septico-pyaemia  follow- 
ing, 52. 

Prostatitis,  gonorrheal,  123;  in  typhoid  fe- 
ver, 30,  45. 

Proteus  bacillus,  in  infectious  jaundice, 
385;  in  pyelitis,  712. 

Protozoan   infections,   237. 

Protozoic  dermatitis,  235. 

Pruritus,  in  diabetes,  432,  434,  439;  in 
exophthalmic  goitre,  879;  in  Hodgkin's 
disease,  748;  in  hypertrophic  cirrhosis, 
581;  in  jaundice,  556;  in  lymphoid  leu- 
kaemia, 745. 

Psammoma,  of  brain,  1010;  of  spinal  cord, 
963. 

Pseudo-angina  in  neurasthenia,   1110. 

Pseudo-apoplectic  attacks,  in  fatty  heart, 
791;  in  Stokes-Adams  disease,  779. 

Pseudo-biliary  colic,  571. 

Pseudo-bulbar  paralysis,  931. 

Pseudo-cavernous  signs,  201,  202. 

Pseudo-chylous   ascites,   610. 

Pseudo-crisis  in  lobar  pneumonia,  83. 

Pseudo-cyesis,    1099. 

Pseudo-diphtheria   bacillus,  59,   60. 

Pseudo-hydrophobia,  371;  pharyngeal 
spasm  in,  1050. 

Pseudo-leukaemia,   747,  749. 

Pseudo-lipoma,   453. 

Pseudo-membranous  pachymeningitis  in- 
terna,  946. 

Pseudo-paralysis,  syphilitic,  confusion  of, 
with  infantile  scurvy,  450. 

Pseudo-paresis  of  rickets,  443. 

Pseudo-ptosis,  1036. 

Pseudo-sclerosis  of  brain,  953,  954. 

Pseudo-tabes,  322;  in  cerebro-spinal  fever, 
118. 

Psilosis,  519. 

Psittacosis,  388. 

Psoas  abscess,  involvement  of  lumbar 
plexus  in,  1060. 

Psoriasis,  buccal,  460. 

Psorospermiasis,   237. 

Psorosperms  in  empyema,  660. 

Psychasthenia,  1111.     (See  Neurasthenia.) 

Psycho-analytical  methods,   1105. 

Psychoses,  excessive  hunger  in,  514;  in 
typhoid  fever,  29. 

Psychosis  polyneuritica,  397. 

Psychotherapy,  1104;  in  treatment  of  hys- 
teria, 1104;  in  treatment  of  neurasthe- 
nia, 1115,  1116. 


Ptomaine  poisoning,  408. 

Ptosis,  1035;  due  to  paralysis  of  third 
nerve,  1035;  hysterical,  1036;  in  acute 
cerebro-spinal  leptomeningitis,  950;  in 
locomotor  ataxia,  915,  919;  in  my  asthe- 
nia gravis,  1133;  in  ophthalmoplegic  mi- 
graine, 1089;  in  syphiloma  of  brain, 
1009. 

Ptyalism,  459,  462,  463. 

Puberty,  epistaxis  at,  613;  palpitation  at, 
770. 

Puerperal  fever,  acute  chorea  and,  1067, 
1069;  acute  endocarditis  and,  798;  peri- 
carditis in,  760. 

Puerperal  state,  bradycardia  in,  777;  cere- 
bral embolism  in,  998;  pernicious  anae- 
mia and,  734. 

Pulex  irritans,  312;  penetrans,  313. 

Pulmonary  actinomycosis,   233. 

Pulmonary  anthrax,  150. 

Pulmonary   apoplexy,   637,  638. 

Pulmonary  artery,  aneurism  of,  861; 
changes  in,  in  hypertrophic  emphysema, 
647. 

Pulmonary  congestion,  in  aortic  stenosis, 
815;  in  mitral  incompetency,  818. 

Pulmonary  distomiasis,   282. 

Pulmonary  form  of  acute  miliary  tuber- 
culosis, 170. 

Pulmonary  haemorrhage,  636-638;  treat- 
ment of,  638,  639. 

Pulmonary  orifice,  congenital  lesions  at, 
834;  insufficiency  of,  826. 

Pulmonary  tuberculosis,  182-211;  abscess 
of  lung  and,  653;  acute  endocarditis  in, 
797,  798;  bronchiectasis  and,  626;  com- 
plications of,  202-206;  complicating 
amoebiasis,  241;  concurrent  infections 
and  diseases  associated  with,  208-210; 
death  due  to,  in  stenosis  of  pulmonary 
orifice,  834;  diagnosis  of,  206-208;  dif- 
ferentiation of  chlorosis  from,  733;  dif- 
ferentiation of  pneumothorax  from,  671; 
echinococcus  confused  with,  293;  fatty 
liver  and,  590;  fibrinous  casts  in  expec- 
toration of,  632;  following  cervical 
adenitis,  176;  haematoporphyrin  in  the 
urine  in,  693;  haemorrhagic  pachymenin- 
gitis in,  947;  hypertrophie  arthropathy 
in,  1143;  laryngitis  secondary  to,  618; 
modes  of  death  in,  210,  211;  modes  of 
infection  in,  182,  183;  phosphaturia  in, 
691;  pleurisy  and,  655;  pleuro-pericar- 
dial  friction  in,  762;  thrombosis  of  cere- 
bral veins  and  sinuses  in,  1005. 

Pulmonary  valve  disease,  825,  826. 

Pulsating  pleurisy,  661;  differentiation  of 
thoracic  aneurism  from,  857. 

Pulse,    capillary,   in   aortic    incompetency, 


1206 


INDEX 


613;  high  tension,  841;  in  acute 
Bright 's  disease,  698 ;  in  acute  cerebro- 
Spinal  leptomeningitis,  950;  in  acute 
diffuse  myelitis,  967;  in  acute  secondary 
anaemia,  728;  in  aneurism  of  abdominal 
aorta,  860;  in  aneurism  of  thoracic  aor- 
ta, 853;  in  angina  pectoris,  838;  in 
aortic  incompetency,  813,  814;  in  aortic 
stenosis,  816;  in  apoplectic  attacks,  991; 
in  arthritis  deformans,  1138,  1139;  in 
brain  abscess,  1017;  in  cardiac  hyper- 
trophy, 782;  in  cardiac  insufficiency, 
790;  in  chlorosis,  733;  in  chronic  gas- 
tritis, 481;  in  chronic  interstitial  nephri- 
tis, 707;  in  chronic  parenchymatous 
nephritis,  703;  in  chronic  ulcerative  tu- 
berculosis, 197,  198;  in  delirium  trem- 
ens,  399;  in  diabetes,  432;  in  gan- 
grene of  lung,  652;  in  haemorrhagic 
pachymeningitis,  947;  in  intestinal  ob- 
struction, 542;  in  lobar  pneumonia,  82, 
86;  in  malaria,  249;  in  measles,  344; 
in  mitral  incompetency,  820;  in  mitral 
stenosis,  823;  in  myeloid  leukaemia,  743; 
in  neurasthenia,  1110;  in  obstructive 
jaundice,  556;  in  palpitation  of  heart, 
771;  in  pericarditis  with  effusion,  764; 
in  peritonitis,  601;  in  pernicious  anae- 
mia, 735;  in  pneumo thorax,  670;  in  re- 
lapsing fever,  262;  in  rheumatic  fever, 
374;  in  scarlet  fever,  336;  in  serous 
meningitis,  1018;  in  small-pox,  318;  in 
Stokes- Adams  disease,  779;  in  suppura- 
tive  tonsillitis,  467;  in  thermic  fever, 
391;  in  transverse  myelitis,  968;  in  tu- 
berculous broncho-pneumonia,  186;  in 
tuberculous  meningitis,  173;  in  tumors 
of  brain,  1011;  in  typhoid  fever,  20;  in 
typhus  fever,  353,  354;  in  yellow  fever, 
359. 

Pulse  rate,  in  bradycardia,  777;  in  tachy- 
cardia, 776,  777. 

Pulsus,  irregularis  perpetuus,  774,  775; 
paradoxus,  764,  772. 

Puncture,  exploratory,  pneumothorax  fol- 
lowing, 669;  in  pleurisy,  663,  664,  666; 
in  cardiac  dropsy,  794;  of  heart,  831, 
832;  of  skin  in  acute  Bright 's  disease, 
701. 

Pupils,  contraction  of,  in  acute  cerebro- 
spinal  leptomeningitis,  950;  in  cerebral 
apoplexy,  997;  in  haemorrhagic  pachy- 
meningitis, 947. 

Pupils,  dilatation  of,  in  apoplectic  at- 
tacks, 991;  in  cerebral  anaemia,  986;  in 
compression  myelitis,  960. 

Purin  bodies  and  gout,  417,  418. 

Purpura,  750,  751;  acute  secondary  anae- 
mia in,  728,  729;  albuminuria  in,  685; 


arthritic,  751-753;  differentiation  of 
scurvy  from,  448;  fulminans,  753;  hae- 
matemesis  in,  507;  haematuria  in,  681; 
haemorrhagic,  753,  754;  haemorrhagic, 
adrenalitis  and,  868;  haemorrhagic,  haem- 
optysis in,  636;  in  cardiac  insufficiency, 
790;  in  diabetes,  434;  in  hypertrophic 
cirrhosis,  581;  in  lobar  pneumonia,  88; 
in  myeloid  leukaemia,  743;  in  polymyo- 
sitis  haemorrhagic.a,  1129;  in  scarlet 
fever,  338;  in  splenic  anaemia,  887;  re- 
tinitis  in,  1030;  rheumatica,  752;  sim- 
plex, 752;  symptomatic,  751;  treatment 
of,  754;  variolosa,  320,  321;  visceral 
lesions  in,  752,  753. 

Purpuric  affections,  acute  Bright 's  disease 
in,  697. 

Purulent  pleurisy,  diagnosis  of,  664;  etiol- 
ogy of,  660;  morbid  anatomy  of,  660; 
symptoms  of,  660-662;  treatment  of, 
666. 

Purulent  pachymeningitis,  946. 

Pus  cocci,  in  pericarditis,  761;  in  septico- 
pyaemia,  51. 

Pustular  rash  in  syphilis,  266,  267. 

Putrefaction  of  meat  causing  poisoning, 
408. 

Putrid  bronchitis,  624. 

Putrid  sore  mouth,  457. 

Pyaemia  (see  Septico-pyaemia)  ;  abscess  of 
lung  associated  with,  652;  acute  chorea 
and,  1067;  acute  interstitial  myocarditis 
in,  787;  confusion  of,  with  typhoid  fe- 
ver, 37;  differentiation  of  acute  endo- 
carditis from,  803;  diphtheroid  enteritis 
in,  520;  ecchymoses  in,  751;  following 
suppurative  myositis,  1128;  formation 
of  septic  infarcts  in,  787;  gonococcus, 
124,  125;  in  thrombosis  of  cerebral 
veins  and  sinuses,  1005;  inflammation  of 
oesophagus  in,  472;  intestinal  catarrh 
and,  517;  jaundice  in,  557;  liver  ab- 
scess and,  585;  membranous  gastritis 
in,  479 ;  peritonitis  in,  600 ;  post-ty- 
phoid, 31,  32;  resemblance  of  rheumatic 
fever  to,  373;  scarlatinal,  338. 

Pyaemic   abscess   of   liver,   583-585. 

Pyelitis,  bacilluric,  687;  Bacillus  eoli  and, 
47;  calculous,  septico-pyaemia  and,  52; 
calculous,  tuberculosis  of  kidneys  con- 
fused with,  219 ;  definition  of,  712 ;  diag- 
nosis of,  714,  715;  due  to  calculi,  719; 
etiology  of,  712;  following  gonococcus 
infection,  124;  in  renal  calculus,  720; 
morbid  anatomy  of,  712,  713;  post-ty- 
phoid, 30;  pyuria  and,  687;  prognosis 
of  715;  symptoms  of,  713,  714;  treat- 
ment of,  715. 

Pyelocystitis,  Bacillus  coli  and,  47. 


INDEX 


1207 


Pyelonephritis  (see  Pyelitis)  ;  pyuria  and, 
687. 

Pyelonephrosis,  sporotrichosis  parasite  in, 
235. 

Pylephlebitis,  adhesive,  562;  appendicitis 
and,  535,  536;  septico-pyaemia  and,  51; 
suppuration  of  mesenteric  veins  in,  554; 
suppurative,  583,  584;  suppurative  an- 
giocholitis  and,  565;  thrombosis  of  mes- 
enteric vessels  and,  554;  typhoid  fever 
and,  12,  26. 

Pylethrombosis,  splenomegaly  and,  887, 
888. 

Pyloric  obstruction,  causing  dilatation  of 
stomach,  487. 

Pylorie  spasm,  511. 

Pylorus,  hypertrophic  stenosis  of,  505,  506; 
insufficiency  of,  511. 

Pyocyanic  disease,  50. 

Pyogenic  infections,  48-53. 

Pyonephrosis  (see  PyeJitis) ;  differentia- 
tion of  hydronephrosis  from,  717;  due 
to  calculi,  719 ;  following  hydroneph- 
rosis, 717;  lipuria  in,  693;  tuberculosis, 
218. 

Pyo-pneumothorax,  179  (see  Pneumotho- 
rax)  ;  in  amoebiasis,  240;  in  pulmonary 
tuberculosis,  203;  subphrenicus,  604. 

Pyorrhoea  alveolaris,  462;  foul  breath  and, 
461 ;  in  pernicious  anaemia,  736. 

Pyosalpinx,  tuberculous  peritonitis  and, 
181. 

Pyothorax,   subphrenic   abscess   and,   604. 

Pyrogallic  acid,  haemoglobinuria  due  to, 
683. 

Pyuria,  687,  688;  in  perinephric  abscess, 
725;  in  pyelitis,  713,  714;  in  renal  cal- 
culus, 721;  in  typhoid  fever,  30. 


Q 


Qun  van  fever,  228,  251,  252. 
Quaternary  stage  of  syphilis,  268. 
Quincke's  disease,  1123,  1124. 
Quinine  in  malaria,  257,  258;  purpura  due 

to,  751. 
Quinine     poisoning,     toxic    amaurosis    in, 

1030. 


E 


Rabies   (see  Hydrophobia) ;  ptyalism  and, 

462. 

Radial  paralysis,   1059. 
fiadiography  in  enteroptosis,  549. 
Radium  treatment  of  leprosy,   154. 
Bag-pickers '   disease,    150. 


Railway  brain.     (See  Traumatic  neuroses.) 

Railway  spine.     (See  Traumatic  neuroses.) 

Rales,  crepitant,  in  chronic  bronchitis,  . 
623;  in  acute  bronchitis,  621;  in  acute 
congestion  of  lungs,  633;  in  acute  mili- 
ary  tuberculosis,  170;  in  acute  sero- 
fibrinous  pleurisy,  659 ;  in  acute  vesicu- 
lar emphysema,  650;  in  asthma,  629; 
in  bronchiectasis,  627;  in  broncho-pneu- 
monia, 104,  105;  in  chronic  interstitial 
pneumonia,  642;  in  chronic  ulcerative 
tuberculosis,  200,  201;  in  diagnosis  of 
pulmonary  tuberculosis,  207;  in  fibrin- 
ous  bronchitis,  632;  in  indurative  me- 
diastino-pericarditis,  675;  in  lobar 
pneumonia,  85,  86;  in  ffidema  of  lungs, 
635;  in  pneumothorax,  671;  in  tubercu- 
lous pneumonia,  186;  in  whooping 
cough,  121. 

Rapid   heart,    776,   777. 

Rash,  in  acute  endocarditis,  801,  802;  in 
dengue,  363;  in  herpes  zoster,  926,  927; 
in  measles,  345,  346;  in  rat-bite  fever, 
389 ;  in  Rocky  Mountain  spotted  fever, 
388;  in  rubella,  348,  349;  in  scarlet  fe- 
ver, 335,  336;  in  small-pox,  318-320;  in 
syphilis,  266,  267;  in  typhoid  fever, 
18;  in  typhus  fever,  353,  354;  in  vari- 
cella, 331,  332;  initial,  in  small-pox,  318. 

Rashes,  drug,  differentiation  of  scarlet  fe- 
ver from,  340;  in  locomotor  ataxia,  918. 

Rat-bite  fever,  389. 

Rats  and  plague,  138,  139,  140,  141. 

Raynaud's  disease,  complications  of,  1121, 
1122;  definition  of,  1120;  etiology  of, 
1120;  haemoglobinuria  and,  683;  local 
anaemia  in,  727;  pathology  of,  1120, 
1121;  scleroderma  and,  1126;  symptoms 
of,  1121;  treatment  of,  1122. 

von  Recklinghausen 's  disease,   1027. 

Rectal  feeding  in  peptic  ulcer,  496,  497. 

Rectum,  as  a  means  of  infection  in  genito- 
urinary tuberculosis,  216;  syphilis  of, 
275;  tuberculosis  of,  213. 

Recurrence  of  pneumonia,  91. 

Recurrent  small-pox,  322. 

Red  granular  kidney.  (See  Chronic  inter- 
stitial nephritis.) 

Red-light  treatment  of  small-pox,  325. 

Red  neuralgia,  1123. 

Redux-crepitus,  86. 

Reeducation  in  hysteria,  1105;  in  locomo- 
tor ataxia,  921. 

Reflexes,  absence  of,  in  hereditary  ataxia, 
944;  in  locomotor  ataxia,  915,  917. 

Regurgitation,  in  cancer  of  oesophagus, 
475;  in  dilatation  of  oesophagus,  476. 

Relapse,  in  acute  dyspepsia  of  children, 
526;  in  dengue,  363;  in  malaria,  252, 


1208 


INDEX 


254,  255;  in  mumps,  350;  in  pneumonia, 
91;  in  scarlet  fever,  339;  in  sprue,  519; 
in  tonsillitis,  381;  in  typhoid  fever,  34, 
35;  in  yellow  fever,  360. 

Relapsing  fever,  African  form  of,  261; 
anatomy  of,  262;  definition  of,  261;  di- 
agnosis of,  263;  etiology  of,  261,  262; 
jaundice  in,  557;  prophylaxis  of,  263; 
symptoms  of,  262,  263;  treatment  of, 
263. 

Ren  mobilis,  676-678  (see  Movable  kidney) . 

Renal  artery,  aneurism  of,  861. 

Renal  calculus,  717-722  (see  Nephrolithia- 
sis). 

Renal  colic,  differentiation  of,  from  intes- 
tinal and  biliary  colic,  721. 

Renal   sand,   718. 

Renal  system  in  typhoid  fever,  29,  30. 

Renal  tuberculosis,  217-219  (see  Tubercu- 
losis of  kidneys). 

Reptilian  heart,   832. 

Resolution,  delayed,  in  pneumonia,  95;  de- 
layed, treatment  of,  101;  in  broncho- 
pneumonia,  104;  in  lobar  pneumonia, 
80. 

Resorts  for  tuberculous  patients,  226,  227. 

Respiration,  in  acute  bronchitis,  621;  in 
apoplectic  attacks,  991;  in  asthma,  629; 
in  broncho-pneumonia,  105 ;  in  cerebral 
anaemia,  986;  in  chronic  interstitial  ne- 
phritis, 707;  in  lobar  pneumonia,  84; 
in  oadema  of  glottis,  616;  in  pneumonic 
tuberculosis,  184;  in  subphrenic  abscess, 
605;  in  tuberculous  broncho-pneumonia, 
186;  relation  of,  to  circulation,  984,985. 

Respiratory  influenza,  117. 

Respiratory  organs  in  typhoid  fever,  12, 
13,  26,  27. 

Respiratory  tract,  care  of,  in  pneumonia, 
100,  101. 

Rest,  in  treatment  of  cardiac  failure,  792. 

Retina,  lesions  of,  1029,  1030. 

Retinal  haemorrhage  in  acute  endocarditis, 
801. 

Retinitis,  1029,  1030;  diabetic,  434; 
hffimorrhagic,  gout  and,  423;  hsemor- 
rhagic,  in  acute  Bright 's  disease,  698; 
in  chronic  interstitial  nephritis,  708;  in 
syphilis,  267;  leuksemic,  743;  pigmen- 
tosa,  1029. 

Retraction    of    diaphragm   in    chronic   ad- 
hesive pericarditis,  768. 
Retro-peritoneal    abscess    following    intes- 
tinal ulcers,  522. 
Retro-pharyngeal   abscess,   466. 
Revaccination,  328,  330. 
Rhabditis  niellyi,  305. 
Rhabdomyoma  of  kidney,  722. 
Rhachitis,  441-446  (see  Rickets). 


Rhagades,  268. 

Rheumatic  fever,  acute  endocarditis  in, 
797,  798,  803;  appendicitis  and,  532;  as 
an  acute  infectious  disease,  373;  brady- 
cardia  following,  777;  chronic  second- 
ary anaemia  in,  729;  complications  of, 
375-377;  course  of,  377;  definition  of, 
371;  dengue  confused  with,  363;  diag- 
nosis of,  377,  378;  differentiation  of 
arthritis  deformans  from,  1140;  dila- 
tation of  heart  in,  784;  etiology  of, 
371-373;  morbid  anatomy  of,  373,  374; 
mycotic  aneurism  and,  848 ;  pericarditis 
in,  760,  761,  763;  prognosis  of,  377; 
symptoms  of,  374,  375;  thyroiditis  in, 
871;  treatment  of,  378-380;  trichiniasis 
confused  with,  300. 

Rheumatic  neuritis,  1021. 

Rheumatic  nodules,  377. 

"Rheumatic"  peritonitis,  600. 

Rheumatism,  acute  chorea  and,  1066, 1067, 
1069;  cardiac  irregularity  associated 
with,  775;  "chronic,"  1142;  differen- 
tiation of  gout  from,  423,  424;  hemato- 
porphyrin  in  urine  in,  693;  purpura  in, 
751,  752;  sciatica  and,  1061,  1063; 
valvulitis  in,  809. 

Rheumatoid  arthritis,  1134,  1135. 

Rhinitis,  hypertrophic,  asthma  associated 
with,  629 ;  membranous  or  fibrinous,  64, 
65;  syphilitic,  268. 

Rhinorrhoea  in  acromegaly,  891. 

Rhizomelia,  1146. 

Rhonchi  in  chronic  bronchitis,  623. 

Ribs,  changes  in,  in  rickets,  443. 

Rice,  beri-beri  and,  414,  415,  416. 

Rice-water  stools  of  cholera,  135. 

Rickets,  amyloid  liver  and,  590;  definition 
of,  441;  dilatation  of  stomach  in,  487; 
etiology  of,  441,  442;  infantile  convul- 
sions and,  1077,  1078,  1079;  lymphatism 
and,  870 ;  morbid  anatomy  of,  442,  443 ; 
predisposing  to  broncho-pneumonia,  102 ; 
prognosis  of,  445;  spasmodic  laryngitis 
in,  617;  symptoms  of,  443-445;  tetany 
and,  882;  treatment  of,  445,  446. 

RiedePs  lobe,  572,  589. 

Riga's  disease,  121,  457. 

Rigidity  in  paralysis  agitans,  1064. 

Eisus  sardonicus,  143. 

Rocky  Mountain  spotted  fever,  388. 

Roger,  'bruit  de,  833. 

Romberg's  symptom,  in  locomotor  ataxia, 
916;  in  neurasthenia,  1110. 

Rose  cold,  612. 

Roseola,  syphilitic,  266. 

Rotch's  sign,  765. 

Rotheln   (see   Rubella)  ;   differentiation   of 


INDEX 


1209 


measles  from,  347;  differentiation  of 
scarlet  fever  from,  340. 

Rubella,  diagnosis  of,  349;  etiology  of, 
348;  symptoms  of,  348,  349;  treatment 
of,  349. 

Rubeola  notha.      (See  Rubella.) 

Rumination,   511. 

Rupia,  267. 

Rupture,  death  from,  in  aneurism  of  ab- 
dominal aorta,  860;  in  aneurism  of  as- 
cending arch,  851;  in  aneurism  of  he- 
patic artery,  861;  of  a  segment,  aortic 
incompetency  due  to,  809;  of  aorta  in 
dissecting  aneurism  of  thoracic  aorta, 
850;  of  bile  duct,  in  biliary  colic,  571; 
of  brachial  plexus,  1058;  of  lung,  em- 
physema of  mediastinum  and,  675;  of 
lung  in  whooping  cough,  121;  of  oesoph- 
agus, 475,  476;  of  spleen,  884,  885. 

Rupture  of  heart,  830,  831;  anemic  ne- 
crosis and,  786;  cardiac  insufficiency  in, 
785;  haemopericardium  in,  769;  in  ar- 
terio-sclerosis,  845;  in  fatty  heart,  791. 


S 


"Sable  intestinal,"  553. 

Saccharomyces  albicans,  458. 

Saccharomycosis,  235. 

Sacculated  exudation  in  tuberculous  peri- 
tonitis, 181. 

Sacculi,  distention  of,  in  constipation,  546. 

Sachs'  disease,  939. 

Sacral  plexus,  lesions  of,   1061. 

St.  Vitus's  dance.     (See  Chorea,  acute.) 

Salaam  convulsion,  1054;  in  hysteria, 
1099;  in  hysterical  chorea,  1077. 

Salicyl  compound  in  treatment  of  rheu- 
matic fever,  379. 

Saliva,  supersecretion  of,  462,  463. 

Salivary  glands,  diseases  of,  462-464;  en- 
largement of,  in  scurvy,  447;  hypertro- 
phy of,  following  mumps,  351;  in  mer- 
curial stomatitis,  459;  in  mumps,  350; 
suppuration  of,  in  mumps,  351;  tuber- 
culosis of,  211. 

Salivation  in  pancreatic  cancer,  599;  in 
ulcerative  stomatitis,  457;  pancreatic, 
598. 

Salpingitis,  gonococcus,  123;  peritonitis 
due  to,  602;  tuberculous,  220. 

Saltatory  spasm,  1076. 

Salvarsan,  279,  280;  in  angina  pectoris, 
840;  in  general  paralysis,  926;  in  loco- 
motor  ataxia,  920;  in  syphilis,  279;  in 
syphilitic  tumors  of  brain,  1014. 

Sanatoria,  treatment  of  tuberculosis  in, 
225,  226. 

78 


Sand  flea,   313. 

Sapraemia,  48. 

Sarcinaa  in  cancer  and  dilatation  of  stom- 
ach, 479;  in  cancer  of  stomach,  502;  in 
pyloric  obstruction,  488. 

Sarcocystis  miescheri,  237. 

Sarcoma,  lymphadenitis  and,  672;  of 
brain,  1009;  of  brain,  treatment  of, 
1014;  of  heart,  831;  of  kidneys,  722, 
723;  of  liver,  588;  of  lung,  653;  of 
mediastinum,  673,  674;  of  pancreas, 
599;  of  pituitary  gland,  891;  of  spinal 
cord,  963 ;  of  stomach,  505 ;  of  supra- 
renal glands,  868;  of  thyroid,  871. 

Saturnism.      (See  Lead  poisoning.) 

Scapulodynia,  1130. 

Scarlet  fever,  acute  Bright 's  disease  due 
to,  697,  699;  acute  chorea  following, 
1067;  acute  chorea  in,  1069;  adenoids 
and,  470;  anginose  form  of,  337; 
broncho-pneumonia  secondary  to,  101, 
102 ;  cancrum  oris  following,  459 ;  com- 
plications and  sequelae  of,  337-339; 
definition  of,  333;  diagnosis  of,  339- 
340;  differentiation  of  measles  from, 
347;  differentiation  of  small-pox  from, 
323;  dilatation  of  heart  and,  784; 
diphtheroid  inflammation  in,  60;  em- 
pyema  following,  660;  endocarditis  in, 
797,  798;  etiology  of,  333,  334;  hsemo- 
globinuria  due  to,  683 ;  history-  of,  333 ; 
hydropericardium  following,  769;  in- 
fantile convulsions  preceding,  1078; 
jaundice  in,  557;  oadema  of  glottis  in, 
616;  Ludwig's  angina  in,  466;  malig- 
nant, 337;  measles  and,  347;  mild  and 
abortive  forms  of,  337;  morbid  anatomy 
of,  334;  multiple  sclerosis  of  brain  due 
to,  952;  pericarditis  in,  760,  761;  period 
of  infectiveness  in,  340,  341;  prognosis 
of,  341;  prophylaxis  of,  341;  purpuric 
rash  in,  751;  retropharyngeal  abscess 
following,  466;  sine  eruptione,  337; 
surgical,  334;  symptoms  of,  335-337; 
treatment  of,  341-343;  typhoid  fever 
and,  32;  ulceration  of  O3sophagus  in, 
473. 

Schistosomum  hsmatobium,  283;  japoni- 
cum,  283;  japonicum  vel  cattoi,  284. 

Schonlein's  disease,  752. 

School-made  chorea,   1068. 

Schott  treatment  in  cardiac  insufficiency, 
796,  797. 

Schweninger  cure  for  obesity,  452. 

Sciatic  nerve,  lesions  of,  10GL 

Sciatica,  1061;  diagnosis  of,  1062;  dura- 
tion and  course  of,  1062;  in  gout,  423; 
symptoms  of,  1062;  treatment  of,  1062, 
1063. 


1210 


INDEX 


Scirrhous  cancer  of  stomach,  499. 

Sclerodactylie,  1126,  1127. 

Scleroclerma,  circumscribed,  1125,  1126; 
definition  of,  1125;  diffuse,  1126;  in 
exophthalmic  goitre,  878,  879 ;  of  fingers 
following  Kaynaud's  disease,  1122; 
treatment  of,  1127. 

Sclerose  en  plaques,  952;   lobaire,  952. 

Sclerosis,  cardiac,  angina  pectoris  and, 
837;  hemiplegia  in  children  due  to, 
1006,  1007;  in  birth  palsies,  937;  in 
malaria,  254;  in  motor  tracts  in  pro- 
gressive central  muscular  atrophy,  929; 
in  tubercle,  166,  188;  interstitial,  in 
pneumonokoniosis,  643;  multiple  and 
diffuse  cerebral,  differentiation  of  chorea 
from,  1072;  multiple,  differentiation  of 
paralysis  agitans  from,  1065;  multiple, 
in  measles,  347 ;  multiple,  spastic  paraly- 
sis secondary  to,  939,  940;  of  arteries, 
in  aortic  incompetency,  811;  of  arteries 
in  polycystic  kidneys,  724;  of  dorsal 
columns  in  ataxic  paraplegia,  943;  of 
heart  valves,  due  to  endocarditis,  799; 
of  heart  valves,  mitral  stenosis  due  to, 
820,  821;  of  heart  valves  (see  Endo- 
carditis, chronic) ;  of  hepatic  artery, 
563;  of  lungs,  chronic  cardiac  insuffi- 
ciency due  to,  786;  of  mesenterie  veins, 
554;  of  nerves  in  Addison's  disease, 
864;  of  portal  vein,  thrombosis  and, 
562;  of  pulmonary  artery  in  arterio- 
sclerosis, 844;  of  spinal  cord  in  heredi- 
tary ataxia,  944;  of  stomach,  prolifera- 
tive  peritonitis  and,  606;  of  veins  in 
arterio-sclerosis,  845;  of  walls  of  heart, 
dilatation  in,  784;  posterior  spinal,  in 
ergotism,  410;  posterior  spinal,  in  loco- 
motor  ataxia,  913,  914;  primary  com- 
bined, 943,  944;  primary  lateral,  935, 
936;  scurvy,  447;  toxic  combined,  945. 

Sclerosis  of  brain,  diagnosis  of,  953,  954; 
diffuse,  952;  general  remarks  on,  951, 
952;  Jacksonian  epilepsy  due  to,  1084; 
miliary,  952;  multiple,  952,  953;  prog- 
nosis of,  954;  treatment  of,  954;  tu- 
berous, 952. 

Scoliosis,  in  hereditary  ataxia,  945;  in 
syringomyelia,  965. 

Scorbutus.     (See  Scurvy.) 

Scotoma  in  migraine,  1088. 

Screw-worm,  313. 

Scrivener's  palsy,   1093. 

Scrofula.  (See  Tuberculosis  of  the  lymph- 
glands.) 

Scurvy,  albuminuria  in,  685;  definition  of, 
446;  diagnosis  of,  448;  differentiation 
of  pellagra  from,  413;  differentiation  of 
purpura  haemorrhagiea  from,  754;  etiol- 


ogy of,  446,  447;  infantile,  449,  450; 
morbid  anatomy  of,  447;  pericarditis  in, 
760;  prognosis  of,  448;  prophylaxis  of, 
448;  purpura  in,  751;  symptoms  of, 
447,  448;  treatment  of,  448,  449. 

Seborrhffia  nigricans  in  hysteria,  1102. 

Secondary  anasmia,  728-730;  treatment  of, 
739. 

Secondary  broncho-pneumonia,  102. 

Secondary  contracted  kidney.  (See  Ne- 
phritis, chronic  interstitial.) 

Secondary  deviation  of  eye,  1037,  1038. 

Secondary  pneumonias,  93. 

Secondary  spastic  paralysis,  939,  940. 

Senile  kidney.  (See  Nephritis,  chronic  in- 
terstitial.) 

Sensitization  in  diphtheria,  73. 

Sensory  system,  903-905. 

Sepsis,  chronic  secondary  anaemia  in,  729; 
leukaemia  and,  746. 

Septic  infarcts,  787. 

Septicaemia,  acute,  108 ;  acute  Bright 's 
disease  in,  697;  acute  endocarditis  in, 
798;  acute  pneumonic,  108;  complicat- 
ing erysipelas,  56;  complicating  influ- 
enza, 118;  crypto-genetic,  50;  differen- 
tiation of  scarlet  fever  from,  340; 
ecchymoses  in,  751;  general,  50;  gono- 
coccic,  124;  in  appendicitis,  535;  in- 
testinal catarrh  and,  517;  mycotic 
aneurism  and,  848;  necrosis  of  liver  in, 
559;  pericarditis  in,  763;  peritonitis  in, 
600;  pneumococcus,  108;  post-typhoid, 
31;  progressive,  from  local  infection, 
49,  50;  puerperal,  pelvic  peritonitis  due 
to,  605. 

Septicaemic  plague,  140. 

Septico-pysemia,  50-53. 

Sero-fibrinous  pleurisy,  course  of,  659, 
660;  etiology  of,  655,  656;  morbid 
anatomy  of,  656,  657;  symptoms  of, 
657-659. 

Serous  meningitis,  1018,  1019. 

Serratus  paralysis,  1058. 

Serum,  antianthrax,  151;  antitetanic,  145; 
antituberculous,  161. 

Serum  diagnosis  of  syphilis,  277. 

"Serum  disease,"  72. 

Serum  therapy,  in  bacillary  dysentery, 
130;  in  cerebro-spinal  fever,  115;  in 
diarrhoea  of  children,  530;  in  erysipelas, 
56;  in  exophthalmic  goitre,  880;  in 
gonococcus  infection,  125;  in  haemo- 
philia, 757;  in  plague,  141,  142;  in 
pneumonia,  78,  79,  100;  in  scarlet  fever, 
343;  in  swine  fever,  389;  in  tonsillitis, 
382;  in  typhoid  fever,  43. 

Seven-day  fever,  261,  363. 


INDEX 


1211 


Sewer-gas    poisoning,    384;    peritonitis    in 
children  and,  604. 

Sex,  diabetes  and,  430;  in  acute  chorea, 
1006;  in  Addison's  disease,  863;  in 
amoebiasis,  238;  in  aneurism,  848;  in 
aneurism  of  cerebral  arteries,  1003;  in 
angina  pectoris,  836;  in  appendicitis, 
532;  in  arthritis  deformans,  1134;  in 
beri-beri,  415;  in  brain  abscess,  1016; 
in  cancer  of  stomach,  498;  in  cancer  of 
liver,  587;  in  cerebral  embolism,  998;  in 
cerebral  haemorrhage,  988;  in  chlorosis, 
730;  in  diabetes  insipidus,  439;  in  epi- 
lepsy, 1080;  in  exophthalmic  goitre, 
877;  in  gall-stones,  569;  in  general 
paralysis,  922;  in  goitre,  872;  in  gout, 
418;  in  haemophilia,  755;  in  hemiplegia 
in  children,  1006;  in  hereditary  spastic 
paraplegia,  939;  in  hysteria,  1096;  in 
intestinal  obstruction  due  to  volvulus, 
540;  in  intestinal  obstruction  from  in- 
tussusception, 539;  in  intestinal  ob- 
struction from  strangulation,  539;  in 
lead  poisoning,  402 ;  in  locomotor  ataxia, 
913;  in  mediastinal  tumors,  673;  in 
meralgia  paraesthetica,  1060;  in  mitral 
stenosis,  821;  in  movable  kidney,  676; 
in  muscular  dystrophies,  932;  in  mye- 
loid  leukaemia,  741;  in  myotonia,  1131; 
in  myxoedema,  875;  in  paralysis  agitans, 
1063 ;  in  paramyoclonus  multiplex,  1132 ; 
in  pellagra,  412;  in  pernicious  anaemia, 
734;  in  pleurisy,  655;  in  pneumonic 
tuberculosis,  183;  in  progressive  central 
muscular  atrophy,  928;  in  Eaynaud's 
disease,  1120;  in  rheumatic  fever,  372; 
in  scleroderma,  1125;  in  splenic  anae- 
mia, 886;  in  syringomyelia,  965;  in 
tuberculosis,  158;  in  writer's  cramp, 
1093;  lobar  pneumonia  and,  75;  peptic 
ulcer  and,  490,  491;  prognosis  of  valve 
lesions  and,  827;  small-pox  and,  315. 

Shaking  palsy.     (See  Paralysis  agitans.) 

Sheep,  anthrax  in,  148. 

Siderodromophobia,  1109. 

Siderosis,  642,  644. 

Sigmoid  flexure,  dilatation  of,  552;  twist 
and  kink  of,  540. 

Sigmoiditis,  553. 

Signal  symptom,  969. 

Silicosis,  642,  644. 

Simple    dynamic  pulsation,   differentiation 
of  aneurism  of  thoracic  aorta  from,  856. 

Simple  ulcerative  colitis,  521. 

Sinus  thrombosis,   autochthonous,   1004. 

Siriasis.     (See  Sunstroke.) 

Sixth  nerve,  paralysis  of,  1037. 

Skin,  actinomycosis  of,  233;  diphtheria  of, 
66;  in  cerebro-spinal  fever,  111,  114;  in 
79 


congenital  syphilis,  268;  in  dengue, 
362;  in  diabetes,  432,  433,  434;  in  ery- 
sipelas, 55;  in  Hodgkin's  disease,  748; 
in  hypertrophic  cirrhosis,  581;  in  lobar 
pneumonia,  88;  in  lymphoid  leukaemia, 
745;  in  pellagra,  412;  in  pulmonary 
tuberculosis,  205,  206;  in  rickets,  444; 
in  scurvy,  447 ;  in  typhoid  fever,  18,  19 ; 
in  yellow  fever,  358 ;  lesions  of,  in  syph- 
ilis, 266,  267;  leukaemic  tumors  of,  742, 
745;  pigmentation  of,  in  ochronosis, 
454. 

Skoda 's  resonance,  85;  in  acute  sero- 
fibrinous  pleurisy,  658. 

Skull,  in  rickets,  444. 

Sleeping  sickness,  258,  259. 

Sleeplessness,  in  cardiac  insufficiency,  790 ; 
in  cardiac  insufficiency,  treatment  of, 
795;  in  neurasthenia,  1108,  1116;  in 
neurasthenia,  treatment  of,  1115. 

Sloughing,  intestinal,  in  typhoid  fever,  10. 

Sloughing  eschar  in  apoplexy,  992. 

Slow  heart,  777. 

Small-pox,  abortive  types  of,  321;  acute 
endocarditif  in,  798;  acute  myelitis  due 
to,  966;  bn>ncho-pneumonia  secondary 
to,  102;  complications  of,  321,  322; 
definition  of,  315;  diagnosis  of,  323, 
324;  differentiation  of  measles  from, 
347;  differentiation  of  purpura  haemor- 
rhagica  from,  754;  etiology  of,  315-317; 
haematemesis  in,  507;  haemorrhagic, 
acute  endocarditis  mistaken  for,  803; 
history  of,  315;  malignant,  differentia- 
tion of  typhus  from,  356;  membranous 
gastritis  in,  479;  mesenteric  haemor- 
rhage in,  553;  morbid  anatomy  of,  317; 
parenchymatous  degeneration  of  heart 
in,  788;  prognosis  of,  322,  323;  prophy- 
laxis of,  324;  ptyalism  in,  462;  pur- 
puric  rash  in,  751;  symptoms  of,  317- 
321;  thyroiditis  in,  871;  treatment  of, 
324-326. 

Small  white  kidney,  702,  703. 

Smell,  adenoids  and,  470;  in  hysteria, 
1100;  loss  of  sense  of,  in  oxycephaly, 
1147. 

Smoker's  tongue,  461. 

Smoking,  chnraic  laryngitis  due  to,  615; 
chronic  pharyngitis  and,  465. 

Snake-poisoning,  purpura  in,  751. 

Snuffles,  268. 

Softening,  cerebral,  Jacksonian  epilepsy 
due  to,  1084. 

Soil  contamination  and  typhoid  fever,  7. 

Solitary  abscess  of  liver,  240,  583;  symp- 
toms of,  584,  585. 

Somnolence,   in    acauired   chronic   hydro« 


1212 


INDEX 


cephalus,  1020;  in  serous  meningitis, 
1019. 

Soor,  458. 

Soreness  in   rickets,   443. 

Sparganum  mansoni,  294. 

Spasm,  clonic,  in  epilepsy,  1082;  due  to 
lesions  of  third  nerve,  1036;  habit, 
1075;  in  ergotism,  410;  mimic,  1044; 
of  arteries  and  arterioles  in  Kaynaud's 
disease,  1120;  of  arteries,  migraine  and, 
1087;  of  bronchial  muscles,  asthma  due 
to,  628;  of  cardia,  511;  of  cardia,  treat- 
ment of,  514;  of  cervical  muscles,  1052- 
1054;  of  diaphragm,  asthma  and,  628; 
of  glottis,  617;  of  oesophagus,  473, 1051; 
of  tongue,  1055;  of  pharynx,  due  to 
lesion  of  pneumogastric  nerve,  1050;  of 
voluntary  muscles  in  tetany,  882;  py- 
loric,  511;  saltatory,  1076;  tonic,  in 
epilepsy,  1082. 

Spasm  of  muscles,  due  to  lesions  of  cere- 
bral cortex,  969;  in  acute  cerebro-spinal 
leptomeningitis,  950;  in  compression 
myelitis,  960;  in  migraine,  1088;  in 
neuralgia,  1090;  of  larynx,  1050;  of 
mastication,  1040;  supplied  by  facial 
nerve,  1044,  1045. 

Spasmodic  croup,  617,  618. 

Spasmodic  laryngitis,  617,  618. 

Spasms,  carpo-pedal,  in  spasmodic  laryn- 
gitis, 617;  hysterical,  1098,  1099;  in 
mycosis  intestinalis,  150;  in  serous  men- 
ingitis, 1019;  in  tumors  of  brain,  1011; 
professional,  1093,  1095. 

Spastic  diplegia,  936-938. 

Spastic  paralysis  of  adults,  definition  of, 
935;  diagnosis  of,  936;  symptoms  of, 
935,  936;  treatment  of,  936. 

Spastic  paralysis  of  infants,  936;  morbid 
anatomy  of,  937;  symptoms  of,  937, 
938;  treatment  of,  938. 

Speech,  auditory  centre  of,  977,  978;  de- 
velopment of,  976,  977;  disturbances  of, 
following  epilepsy,  1083;  in  acute 
chorea,  1070;  in  bulbar  paralysis,  931; 
in  chronic  chorea,  1077;  in  general 
paralysis,  923;  in  hereditary  ataxia, 
945 ;  in  paralysis  agitans,  1065 ;  motor 
centre  of,  978,  979;  scanning,  in  sclero- 
sis of  brain,  953;  visual  center  of,  979. 

Spes  phthisica,  205. 

Spider  angiomata,  in  alcoholic  cirrhosis  of 
the  liver,  579;  in  catarrhal  jaundice, 
564. 

Spinal  accessory  nerve,  paralysis  of,  1052; 
spasm  due  to  affections  of,  1052-1054. 

Spinal  cord,  cysticercus  cellulosae  iii,  288; 
diffuse  and  focal  diseases  of,  954-968; 
in  acute  poliomyelitis,  365;  in  anaemia. 


735,  736;  in  cerebro-spinal  fever,  110  j 
in  hydrophobia,  369 ;  in  pellagra,  412 : 
localization  of  functions  in  segments  of, 
898-900;  syphilis  of,  270,  271;  tubercu- 
losis of,  215. 

Spinal  curvature,  acute  bronchitis  and, 
620. 

Spinal  disease,  dilatation  of  stomach  and 
486. 

Spinal  epilepsy,  936. 

Spinal  nerves,  diseases  of,  1055-1063. 

Spinal  paralysis,  infantile,  convulsions 
preceding,  1078, 

Spine,  in  rickets,  444;  involvement  of,  in 
tuberculous  meningitis,  172;  railway 
(see  Traumatic  neuroses). 

Spirillum  duttoni,  261;  novyi,  261. 

Splanchnoptosis,  549. 

Spleen,  abscess  of,  case  of,  in  dysentery, 
128;  amyloid  degeneration  of,  in  fibroid 
phthisis,  202;  changes  in,  in  myeloid 
leukaemia,  742;  diseases  of,  883-888;  in 
acute  polio-myelitis,  365;  in  acute  yel- 
low atrophy,  560;  in  alcoholic  cirrhosis, 
578;  in  cerebro-spinal  fever,  110,  112; 
in  cholera  asiatica,  135 ;  in  chronic 
ulcerative  tuberculosis,  190 ;  in  diarrhoea 
of  children,  526;  in  diphtheria,  63;  in 
erysipelas,  54;  in  general  tuberculosis, 
169;  in  haemochromatosis,  454;  in  In- 
dian kala-azar,  260;  in  infectious  jaun- 
dice, 384;  in  lobar  pneumonia,  81,  188; 
in  lymphatism,  870;  in  malaria,  247, 
248,  250,  252,  254,  255;  in  Malta  fever, 
131;  in  mycosis  intestinalis,  150;  in 
pernicious  anaemia,  734;  in  pneumonic 
plague,  140;  in  progressive  septicaemia, 
49;  in  relapsing  fever,  262,  263;  in 
rickets,  443,  445;  in  scurvy,  447,  448; 
in  septico-pyaemia,  52;  in  small-pox, 
317;  in  typhoid  fever,  12,  26;  infarcts 
in,  in  acute  endocarditis,  800;  metas- 
tases  in,  in  cancer  of  stomach,  503;  mo- 
bility of,  in  enteroptosis,  550. 

Spleen,  enlargement  of,  gastrorrhagia  in, 
507,  508,  509;  in  Addison's  disease, 
864;  in  aortic  incompetency,  812;  in 
arthritis  deformans,  1138;  in  cirrhosis 
of  liver,  579,  580,  581;  in  congenital 
syphilis,  268,  269,  270;  in  erythraemia, 
757;  in  epidemic  haemoglobinuria,  754; 
in  hereditary  icterus,  558;  in  Hodgkin's 
disease,  747,  748,  749;  in  lymphoid 
leukaemia,  745 ;  in  multilocular  echino- 
coccus,  294;  in  purpura,  752,  753;  in 
sarcoma  of  kidney,  723. 

Splenic  anaemia,  885;  definition  of,  885; 
sis  of  M7;  etiology  of,  885; 


INDEX 


1213 


morbid  anatomy  of,  886;  symptoms  of, 
886;  treatment  of,  888. 

Splenic  fever.      (See  Anthrax.) 

Splenomegaly,  course  of,  887;  definition 
of,  885;  diagnosis  of,  887,  888;  eti- 
ology of,  885,  886;  forms  of,  887;  Gau- 
cher's  type,  887;  hepatic,  888;  history 
of,  885;  morbid  anatomy  of,  886;  symp- 
toms of,  886,  887;  treatment  of,  888. 

Spondylitis,  1137,  1138;  prognosis  of, 
1140,  1141;  treatment  of,  1142. 

Spondylose  rhizomelique,  1138. 

Sporadic  cerebro-spinal  fever,   109. 

Sporotrichosis,  definition  of,  234;  diag- 
nosis of,  235;  clinical  forms  of,  234, 
235;  history  of,  234;  parasite  of,  234; 
treatment  of,  235. 

Sporotrichum  schenckii,   234. 

Spotted  fever,  108;  (see  also  Cerebro- 
spinal  fever)  ;  of  Rocky  Mountains,  388. 

Sprue,  519;  differentiation  of  pellagra 
from,  413. 

Sputum,  calcareous  fragments  in,  194; 
in  asthma,  629,  630;  in  chronic  ulcera- 
tive  tuberculosis,  193,  194;  in  diagnosis 
of  pulmonary  tuberculosis,  207;  in  lobar 
pneumonia,  84;  in  transmission  of  tu- 
berculosis, 157;  in  tuberculous  broncho- 
pneumonia,  186. 

Squamous  syphilide,  267. 

Squirrels  and  plague,  138. 

Staphylococcus,  albus,  in  broncho-pneu- 
monia, 104;  albus,  in  diphtheria,  59; 
aureus,  in  broncho-pneumonia,  104; 
aureus,  in  diphtheria,  59;  aureus,  in 
pulmonary  tuberculosis,  208;  in  acute 
bronchitis,  621;  in  acute  sero-fibrinous 
pleurisy,  656;  in  cholecystitis,  566;  in 
endocarditis,  800;  in  gall-stones,  569; 
in  methaemoglobinaemia,  759 ;  in  perito- 
nitis, 601;  in  pyelitis,  712;  in  septicae- 
mia, 49,  50;  in  septico-pyaemia,  51;  in 
terminal  infections,  53;  pyogenes,  in 
lobar  pneumonia,  77;  pyogenes,  in  pul- 
monary tuberculosis,  209;  pyogenes, 
septicaemia  due  to,  50. 

Starvation,  cerebral  anaemia  due  to,  986. 

Status  epilepticus,  1082;  hystericus,  1102; 
thymico-lymphaticus,  869,  870. 

Steatorrhoea,  592;  in  chronic  pancreatitis, 
596. 

Steeplehead,  1147. 

Stegomyia  fasciata,  356,  357,  358;  eradi- 
cation of,  361. 

Stellwag's  sign,  879. 

Stenocardia.      (See  Angina  pectoris.) 

Steno's  duct,  gaseous  tumors  of,   464. 

Stenosis,  aortic,  781,  810,  814-817;  due  to 
sclerosis,  805;  laryngeal,  in  syphilis, 


619;  mitral,  820-824;  cesophageal,  476; 
of  aorta,  cardiac  hypertrophy  and,  781; 
of  bile-ducts,  567;  of  conus  arteriosus, 
834;  of  larynx,  618;  of  oesophagus, 
congenital,  474;  of  orifices  of  hepatic 
veins,  562;  of  pulmonary  orifice,  834; 
of  pulmonary  valve,  826;  of  pylorus, 
dilatation  of  stomach  due  to,  487;  of 
pylorus,  hypertrophic,  505,  506;  simple 
cicatricial,  causing  intestinal  obstruc- 
tion, 540;  tricuspid,  825. 

Steppage  gait,  in  alcoholic  neuritis,  1024; 
in  arsenical  poisoning,  407;  in  diabetic 
tabes,  434;  in  lead-palsy,  405;  in 
paralysis  of  external  popliteal  nerve, 
1061. 

Stercoral  ulcers,  521. 

Stiff  neck,   1130. 

Stiffness  in  spastic  paralysis  of  adults, 
935;  in  spastic  paralysis  of  infants, 
937;  of  muscles  in  acute  cerebro-spinal 
leptomeningitis,  950. 

Stokes-Adams  disease,  778,  779;  arrhyth- 
mia due  to,  772;  cerebral  anaemia  in, 
984. 

Stomach,  cancer  of,  498;  catarrh  of,  479; 
catarrh  of,  in  alcoholism,  397;  cirrhosis 
of,  486;  dilatation  of,  486;  dilatation 
of,  in  alcoholism,  397;  dilatation  of,  in 
diabetes,  4'32;  dilatation  of,  in  lo- 
bar pneumonia,  90;  diseases  of,  476- 
516;  disturbances  of,  in  movable  kid- 
ney, 677;  haemorrhage  from,  506;  in 
malarial  cachexia,  248;  in  pulmonary 
tuberculosis,  204;  in  yellow  fever,  358; 
leukaemic  growths  in,  742;  neuroses  of, 
509;  pyloric  stenosis,  505;  syphilis  of, 
275;  tuberculosis  of,  212;  ulcer  of, 
490. 

Stomatitis,  acute,  456 ;  aphthous,  456,  457 ; 
aphthous,  differentiation  of  thrush  from, 
458;  aphthous,  in  diabetes,  432;  epi- 
demic, 387;  foul  breath  and,  461;  gan- 
grenous, 459;  herpetic,  458;  in  chronic 
gastritis,  480;  in  measles,  346;  in  pel- 
lagra, 412;  mercurial,  459,  460;  para- 
sitic, 458,  459 ;  pemphigoid,  458 ;  ulcera- 
tive,  457,  458;  uraemic,  695. 

Stone,  in  ureter,  haematuria  due  to,  681; 
renal,  anuria  in,  680;  renal,  haematuria 
in,  681. 

Stools,  clay-colored  in  catarrhal  jaundice, 
564;  clay-colored,  in  obstructive  jaun- 
dice, 556;  in  catarrhal  enteritis,  518;  in 
chronic  pancreatitis,  596;  in  hyper- 
trophic  cirrhosis,  580;  in  pancreatic 
cancer,  599;  in  pancreatic  insufficiency,. 
592;  in  sprue,  519. 

Strabismus,    1037;     due    to    paralysis    of 


1214 


INDEX 


third  nerve,  1035;  in  acute  cerebro- 
spinal  leptomeningitis,  950;  in  paralysis 
of  sixth  nerve,  1037;  in  tumors  of  brain, 
1012. 

Strangulation,  acute  cardiac  insufficiency 
and,  785;  causing  intestinal  obstruction, 
538,  539;  diagnosis  of,  544;  of  bowel, 
following  appendicitis,  536. 

Streptococcus,  empyema,  664;  erysipelatis, 
54;  in  acute  suppurative  gastritis,  478; 
in  l  ppendicitis,  532 ;  in  broncho-pneu- 
monia, 104;  in  cholecystitis,  566;  in 
chronic  pancreatitis,  596;  in  diarrhoea 
in  children,  525;  in  diphtheria,  59,  60; 
in  endocarditis,  800;  in  gall-stones, 
569;  in  general  septicaemia,  50;  in  mem- 
branous croup,  65;  in  peritonitis,  601; 
in  pleurisy,  656;  in  pneumonia,  77;  in 
pulmonary  tuberculosis,  208,  209;  in 
scarlet  fever,  334;  in  tonsillitis,  381; 
in  urine,  687;  mitior,  800;  relation  of 
pneumococcus  to,  77. 

Streptothrix  actinomyces,  232;  madurse, 
236. 

Stricture,  cicatricial,  hydronephrosis  due 
to,  715;  of  bowel,  constipation  due  to, 
545 ;  of  bowel,  following  amcebiasis,  239 ; 
of  bowel,  intestinal  obstruction  due  to, 
510,511;  of  oesophagus,  474;  of  urethra, 
hydronephrosis  due  to,  716;  pyloric, 
dilatation  of  stomach  due  to,  487. 

Stridor,  inspiratory,  in  laryngeal  paraly- 
sis, 1050;  thymic,  869. 

Strongyloides  intestinalis,  309;  infection 
complicating  amcebiasis,  241. 

Strongylus  armatus,  aneurism  due  to,  849. 

Strophanthus   in   cardiac   failure,    794. 

Struma  (see  Goitre) ;  of  pituitary  gland, 
1013. 

Striimpell-Marie  type  of  spondylitis,  1138. 

Strychnia  poisoning,  paroxysms  of,  com- 
pared with  tetanus,  144. 

Stupor  in  alcoholic  cirrhosis,  579;  in  car- 
diac insufficiency,  790. 

Stuttering,  mouth-breathing  and,  470; 
spasm  of  tongue  in,  1055. 

Subacidity,  nervous,  512;  treatment  of, 
515. 

Subcortical  motor  aphasia,  977. 

Sub-infections  due  to  Bacillus  coli,  47. 

Subphrenic  peritonitis,  604,  605. 

Subsultus  tendinum  in  typhus  fever, 
354. 

Sugar  in  urine.     (See  Glycosuria.) 

Suggestion,  in  treatment  of  hysteria, 
1104;  in  treatment  of  neurasthenia, 
1115. 

Suicidal  tendencies  in  aortic  incompe- 
tency,  812. 


Sulphsemoglobinsemia,  758,  759. 

Sunstroke,  390;  bradycardia  in,  777; 
treatment  of,  392. 

Superacidity,  511,  512. 

Supermotility  of  stomach,  509. 

Supernumerary  cardiac  valves,  833. 

Supersecretion,  gastric,  intermittent  and 
continuous,  512;  gastric,  treatment  of, 
515;  of  saliva,  462,  463. 

Suppuration,  broncho-pneumonia  terminat- 
ing in,  104;.  chronic,  chronic  secondary 
anaemia  in,  730;  in  glandular  disease, 
386;  of  mesenteric  veins,  554. 

Suppurative  angiocholitis,   565. 

Suppurative   lymphadenitis,  672,   673. 

Suppurative  myositis,  1128. 

Suppurative  tonsillitis,  467. 

Suprarenal   bodies,   diseases   of,   863-868. 

Surgical  kidney,  713. 

Surra,  258. 

Sweating  in  abscess  of  liver,  584;  in  an- 
gina pectoris,  838;  in  arthritis  defor- 
mans,  1138;  in  biliary  colic,  570;  in 
chronic  ulcerative  tuberculosis,  197;  in 
malaria,  249;  in  neurasthenia,  1110;  in 
obstructive  jaundice,  556;  in  rickets, 
443 ;  in  treatment  of  acute  Bright 's  dis- 
ease, 700;  in  tuberculosis,  treatment  of, 
230. 

Sweating  sickness,  386,  387. 

Sweats,  due  to  failure  of  left  ventricle, 
789;  in  acute  endocarditis,  801,  802;  in 
diabetes,  432,  434;  in  empyema,  660; 
in  lobar  pneumonia,  88;  in  locomotor 
ataxia,  917,  918;  in  mediastinal  abscess, 
675;  in  morphia  habit,  401;  in  relaps- 
ing fever,  262;  in  rheumatic  fever,  374; 
in  tuberculous  broncho-pneumonia,  186; 
in  typhoid  fever,  19. 

Swine  fever,  388,  389. 

Sydenham's  chorea.     (See  Chorea,  acute.) 

Sympathetic  neuritis,   1022. 

Syncope,  death  by,  in  pulmonary  tubercu- 
losis, 210;  differentiation  of  petit  mal 
from,  1084;  in  Addison's  disease,  865, 
867;  in  fatty  heart,  791;  in  haemor- 
rhage from  stomach,  508;  in  Raynaud's 
disease,  1120;  in  Stokes- Adams  disease, 
779;  in  transverse  myelitis,  968. 

Syndrome  of  Weber,  1012. 

Syphilide,  late,  267;  macular,  266;  papu- 
lar, 266;  pustular,-  resembling  small- 
pox, 324;  squamous,  267. 

Syphilis,  acquired,  266,  267 ;  acute  Bright 's 
disease  due  to,  697;  acute  myelitis  due 
to,  966;  acute  nephritis  in,  276;  al- 
buminuria  in,  685;  amyloid  degenera- 
tion of  kidneys  in,  711;  amyloid  liver 
and,  590;  aneurism  and,  848,  850,  851; 


INDEX 


1215 


angina  pectoris  and,  837,  840;  aortic 
incompetency  due  to,  809;  arterio- 
sclerosis and,  843,  844;  cerebral,  dia- 
betes insipidus  and,  440;  cerebral,  dif- 
ferentiation of  general  paralysis  from, 
925;  cerebro-spinal,  differentiation  of 
locomotor  ataxia  from,  919 ;  chronic 
leptomeningitis  and,  951;  chronic  pa- 
renchymatous  nephritis  due  to,  702; 
chronic  secondary  anaemia  in,  729; 
congenital,  265,  268-270,  277,  280;  con- 
genital, hypertrophic  pulmonary  arthro- 
pathy  in,  1143;  cutaneous  reaction  in, 
277;  definition  of,  263;  diagnosis  of, 
276,  277;  diagnosis  of  sporotrichosis 
from,  235;  echinococcus  of  liver  differ- 
entiated from,  292;  endarteritis  of 
spinal  cord  and,  957;  epilepsy  and,  1080, 
1081,  1084;  etiology  of,  264,  265;  fetal 
peritonitis  due  to,  603;  general  paraly- 
sis due  to,  922;  hsemoglobinuria  due  to, 
683,  684;  haemorrhagica  neonatorum, 
269,  754;  history  of,  264;  in  spastic 
paralysis  of  adults,  936;  infantilism 
and,  892;  laryngeal,  oedema  of  glottis 
and,  616;  leukoplakia  buccalis  and,  461; 
life  insurance  and,  281;  locomotor 
ataxia  and,  913,  919,  920;  marriage  and, 
281;  Meniere's  disease  and,  1047; 
modes  of  infection  in,  265;  morbid 
anatomy  of,  265,  266;  multiple  neuritis 
in,  1024;  necrosis  of  liver  in,  559; 
neurasthenia  following,  1107;  of 
arteries,  275;  of  brain  and  cord,  270, 
271;  of  digestive  tract,  275;  of  heart, 
275;  of  liver,  273-275;  of  liver,  peri- 
gastric  adhesions  following,  493;  of 
liver,  thrombosis  of  portal  vein  in,  562; 
of  lung,  272,  273;  of  pancreas,  599;  of 
testes,  276;  of  thymus,  869;  of  thyroid, 
871;  of  trachea  and  bronchi,  272; 
pachymeningitis  externa  due  to,  946; 
parotitis  in,  463;  prophylaxis  of,  277, 
278;  pulmonary  fibrosis  and,  641;  renal, 
276;  salvarsan  treatment  of,  279; 
sclerosis  of  brain  due  to,  952;  spinal 
paralysis  and,  939,  940;  Stokes- Adams 
disease  and,  779;  thrombosis  of  mesen- 
teric  vessels  and,  554;  transmission  of, 
by  vaccination,  329;  treatment  of,  278- 
281;  Wassermann  reaction  in,  264,  275. 

Syphilitic  cachexia,  266. 

Syphilitic  cirrhosis  of  liver,  576,  581;  dif- 
ferentiation of  splenic  anaemia  from, 
888. 

Syphilitic  endarteritis,  1004. 

Syphilitic  laryngitis,  619,  620. 

Syphilitic  retinitis,  1029. 


Syphilitic  ulcers,  of  oesophagus,  473;  of 
pharynx,  465,  466. 

Syphiloma  of  brain,  1009;  treatment  of. 
1014. 

Syringomyelia,  definition  of,  964;  diag- 
nosis of,  965;  differentiation  of  hsemor- 
rhagic  pachymeningitis  from,  948;  dif- 
ferentiation of  progressive  central  mus- 
cular atrophy  from,  930;  differentiation 
of  tumor  of  spinal  cord  from,  964;  eti- 
ology and  morbid  anatomy  of,  964, 
965;  sclerosis  of  brain  and,  952;  symp- 
toms of,  965;  tetany  in,  881;  treatment 
of,  965;  tumors  leading  to,  963. 

System  diseases,  912-945. 

Systemic  gonococeus  infection,  124,  125. 

Systolic  brain  murmur  in  rickets,  444. 


Tabarillo,  or  Mexican  typhus  fever,  353. 

Tabes,  cycloplegia  in,  1036;  diabetic,  431, 
434;  differentiation  of  neurasthenia 
from,  1112;  dorsalis  (see  Locomotor 
ataxia)  ;  dorsalis  spasmodique,  935, 936 ; 
laryngeal  paralysis  in,  1050;  mesen- 
terica,  177,  178. 

Tabetic  crises,  917. 

Tabo-paralysis,  924. 

Tdche  cerebrale,  172. 

T aches  bleudtres,  caused  by  phthirius  pu- 
bis,  312;  in  typhoid  fever,  19. 

Tachycardia,  776,  777;  dilatation  of  heart 
in,  783;  in  exophthalmic  goitre,  878; 
neurasthenic,  1110;  typhoid  fevei  and, 
20. 

Ta?nia  confusa,  285;  cucumerina,  285; 
echinococcus,  289;  elliptica,  285;  flavo- 
punctata,  285;  madigascariensis,  285; 
nana,  285;  saginata,  285;  solium,  284, 
285,  287. 

Tseniasis,  somatic,  287-294. 

Talipes,  ealcaneus,  following  paralysis  of 
internal  popliteal  nerve,  1061;  equinus, 
in  hereditary  ataxia,  945. 

Tapeworm,  284-287;  diagnosis  of,  286; 
prophylaxis  of,  286;  symptoms  of,  285, 
286;  treatment  of,  286. 

Tapping,  in  alcoholic  cirrhosis  of  liver, 
580;  in  ascites,  611;  in  chronic  peri- 
tonitis, 611;  in  cirrhoses  of  liver,  582; 
in  hydrothorax  in  cardiac  insufficiency, 
794;  in  pericarditis  with  effusion,  767; 
in  pleurisy,  665,  666. 

Taste,  adenoids  and,  470;  hysterical  dis- 
turbances of,  1100;  loss  of  sense  of,  due 
to  lesion  of  glosso-pharyngeal  nerve, 
1049;  loss  of  sense  of,  due  to  paralysis 


1216 


INDEX 


of  fifth  nerve,  1040;  loss  of  sense  of,  in 
paralysis  of  facial  nerve,  1043. 

Teeth,  care  of,  462;  carious,  foul  breath 
and,  461;  carious,  ulcerative  stomatitis 
and,  457;  mercurial  stomatitis  and,  460. 

Teething,  in  rickets,  444;  tuberculous 
broncho-pneumonia  and,  186. 

Teichopsia  in  migraine,  1088. 

Telangiectasis,  epistaxis  in,  613;  in  hyper- 
trophic  cirrhosis,  581;  in  obstructive 
jaundice,  556;  multiple,  in  exophthalmic 
goitre,  879. 

Telegrapher's  cramp,   1093. 

Temperature,  in  acute  miliary  tuberculosis, 
170;  in  apoplectic  attacks,  991;  in 
arthritis  deformans,  1138;  in  cerebro- 
spinal  fever,  111;  in  intestinal  obstruc- 
tion, 542;  in  tuberculous  broncho-pneu- 
monia, 186;  in  tuberculous  meningitis, 
172,  173;  in  typhoid  fever,  17,  18;  in 
typhoid  form  of  tuberculosis,  169 ;  rela- 
tion of,  to  diarrhoea  in  children,  524. 

Tender  toes  in  typhoid  fever,  58. 

Tenderness,  following  renal  colic,  720;  in 
appendicitis,  534,  535;  in  biliary  colic, 
570;  in  cancer  of  bile-passages,  567;  in 
cancer  of  stomach,  502;  in  cholecystitis, 
566;  in  myeloid  leukaemia,  742;  in  pep- 
tic ulcer,  494;  in  pyelitis,  713,  714. 

Tendons   in   gonococcus   infections,   125. 

Tenotomy  in  treatment  of  congenital  torti- 
collis, 1053. 

Terminal  pneumonia,  92,  93. 

Terminal  pyogenic  infections,  53. 

Tertian  fever,  248,  250,  251. 

Tertiary  stage  of  syphilis,  267,  268. 

Test  meals  in  cancer  of  stomach,  502. 

Testes,  syphilis  of,  276;  tuberculosis  of, 
219,  220. 

Tetanus,  bacillus  of,  142,  143;  definition 
of,  142;  diagnosis  of,  144,  145;  etiology 
of,  142,  143;  hydrophobic,  144;  in  in- 
fants, 142;  Kopf.,  144;  morbid  anat- 
omy of,  143;  neonatorum,  -143,  144; 
post-operative,  143;  prognosis  of,  145; 
prophylaxis  of,  145;  spasm  of  cardia 
in,  511;  symptoms  of,  143,  144;  treat- 
ment of,  145;  transmission  of,  by  vac- 
cination, 329;  trismus  in,  1040;  vacci- 
nation and,  142. 

Tetany,  definition  of,  881;  diagnosis  of, 
882,  883;  etiology  of,  881,  882;  in  ty- 
phoid fever,  29;  morbid  anatomy  of, 
882 ;  rickets  and,  445 ;  spasmodic  laryn- 
gitis and,  617;  symptoms  of,  882;  treat- 
ment of,  883;  trismus  in,  1040. 

Thalamic  syndrome,  972;  in  tumors  of 
brain,  1012. 

Therapeutic  test  for  syphilis,  277, 


Thermic  fever,  391,  392;  treatment  of, 
392,  393. 

Third  nerve,  paralysis  of,  1035,  1036; 
spasm  of,  1036. 

Thomsen's  disease.     (See  Myotonia.) 

Thorax,  changes  in,  in  rickets,  443,  444; 
deformity  of,  in  adenoids,  469,  470. 

Thorn-headed  worms,  310. 

Thornwaldt's  disease,  471. 

Thread  test,  for  peptic  ulcer,  496. 

Thread- worm,  -295,  296. 

Throbbing  aorta,  in  neurasthenia,  1111. 

Thrombi  in  heart  cavity,  acute  cardiac  in- 
sufficiency due  to,  785. 

Thrombosis,  cervical  rib  pressure  and, 
1057;  complicating  bacillary  dysentery, 
128;  complicating  influenza,  118;  hemi- 
plegia  in  children  due  to,  1006;  in 
acute  endocarditis,  799;  in  angina  pec- 
toris,  839;  in  arterio-sclerosis,  845;  in 
cancer  of  stomach,  501 ;  in  lobar  pneu- 
monia, 90;  in  measles,  346;  in  mitral 
stenosis,  821;  in  pulmonary  apoplexy, 
637;  in  splenic  veins,  infarcts  follow- 
ing, 885;  in  typhoid  fever,  13,  21;  of 
blood-vessels,  ascites  and,  610;  of  cere- 
bral arteries,  998,  999;  (see  also  Cere- 
bral softening) ;  of  cerebral  sinuses  and 
veins,  primary,  1004,  1005;  of  cerebral 
sinuses  and  veins,  secondary,  1005;  of 
cerebral  sinuses  and  veins,  symptoms  of, 
1005,  1006;  of  cerebral  sinuses  and 
veins,  treatment  of,  1006;  of  cerebral 
sinuses  in  pulmonary  tuberculosis,  211; 
of  cerebral  veins  in  scarlet  fever,  339 ; 
of  coronary  artery,  787;  of  iliac  or 
femoral  veins  in  appendicitis,  536 ;  of 
lateral  sinus,  following  scarlet  fever, 
339;  of  mesenteric  vessels,  553,  554;  of 
portal  vein,  562;  of  portal  vein  causing 
ascites,  608;  of  portal  vein,  differentia- 
tion of  alcoholic  cirrhosis  from,  579;  of 
portal  vein,  following  pancreatic  ab- 
scess, 595;  of  portal  vein,  hffimatemesis 
in,  507;  of  pulmonary  artery,  gangrene 
following,  651 ;  of  spinal  blood  vessels, 
957;  of  veins  in  chlorosis,  733;  pancre- 
atic necrosis  and,  593;  venous,  in  rheu- 
matic fever,  375. 

Thrombotic   phlebo-arteritis,   1122. 

Thrush,  458. 

Thymic  asthma,  617. 

Thymic   stridor,  869. 

"Thymic  tracheostenosis, "  868. 

Thymus  gland,  diseases  of,  868,  870; 
enlargement  of,  in  myeloid  leukaemia, 
742. 

Thyroid  extract  in  cretinism  and  myx- 
cedema,  876;  in  lipomatoses,  453;  in 


INDEX 


1217 


obesity,   452;    in   scleroderma,   1127;    in 
tetany,  883. 

Thyroid  gland,  diseases  of,  870-880;  en- 
larged, oesophageal  stricture  and,  474; 
enlargement  of,  in  mumps,  351;  glyco- 
suria  and,  428,  429. 

Thyroid  therapy,  873,  876,  877. 

Thyroidectomy  in  exophthalmic  goitre, 
880;  tetany  following,  881,  882. 

Thyroidism,  876;  hypo-,  873;  hyper-,  877. 

Thyroiditis,  etiology  of,  871;  in  typhoid 
fever,  22;  sclerotic,  871;  symptoms  of, 
871. 

Tic  convulsif,  1044. 

Tic,  convulsive,  1075;  douloureux,  1090, 
1091;  impulsive,  1075,  1076. 

Tick  fever,  African,  261;  of  Kocky  Moun- 
tains, 388. 

Ticks,  310,  311;  in  transmission  of  Afri- 
can relapsing  fever,  261;  in  transmis- 
sion of  Rocky  Mountain  fever,  388. 

Tingling,  in  Landry's  paralysis,  942;  in 
pernicious  anaemia,  736;  of  fingers  in 
urasmia,  695. 

Tinnitus  aurium,  1046. 

Tobacco,  chronic  gastritis  and,  480. 

Tobscco  amblyopia,  1030. 
*  Tongue,  atrophy  of,  1055;  geographical, 
460;  in  actinomycosis,  232;  in  acute 
gastritis,  477;  in  acute  stomatitis,  457; 
in  acute  tonsillitis,  381;  in  alcoholic 
cirrhosis,  578;  in  appendicitis,  533,535; 
in  catarrhal  enteritis,  518;  in  chronic 
gastritis,  480;  in  constipation,  546;  in 
delirium  tremens,  399 ;  in  dengue,  362 ; 
in  diabetes,  432;  in  intestinal  obstruc- 
tion, 542;  in  lobar  pneumonia,  88;  in 
measles,  344;  in  mercurial  stomatitis, 
459;  in  milk-sickness,  385;  in  perito- 
nitis, 601;  in  pulmonary  tuberculosis, 
204;  in  rheumatic  fever,  374;  in  scarlet 
fever,  335;  in  scurvy,  447;  in  small- 
pox, 317;  in  sprue,  519;  in  typhoid 
fever,  21,  22;  in  typhus  fever,  353, 
354;  in  ulcerative  stomatitis,  457;  in 
yellow  fever,  359;  paralysis  of,  1054; 
paralysis  of,  in  bulbar  paralysis,  931; 
spasm  of,  1055;  tuberculosis  of,  211. 

Tonsillitis,  acute  Bright 's  disease  in,  697; 
acute,  definition  of,  380;  acute,  diag- 
nosis of,  381;  acute  endocarditis  and, 
797;  acute,  epidemic  form  of,  380; 
acute,  etiology  of,  380,  381;  acute,  mor- 
bid anatomy  of,  381;  acute,  sporadic 
form  of,  380;  acute,  symptoms  of,  381; 
acute,  treatment  of,  381,  382;  albumi- 
nuria  in,  685;  chronic,  468-471;  epi- 
demic, 380;  of  scarlet  fever,  336;  peri- 
carditis and,  760;  preceding  Hodgkin's 


disease,  748;  preceding  rheumatic  fever, 
373,  374;  suppurative,  467. 

Tonsils,  disease  of,  467-471;  diseases  of, 
foul  breath  and,  461;  enlarged,  follow- 
ing measles,  346;  in  Hodgkin's  disease, 
747;  in  measles,  344,  346;  in  syphilis, 
267;  in  tuberculosis,  164,  211;  involve- 
ment of,  in  rheumatic  fever,  373;  in- 
volvement of,  in  tuberculous  laryngitis, 
618;  removal  of,  in  rheumatic  fever, 
380;  tuberculosis  of,  211. 

Tophi,  in  gout,  421-423. 

Topical  diagnosis,  of  complete  transverse 
lesions,  955;  of  diffuse  and  focal  dis- 
eases of  the  brain,  968-976;  of  focal 
lesions,  954,  955;  of  lesions  of  nervous 
system,  905-911;  of  unilateral  lesions, 
955,  956. 

Torpor  in  cerebral  syphilis,  271. 

Torticollis,  1129,  1130;  congenital,  1052, 
1053 ;  occipito-cervical  neuralgia  in, 
1055;  spasmodic,  1053,  1054. 

Tower  head,  1147. 

ToxaBmic  jaundice,  557. 

Toxic  amaurosis,  1030. 

Toxic  cirrhosis  of  liver,  576. 

Toxic  combined  sclerosis,  945. 

Toxic  gastritis,  478,  479. 

Toxic  hsemoglobinuria,  683. 

Toxic  infantilism,  893. 

Toxic  pneumonia,  93. 

Toxin,  cholera,  133. 

Trachea,  in  small-pox,  317;  syphilis  of, 
272;  systolic  murmur  in,  854. 

Tracheal  tugging  in  aneurism  of  thoracic 
aorta,  854. 

Tracheitis,  in  pulmonary  tuberculosis,  203. 

Tracheo-bronchial   adenitis,   176,   177. 

Tracheotomy,  emphysema  of  mediastinum 
following,  675;  in  diphtheria,  71;  in 
oedema  of  glottis,  616;  in  suppurative 
tonsillitis,  467;  in  syphilitic  laryngitis, 
620. 

Traction  aneurism,  849. 

Traction  kinks,  540. 

Trance   following  hysteroid  attacks,   1103. 

Transfusion,  after  haemorrhage  in  peptic 
ulcer,  497;  in  haemophilia,  757;  in  pel- 
lagra, 413. 

Transposition  of  large  arterial  trunks, 
834. 

Trauma,  acute  Bright 's  disease  due  to, 
697;  acute  laryngitis  due  to,  615;  acute 
myelitis  due  to,  966;  brain  abscess  due 
to,  1015;  cancer  of  liver  due  to,  587; 
causing  epistaxis,  613;  causing  pneu- 
monia, 76;  diabetes  insipidus  and,  440; 
emphysema  of  mediastinum  due  to,  675; 
epilepsy  due  to,  1081;  followed  by 


1218 


INDEX 


chronic  dry  pleurisy,  667 ;  heematuria  due 
to,  682;  haemorrhage  into  spinal  cord 
due  to,  958;  haemorrhage  into  spinal 
membranes  due  to,  957;  Jacksonian  epi- 
lepsy due  to,  1084;  lesions  of  cauda 
equina  and  conus  medullaris  due  to, 
962;  liver  abscess  due  to,  583;  loss  of 
sense  of  smell  due  to,  1028;  Ludwig's 
angina  and,  466;  mediastinal  abscess 
due  to,  675;  myalgia  due  to,  1129; 
neuritis  due  to,  1021;  pancreatic  cysts 
due  to,  597;  pancreatic  necrosis  and, 
593;  paralysis  agitans  due  to,  1064; 
pericarditis  due  to,  760;  perinephric 
abscess  due  to,  725;  peritonitis  in  chil- 
dren due  to,  603 ;  poliencephalitis  due  to, 
1014;  predisposing  to  local  tuberculosis, 
159;  subphrenic  abscess  following,  604; 
tuberculous  peritonitis  and,  180. 

Traumatic  hysteria.  (See  Traumatic  neu- 
roses. ) 

Traumatic  neuroses,  definition  of,  1116; 
diagnosis  of,  1118;  etiology  of,  1116; 
prognosis  of,  1118,  1119;  symptoms  of, 
1116-1118. 

Trembles,  in  cattle,  and  milk-sickness,  385. 

Tremor,  due  to  lesion  of  internal  capsule, 
972;  due  to  tumor  of  cerebellum,  976; 
hereditary,  1066;  hysterical,  1066,  1099; 
in  chronic  alcoholism,  397;  in  exophthal- 
mic goitre,  879;  in  hemiplegia,  996;  in 
lead  poisoning,  405;  in  paralysis  agi- 
tans, 1064;  in  progressive  central  mus- 
cular atrophy,  930;  in  traumatic  hys- 
teria, 1117;  in  writer's  cramp,  1094;  of 
tongue  and  lips  in  general  paralysis, 
923;  senile,  1066;  simple,  1066;  toxic, 
1066;  volitional  or  so-called  intention, 
in  multiple  sclerosis  of  brain,  953. 

Tremors  in  paramyoclonus  multiplex,  1132. 

Treponema   pallidum,   263,   264,   265,   277. 

Trichina  spiralis,  296. 

Trichiniasis,  anatomical  changes  in,  297; 
dermato-myositis  and,  1128,  1129;  diag- 
nosis of,  299,  300;  frequency  of  infec- 
tion with,  298;  incidence  of,  297,  298; 
modes  of  infection  in,  298;  parasites 
of,  296;  prognosis  of,  299;  prophylaxis 
of,  300;  symptoms  of,  298,  299;  treat- 
ment of,  300. 

Trichocephalus  dispar,  309. 

Trichomonas  hominis,  281;  vaginalis,  281. 

Trichterbrust,  470. 

Tricuspid  regurgitation,  824,  825. 

Tricuspid  stenosis,  825. 

Trigeminal  neuralgia,  1090,  1091;  treat- 
ment of,  1093. 

Trilocular  heart,   832. 

Trismus,  1040;  hysterical,  1099;  in  acute 


cerebro-spinal    leptomeningitis,    950;    in 
tetanus,  143;   in  tetany,  882. 

Tropical  abscess,  583;  symptoms  of,  584, 
585. 

Tropical  sore,  260,  261. 

Tropical  splenomegaly,  888. 

Trousseau's  symptom,  882. 

Trypanosoma  brucei,  258;  equinum,  258; 
evansi,  258 ;  gambiense,  258 ;  lewisi,  258 ; 
sanguinis,  258;  theileri,  258. 

Trypanosomiasis,  definition  of,  258;  his- 
tory of,  258;  in  man,  259;  prognosis  of, 
260;  symptoms  of,  259,  260;  treatment 
of,  260. 

Tsetze  fly  disease,  258. 

Tubal  pregnancy,  ruptured,  resembling 
acute  peritonitis,  603. 

Tubercle,  hydronephrosis  due  to,  716;  in 
acute  sero-fibrinous  pleurisy,  655;  laryn- 
geal  oedema  of  glottis  and,  616;  of 
brain,  1009;  of  brain,  treatment  of, 
1014;  pulmonary,  fibroid  changes  due 
to,  640;  stages  of  development  of,  182. 

Tubercle  bacillus,  156;  causing  broncho- 
pneumonia,  102;  in  acute  sero-fibrinous 
pleurisy,  655,  656;  in  empyema,  660;  in 
pericarditis,  761;  in  pyelitis,  712;  in 
septico-pyaemia,  51. 

Tubercles,  degeneration  of,  166;  diffused 
inflammatory,  167;  distribution  of,  in 
body,  165;  evolution  of,  165,  166;  in 
chronic  dry  pleurisy,  668;  medullary, 
963. 

"Tubercula  dolorosa,"   1027. 

Tubercular   leprosy,    153. 

Tuberculin  reaction,  159,  160,  161;  in  Ad-, 
dison's  disease,  866,  867;  in  differentia- 
tion of  Hodgkin's  disease  and  tubercu- 
lous adenitis,  749 ;  in  pleurisy,  655 ;  in 
tuberculosis,  159-161,  207,  208. 

Tuberculin  treatment  for  tuberculosis,  227. 

Tuberculo-pneumonic  phthisis,  pneumonia 
and,  97,  98. 

Tuberculosis,  acquired  disposition  to,  158; 
actinomycosis  and,  233;  active  conges- 
tion of  lungs  in,  633;  acute,  167;  acute 
Bright 's  disease  in,  697;  acute  miliary, 
167-174;  acute  pneumonic  form  of,  183; 
Addison's  disease  and,  863,  864,  865, 
867;  amyloid  degeneration  of  kidneys 
in,  711;  amyloid  liver  and,  590;  anthra- 
cosis  and,  644 ;  ascites  in,  610 ;  associa- 
tion of,  with  pleurisy,  655;  broncho- 
pneumonia  and,  104;  broncho-pneu- 
monia, form  of,  185;  Calmette  re- 
action, 159;  chlorosis  and,  730;  chronic 
alcoholism  and,  398;  chronic  gastritis 
and,  480;  chronic  leptomeningitis  and, 
951;  chronic  haemorrhagic  peritonitis 


INDEX 


1219 


and,  607;  chronic  parenchymatous 
nephritis  due  to,  702;  chronic,  terminal 
infections  in,  53;  cirrhosis  of  liver  and, 
577;  climatic  treatment  of,  226;  clin- 
ical forms  of,  168 ;  compensatory 
emphysema  in,  645;  concurrent  infec- 
tions in,  208;  confusion  of,  with  septi- 
caemia, 52;  confusion  of,  with  typhoid 
fever,  37;  cutaneous  reaction  in,  160; 
death  from,  in  myxo3dema,  875;  defini- 
tion of,  154;  diagnosis  of  sporotrichosis 
from,  235;  differentiation  of  Hodgkin's 
disease  from,  749;  diseases  associated 
with,  208;  distribution  of,  155,  156; 
endocarditis  in,  191,  221;  etiology  of, 
156-165;  fibrinous  bronchitis  and,  632; 
fibroid,  202;  fistula  in  ano  in,  213; 
gangrene  of  lung  and,  651;  general 
serous  membrane,  178;  hsematuria  in, 
681;  haemoptysis  in,  194;  history  of, 
154,  155;  Hodgkin's  disease,  and,  747, 
748;  immunity  changes  in,  160;  in  dia- 
betes, 431;  in  fibrinous  bronchitis,  633; 
in  infancy,  210;  in  old  age,  210;  inocu- 
lation in,  162;  intestinal  catarrh  and, 
517;  intestinal  infection  and,  164; 
latency  of,  162;  lesions  in,  general  mor- 
bid anatomy  and  histology  of,  165; 
leukaemia  and,  746;  mammitis  in,  221; 
marriage  and,  222;  modes  of  death  in, 
210;  multiple  neuritis  in,  1024;  natural 
cure  in,  223;  of  arteries,  221;  of  brain 
and  cord,  214,  215;  of  caecum,  213;  of 
endocardium,  221;  of  Fallopian  tubes, 
ovaries  and  uterus,  220;  of  hip  joint, 
differentiation  of  arthritis  deformans 
from,  1140;  of  intestines,  204,  212,  213; 
of  kidneys,  217-219;  of  lips,  211;  of 
liver,  213,  214;  of  lymphatic  system, 
174-182;  of  lymph-glands,  174-178;  of 
mammary  gland,  220,  221;  of  myocar- 
dium, 221;  of  oesophagus,  212;  of  pal- 
ate, 211;  of  pericardium,  179;  of  peri- 
toneum, 179-182;  of  pharynx,  211,  212; 
of  pleura,  178,  179;  of  prostate  and 
vesiculae  seminales,  219;  of  rectum,  213; 
of  salivary  glands,  211;  of  serous  mem- 
branes, 178-182;  of  spleen,  erythraemia 
and,  758;  of  stomach,  212;  of  testes, 
219,  220;  of  thymus,  869;  of  thyroid, 
871;  of  tongue,  211;  of  tonsils,  211;  of 
ureter  and  bladder,  219 ;  opthalmo-re- 
action  in,  159;  opsonic  index  in,  160; 
pelvic  peritonitis  due  to,  605;  pericar- 
ditis in,  760,  761,  763;  perigastric  ad- 
hesions following,  493 ;  pneumonia  and, 
94,  98;  pneumonic  form  of,  183;  pneu- 
mothorax  in,  229;  polyorrhomenitis  in, 
178;  prognosis  in,  221-222;  prophylaxis 


in,  222,  223;  purpura  in,  751;  sanatoria 
treatment  of,  225;  septicaemia  in,  50; 
serums  in,  161;  specific  reaction  in,  207; 
specific  treatment  of,  227;  tabes  mesen- 
terica  and,  177,  181;  terminal  pneu- 
monia in,  93,  97;  tonsillar  infection 
and,  164,  211;  transmission  of,  by  vac- 
cination, 329;  treatment  of,  223-231; 
treatment  of,  by  induced  pneumothorax, 
229;  tuberculin  reaction  of,  159;  tuber- 
culous broncho-pneumonia  in,  185; 
tumor  of  brain  in,  214;  typhoid  fever 
and,  32;  von  Pirquet  reaction  and,  159; 
X-ray  diagnosis  of,  208. 

Tuberculosis,  pulmonary,  182-211;  acute 
plastic  pleurisy  in,  655;  carcinoma  con- 
fused with,  654;  chronic  ulcerative,  187- 
202;  chronic  ulcerative,  morbid  anatomy 
of,  187-192;  chronic  ulcerative,  symp- 
toms of,  192-202;  influenza  and,  117; 
lymphadenitis  in,  672. 

Tuberculous  abscesses  of  liver,  583. 

Tuberculous  aspiration  pneumonia,  185. 

Tuberculous  broncho-pneumonia,  106,  185; 
chronic  ulcerative  tuberculosis  and,  188. 

Tuberculous  cavity,  perforation  of,  causing 
pneumothorax,  670. 

Tuberculous  chronic  interstitial  pneu- 
monia, 640,  641. 

Tuberculous  cirrhosis  of  liver,  214. 

Tuberculous  laryngitis,  618,  619. 

Tuberculous  meningitis.  (See  Meningeal 
form  of  acute  miliary  tuberculosis.) 

Tuberculous  peritonitis,  608;  treatment 
of,  611. 

Tuberculous  pleurisy,  haemorrhagic,  662. 

Tuberculous  primitive  dry  pleurisy,  668. 

Tuberculous  pyelitia,  713. 

Tuberculous  pyo-nephrosis,  218. 

Tuberculous  ulcers  of  oesophagus,  473;  of 
pharynx,  465,  466. 

Tuberous  sclerosis  of  brain,  952. 

Tubo-ovarian  disease,  confusion  of,  with 
appendicitis,  536. 

Tubular   diarrhoea,   551. 

Turgescence  of  mucosa  in  asthma,  628, 
629. 

Tumor,  abdominal,  causing  ascites,  608, 
610;  abdominal,  hypostatic  congestion 
of  lungs  in,  634;  causing  dilatation  of 
colon,  552;  causing  dilatation  of  stom- 
ach, 487;  causing  obstructive  jaundice, 
555;  chronic  secondary  anaemia  due  to, 
730;  compression  myelitis  due  to,  960; 
confusion  of  movable  kidney  with,  678; 
constipation  and,  545;  differentiation 
of,  from  acute  pleurisy,  664;  differen- 
tiation of  aneurism  from,  856;  differ- 
entiation of,  from  general  paralysis,  925 ; 


3220 


INDEX 


differentiation  of  haemorrhagic  pachy- 
meningitis  from,  948;  differentiation  of 
hydronephrosis  from,  716;  due  to  aber- 
rant thyroids,  871;  gaseous,  of  Steno's 
duct  and  parotid  gland,  464;  haematuria 
in,  681 ;  in  actinomycosis,  232 ;  in  acute 
suppurative  gastritis,  478;  in  aneurism 
of  abdominal  aorta,  860;  in  aneurism  of 
heart,  830;  in  cirrhosis  ventriculi,  486; 
in  empyema,  661 ;  in  intussusception, 
540,  544;  indurative  changes  in  lung  due 
to,  641 ;  intestinal  obstruction  due  to, 
540,  541,  543;  Jacksonian  epilepsy  due 
to  1084;  lesions  of  cauda  equina  and 
conus  medullaris  due  to,  962;  leuksemic, 
742,  745 ;  loss  of  sense  of  smell  due  to, 
1028;  oesophageal  stricture  and,  474;  of 
bladder,  hsematuria  due  to,  681;  of 
cerebellum,  975;  of  heart,  831;  of  kid- 
ney, 722,  723;  of  lungs,  653,  654;  of 
mediastinum,  673-675;  of  nerve  fibres 
(see  Neuromata)  ;  of  ovaries  and  uterus, 
causing  hydronephrosis,  716;  of  pan- 
creas, 598,  599;  of  pituitary  gland,  889, 
891;  of  renal  pelvis,  hsematuria  due  to, 
682;  of  spleen,  885;  of  spinal  cord, 
acute  myelitis  due  to,  966;  of  spinal 
cord  and  its  membranes,  963,  964;  of 
stomach,  non-cancerous,  505;  of  supra- 
renal bodies,  868;  of  thymus,  869;  of 
thyroid,  871;  phantom,  in  hysteria, 
1099;  pulmonary,  fibroid  changes  due 
to,  640;  sciatica  due  to,  1061;  spastic 
paralysis  secondary  to,  939;  spinal 
pachymeningitis  due  to,  946;  tuber- 
culous peritonitis  and,  181,  182. 

Tumor,  cerebral,  1009,  1010;  albuminuria 
in,  686;  bradycardia  in,  777;  diabetes 
insipidus  and,  440;  differentiation  of 
abscesses  of  brain  from,  1017;  differen- 
tiation of  uraemia  from,  696;  in  acquired 
chronic  hydrocephalus,  1019,  1020;  mi- 
graine and,  1088;  neuro-fibromatosis 
and,  1027;  optic  neuritis  in,  1031;  site 
of,  1010;  symptoms  of,  1010-1013; 
tetany  in,  881;  tuberculous,  214. 

Turpentine,  acvte  Bright 's  disease  due  to, 
697;  congestion  of  kidney  due  to,  679; 
haematuria  due  to,-  681. 

Turpentine   poisoning,   anuria   in,   680. 

Tympanites,  hysterical,  1101;  in  acute 
peritonitis,  treatment  of,  611;  in  ascites, 
609;  in  catarrhal  enteritis,  518;  in  hys- 
teria, 1101;  in  peritonitis,  602;  in  tu- 
berculous peritonitis,  180,  181;  in  ty- 
phoid fever,  23,  44. 

Typho-coil  organisms,  meat  poisoning  and, 
408. 

Typhoid  bacillus,  acute  ascending  paralysis 


produced  by,  941;  in  acute  bronchitis, 
621;  in  acute  sero-fibrinous  pleurisy, 
656;  in  cholecystitis,  566;  in  chronic 
pancreatitis,  596;  in  gall-stones,  569. 

Typhoid  carriers,  6. 

Typhoid  fever,  abscess  of  liver  following. 
583;  abscess  of  lung  in,  653;  actinomy- 
cosis simulating,  233;  acute  bronchitis 
and,  620;  acute  endocarditis,  mistaken 
for,  803;  acute  interstitial  myocarditis 
in,  787;  aestivo-autumnal  fever  compared 
with,  253;  age  and,  3;  albuminuria  in, 
685;  appendicitis  and,  532,  536;  appen- 
dix in,  12;  arteritis  in,  21;  arterio-scler- 
osis  following,  843;  arthritis  in,  31; 
association  of  other  diseases  with,  32; 
bacillary  dysentery  and,  128;  bacilluria 
in,  30 ;  bacillus  of,  4,  5 ;  bacteriuria 
in,  687;  bladder  in,  12;  bone-marrow  in, 
12;  bradycardia  following,  777;  broncho- 
pneumonia  secondary  to,  102;  cancrum 
oris  following,  459;  catarrhal  jaundice 
in,  563;  cerebro-spinal  form  of,  27; 
character  of,  17;  chronic  secondary  ane- 
mia in,  729 ;  circulatory  system  in,  13, 
19-21;  complicating  amoebiasis,  241; 
confusion  of,  with  septico-pyaemia,  52; 
convulsions  in,  28 ;  definition  of,  1 ;  di- 
agnosis of,  35-38;  differentiation  of 
endocarditis  from,  803;  differentiation 
of,  from  general  miliary  tuberculosis, 
169 ;  differentiation  of  typhus  fever 
from,  355;  dilatation  of  heart  in,  784; 
diphtheroid  enteritis  in,  520 ;  diphtheroid 
inflammation  in,  60;  distribution  of,  2; 
epistaxis  and,  614;  etiology  of,  2-9;  eye 
symptoms  in,  29 ;  flies  and,  7 ;  gall  blad- 
der in,  12;  gall-stones  and,  569;  gan- 
grene of  lung  in,  651;  haemoglobinuria 
due  to,  683;  haemoptysis  in,  27;  haemor- 
rhage in,  12;  hemiplegia  and  aphasia  in, 
29 ;  historical  note  on,  1 ;  house  and  hos- 
pital infection  and,  5 ;  hypostatic  con- 
gestion of  lungs  in,  634;  hypothermia 
in,  18;  immunity  to,  3,  4;  in  armies,  2, 
3;  in  the  aged,  34;  incubation  period 
of,  14;  infarcts  of  spleen  in,  885;  in- 
flammation of  oesophagus  in,  472;  intes- 
tinal catarrh  and,  517.;  intestines  in, 
9-11,  22,  23;  jaundice  in,  557;  kidneys 
in,  12;  liver  in,  12,  26;  membranous 
gastritis  in,  479;  meningism  in,  27,  951; 

'  meningitis  in,  28;  mesenteric  glands  in, 
12;  modes  of  conveyance  of,  5-8;  modes 
of  infection  of,  8,  9 ;  morbid  anatomy 
of,  9-14;  muscles  in,  14,  29;  necrosis  of 
liver  in,  559 ;  nervous  system  in,  13,  27- 
29;  neuralgia  and,  1090;  neurasthenia 
following,  1107;  neuritis  in,  28;  oedema 


INDEX 


1221 


of  glottis  in,  616;  ophthalmo-reaction 
in,  36;  orchitis  in,  12,  30;  parenchy- 
matous  degeneration  of  heart  in,  788; 
parotitis  in,  463;  perforation  of  bowel 
in,  11;  periostitis  in,  31;  peritonitis  in, 
603;  pharyngeal  ulcers  and,  466;  phle- 
bitis in,  21,  45,  46;  plantar  neuralgia 
in,  1092;  pneumonia  and,  98;  pneumo- 
thorax  in,  27;  post-typhoid  septicaemia 
and,  31;  prognosis  of,  38;  prophylaxis 
of,  38,  41;  recrudescences  in,  17;  respi- 
ratory organs  in,  12,  13,  26,  27;  scarlet 
fever  and,  340;  seasonal  distribution  of, 
3;  secondary  pneumonia  in,  93;  septi- 
caemia in,  50;  sex  and,  3,  38;  spleen  in, 
12,  26;  sudden  death  in,  38;  symptoms 
of,  14-31;  tetany  and,  881;  thrombosis 
in,  21;  thyroiditis  in,  871;  treatment  of , 
41-46;  trichiniasis  confused  with,  300; 
tuberculosis  and,  209;  tuberculous  peri- 
tonitis confused  with,  180;  uraemia  sim- 
ulating, 696;  vaccination  in,  40;  va- 
rieties of,  32-35. 

Typhoid  form  of  tuberculosis,  diagnosis 
of,  169;  symptoms  of,  168,  169. 

Typhoid   pneumonia,   93. 

Typhoid  spine,  31 ;   treatment   of,  45. 

Typhoid  state  following  mumps,  350;  fol- 
lowing scarlet  fever,  339;  in  acute  yel- 
low atrophy,  560 ;  in  milk-sickness,  385 ; 
in  obstructive  jaundice,  556;  in  suppu- 
rative  nephritis,  714;  in  tuberculous 
broncho-pneumonia,  186. 

Typho-lumbricosis,    295. 

Typhus  fever,  38;  acute  endocarditis  mis- 
taken for,  803;  acute  myelitis  due  to, 
966;  Brill's  disease  and,  352;  compli- 
cations and  sequelae  of,  355;  definition 
of,  351,  352;  diagnosis  of,  355,  356; 
dilatation  of  heart  in,  784;  etiology  of, 
352,  353;  gangrene  of  lung  in,  651; 
jaundice  in,  557;  Manchurian  type  of, 
352;  measles  resembling,  347;  membran- 
ous gastritis  in,  479;  morbid  anatomy 
of,  353;  osdema  of  glottis  in,  616; 
parenchymatous  degeneration  of  heart 
in,  788 ;  prognosis  of,  355 ;  purpuric  rash 
in,  751;  scarlet  fever  and,  340;  second- 
ary pneumonia  in,  93;  siderans,  355; 
sporadic,  352;  symptoms  of,  353-355; 
treatment  of,  356. 

Tyrotoxicon,  409. 


U 


Ulcer,  amoebic,  in  intestines,  239;  causing 
epistaxis,  613;  follicular,  521;  in  aph- 
thous  stomatitis,  456,  457;  in  colon  in 


sprue,  519;  in  gastro-intestinal  tract, 
and  Bacillus  coli,  48;  in  scurvy,  447;  in 
ulcerative  stomatitis,  457;  intestinal, 
cancerous,  521;  intestinal  diagnosis  of 
522;  of  foot  in  diabetes,  434;  of  heart, 
acute,  due  to  septic  infarcts,  787;  of 
oesophagus,  473;  of  oesophagus,  in  ty- 
phoid fever,  22;  of  pharynx,  465,  466; 
of  stomach,  bradycardia  in,  777;  of 
stomach,  chronic  gastritis  and,  480;  of 
stomach,  differentiation  of  cancer  from, 
504;  of  stomach,  gastralgia  in,  513;  of 
stomach,  haemorrhage  in,  506,  507,  508, 
509;  oral,  in  pernicious  anaemia,  736; 
peptic,  290-298;  peptic,  gastric  and  duo- 
denal, 490-498 ;  perforating,  in  locomotor 
ataxia,  915,  918;  solitary,  intestinal, 

521,  522;    stercoral,   521;   syphilitic,   in 
larynx,   619 ;   tuberculous,   in  intestines, 
212,  213;  tuberculous,  in  larynx,  618. 

Ulceration,  catarrhal,  of  oesophagus,  473; 
from  intestinal  perforation,  521 ;  in  ap- 
pendicitis, 534,  535;  in  diarrhoea  of 
children,  525;  of  colon  in  chronic  paren- 
chymatous nephritis,  703;  of  colon  in 
constipation,  546;  of  intestines  in  ty- 
phoid fever,  10,  11;  of  intestines  in 
pulmonary  tuberculosis,  204,  205;  of 
larynx,  in  typhoid  fever,  12,  13; 
of  mouth  and  tongue  in  sprue,  519; 
of  oesophagus,  stricture  following,  474; 
of  stomach  in  pulmonary  tuberculosis, 
204. 

Ulcerative   angiocholitis,   565. 

Ulcerative  colitis,  constipation  following, 
545. 

Ulcerative  enteritis,  520-522;  treatment  of, 

522,  523. 

Ulcerative  stomatitis,  457,  458. 

Ulceres  du  poumon,  644. 

Ulcus  carcinomatosum,  504. 

Ulnar  nerve,  lesions  of,  1059;  neuralgia 
of,  1091. 

Unarmed  tapeworm,  285. 

Uncinariasis,    300. 

Under-development  in  hook-worm  disease, 
303. 

Undulant  fever.     (See  Malta  fever.) 

Uraemia,  bradycardia  in,  777;  confusion 
of  alcoholic  cirrhosis  with,  579;  death 
from,  in  renal  colic,  720;  definition  of, 
693;  diagnosis  of,  695,  696;  epilepsy 
due  to,  1081;  following  hydronephrosis, 

.  717;  functional  test  in,  695;  in  acute 
Bright 's  disease,  699;  in  chronic  gout, 
422;  in  chronic  interstitial  nephritis, 
705;  in  mumps,  351;  in  polycystic  kid- 
neys, 724;  Jaeksonian  epilepsy  due  to, 
1084;  symptoms  of,  694;  theories  of, 


1222 


INDEX 


693,  694;  toxic  amaurosis  in,  1031; 
treatment  of,  710. 

Ursemic   amaurosis,   694,   708. 

Ursemic  symptoms  in  acute  Bright 's  dis- 
ease, 698;  in  chronic  Bright 's  disease, 
710;  in  chronic  parenchymatous  nephri- 
tis, 703. 

Urates,  calculi   of,   718. 

Ureter,  coccidia  in,  237;  tuberculosis  of, 
219. 

Urethral  tuberculosis,   219. 

Urethritis,  125;  gout  and,  423;  pyuria  in, 
688. 

Uric  acid,  calculi,  718;  gout  and,  417,  418, 
419,  421;  occurrence  of,  in  urine,  689. 

Urinary  secretion,  anomalies  of,  680-693. 

Urinary  tract,  infections  of,  due  to  Bacil- 
lus coli,  47. 

Urine,  bacilli  in,  in  genito-urinary  tuber- 
culosis, 217;  decrease  of,  in  cardiac  in- 
sufficiency, treatment  of,  795,  796;  in 
acute  Bright 's  disease,  698 ;  in  acute 
gastritis,  477;  in  acute  transverse  mye- 
litis, 967,  968;  in  acute  yellow  atrophy, 
560;  in  alcoholic  cirrhosis,  578;  in  amy- 
loid disease  of  kidneys,  711;  in  appendi- 
citis, 534,  535;  in  arterio-sclerosis,  845; 
in  biliary  colic,  570;  in  cancer  of  stom- 
ach, 501;  in  cardiac  insufficiency,  790; 
in  catarrhal  jaundice,  564;  in  cerebro- 
spinal  fever,  112;  in  chronic  bronchitis, 
624;  in  chronic  gastritis,  481;  in  chronic 
gout,  422;  in  chronic  interstitial  neph- 
ritis, 706,  707;  in  chronic  pancreatitis, 
596;  in  chronic  parenchymatous  neph- 
ritis, 703,  704;  in  congestion  of  the 
liver,  562;  in  diabetes,  432,  433;  in 
diabetes  insipidus,  440;  in  epidemic 
haemoglobinuria,  754;  in  epilepsy,  1083; 
in  gout,  420,  423;  in  hypertrophic  cir- 
rhosis, 580 ;  in  hysteria,  1103 ;  in  icterus 
neonatorum,  558;  in  intestinal  obstruc- 
tion, 542;  in  malaria,  249;  in  mitral  in- 
competency,  819 ;  in  movable  kidney, 
678;  in  myeloid  leukaemia,  743;  in  neu- 
rasthenia, 1111;  in  obstructive  jaundice, 
556;  in  chronic  ochronosis,  454;  in  pep- 
tic ulcer,  495;  in  perinephric  abscess, 
725;  in  peritonitis,  602;  in  pernicious 
anaemia,  736;  in  pernicious  malaria,  253; 
in  polyarteritis  acuta  nodosa,  862;  in 
polycystic  kidneys,  724;  in  pulmonary 
tuberculosis,  205;  in  pyelitis,  713;  in 
renal  colic,  720 ;  in  rheumatism,  375 ;  in 
rickets,  445;  in  Schonlein's  disease,  752; 
in  scurvy,  448;  in  toxsemic  jaundice, 
557;  in  tuberculosis  of  the  kidneys,  218, 
21 9  j  in  typhoid  fever,  29;  in  typhus 


fever,  355;  retention  of,  in  locomotor 
ataxia,  918. 

Urostealith,  calculi  of,  718. 

Urticaria,  due  to  gall-stones,  570;  epi- 
demica,  314;  in  asthma,  629;  in  cerebro- 
spinal  fever,  112;  in  diphtheria,  66,  67; 
in  hypertrophic  cirrhosis,  581;  in  ob- 
structive jaundice,  556;  in  Schonlein's 
disease,  752;  in  small-pox,  318;  purpuric, 
in  acute  chorea,  1072. 

Urticarial  fever,  284. 

Uterus,  tuberculosis  of,  220. 

Uvula,  circulatory  disturbances  of,  464; 
in  pharyngitis,  465. 


Vaccination,  against  anthrax,  150;  against 
typhoid  fever,  40,  41;  complications  of, 
328,  329;  history  of,  326,  327;  in  ty- 
phoid fever,  40;  influence  of,  on  other 
diseases  than  small-pox,  330;  irregular, 
328-330;  literature  on,  329;  normal, 
327,  328;  small-pox,  324;  technique  of, 
330;  tetanus  and,  329;  transmission  of 
diseases  by,  329;  value  of,  329,  330, 
331. 

Vaccine,  326 ;  in  erysipelas,  56 ;  in  leprosy, 
154;  in  Malta  fever,  132;  tetanus  bacil- 
lus in,  142. 

Vaccine  therapy  in  acute  bronchitis,  622; 
in  acute  coryza,  383;  in  arthritis  de- 
formans,  1142;  in  bacteriuria,  687;  in 
gonococcus  infection,  125;  in  pneu- 
monia, 78,  79,  100;  in  pyelitis,  715;  in 
septico-pyaamia,  53 ;  in  tonsillitis,  382. 

Vaccinia,  definition  of,  326;  generalized, 
328;  history  of,  326,  327;  nature  of, 
327. 

Vaccino-syphilis,  329. 

Vagabond's  disease,  312. 

Vaginitis,  gonorrheal,  123. 

Valleix's   points   in   neurasthenia,    1108. 

Valsalva,  sinuses  of,  851;  aneurism  of, 
851. 

Valve  lesions,  acute  cardiac  insufficiency 
due  to,  786;  acute  endocarditis  and, 
797,798;  cardiac  hypertrophy  and,  781; 
congenital,  833,  834;  dilatation  of 
heart  in,  783;  effects  of,  805-808;  prog- 
nosis of,  826-829;  treatment  of,  828, 
829. 

Valvular  disease,  chronic,  805-808. 

Vaquez's  disease,  757,  758. 

Varicella,  broncho-pneumonia  secondary 
to,  101;  definition  of,  331;  diagnosis  of, 
332;  differentiation  of  small-pox  from, 
323;  escharotica^  332  j  etiology  of,  331  \ 


INDEX 


1223 


history  of,  331;  symptoms  of,  331,332; 
treatment  of,  332. 

Varicose  aneurism,  861. 

Varicose  veins,  haemorrhage  from  stomach 
and,  506;  in  oesophagus,  473. 

Variola  (see  Small-pox) ;  acute  glanders 
confused  with,  146. 

Variola  pustulosa  haemorrhagica,  321;  sine 
eruptione,  321;  vera,  317-320. 

Varioloid,  321. 

Varioloid  varicella,  316. 

Varix,  aneurismal,  861. 

Vaso-motor  paralysis,  984. 

Vaso-motor  turgescence,  asthma  due  to, 
628. 

Vegetable  poisoning,  409,  410. 

Veins,  distention  of,  in  myeloid  leukaemia, 
741;  in  rickets,  444.  (See  also  Blood 
vessels.) 

Venesection  in  cardiac  failure,  792;  in 
cerebral  apoplexy,  1002;  in  pneumonia, 
99,  101. 

Venous  stasis  in  thrombosis  of  cerebral 
veins  and  sinuses,  1006. 

Ventricular  haemorrhage,   989,   990. 

Vermiform  appendix,  inflammation  of. 
(See  Appendicitis.) 

Verruca  necrogenica,  162. 

Vertebrae,  tuberculosis  of,  followed  by  tu- 
berculosis of  kidneys,  216. 

Vertebral  artery,  blocking  of,   1000. 

Vertigo,  auditory,  1047,  1048;  cardio- 
vascular, 1048;  endemic  paralytic,  1048; 
following  influenza,  118;  gastric,  1048; 
in  Addison's  disease,  865;  in  arterio- 
sclerosis, 846;  in  cerebral  softening, 
1000;  in  chronic  gastritis,  4-80,  481,  485; 
in  locomotor  ataxia,  917;  in  neuras- 
thenia, 1108;  in  pellagra,  412;  in  per- 
nicious anaemia,  736;  in  sclerosis  of 
brain,  953;  in  Stokes-Adams  disease, 
779;  in  traumatic  hysteria,  1117;  in 
tumors  of  brain,  1010;  ocular,  1038;  of 
M6niere's  disease,  differentiation  of 
petit  mal  from,  1084. 

Vesiculae  seminales,   tuberculosis  of,  219. 

Vesicular  stomatitis,  456,  457. 

Vestibular  nerve,  disease  of,  1047. 

Vicarious  haemorrhage,  636. 

Villous  arthritis,  1136. 

Vincent's  bacillus,  60. 

Visceral  neuralgias,  1092. 

Visceral  tetanus,  144. 

Visceroptosis,  548;   constipation  and,  546. 

Visual  aphasia,  980,  981. 

Voice,  in  acute  sero-fibrinous  pleurisy, 
659;  in  adenoids,  470;  in  laryngitis, 
615,  616 ;  in  tuberculous  laryngitis,  618 ; 
loss  of,  in  aneurism  of  thoracic  aorta, 


855;  loss  of,  in  cardiac  insufficiency, 
790;  over  use  of,  acute  laryngitis  due 
to,  614. 

Volitional  tremor  in  multiple  sclerosis  of 
the  brain,  953. 

Volvulus,  causing  dilatation  of  colon,  552; 
causing  intestinal  obstruction,  540; 
diagnosis  of,  544. 

Vomiting,  hysterical,  1101;  in  abscess  of 
brain,  1016,  1017;  in  acute  arsenical 
poisoning,  406;  in  acute  Bright 's  dis- 
ease, 698,  701;  in  acute  cerebro-spinal 
leptomeningitis,  950;  in  acute  gastritis, 
477;  in  acute  pancreatitis,  595;  in  acute 
peritonitis,  treatment  of,  611;  in  acute 
polio-myelitis,  366;  in  acute  secondary 
anaemia,  728;  in  acute  yellow  atrophy, 
560;  in  Addison's  disease,  865;  in  alco- 
holic cirrhosis  of  liver,  578;  in  aneurism 
of  abdominal  aorta,  860;  in  angio- 
neurotic  oedema,  1124;  in  appendicitis, 
533,  535 ;  in  biliary  colic,  570 ;  in  can- 
cer of  liver,  588;  in  cancer  of  stomach, 
501,  502;  in  cardiac  insufficiency,  790, 
795;  in  cerebral  anaemia,  986;  in  cere- 
bral syphilis,  271;  in  cerebro-spinal 
fever,  112,  114;  in  cholecystitis,  566; 
in  cholera  infantum,  526;  in  chronic 
interstitial  nephritis,  707;  in  chronic 
parenchymatous  nephritis,  703;  in  cir- 
rhosis ventriculi,  486;  in  constipation, 
547;  in  dilatation  of  stomach,  486,  487, 
488;  in  exophthalmic  goitre,  878,  879; 
in  gastric  crises  of  locomotor  ataxia, 
917;  in  gastric  supersecretion,  512;  in 
glandular  fever,  386;  in  gout,  421;  in 
haemorrhagic  pachymeningitis,  947;  in 
intestinal  obstruction,  542,  543;  in  lead 
poisoning,  404;  in  leukaemia,  743;  in 
lobar  pneumonia,  88;  in  malaria,  249; 
in  meat  poisoning,  408;  in  MSniere'g 
disease,  1047;  in  migraine, '  1088 ;  in 
milk-sickness,  385;  in  movable  kidney, 
678 ;  in  pancreatic  cancer,  599 ;  in  pan- 
creatic cysts,  598;  in  pancreatic  haemor- 
rhage, 594;  in  paroxysmal  haemoglobi- 
nuria,  683;  in  pellagra,  412;  in  peptie 
ulcer,  493;  in  peritonitis,  601;  in  per- 
nicious malaria,  253;  in  pulmonary  tu- 
berculosis, 204;  in  purpura,  752;  in 
pyloric  stenosis,  506;  in  relapsing  fever, 
262;  in  renal  colic,  719;  in  scarlet 
fever,  335;  in  small-pox,  318;  in  sub- 
phrenic  abscess,  605;  in  thrombosis  of 
cerebral  veins  and  sinuses,  1005;  in 
thrombosis  of  mesenteric  vessels,  554; 
in  tuberculous  meningitis,  172;  in  tu- 
mor of  brain,  1010;  in  tumor  of  cere- 
bellum, 957;  in  typhus  fever,  353;  in 


1224 


INDEX 


uleeratiou  of  oesophagus,  473;  in  urae- 
mia, 695;  in  whooping  cough,  120;  in 
yellow  fever,  359,  360 ;  nervous,  510, 
511;  pneumogastric  nerve  and,  1051; 
rupture  of  oasophagus  due  to,  475,  476. 

Vulvitis,  gonorrheal,  peritonitis  and,  604; 
in  measles,  346. 

Vulvo-vaginitis  in  mumps,  351. 


W 


Wandering  spleen,  884. 

Warts,  syphilitic,  267. 

Wassermann  reaction,  264,  271,  273,  276, 
277;  in  general  paralysis,  925;  in  loco- 
motor  ataxia,  919;  in  tumors  of  brain, 
1014. 

Water,  cholera  infection  and,  134;  in- 
fected, typhoid  fever  and,  6. 

"Water  on  the  brain,"  171.  (See  also 
Meningeal  form  of  acute  miliary  tuber- 
culosis.) 

Water  supply  and  goitre,  872. 

Waxy  degeneration  of  kidneys,  711,  712. 

Waxy  liver,  590,  591. 

Weakness  in  paralysis  agitans,  1034. 

Weather,  relation  of,  to  catarrhal  enteritis, 
517. 

Weber's  syndrome,  993. 

Weil's  disease,  384,  385,  557. 

Weir-Mitchell  treatment  in  angina  pec- 
toris,  840;  in  enteroptosis,  550;  in  gas- 
tric neuroses,  514;  in  hysteria,  1105;  in 
neurasthenia,  1114;  in  palpitation,  780. 

Wernicke's  hemiopic  pupillary  reaction, 
1034. 

Wernicke's  zone,  978. 

Westphall-Strumpell  disease,  953,  954. 

"Wet  brain,"  397. 

Whip- worm,  309. 

White  infarct,  786. 

White  pneumonia  of  fetus,  272. 

Whooping  cough,  acute  bronchitis  and, 
620,  621 ;  acute  chorea  and  1067 ;  asth- 
ma and,  628;  broncho-pneumonia 
secondary  to,  101,  102,  106;  complica- 
tions and  sequelae  of,  121 ;  definition  of, 
119;  diagnosis  of,  122;  diphtheroid  in- 
flammation in,  60 ;  emphysema  of 
mediastinum  in,  675;  etiology  of,  119; 
following  measles,  347;  history  of,  119; 
hypertrophic  emphysema  and,  646,  647; 
infantile  convulsions  in,  1078;  mitral 
stenosis  and,  821 ;  morbid  anatomy  of, 
120;  predisposing  to  tuberculosis,  159; 
prognosis  of,  122;  prophylaxis  of, 
122;  purpura  in,  751;  scarlet  fever 
and,  340;  symptoms  of,  120;  treat- 


ment of,  122;  tuberculous  adenitis  and, 
175;  tuberculous  broncho-pneumonia 
and,  186. 

Widal  reaction,  37. 

Winckel  's  disease,  754 ;  methsemoglobinge- 
mia  in,  759. 

Wintrich's  sign,  85,  201. 

Wool-sorters'  disease    (see  Anthrax,  150). 

Word-blindness,  980;  in  tumors  of  brain, 
1011,  1012. 

Word-deaf  ness, '980;  due  to  destruction  of 
superior  temporal  gyrus,  1045;  in  tu- 
mors of  brain,  1012. 

Wormian  bones  in  congenital  hydrocepha- 
lus,  1019. 

Worms,  epilepsy  and,   1081,   1087. 

Wounds,  arterio-venous  aneurism  due  to, 
861,  862;  diphtheria  of,  66;  of  chest, 
pneumothorax  due  to,  669 ;  of  heart, 
831,  832;  of  heart,  cardiac  insufficiency 
due  to,  785;  of  neck,  abscess  of  the 
lung  following,  652;  self-inflicted  in 
hysteria,  1103. 

Wrist-drop,  in  alcoholic  neuritis,  1023 ;  in 
lead  poisoning,  404;  in  radial  paralysis, 
1059. 

Writers'  cramp,  1093;  diagnosis  of,  1094, 
1095;  prognosis  of,  1095;  symptoms  of, 
1094;  treatment  of,  1095. 

Writing,  979;  in  general  paralysis,  923. 

Wryneck,  congenital,  1052,  1053;  spas- 
modic, 1053,  1054. 


Xanthine,  calculi  of,  718. 

Xanthoma,  in  diabetes,  434;  in  hyper- 
trophic  cirrhosis,  581;  multiplex,  in  ob- 
structive jaundice,  556;  of  bile  passages 
in  biliary  colic,  571. 

Xanthopsia  in  obstructive  jaundice,  556. 

Xerostoma,   463 ;   parotitis  and,  464. 

X-ray,  in  acute  sero-fibrinous  pleurisy, 
659 ;  in  aneurism  of  thoracic  aorta,  856 ; 
in  cutaneous  actinomycosis,  234;  in  de- 
layed resolution  in  pneumonia,  101;  in 
diagnosis  of  aneurism,  850;  in  diagnosis 
of  bronchiectasis,  627;  in  diagnosis  of 
cirrhosis  ventriculi,  486;  in  diagnosis  of 
compression  myelitis,  961 ;  in  diagnosis 
of  mediastinal  tumor,  674;  in  diagnosis 
of  oesophageal  cancer,  475;  in  diagnosis 
of  ossophageal  diverticula,  476;  in  diag- 
nosis of  pancreatic  calculi,  599 ;  in  diag- 
nosis of  pulmonary  tuberculosis,  208; 
in  diagnosis  of  pyelitis,  715;  in  diag- 
nosis of  renal  calculus,  721;  in  leuko- 
plakia  oris,  461;  in  lymphadenitis,  672  j 


INDEX 


1225 


in  sporotrichosis,  236;  in  tracheo-bron- 
chial  adenitis,  177;  in  treatment  and 
diagnosis  of  lymphatism,  870;  in  treat- 
ment of  exophthalmic  goitre,  880;  in 
treatment  of  Hodgkin's  disease,  750; 
in  treatment  of  leprosy,  154;  in  treat- 
ment of  leukaemia,  746;  use  of,  in  con- 
stipation, 545,  546. 


Yellow  fever,  anuria  in,  680;  definition  of, 
356;  diagnosis  of,  360,  361;  etiology  of, 
356,  357;  haematemesis  in,  507;  haemo- 
globinuria  due  to,  683;  jaundice  in, 
557;  mode  of  transmission  of,  357,358; 
morbid  anatomy  of,  358,  359;  progno- 
sis of,  361 ;  prophylaxis  of,  361 ;  symp- 
toms of,  359,  360;  treatment  of,  361, 
362. 


Feast  fungus,  in  cancer  and  dilatation  of       Zinc,  neuritis  from,  1024 
stomach,   479,    502;    in   vomitus   in   py-       Zomotherapy,  228. 
lorie  stenosis,  488;  in  pneumaturia,  692.       Zuckerkandl  bodies,  863. 


(52) 


THE 


i  inivprsitv  of  California 
SOUTHERN  REGNAL  LIBRAE ' 
405  Hiloard  Avenue,  Los  Angeles,  CA  90024 
Return  this  material  to  the  library 
from  which  it  was  borrowed. 


(M.APR18 
(M.APR  1  8 


REC'I  LB-UR 
MAR 


WB100 
n  -,  °  S2p 

ThT  1916 

-he  principles  and  practice 
or  medicine 


WB100 
0  82p 
1916 
Osier. 

The  principles  and  practice  of 

medicine 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


mtlNTOO  M  U   •   » 


